Recognizing and reporting osteoporotic vertebral fractures

Characteristics of Prevalent Vertebral Fractures Predict New Fractures in Elderly Men

BACKGROUND

Studies have shown that specific characteristics of prevalent vertebral fractures are associated with a markedly low bone mineral density. This study evaluates if these characteristics also predict subsequent fractures.

METHODS

MrOS (Mister Osteoporosis) Sweden is a population-based, prospective observational study that includes 3014 community-living men who are sixty-nine to eighty-one years of age. At baseline, 1453 men underwent lateral thoracic and lumbar spine radiography; radiographs of 1427 men were readable. A radiologist identified and characterized prevalent vertebral fractures. Incident fractures during the next five and ten years were objectively registered with use of radiographs. The annual fracture incidence and relative risk of sustaining new fractures were assessed for men with and without baseline prevalent vertebral fracture. Data are presented as the mean and the 95% confidence interval.

RESULTS

There were 215 men (15.1%) with at least one prevalent vertebral fracture. During the five-year follow-up, these men had a relative risk of 3.3 (95% confidence interval, 2.6 to 4.3) of sustaining new fractures. The relative risk of sustaining any fracture was especially high in men with two or more prevalent vertebral fractures at 5.5 (95% confidence interval, 3.7 to 7.8), in men with different types of prevalent vertebral fractures at 5.7 (95% confidence interval, 3.6 to 8.5), in men with prevalent fractures in both the thoracic and lumbar regions at 6.4 (95% confidence interval, 4.5 to 8.8), and in men with prevalent fractures with a degree of vertebral body compression in the three worst quartiles, with the relative risk for the worst quartile at 4.0 (95% confidence interval, 2.6 to 5.9).

CONCLUSIONS

Older men with a prevalent vertebral fracture have three times increased risk of sustaining new fractures compared with men without a vertebral fracture. Older men with two or more prevalent vertebral fractures, different types of fractures (wedge, biconcave, and/or crush), fractures in both the thoracic and lumbar regions, and a degree of vertebral body compression in the three worst quartiles are at an especially high risk of sustaining new fractures. Older men with prevalent vertebral fractures should be considered for fracture-prevention efforts.

High prevalence of radiological vertebral fractures in adult patients with Ehlers-Danlos syndrome

Previous studies have reported an increased prevalence of osteoporosis in Ehlers–Danlos syndrome (EDS), but these were limited by a small number of patients and lack of information on fragility fractures. In this crosssectional study, we evaluated the prevalence of radiological vertebral fractures (by quantitative morphometry) and bone mineral density (BMD, at lumbar spine, total hip and femoral neck by dual-energy X-ray absorptiometry) in 52 consecutive patientswith EDS (10 males, 42 females; median age 41 years, range: 21–71; 12with EDS classic type, 37 with EDS hypermobility type, 1 with classic vascular-like EDS, and 2 without specific classification) and 197 control subjects (163 females and 34 males; median age 49 years, range: 26–83) attending an outpatient bone clinic. EDS patients were also evaluated for back pain by numeric pain rating scale (NRS- 11).Vertebral fractures were significantly more prevalent in EDS as compared to the control subjects (38.5% vs. 5.1%; p b 0.001) without significant differences in BMD at either skeletal sites. In EDS patients, the prevalence of vertebral fractures was not significantly (p = 0.72) different between classic and hypermobility types. BMD was not significantly different between fractured and non-fractured EDS patients either at lumbar spine (p = 0.14), total hip (p=0.08), or femoral neck (p=0.21). Severe back pain(≥7 NRS)was more frequent in EDS patients with vertebral fractures as compared to thosewithout fractures (60% vs. 28%; p=0.04). Inconclusion, this is the first study showing high prevalence of vertebral fractures in a relatively large population of EDS patients. Vertebral fractures were associated with more severe back pain suggesting a potential involvement of skeletal fragility in determining poor quality of life. The lack of correlation between vertebral fractures and BMD is consistent with the hypothesis that bone quality may be impaired in EDS.

Prevalence and "Red Flags" Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice

BACKGROUND

In a small proportion of patients experiencing unspecified back pain, a specified underlying pathology is present.

OBJECTIVE

The purposes of this study were: (1) to identify the prevalence of physician-specified causes of back pain and (2) to assess associations between "red flags" and vertebral fractures, as diagnosed by the patients' general practitioner (GP), in older adults with back pain.

METHODS

The Back Complaints in the Elders (BACE) study is a prospective cohort study. Patients (aged >55 years) with back pain were included when consulting their GP. A questionnaire was administered and a physical examination and heel bone densitometry were performed, and the results determined back pain and patient characteristics, including red flags. Participants received a radiograph, and reports were sent to their GP. The final diagnoses established at 1 year were collected from the GP's patient registry.

RESULTS

Of the 669 participants included, 6% were diagnosed with a serious underlying pathology during the 1-year follow-up. Most of these participants (n=33, 5%) were diagnosed with a vertebral fracture. Multivariable regression analysis showed that age of ≥75 years, trauma, osteoporosis, a back pain intensity score of ≥7, and thoracic pain were associated with a higher chance of getting the diagnosis of a vertebral fracture. Of these variables, trauma showed the highest positive predictive value for vertebral fracture of 0.25 (95% confidence interval=0.09, 0.41) and a positive likelihood ratio of 6.2 (95% confidence interval=2.8, 13.5). A diagnostic prediction model including the 5 red flags did not increase these values.

LIMITATIONS

Low prevalence of vertebral fractures could have led to findings by chance.

CONCLUSIONS

In these older adults with back pain presenting in general practice, 6% were diagnosed with serious pathology, mainly a vertebral fracture (5%). Four red flags were associated with the presence of vertebral fracture.

Vertebral Morphometry

There is as yet no agreement about the criteria by which to arrive at an imaging diagnosis of a vertebral fracture. Because high-grade fractures result in alterations in vertebral shape, 1 possible avenue of diagnosis has been to quantitate changes in vertebral shape. The result has been a variety of methods for the relative and absolute measurements of vertebral dimensions. Such measurements have also lent themselves to automated computed analysis. The number of techniques reflects the absence of any consensus about the best. The semiquantitative technique proposed by Genant has become the most widely used and has served the field well for comparative purposes. Its use in higher grade fractures has been widely endorsed, if some concepts (e.g., short vertebral height-vertebrae) are at variance with lower grades of fracturing. Vertebral morphometry may be the only recourse in high volume epidemiological and interventional studies.

PROXIMAL DISABILITY AND SPINAL DEFORMITY INDEX IN PATIENTS WITH PROXIMAL FEMUR FRACTURES

Objective : To evaluate the quality of life related to the spine in patients with proximal femoral fractures. Methods : Study conducted in a tertiary public hospital in patients with proximal femoral fractures caused by low-energy trauma, through the Oswestry Disability Index questionnaire to asses complaints related to the spine at the time of life prior to the femoral fracture. The thoracic and lumbar spine of patients were also evaluated applying the radiographic index described by Gennant (Spinal Deformity Index), which assesses the number and severity of fractures. Results : Seventeen subjects completed the study. All had some degree of vertebral fracture. Patients were classified in the categories of severe and very severe disability in the questionnaire about quality of life. It was found that the higher SDI, the better the quality of life. Conclusion : There is a strong association of disability related to the spine in patients with proximal femoral fracture, and this complaint must be systematically evaluated in patients with appendicular fracture.

The number and characteristics of prevalent vertebral fractures in elderly men are associated with low bone mass and osteoporosis

We sought to determine whether specific characteristics of vertebral fractures in elderly men are associated with low bone mineral density (BMD) and osteoporosis. Mister Osteoporosis Sweden is a population based cohort study involving 3014 men aged 69 to 81 years. Of these, 1427 had readable lateral radiographs of the thoracic and lumbar spine. Total body (TB) BMD (g/cm²) and total right hip (TH) BMD were measured by dual energy x-ray absorptiometry. The proportion of men with osteoporosis was calculated from TH BMD. There were 215 men (15.1%) with a vertebral fracture. Those with a fracture had lower TB BMD than those without (p < 0.001). Among men with a fracture, TB BMD was lower in those with more than three fractures (p = 0.02), those with biconcave fractures (p = 0.02) and those with vertebral body compression of > 42% (worst quartile) (p = 0.03). The mean odds ratio (OR) for having osteoporosis when having any type of vertebral fracture was 6.1 (95% confidence interval (CI) 3.9 to 9.5) compared with those without a fracture. A combination of more than three fractures and compression in the worst quartile had a mean OR of 114.2 (95% CI 6.7 to 1938.3) of having osteoporosis compared with those without a fracture. We recommend BMD studies to be undertaken in these subcohorts of elderly men with a vertebral fracture.

Coexistent osteoporosis and multiple myeloma: when to investigate further in osteoporosis

Osteoporosis commonly causes vertebral collapse fractures. We present a patient with multiple vertebral fractures in the context of severe osteoporosis, who, in the course of investigation for intractable spine and hip pain, was found to have an IgA myeloma. At 2 months post diagnosis, she was discharged home to continue outpatient chemotherapy.

Identifying osteoporotic vertebral fracture

Osteoporosis per se is not a harmful disease. It is the sequela of osteoporosis and most particularly the occurrence of osteoporotic fracture that makes osteoporosis a serious medical condition. All of the preventative measures, investigations, treatment and research into osteoporosis have one primary goal and that is to prevent the occurrence of osteoporotic fracture. Vertebral fracture is by far and away the most prevalent osteoporotic fracture. The significance and diagnosis of vertebral fracture are discussed in this article.

Validation of the simplified Chinese version of the quality of life questionnaire of the European foundation for osteoporosis (QUALEFFO-31)

PURPOSE

To translate quality of life questionnaire of the European foundation for osteoporosis (QUALEFFO-31) into a simplified Chinese version, and test its reliability and validity in osteoporosis patients from mainland Chinese population.

METHODS

Postmenopausal osteoporosis women with history of vertebral fracture were included as cases, and age-matched healthy female were included as controls. All subjects were from mainland China. The simplified Chinese version of QUALEFFO-31 and SF-36 were assigned to the two groups. Reliability was assessed using kappa statistics of agreement for each item and the intra-class correlation coefficient (ICC). The internal consistency was assessed with Cronbach's α. Pearson's correlation was used to assess convergent and discriminant validity.

RESULTS

Overall, 66 cases and 66 age-matched controls were included. The ICC for the test-retest reliability ranged from 0.76 to 0.91. Cronbach's α for pain, physical function, and mental function domains were 0.94, 0.87, and 0.79, respectively. Convergent validity and discriminant validity showed that each correlation coefficient between score of each item with total score of related domain was higher than that with total score of unrelated domain. Pearson's correlation coefficients indicated significantly high correlations between corresponding domains of QUALEFFO-31 and SF-36.

CONCLUSIONS

The simplified Chinese version of the QUALEFFO-31 is a reliable and valid outcome measure of functional status in patients with osteoporosis. This Chinese version of the QUALEFFO-31 can be utilized for future clinical studies in mainland China.

Prevalence and predictors of low bone mineral density and fragility fractures among HIV-infected patients at one Italian center after universal DXA screening: sensitivity and specificity of current guidelines on bone mineral density management

Low bone mineral density (BMD) is frequent in HIV infection regardless of the use of antiretroviral therapy (ART). Uncertainties remain, however, as to when in HIV infection BMD screening should be performed. We designed a prospective study to estimate the efficacy of universal BMD screening by dual-energy X-ray absorptiometry (DXA). Since April 2009 through March 2011, HIV patients attending our Center were offered femoral/lumbar DXA to screen BMD. Low BMD for chronological age, that is significant osteopenia, was defined as a Z-score ≤ -2.0 at femur and lumbar spine. Nontraumatic bone fractures (NTBFs) were evaluated. The final sample included 163 patients. A Z-score ≤ -2.0 at any site was observed in 19.6% of cases: among these, 18.8% had no indication to DXA using current Italian HIV guidelines for BMD screening. A lower femoral Z-score was independently associated with lower BMI, AIDS diagnosis, HCV co-infection, antiretroviral treatment, and NTBFs; a lower lumbar Z-score with age, BMI, Nadir CD4 T-cell counts, and NTBFs. Prevalence of NTBFs was 27.0%, predictors being male gender, HCV co-infection, and lower femoral Z-scores. Our results suggest that measuring BMD by DXA in all HIV patients regardless of any further specification may help retrieving one-fifth of patients with early BMD disorders not identified using current criteria for selective screening of BMD.

Low clinical relevance of a prevalent vertebral fracture in elderly men--the MrOs Sweden study

BACKGROUND CONTEXT

The epidemiology, the fracture pattern, and the clinical relevance of prevalent vertebral fractures in old men are debated wherefore we set out to clarify these issues.

METHODS

Mister Osteoporosis (MrOs) Sweden is a population-based cohort of community-living men aged 69-81 years that includes 3,014 men. Out of these, 1,453 men underwent a lateral radiograph of the thoracic and lumbar spine of which 1,427 were readable and classified by a radiologist, that is the sample size in this study. The men also answered a questionnaire evaluating back pain and limitation in activities of daily living (ADLs) because of back pain during the preceding 12 months in addition with fracture history and life style.

RESULTS

Fifteen percentage of the men had at least one prevalent vertebral fracture, but only 1/10th of these were aware of their fracture. Among the men with a fracture, 58% had one, 21% two, 9% three, and 11% four or more fractures. In men with only one fracture, 70% of the fractures were located in the thoracic and 30% in the lumbar spine, 85% had a wedge, 13% a biconcave, and 2% a crush-type configuration; one-quarter had a maximum vertebral body compression degree of less than 24% and one-quarter of more than 38%. Among the men with one or several vertebral fracture, 57% reported back pain compared with 55% in those without a fracture (p=.53). Most ADL functions were similar in the men with or without a prevalent vertebral fracture. In the men with one fracture, there was no difference in the occurrence of back pain depending on the fractured region (p=.49), type of the fracture (p=.77), or degree of compression (p=.85). In men with one or several fractures, there were no significant differences in the presence of back pain in any ages (p=.08), nor there were differences in presence of back pain regarding type (p=.08) or number of fractures (p=.21).

CONCLUSIONS

A prevalent vertebral fracture is common in old men but has low clinical relevance. There does not seem to be a specific fracture pattern that predisposes for back pain.

Association between l-thyroxine treatment, GH deficiency, and radiological vertebral fractures in patients with adult-onset hypopituitarism

OBJECTIVE

In this study, we aimed at evaluating the association between radiological vertebral fractures and levo-thyroxine (l-T4) replacement doses in adult patients with hypopituitarism.

DESIGN

Cross-sectional study.

METHODS

We studied 74 adult hypopituitary patients (males, 43; females, 31; mean age, 57 years; and range, 23-79) with central hypothyroidism treated with l-T4 (median daily dose: 1.1  μg/kg). All patients also had severe GH deficiency (GHD) and 38 of them were replaced with recombinant GH. Vertebral fractures were assessed by a quantitative morphometric analysis performed on thoracic and lumbar spine lateral X-ray.

RESULTS

Radiological vertebral fractures were found in 23 patients (31.1%) in association with untreated GHD (P=0.02), higher serum free T4 levels (P=0.03), a higher daily dose of l-T4 (P=0.005), and a longer duration of hypopituitarism (P=0.05). When GHD was treated, the prevalence of vertebral fractures was more frequent (P=0.03) in patients receiving high l-T4 doses (third tertile: >1.35  μg/kg per day) as compared with patients who were treated with lower drug doses (first tertile: <0.93  μg/kg per day). Such a difference was not observed in patients with untreated GHD who showed a higher prevalence of vertebral fractures regardless of l-T4 daily doses. Multivariate analysis showed that untreated GHD (odds ratio: 4.27, 95% CI 1.27-14.33; P=0.01) and the daily dose of l-T4 (odds ratio: 4.01, 95% CI 1.16-14.39; P=0.03) maintained a significant and independent association with vertebral fractures in patients with central hypothyroidism.

CONCLUSIONS

Our data suggest for the first time that a relative overtreatment with l-T4 may influence the fracture risk in some patients with hypopituitarism.

Imaging of vertebral fractures

Vertebral fracture is a common clinical problem. Osteoporosis is the leading cause of non-traumatic vertebral fracture. Often, vertebral fractures are not clinically suspected due to nonspecific presentation and are overlooked during routine interpretation of radiologic investigations. Moreover, once detected, many a times the radiologist fails to convey to the clinician in a meaningful way. Hence, vertebral fractures are a constant cause of morbidity and mortality. Presence of vertebral fracture increases the chance of fracture in another vertebra and also increases the risk of subsequent hip fracture. Early detection can lead to immediate therapeutic intervention improving further the quality of life. So, in this review, we wish to present a comprehensive overview of vertebral fracture imaging along with an algorithm of evaluation of vertebral fractures.

Dual-energy X-ray absorptiometry interpretation and reporting in children and adolescents: the revised 2013 ISCD Pediatric Official Positions

The International Society for Clinical Densitometry Official Revised Positions on reporting of densitometry results in children represent current expert recommendations to assist health care providers determine which skeletal sites should be measured, which, if any, adjustments should be made, reference databases to be used, and the elements to include in a dual-energy X-ray absorptiometry report. The recommended scanning sites remain the total body less head and the posterior-anterior spine. Other sites such as the proximal femur, lateral distal femur, lateral vertebral assessment, and forearm are discussed but are only recommended for specific pediatric populations. Different methods of interpreting bone density scans in children with short stature or growth delay are presented. The use of bone mineral apparent density and height-adjusted Z-scores are recommended as suitable size adjustment techniques. The validity of appropriate reference databases and technical considerations to consider when upgrading software and hardware remain unchanged. Updated reference data sets for all contemporary bone densitometers are listed. The inclusion of relevant demographic and health information, technical details of the scan, Z-scores, and the wording "low bone mass or bone density" for Z-scores less than or equal to -2.0 standard deviation are still recommended for clinical practice. The rationale and evidence for the development of the Official Positions are provided. Changes in the grading of quality of evidence, strength of recommendation, and worldwide applicability represent a change in current evidence and/or differences in opinion of the expert panelists used to validate the position statements for the 2013 Position Development Conference.

Locally measured microstructural parameters are better associated with vertebral strength than whole bone density

Whole vertebrae areal and volumetric bone mineral density (BMD) measurements are not ideal predictors of vertebral fractures. We introduce a technique which enables quantification of bone microstructural parameters at precisely defined anatomical locations. Results show that local assessment of bone volume fraction at the optimal location can substantially improve the prediction of vertebral strength.

INTRODUCTION

Whole vertebrae areal and volumetric BMD measurements are not ideal predictors of vertebral osteoporotic fractures. Recent studies have shown that sampling bone microstructural parameters in smaller regions may permit better predictions. In such studies, however, the sampling location is described only in general anatomical terms. Here, we introduce a technique that enables the quantification of bone volume fraction and microstructural parameters at precisely defined anatomical locations. Specific goals of this study were to investigate at what anatomical location within the vertebrae local bone volume fraction best predicts vertebral-body strength, whether this prediction can be improved by adding microstructural parameters and to explore if this approach could better predict vertebral-body strength than whole bone volume fraction and finite element (FE) analyses.

METHODS

Eighteen T12 vertebrae were scanned in a micro-computed tomography (CT) system and FE meshes were made using a mesh-morphing tool. For each element, bone microstructural parameters were measured and correlated with vertebral compressive strength as measured experimentally. Whole bone volume fraction and FE-predicted vertebral strength were also compared to the experimental measurements.

RESULTS

A significant association between local bone volume fraction measured at a specific central region and vertebral-body strength was found that could explain up to 90% of the variation. When including all microstructural parameters in the regression, the predictive value of local measurements could be increased to 98%. Whole bone volume fraction could explain only 64% and FE analyses 76% of the variation in bone strength.

CONCLUSIONS

A local assessment of volume fraction at the optimal location can substantially improve the prediction of bone strength. Local assessment of other microstructural parameters may further improve this prediction but is not clinically feasible using current technology.

Vertebral fracture assessment (VFA) by lateral DXA scanning may be cost-effective when used as part of fracture liaison services or primary care screening

SUMMARY

We identified that use of VFA may be cost-effective in either selected women from primary care or women attending after a low trauma fracture.

INTRODUCTION

Lateral DXA scanning of the spine for vertebral fracture assessment (VFA) is used for research, but its wider role is unclear. We aimed to establish whether VFA is cost-effective in women based on two different scenarios: following a low-trauma fracture, and after screening of high-risk women identified in primary care.

METHODS

The fracture cohort (FC) consisted of 377 women and the primary care cohort (PCC) of 251. Vertebral fractures were identified on VFA images by quantitative morphometry (QM). Outcome was cost-effectiveness of VFA, based on predicted change in clinical management defined as the identification of a vertebral fracture in a patient who otherwise falls below the threshold for treatment. FRAX treatment thresholds assessed were (1) 20/3 % thresholds and (2) National Osteoporosis Guidelines Group (NOGG) thresholds.

RESULTS

As a result, 9.8 % from FC and 13.9 % from PCC were identified with vertebral fractures. Management was changed in 21 to 22/377 (5.6-5.8 %) in FC and 12 to 26/251 (4.8-10.4 %) from PCC depending on which thresholds were used. Sensitivity analyses identified medication adherence as the assumption which most influenced the model. The best-estimate cost-per-QALY for use of VFA in FC was £3,243 for 20/3 threshold and £2,130 for NOGG; for PCC, this was £7,831 for 20/3 and was cost-saving for NOGG. Further analyses to adjust for potential false-positive vertebral fracture identification with QM showed VFA was no longer cost-effective.

CONCLUSION

VFA appears to be cost-effective in routine clinical practise, particularly when relatively inaccurate methods of identification of vertebral fractures are used such as QM.

Vertebral deformities and fractures are associated with MRI and pQCT measures obtained at the distal tibia and radius of postmenopausal women

SUMMARY

We investigated the association of postmenopausal vertebral deformities and fractures with bone parameters derived from distal extremities using MRI and pQCT. Distal extremity measures showed variable degrees of association with vertebral deformities and fractures, highlighting the systemic nature of postmenopausal bone loss.

INTRODUCTION

Prevalent vertebral deformities and fractures are known to predict incident further fractures. However, the association of distal extremity measures and vertebral deformities in postmenopausal women has not been fully established.

METHODS

This study involved 98 postmenopausal women (age range 60-88 years, mean 70 years) with DXA BMD T-scores at either the hip or spine in the range of -1.5 to -3.5. Wedge, biconcavity, and crush deformities were computed on the basis of spine MRI. Vertebral fractures were assessed using Eastell's criterion. Distal tibia and radius stiffness was computed using MRI-based finite element analysis. BMD at the distal extremities were obtained using pQCT.

RESULTS

Several distal extremity MRI and pQCT measures showed negative association with vertebral deformity on the basis of single parameter correlation (r up to 0.67) and two-parameter regression (r up to 0.76) models involving MRI stiffness and pQCT BMD. Subjects who had at least one prevalent vertebral fracture showed decreased MRI stiffness (up to 17.9 %) and pQCT density (up to 34.2 %) at the distal extremities compared to the non-fracture group. DXA lumbar spine BMD T-score was not associated with vertebral deformities.

CONCLUSIONS

The association between vertebral deformities and distal extremity measures supports the notion of postmenopausal osteoporosis as a systemic phenomenon.

Radiographic Detection of Osteoporotic Vertebral Fracture without Collapse

Background

On retrospective basis, we investigated the detection of osteoporotic vertebral fractures (OVFs) without radiologic collapse using a modified Yoshida's classification, which was designed by the authors.

Methods

We observed 82 cases in 76 patients with confirmed OVFs without collapse at the thoracolumbar junction. The following factors were measured: age, gender, body mass index (BMI, kg/m²), bone mineral density (BMD, mg/cm³), type of a modified Yoshida's classification. The correct diagnosis rate for the presence and location of OVFs and the correct diagnosis rate according to the morphological type by a modified Yoshida's classification of the OVFs were analyzed.

Results

The mean BMI was 21.2; mean BMD, 44.1; and T-score, -4.4. As for the four subtypes of anterior cortical morphological change, there were 14 cases of the protruding type, 12 cases of the indented type, 5 cases of the disrupted type and 8 cases of the prow type. As for the three subtypes of endplate depression, there were 20 cases of upper endplate depression, 12 cases of lower endplate depression and 11 cases of endplate slippage type. According to the examiners, there was a significant difference between being informed before and after the modified Yoshida's classification. For the relationship of examiners and the type of fracture, there was a significant difference between being informed before and after the modified Yoshida's classification, particularly in the protruding type and the upper plate type.

Conclusions

A modified Yoshida's classification can be helpful for the diagnosis of OVFs without radiologic collapse in a simple radiograph.

Cross-sectional associations between prevalent vertebral fracture and pulmonary function in the sixth Tromsø study

Background

Persons with vertebral fracture may have reduced pulmonary function, but this association has not been much studied. The aim of this cross-sectional study was therefore to examine the relationship between vertebral fracture and pulmonary function in a general, elderly population.

Methods

Vertebral morphometry was used for vertebral fracture assessment in 2132 elderly men (n = 892) and women (n = 1240) aged 55 to 87 years in the population-based Tromsø Study 2007–08. Pulmonary function was examined by spirometry. Pulmonary function was expressed as FVC% predicted, FEV₁% predicted, and FEV₁/FVC% predicted values, adjusted FVC, FEV₁, and FEV₁/FVC, and obstructive and restrictive ventilatory impairment. Vertebral fracture was classified according to appearance, number, severity, and location of fractures. Associations were analyzed using general linear and logistic models.

Results

FVC% predicted and FEV₁% predicted values were not associated with vertebral fracture (P > 0.05), whereas FEV₁/FVC% predicted ratio was associated with both prevalent fracture, number of fractures, severity of fractures, and fracture site in men (P < 0.05), but not in women. When FVC, FEV₁, and FEV₁/FVC values were adjusted for multiple covariates, we found no significant association with vertebral fracture. Obstructive and restrictive ventilatory impairment was not associated with prevalent vertebral fracture.

Conclusions

In conclusion, this study did not confirm any clinically relevant associations between prevalent vertebral fracture and ventilatory impairment in elderly individuals.

Vertebral fractures and self-perceived health in elderly women and men in a population-based cross-sectional study: the Tromsø Study 2007-08

Background

Health-related quality of life (HRQL) may be associated with increased mortality in the elderly. The effect of prevalent vertebral fractures on HRQL in elderly women and men is not well described. The purpose of this study was to examine the association between prevalent vertebral fractures and back pain, neck pain, and HRQL in elderly women and men, and to study possible gender differences in the reported pain and HRQL.

Methods

Information on prevalent vertebral fractures was ascertained by a vertebral fracture assessment (VFA) method (dual-energy X-ray absorptiometry (DXA), GE Lunar Prodigy) in 2887 women and men, mean age 65.4 (SD 9.4) who participated in the population-based Tromsø Study which was conducted in 2007–08. Bone mineral density (BMD; g/cm²) was measured by DXA at the femoral sites. Self-reported HRQL was assessed using the standardized measures EQ-5D-3 L and EQ VAS from the EuroQol Group. Lifestyle information was collected by questionnaires. The association between vertebral fractures and pain was analyzed using logistic regression, between vertebral fractures and EQ-5D-3 L and EQ VAS scores by multiple regression analyses.

Results

In women, presence of vertebral fractures was associated with an increased risk of back pain with an OR of 1.76 (95% CI: 1.24 – 2.50) after adjustments for age, height, weight, and BMD. Women with vertebral fractures had lower EQ-5D-3 L scores (p < 0.001) than women without vertebral fractures, also after adjustments. These associations were not present in men. Type of fracture was not associated with EQ-5D-3 L scores, but increasing numbers (p < 0.001) and severity of fractures (p < 0.002) were associated with decreasing EQ-5D-3 L score in women.

Conclusion

Prevalent vertebral fractures are associated with increased risk of back pain and reduced HRQL in postmenopausal women, but not in men.

Vertebral fracture assessment by dual X-ray absorptiometry: a valid tool to detect vertebral fractures in community-dwelling older adults in a population-based survey

OBJECTIVE

Vertebral fractures are associated with higher morbidity and mortality. Since 70% of vertebral fractures are clinically silent, a radiologic image of the spine has to be acquired for the diagnosis. The aim of this study was to compare the performance of Vertebral Fracture Assessment (VFA) by dual x-ray absorptiometry (DXA) with radiographs to identify vertebral fractures in community-dwelling older adults.

METHODS

A total of 429 older adults (ages ≥65 years) were enrolled in this cohort. VFA by DXA measurements were evaluated by 2 expert rheumatologists by consensus, and spine radiographs were analyzed according to the semiquantitative method by an expert radiologist. The correlation between VFA and spine radiographs to identify vertebral fractures was analyzed by kappa scores.

RESULTS

The prevalence of vertebral fractures in VFA and radiographs was 29.1% and 29.4%, respectively (P = 0.99). The frequency of unavailable vertebrae was significantly lower in spinal radiographs than in VFA (0.9% and 5.6%, respectively; P < 0.001), particularly in T4-T6. According to VFA, 5,013 vertebrae (96%) were identified as normal and 144 (2.7%) had grade 1, 58 (1.1%) had grade 2, and 12 (0.2%) had grade 3 fractures. The sensitivity of VFA was 72.9% and the specificity was 99.1% to identify vertebral fractures. The sensitivity increased to 92% and the specificity increased to 99.9% when excluding grade 1 deformities. A good correlation between VFA and radiographs (κ = 0.74) was observed, and the exclusion of grade 1 resulted in even better agreement (κ = 0.84).

CONCLUSION

In community-dwelling older adults, VFA and radiographs had comparable performances in identifying vertebral fractures, particularly if mild deformities are excluded. Therefore, this methodology is a feasible and promising alternative to improve the management of patients with a high risk of osteoporotic fractures.

Prevalence and risk factors of radiographic vertebral fractures in elderly Chinese men and women: results of Mr. OS (Hong Kong) and Ms. OS (Hong Kong) studies

This study investigated the prevalence of radiographic vertebral fractures using Genant's semiquantitative (SQ) scoring system in elderly Chinese men (n = 2,000; mean age, 72.4 years) and women (n = 2,000; mean age, 72.6 years). Vertebral deformities had similar prevalence in elderly men (14.9 %) and women (16.5 %). Majority of the deformities in men were mild (9.9 %, grade = 1). The prevalence of vertebral fractures (grade ≥ 2) was 5.0 % among men and 12.1 % among women.

INTRODUCTION

Vertebral fracture is a serious consequence of osteoporosis and is often under-diagnosed. Researches on different ethnicities and territories to estimate the prevalence of vertebral fractures and to identify the risk factors are necessary.

METHODS

Mr. OS (Hong Kong) and Ms. OS (Hong Kong) represent the first large-scale cohort studies ever conducted on bone health in elderly Chinese men (n = 2,000) and women (n = 2,000). The current study investigated the prevalence of radiographic vertebral fractures in these subjects using Genant's SQ scoring system and identified risk factors for vertebral fractures.

RESULTS

The radiographs of all men (mean age, 72.4 years) and women (mean age, 72.6 years) were obtained. Six hundred twenty-seven subjects (15.7 %) had at least one vertebral deformity (SQ grade ≥ 1), including 297 men (14.9 %) and 330 women (16.5 %, p = 0.151). Three hundred forty-two participants (8.6 %) were defined as having at least one vertebra fracture (SQ grade ≥ 2), consisted of 100 men (5.0 %) and 242 women (12.1 %, p < 0.001). Older age, lower bone mineral density, lower physical activity, lower grip strength, fracture history, and low back pain were significantly associated with higher vertebral fracture rate for both men and women.

CONCLUSION

Vertebral deformity had similar prevalence in older men and women, while vertebral fracture was more common in women. Majority of deformities in men was mild. The vertebral deformity prevalence of women from this study is similar to previous reports of other East Asian women and Latin American women.

Biochemical markers for bone turnover predict risk of vertebral fractures in postmenopausal women over 10 years: the Japanese Population-based Osteoporosis (JPOS) Cohort Study

We evaluated how bone turnover might predict vertebral fracture risk in postmenopausal women over 10 years. After adjusting for age and femoral neck bone mineral density, high bone-specific alkaline phosphatase and total and free deoxypyridinoline at baseline predicted increased vertebral fracture risk in women with ≥ 5 years since menopause.

INTRODUCTION

The aim was to evaluate the ability of bone turnover markers (BTMs) in predicting vertebral fractures.

METHODS

Participants in the 1996 baseline survey of the JPOS Cohort Study included 522 postmenopausal women, with no diseases or medications affecting bone metabolism. Vertebral fractures were ascertained in three follow-up surveys (1999, 2002, and 2006). Initial fracture events were diagnosed morphometrically. The Poisson regression model was applied to estimate the rate ratio (RR) of the following log-transformed BTM values at baseline: osteocalcin and bone-specific alkaline phosphatase (BAP) in serum and C-terminal cross-linked telopeptide of type I collagen, total deoxypyridinoline (tDPD), and free deoxypyridinoline (fDPD) in urine.

RESULTS

Eighty-three fracture events were diagnosed over a median follow-up period of 10.0 years. RR per standard deviation (SD) (95 % confidence interval) for BAP was 4.38 (1.45, 13.21) among 65 subjects with years since menopause (YSM) < 5 years. RRs per SD (95 % confidence interval) for BAP, tDPD, and fDPD were 1.39 (1.12, 1.74), 1.32 (1.05, 1.67), and 1.40 (1.12, 1.76), respectively, after adjusting for age and femoral neck bone mineral density (FN BMD) among 457 subjects with YSM ≥ 5 years. Of the 451 women followed at least once until 2002, RRs per SD for BAP, tDPD, and fDPD adjusted for age and FN BMD over 6 years were not significantly different from those over 10 years.

CONCLUSION

BAP was associated with vertebral fracture risk among early postmenopausal women. BTMs can predict vertebral fractures independently of BMD among late postmenopausal women over a 10-year follow-up period.

Red flags to screen for vertebral fracture in patients presenting with low-back pain

BACKGROUND

Low-back pain (LBP) is a common condition seen in primary care. A principal aim during a clinical examination is to identify patients with a higher likelihood of underlying serious pathology, such as vertebral fracture, who may require additional investigation and specific treatment. All 'evidence-based' clinical practice guidelines recommend the use of red flags to screen for serious causes of back pain. However, it remains unclear if the diagnostic accuracy of red flags is sufficient to support this recommendation.

OBJECTIVES

To assess the diagnostic accuracy of red flags obtained in a clinical history or physical examination to screen for vertebral fracture in patients presenting with LBP.

SEARCH METHODS

Electronic databases were searched for primary studies between the earliest date and 7 March 2012. Forward and backward citation searching of eligible studies was also conducted.

SELECTION CRITERIA

Studies were considered if they compared the results of any aspect of the history or test conducted in the physical examination of patients presenting for LBP or examination of the lumbar spine, with a reference standard (diagnostic imaging). The selection criteria were independently applied by two review authors.

DATA COLLECTION AND ANALYSIS

Three review authors independently conducted 'Risk of bias' assessment and data extraction. Risk of bias was assessed using the 11-item QUADAS tool. Characteristics of studies, patients, index tests and reference standards were extracted. Where available, raw data were used to calculate sensitivity and specificity with 95% confidence intervals (CI). Due to the heterogeneity of studies and tests, statistical pooling was not appropriate and the analysis for the review was descriptive only. Likelihood ratios for each test were calculated and used as an indication of clinical usefulness.

MAIN RESULTS

Eight studies set in primary (four), secondary (one) and tertiary care (accident and emergency = three) were included in the review. Overall, the risk of bias of studies was moderate with high risk of selection and verification bias the predominant flaws. Reporting of index and reference tests was poor. The prevalence of vertebral fracture in accident and emergency settings ranged from 6.5% to 11% and in primary care from 0.7% to 4.5%. There were 29 groups of index tests investigated however, only two featured in more than two studies. Descriptive analyses revealed that three red flags in primary care were potentially useful with meaningful positive likelihood ratios (LR+) but mostly imprecise estimates (significant trauma, older age, corticosteroid use; LR+ point estimate ranging 3.42 to 12.85, 3.69 to 9.39, 3.97 to 48.50 respectively). One red flag in tertiary care appeared informative (contusion/abrasion; LR+ 31.09, 95% CI 18.25 to 52.96). The results of combined tests appeared more informative than individual red flags with LR+ estimates generally greater in magnitude and precision.

AUTHORS' CONCLUSIONS

The available evidence does not support the use of many red flags to specifically screen for vertebral fracture in patients presenting for LBP. Based on evidence from single studies, few individual red flags appear informative as most have poor diagnostic accuracy as indicated by imprecise estimates of likelihood ratios. When combinations of red flags were used the performance appeared to improve. From the limited evidence, the findings give rise to a weak recommendation that a combination of a small subset of red flags may be useful to screen for vertebral fracture. It should also be noted that many red flags have high false positive rates; and if acted upon uncritically there would be consequences for the cost of management and outcomes of patients with LBP. Further research should focus on appropriate sets of red flags and adequate reporting of both index and reference tests.

Systematic vertebral fracture assessment in asymptomatic postmenopausal women

INTRODUCTION

Recognition of vertebral fractures (VFs) changes the patient's diagnostic classification, estimation of fracture risk, and threshold for pharmacological intervention. Vertebral fracture assessment (VFA) enables the detection of VFs in the same session as bone mineral density (BMD) testing.

OBJECTIVE

To study prevalence and risk factors of VFs using VFA in asymptomatic women and measure its effect on treatment recommendations.

METHODS

We enrolled 908 postmenopausal women (mean age, weight and BMI of 60.9 ± 7.7 (50-91) years, 73.2 ± 13.2 (35-150) kg and 29.8 ± 5.3 (14.5-50.8) kg/m(2), respectively. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry.

RESULTS

VFs were identified in 382 patients (42.0%): 203 (22.3%) had grade 1 and 179 (19.7%) had grade 2 or 3. The prevalence of VFA-detected fractures globally increased significantly with age and as BMI and BMD declined. A fracture was identified on VFA in 63 (28.3%) women with normal BMD (8.5% had grade 2/3 VFs) and in 145 (38.5%) with osteopenia (15.7% had grade 2/3 VFs). Stepwise regression analysis showed that presence of VFs was independently related to age, BMI, number of parity, history of peripheral fracture and lumbar spine BMD.

CONCLUSION

A high proportion of women with asymptomatic VFs would not receive treatment if screening were based only on BMD evaluation. Our results support the recommendation to enlarge the indications of VFA in the presence of risk factors such as age over 60, multiparity, history of peripheral traumatic fractures and low BMI.

Prevalence of thoracic vertebral fractures in hospitalized elderly patients with heart failure

OBJECTIVE

Heart failure (HF) has been associated with increased risk of fragility fractures. Indeed, most literature data on fractures were based on an historical and clinical approach focused on the identification of peripheral fractures, whereas the risk of vertebral fractures in this clinical setting is still unclear.

DESIGN

Cross-sectional study.

AIM

To evaluate the prevalence and determinants of radiological thoracic vertebral fractures in patients with HF.

METHODS

The study includes 1031 elderly hospitalized patients (491 females and 540 males; median age, 75 years; range, 65-90; 430 patients with HF) who were evaluated for the presence of thoracic vertebral fractures by quantitative morphometric analysis, using chest X-ray routinely performed in the diagnostic work-up of HF.

RESULTS

Vertebral fractures were found in 166 patients (16.1%), the prevalence being significantly higher in patients with HF as compared with those without HF, both in females (30.9 vs 15.8%; P<0.001) and in males (16.4 vs 7.4%; P=0.001). The association between HF and vertebral fractures remained statistically significant (odds ratio, 2.14; 95% CI, 1.25-3.66; P=0.01) even after adjustment for age, sex, loop diuretic therapy, anticoagulant therapy, proton pump therapy, coexistent chronic obstructive pulmonary disease, diabetes mellitus, renal insufficiency, and chronic liver diseases. In patients with HF, vertebral fractures were positively correlated with female sex, duration of HF, ischemic heart disease, cigarette smoking, and treatment with anti-osteoporotic drugs, and inversely correlated with left ventricular ejection fraction.

CONCLUSIONS

Hospitalized patients suffering from HF are at higher risk of vertebral fractures than patients without HF in the same clinical context.

Important risk factors and attributable risk of vertebral fractures in the population-based Tromsø study

Background

Vertebral fractures, the most common type of osteoporotic fractures, are associated with increased risk of subsequent fracture, morbidity, and mortality. The aim of this study was to examine the contribution of important risk factors to the variability in vertebral fracture risk.

Methods

Vertebral fracture was ascertained by VFA method (DXA, GE Lunar Prodigy) in 2887 men and women, aged between 38 and 87 years, in the population-based Tromsø Study 2007/2008. Bone mineral density (BMD; g/cm²) at the hip was measured by DXA. Lifestyle information was collected by questionnaires. Multivariable logistic regression model, with anthropometric and lifestyle factors included, was used to assess the association between each or combined risk factors and vertebral fracture risk. Population attributable risk was estimated for combined risk factors in the final multivariable model.

Results

In both sexes, age (odds ratio [OR] per 5 year increase: 1.32; 95% CI 1.19-1.45 in women and 1.21; 95% CI 1.10-1.33 in men) and BMD (OR per SD decrease: 1.60; 95% CI 1.34-1.90 in women and1.40; 95% CI 1.18-1.67 in men) were independent risk factors for vertebral fracture. At BMD levels higher than 0.85 g/cm², men had a greater risk of fracture than women (OR 1.52; 95% CI 1.14-2.04), after adjusting for age. In women and men, respectively, approximately 46% and 33% of vertebral fracture risk was attributable to advancing age (more than 70 years) and low BMD (less than 0.85 g/cm²), with the latter having a greater effect than the former.

Conclusions

These data confirm that age and BMD are major risk factors for vertebral fracture risk. However, in both sexes the two factors accounted for less than half of fracture risk. The identification of individuals with vertebral fracture is still a challenge.

Homocysteine, folate, and vitamin B12 levels and vertebral fracture risk in postmenopausal women

The objective of this study was to examine the influence of homocysteine, vitamin B(12), and folate on the prevalence of asymptomatic osteoporotic vertebral fractures (VFs) using vertebral fracture assessment (VFA) in postmenopausal women. The study cohort consisted of 188 consecutive postmenopausal women (mean age, weight, and body mass index of 57.9 ± 8.5 [41-91]yr, 74.4 ± 13.5 [38-150]kg, and 30.4 ± 5.2 [17.1-50.7]kg/m(2), respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a Lunar Prodigy Vision densitometer (GE Healthcare Inc., Waukesha, WI). VFs were defined using a combination of Genant's semiquantitative approach and morphometry. Fifty-eight (30.9%) patients had densitometric osteoporosis. VFs were identified using VFA in 76 (40.4%) patients: 61 women had grade 1 VFs and 15 had grade 2 or 3 VFs. No statistical difference was shown between the 3 groups (absence of VFs, VFs grade 1, and VFs grade 2/3) concerning the biological parameters. Comparison of patients according to quartiles of homocysteine levels showed that women in the highest quartile were older and had a lower bone mineral density (BMD); however, the prevalence of VFs was not statistically different from that of women in the other quartile groups. Stepwise regression analysis showed that homocysteine was not independently associated with the presence of VFs, which was mainly related to the osteoporotic status. Although a weak association was observed between hyperhomocysteinemia and low BMD and a trend to higher prevalence of grade 2/3 VFs was observed, our study did not confirm that homocysteine, vitamin B(12), and folate status are important determinants of prevalent asymptomatic VFs in postmenopausal women.

High frequency of vertebral fractures in early spondylarthropathies

We demonstrated that vertebral fractures (VF) are commonly found in early SpA. Patients with VF had lower lumbar BMD than patients without VF. VF remained frequently 'unrecognized' and untreated. VF have been associated with more back pain, reduced Qol, and increased risk of future fractures which stresses the importance of recognition also in early stage SpA.

INTRODUCTION

VF are a common complication of long-standing ankylosing spondylitis (AS). However, data of VF in early AS patients and in other spondylarthropathies (SpA) are scarce. Therefore we examined the prevalence of VF in early SpA patients and investigated the associations between VF and demographic and disease-related variables.

METHODS

SpA patients were included consecutively and radiographs of the spine were made. VF were assessed according to the method of Genant et al.: fractures were defined as reduction of ≥20% of the vertebrae. Descriptive statistics, t-tests and logistic regression analyses were used to study the relationship between VF and demographic and disease-related variables, radiographic damage and BMD.

RESULTS

A total of 113 early SpA patients were included with a disease duration of 7 months, a mean age of 37 years. Seventeen patients (15%) had at least one VF. Fourteen patients had one VF, three patients had two VF. Most VF were located at Th6-Th8. In patients with VF, bone mineral density (BMD) of lumbar spine was lower than BMD of patients without VF (t-test: p = 0.043). Axial Psoriatic Arthritis (PsA) was significantly associated with a higher risk for VF (odds ratio [OR]: 4.62, 95% confidence interval [CI] 1.15-18.58, p = 0.031). No significant associations were found with disease activity variables nor with radiographic severity.

CONCLUSION

In a group of 113 early, young SpA patients, 15% already had at least one VF. Most VF were asymptomatic, undetected by routine diagnostic procedures and located at the mid-thoracic spine. The VF were associated with low BMD of the lumbar spine and with axial PsA.

High prevalence of radiological vertebral fractures in HIV-infected males

Age-related co-morbidities including osteoporosis are relevant in patients responding to combination antiretroviral therapy (cART). Vertebral fractures are common osteoporotic fractures and their diagnosis is useful for managing at-risk individuals. However, there are few data from HIV-infected patients. Therefore, the aim of this study was to determine the prevalence of and factors associated with vertebral fractures in a population of HIV-infected males. A cross-sectional study of 160 HIV-infected patients with available chest X-rays was conducted from 1998 to 2010. One hundred and sixty-three males with comparable age and with no history of HIV infection were recruited as controls. Semi-quantitative evaluation of vertebral heights in lateral chest X-rays and quantitative morphometry assessment of centrally digitized images using dedicated morphometry software were utilized to detect prevalent vertebral fractures. The result showed that the vertebral fractures were detected in 43/160 (26.9%) HIV-infected patients and in 21/163 (12.9%) controls (P = 0.002). In HIV-infected patients with fractures, 27 had two or more fractures and ten patients had severe fractures. The prevalence of any fractures and multiple fractures in HIV-infected patients receiving cART (29.6 and 20.0%) was slightly higher than in HIV-infected patients not exposed to cART (17.1 and 5.7%), but significantly higher than control subjects (12.9 and 3.7%). At multivariable analyses, body mass index and diabetes mellitus were independently correlated with vertebral fractures in HIV-infected patients. We concluded that a significant proportion of HIV-infected males receiving cART showed vertebral fractures. Furthermore, proactive diagnosis of vertebral fragility fractures is particularly relevant in patients who are overweight or suffer from diabetes.

Vertebral fracture assessment in asymptomatic men and its impact on management

INTRODUCTION

Recognition of vertebral fractures (VFs) change the patient's diagnostic classification, estimation of fracture risk, and threshold for pharmacological intervention. Vertebral fracture assessment (VFA) enables the detection of VFs in the same session as bone mineral density (BMD) testing.

OBJECTIVE

To study prevalence and risk factors of VFs using VFA in asymptomatic men and measure its impact on patients' management.

METHODS

We enrolled 791 men aged between 45 and 89 (mean age, weight and BMI of 62.4±8.6) (45 to 89) years, 74.9±12.7 (40 to 163) and 26.3±4.0 (16.6 to 43.8) kg/m(2), respectively. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry.

RESULTS

VFs were identified in 318 (40.3%): 206 (26.0%) had grade 1 and 112 (14.2%) had grade 2 or 3. As would be expected, the prevalence of VFA-detected fractures globally increased significantly with age and as BMI and BMD declined. A fracture was identified on VFA in 85 (32.4%) of men with normal BMD (6.9% had grade 2/3 VFs) and in 144 (35.8%) with osteopenia (11.7% had grade 2/3 VFs). Stepwise regression analysis showed that presence of VFs was independently related to the osteoporotic status (OR=4.761, 95%CI [2.956-7.668]; p<0.0001) and current smoking (OR=1.717, 95%CI [1.268-2.323]; p=0.002).

CONCLUSION

Our results support the recommendation to enlarge the indications of VFA to all the men referred for DXA measurement.

Prevalence of non-fracture short vertebral height is similar in premenopausal and postmenopausal women: the osteoporosis and ultrasound study

We observed similar prevalence of short vertebral height without endplate depression (SVH) in young women aged 20-39 years and older women aged 55-79 years. There was no association between SVH and low bone density. In older women, therefore, SVH may be largely long standing and not indicative of osteoporotic fracture.

INTRODUCTION

Algorithm-based qualitative (ABQ) definition of osteoporotic vertebral fracture (VF) requires evidence of endplate fracture, and there is no minimum threshold for apparent 'reduction' in vertebral height. In older women, SVH without endplate fracture identified on baseline assessment may be long standing and unrelated to VF. If this is so, we would expect to see a similar prevalence of SVH in younger women. We aimed to compare the prevalence of pre- and postmenopausal women with SVH and the characteristics of women with and without SVH.

METHODS

We used the ABQ method to classify baseline vertebral images (DXA-based imaging) from 257 premenopausal and 1,361 postmenopausal women participating in the population-based Osteoporosis and Ultrasound Study. Images were classified as follows: normal (no VF, no SVH), SVH (no VF) or VF (with/without SVH in unfractured vertebrae). We compared proportions of women with SVH (chi-squared test) and compared age, height, weight and bone mineral density (BMD) by ABQ classification (two-sample t test/analysis of variance).

RESULTS

The prevalence of pre- and postmenopausal women with SVH was 37% and 33%, respectively (P>0.05). Compared to women without SVH, premenopausal women with SVH were older (P<0.001) and heavier (P=0.05), and postmenopausal women with SVH were taller (P<0.05), with higher spine BMD (P<0.01). Postmenopausal women with VF were older (P<0.001) and shorter (P<0.01) with lower BMD (P<0.001) than women without VF.

CONCLUSIONS

Short vertebral height without endplate fracture is equally prevalent in pre- and postmenopausal women and not associated with low bone density.

Ethnic difference of clinical vertebral fracture risk

Vertebral fractures are the most common osteoporotic fractures. Data on the vertebral fracture risk in Asia remain sparse. This study observed that Hong Kong Chinese and Japanese populations have a less dramatic increase in hip fracture rates associated with age than Caucasians, but the vertebral fracture rates were higher, resulting in a high vertebral-to-hip fracture ratio. As a result, estimation of the absolute fracture risk for Asians may need to be readjusted for the higher clinical vertebral fracture rate.

INTRODUCTION

Vertebral fractures are the most common osteoporotic fractures. Data on the vertebral fracture risk in Asia remain sparse. The aim of this study was to report the incidence of clinical vertebral fractures among the Chinese and to compare the vertebral-to-hip fracture risk to other ethnic groups.

METHODS

Four thousand, three hundred eighty-six community-dwelling Southern Chinese subjects (2,302 women and 1,810 men) aged 50 or above were recruited in the Hong Kong Osteoporosis Study since 1995. Baseline demographic characteristics and medical history were obtained. Subjects were followed annually for fracture outcomes with a structured questionnaire and verified by the computerized patient information system of the Hospital Authority of the Hong Kong Government. Only non-traumatic incident hip fractures and clinical vertebral fractures that received medical attention were included in the analysis. The incidence rates of clinical vertebral fractures and hip fractures were determined and compared to the published data of Swedish Caucasian and Japanese populations.

RESULTS

The mean age at baseline was 62 ± 8.2 years for women and 68 ± 10.3 years for men. The average duration of follow-up was 4.0 ± 2.8 (range, 1 to 14) years for a total of 14,733 person-years for the whole cohort. The incidence rate for vertebral fracture was 194/100,000 person-years in men and 508/100,000 person-years in women, respectively. For subjects above the age of 65, the clinical vertebral fracture and hip fracture rates were 299/100,000 and 332/100,000 person-years, respectively, in men, and 594/100,000 and 379/100,000 person-years, respectively, in women. Hong Kong Chinese and Japanese populations have a less dramatic increase in hip fracture rates associated with age than Caucasians. At the age of 65 or above, the hip fracture rates for Asian (Hong Kong Chinese and Japanese) men and women were less than half of that in Caucasians, but the vertebral fracture rate was higher in Asians, resulting in a high vertebral-to-hip fracture ratio.

CONCLUSIONS

The incidences of vertebral and hip fractures, as well as the vertebral-to-hip fracture ratios vary in Asians and Caucasians. Estimation of the absolute fracture risk for Asians may need to be readjusted for the higher clinical vertebral fracture rate.

Prevalence of vertebral fractures in women and men in the population-based Tromsø Study

Background

Osteoporotic vertebral fractures are, as the hip fractures, associated with increased morbidity and mortality. Norway has one of the highest reported incidences of hip fractures in the world. Because of methodological challenges, vertebral fractures are not extensively studied. The aim of this population based study was to describe, for the first time, the age- and sex specific occurrence of osteoporotic vertebral fractures in Norway.

Methods

Data was collected in the Tromso Study, 2007/8 survey. By the use of dual x-ray absorptiometry (GE Lunar Prodigy) vertebral fracture assessments were performed in 2887 women and men aged from 38 to 87 years, in addition to measurements of bone mineral density at the femoral sites. Information on lifestyle was collected through questionnaires. Comparisons between fractures and non-fractures were done sex stratified, by univariate analyses, adjusting for age when relevant.

Results

The prevalence of vertebral fractures varied from about 3% in the age group below 60 to about 19% in the 70+ group in women, and from 7.5% to about 20% in men, with an overall prevalence of 11.8% in women and 13.8% in men (p = 0.07). Among those with fractures, only one fracture was the most common; two and more fractures were present in approximately 30% of the cases. Fractures were seen from the fourth lumbar to the fifth thoracic vertebrae, most common between first lumbar and sixth thoracic vertebrae. The most common type of fracture was the wedge type in both sexes. Bone mineral density at the hip differed significantly according to type of fracture, being highest in those with wedge fractures and lowest in those with compression fractures.

Conclusions

The prevalence of vertebral fractures increased by age in women and men, but the overall prevalence was lower than expected, considering the high prevalence of hip and forearm fractures in Norway. In both sexes, the wedge type was the fracture type most frequently observed and most common in the thoracic region.

High prevalence of radiological vertebral fractures in women with prolactin-secreting pituitary adenomas

Hyperprolactinemia may cause bone loss but data on fractures are scanty. The aim of this study was to evaluate the prevalence of vertebral fractures in women with prolactin (PRL)-secreting adenoma. In this cross-sectional study, 78 women (median age 45.5 years, range: 20-81) with PRL-secreting pituitary adenoma (66 with microadenoma and 12 with macroadenoma) and 156 control subjects, with normal PRL values and with comparable age to patients with hyperprolactinemia, were evaluated for vertebral fractures by a morphometric approach and for bone mineral density (BMD) by a dual-energy X-ray absorptiometry at lumbar spine. Vertebral fractures were shown in 25 patients with PRL-secreting adenoma (32.6%) and in 20 controls (12.8%, P < 0.001). Fractured patients were significantly older (P < 0.001) and had lower BMD T-score (P < 0.001), longer duration of disease (P < 0.001), higher serum PRL (P = 0.004) and lower serum IGF-I (P < 0.001) values as compared to patients who did not fracture. The prevalence of vertebral fractures was significantly (P < 0.001) higher in post-menopausal women with PRL-secreting adenoma as compared to pre-menopausal patients. Fractures occurred more frequently (P = 0.01) in patients with untreated hyperprolactinemia versus patients treated with cabergoline. Logistic regression analysis demonstrated that duration of disease maintained a significant correlation with vertebral fractures (odds ratio 1.16, C.I. 95% 1.02-1.33) even after correction for age, menopausal status, treatment with cabergoline, BMD, serum IGF-I and serum PRL values. Hyperprolactinemia is associated with high prevalence of radiological vertebral fractures in women with PRL-secreting adenoma.

Bone mineral density enhances use of clinical risk factors in predicting ten-year risk of osteoporotic fractures in Chinese men: the Hong Kong Osteoporosis Study

This prospective study aimed to determine the risk factors and the 10-year probability of osteoporotic fracture in Southern Chinese men. The findings show substantial population differences in fracture incidence and risk prediction compared to the FRAX(TM) model, and the addition of BMD information to clinical risk factor assessment improved fracture risk prediction in Chinese men.

INTRODUCTION

Clinical risk factors with or without bone mineral density (BMD) measurements are increasingly recognized as reliable predictors of fracture risk. Prospective data on fracture incidence in Asian men remain sparse. This prospective study aimed to determine the risk factors and the 10-year absolute fracture risk in Southern Chinese men.

METHODS

This is a part of the Hong Kong Osteoporosis Study. One thousand eight hundred ten (1,810) community-dwelling, treatment-naive men aged 50 years or above were evaluated. Baseline demographic characteristics, clinical risk factors and BMD were recorded. Ten-year risk of osteoporotic fracture was calculated using Cox proportional hazards models.

RESULTS

The mean age of subjects was 68.0 ± 10.3 years. After a mean follow-up period of 3.5±2.9 years (range 1 to 14 years), 37 incident low-trauma fractures were recorded. The incidence for all osteoporotic fractures and hip fractures was 635/100,000 and 123/100,000 person-years, respectively. The most significant predictors of osteoporotic fracture were history of fall (RR 14.5), femoral neck BMD T-score < -2.5 (RR 13.8) and history of fracture (RR 4.4). Each SD reduction in BMD was associated with a 1.8 to 2.6-fold increase in fracture risk. Subjects with seven clinical risk factors and BMD T-score of -1 had an absolute 10-year risk of osteoporotic fracture of 8.9%, but this increased to 22.7% if they also had a femoral neck BMD T-score of -2.5.

CONCLUSIONS

These findings show substantial population differences in fracture incidence and risk prediction. The addition of BMD information to clinical risk factor assessment improved fracture risk prediction in Chinese men.

The relationship between sex steroids, bone turnover and vertebral fracture prevalence in asymptomatic men

OBJECTIVE

To examine the association between oestradiol (E2), testosterone (T), SHBG levels and vertebral fractures' (VFs) prevalence in asymptomatic men.

METHODS

The study cohort consists of a population of 112 consecutive men (mean±SD (range) age, weight and BMI were 62.9±9.2 (41-84) years, 75.0±13.8 (45-120) kgs and 26.4±4.7 (18.0-39.6) kg/m(2), respectively). Lateral vertebral fracture assessment (VFA) images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative approach and morphometry. Serum levels of T, E2, CTx and osteocalcine were measured. Free androgen index (FAI) and free estradiol index (FEI) were calculated respectively from the ratio of serum T and E2 to SHBG.

RESULTS

Among the 112 men, 38 (33.9%) had densitometric osteoporosis, and on VFA, VFs were identified in 60 (53.5%): 24 men had grade 1 and 36 had grade 2 or 3 VFs (32.1%). Men with VFs weighted less and had a statistically significant lower lumbar spine and total hip BMD and T-scores than those without a VFA-identified vertebral fracture. Levels of osteocalcine, CTx, and SHBG were statistically higher in men with grades 2 and 3 VFs than men with grade 1 VFs and those without VFs whereas FAI and FEI levels were significantly lower. Comparison of patients according to quartiles of SHBG levels showed that men in the highest quartile were older, had a lower lumbar spine and total hip BMD and a higher prevalence of osteoporosis and VFs. They had also higher levels of CTx. Stepwise regression analysis showed that the osteoporotic status and SHBG was independently associated to the presence of VFs.

CONCLUSION

Men with asymptomatic densitometric VFs have lower BMD than subjects without VFs. They have evidence of higher SHBG levels and hence lower free sex steroids as well as increased bone resorption. This study confirms that BMD and CTx are the most important determinant of asymptomatic VFs, and that SHBG is an independent risk factor that must be taken into account.

The Prevalence of Undetected Vertebral Fracture in Patients with Back Pain by Dual-Energy X-ray Absorptiometry (DXA) of the Lateral Thoracic and Lumbar Spine

STUDY DESIGN

This is a prospective study.

PURPOSE

This study is conducted to determine the prevalence of unrecognized vertebral fracture (VF) in patients who present with back pain.

OVERVIEW OF LITERATURE

VF is often unrecognized, and significantly increases the risk of further fractures. Unfortunately, the patients at a high risk for VF usually do not receive adequate therapy to reduce the fracture risk.

METHODS

This is a prospective study of 344 patients who presented with back pain from April 2008 to May 2009. The patients underwent dual-energy X-ray absorptiometry (DXA) evaluation and vertebral fracture assessment from T4 to L4 using a hologic densitometer.

RESULTS

Three hundred forty four of 386 patients who presented with back pain were included. Forty two patients were excluded because of a prior history of VF or the lack of written consent. Most of the patients were female (95.3%). The mean age of the patients was 58.21 ± 11.74 years. According to the World Health Organization definition (based on the T-score), 13.4% of the patients had normal lumbar spine bone mineral density (BMD). 27.9% of them were osteopenic and 58.7% were osteoporotic. The overall prevalence of VF, as established by lateral vertebral assessment, was 39% (n = 134). Moreover, 62.6% (n = 84) of the patients with VF had more than one fracture and 64.1% (n = 86) of them had Grade 2 or 3 fracture.

CONCLUSIONS

We recommend performing not only DXA scanning for BMD evaluation, but also VFA by DXA in old patients with back pain.

New imaging modalities in bone

The digital era has witnessed an exponential growth in bone imaging as new modalities and analytic techniques improve the potential for noninvasive study of bone anatomy, physiology, and pathophysiology. Bone imaging very much lends itself to input across medical and engineering disciplines. It is in part a reflection of this multidisciplinary input that developments in the field of bone imaging over the past 30 years have in some respects outshone those in many other fields of medicine. These developments have resulted in much deeper knowledge of bone macrostructure and microstructure in osteoporosis and a much better understanding of the subtle changes that occur with age, concurrent disease, and treatment. This new knowledge is already being translated into improved day-to day clinical care with better recognition, treatment, and monitoring of the osteoporotic process. As "the more you know, the more you know you don't know" certainly holds true with osteoporosis and bone disease, there is little doubt that further advances in bone imaging and analytical techniques will continue to hold center stage in osteoporosis and related research.

Abdominal aortic calcification detected by dual X-ray absorptiometry: A strong predictor for cardiovascular events

BACKGROUND

Vertebral fracture assessment (VFA) using dual-energy X-ray absorptiometry can visualize abdominal aortic calcification (AAC). AAC correlates with total atherosclerosis burden. We questioned whether VFA-detected AAC could be used for cardiovascular risk assessment.

METHODS

VFA images of 2,500 subjects were evaluated to detect and score AAC (n = 164). A random age- and gender-matched set of subjects (n = 325) without AAC served as control group. Patients with prior cardiovascular disease or procedures were excluded. Base-line cardiovascular risk factors and further cardiovascular events were checked. Design-based Cox regression analysis was used to examine the prognostic value of AAC for cardiovascular outcomes.

RESULTS

AAC-positive subjects were divided into two groups: low-AAC (score 1–3), and high-AAC group (score > 3). Mean age in the groups was 68, 68, and 71 years, percentage of females was 64.4%, 61%, and 66.1%, and the proportion of cardiovascular events within groups was 1.5%, 6.7%, and 11.9% in control, low-AAC, and high-AAC groups, respectively. Age- and gender-adjusted as well as multivariable analysis showed a significant, higher risk for cardiovascular events incidence in AAC-positive, low-AAC, and high-AAC when compared to the control group.

INTERPRETATION

AAC assessed with routine VFA was shown to be a strong predictor for cardiovascular events.

Prevalent vertebral deformity independently increases incident vertebral fracture risk in middle-aged and elderly Japanese women: the Japanese Population-based Osteoporosis (JPOS) Cohort Study

SUMMARY

Prevalent vertebral deformity increases incident vertebral fracture risk according to studies focusing primarily on Caucasian elderly populations. We report a 3-fold increase in this risk in a population-based cohort of Japanese women after adjusting for subject propensity for having vertebral deformities. This relationship tended to be stronger in middle-aged women.

INTRODUCTION

Evidence on increased risk of incident vertebral fractures associated with vertebral deformity in middle-aged women is limited. We aimed to evaluate this risk in a population-based cohort of Japanese women.

METHODS

We followed 712 women aged 50-79 years at baseline randomly selected from 3 municipalities in Japan for 6 years. McCloskey-Kanis criteria identified vertebral deformities on X-ray absorptiometric images. At follow-up, vertebra with > or = 20% height reduction from baseline were considered incident fractures. Rate ratio (RR) of incident fracture for prevalent vertebral deformities was calculated using the Poisson regression equation adjusted for propensity of having vertebral deformities based on potential risk factors.

RESULT

Vertebral fractures occurred in 73 women (10.3%). Crude RR of vertebral deformity-associated fracture was 4.63 [95% confidence interval (CI), 3.04-7.04] and decreased to 2.96 (95% CI, 1.77-4.94) after propensity score adjustment. Adjusted RR was generally greater in younger women at 7.19 (95% CI, 1.04-49.6), 3.19 (95% CI, 1.27-7.97), and 2.34 (95% CI, 1.33-4.11) for women aged 50-59, 60-69, and 70-79 years, respectively (p = 0.0527 for those aged 50-59 vs 70-79).

CONCLUSION

Vertebral deformity was associated with a 3-fold increase in subsequent vertebral fracture risk in Japanese women, and this association was stronger in middle-aged women.

[Radiological diagnosis of osteoporosis]

Having at their disposal a wide range of imaging techniques, radiologists play a crucial role in the diagnostic evaluation of patients with osteoporosis. The radiological tests range from dual energy X-ray absorptiometry (DXA), which is the only reference method accepted by the WHO, to conventional radiographs for fracture characterization, to more recent techniques for analyzing trabecular structure, and the findings are decisive in initiating correct management of osteoporosis patients. This review provides an overview of established radiological techniques and an outline of new diagnostic approaches.