Identification of vertebral fractures: an update

Comparison of the Clinical Efficacy of Anabolic Agents and Bisphosphonates in the Patients With Osteoporotic Vertebral Fracture: Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

We investigated the clinical efficacy of anabolic agents compared with bisphosphonates (BPs) for the incidence of new osteoporotic vertebral fracture (OVF) and fracture healing of OVF in the patients with OVF via meta-analyses of randomized controlled trials (RCTs).

METHODS

Electronic databases, including PubMed, Embase, and Cochrane Library were searched for published RCTs till December 2022. The RCTs that recruited participants with osteoporosis at high-/very high-risk of fracture (a history of osteoporotic vertebral or hip fracture) or fresh OVF were included in this study. We assessed the risk of bias on every included RCTs, estimated relative risk (RR) for the incidence of new OVF and fracture healing of OVF, and overall certainty of evidence. Meta-analyses were performed by Cochrane review manager (RevMan) ver. 5.3. Cochrane risk of bias 2.0 and GRADEpro/GDT were applied for evaluating methodological quality and overall certainty of evidence, respectively.

RESULTS

Five hundred eighteen studies were screened, and finally 6 eligible RCTs were included in the analysis. In the patients with prevalent OVF, anabolic agents significantly reduced the incidence of new OVF (teriparatide and romosozumab vs. alendronate and risedronate [RR, 0.57; 95% confidence interval, 0.45-0.71; p < 0.00001; high-certainty of evidence]; teriparatide vs. risedronate [RR, 0.50; 95% confidence interval, 0.37-0.68; p < 0.0001; high-certainty of evidence]). However, there was no evidence of teriparatide compared to alendronate in fracture healing of OVF (RR, 1.23; 95% confidence interval, 0.95-1.60; p = 0.12; low-certainty of evidence).

CONCLUSION

In the patients with prevalent OVF, anabolic agents showed a significant superiority for preventing new OVF than BPs, with no significant evidence for promoting fracture healing of OVF. However, considering small number of RCTs in this study, additional studies with large-scale data are required to obtain more robust evidences.

Risk Factors for Residual Back Pain After Balloon Kyphoplasty for Osteoporotic Vertebral Fracture

Background

Balloon kyphoplasty (BKP) is a method for the management of osteoporotic vertebral body fracture (OVF). However, improvement in back pain (BP) is poor in some patients, also previous reports have not elucidated the exact incidence and risk factors for residual BP after BKP. We clarified the characteristics of residual BP after BKP in patients with OVF.

Hypothesis

In this study, we hypothesize that some risk factors may exist for residual BP 2 years after the treatment of OVF with BKP.

Patients and Methods

A multicenter cohort study was performed where patients who received BKP within 2 months of OVF injury were followed-up for 2 years. BP at 6 months after surgery and final observation was evaluated by Visual Analog Scale (VAS) score. Patients with a score of 40 mm or more were allocated to the residual BP group, and comparisons between the residual back pain group and the improved group were made for bone density, kyphosis, mobility of the fractured vertebral body, total spinal column alignment, and fracture type (fracture of the posterior element, pedicle fracture, presence or absence of posterior wall damage, etc.). Also, Short Form 36 (SF-36) for physical component summary (PCS) and mental component summary (MCS) at the final follow-up was evaluated in each radiological finding.

Results

Of 116 cases, 79 (68%) were followed-up for 2 years. Two years after the BKP, 26 patients (33%) experienced residual BP. Neither age nor sex differed between the groups. In addition, there was no difference in bone mineral density, BKP intervention period (period from onset to BKP), and osteoporosis drug use. However, the preoperative height ratio of the vertebral body was significantly worse in the residual BP group (39.8% vs. 52.1%; p = 0.007). Two years after the operation, the vertebral body wedge angle was significantly greater in the residual BP group (15.7° vs. 11.9°; p = 0.042). In the multiple logistic regression model with a preoperative vertebral body height ratio of 50% or less [calculated by receiver operating characteristic (ROC) curve], the adjusted odds ratio for residual BP was 6.58 (95% confidence interval 1.64-26.30; p = 0.007); similarly, patients with vertebral body height ratio less than 50% had a lower score of SF-36 PCS 24.6 vs. 32.2 p = 0.08.

Conclusion

The incidence of residual BP 2 years after BKP was 33% in the current study. The risk factor for residual BP after BKP was a preoperative vertebral body height ratio of 50% or less, which should be attentively assessed for the selection of a proper treatment scheme and to provide adequate stabilization.

Level of Evidence

III.

Relationship of protein, calcium and vitamin D consumption with body composition and fractures in oldest-old independent people

BACKGROUND & AIM

Some studies state that the protein intake has a protective effect against bone mass loss, while others show that the combination of low calcium intake and high protein consumption increases the risk of fractures. Perhaps this phenomenon is also altered by the consumption of vitamin D after the age 80 years. This study aimed to identify if there is an association of protein, calcium and vitamin D intake with body composition and fractures in community dwelling 80 years or older independent people.

METHODS

This is a cross-sectional observational analytic study. We invited community dwelling 80 years or older independent people, with chronic diseases under control, according to the scientific guidelines. The food intake was obtained through a one-day food record (FR) and Avanutri software (4.1 version) was used to calculate the intake of total calories, calcium, protein, and other food nutrients. The body composition and bone densitometry were evaluated by whole-body Dual Energy X-ray Absorptiometry (DXA). The morphometric vertebral fractures were assessed through conventional X-ray of the vertebral, level T4 to L4, on side face position - semi quantitative technique.

RESULTS

One hundred and fifty-nine 80 years or older independent people, mean age 87.0 ± 3.9 years old were studied. The mean calcium intake was 834.6 ± 374.7 mg/day and vitamin D was 6.1 ± 24.3 μg/day, in both cases they were complemented by supplements to reach the recommendations. The mean protein intake was 72.9 ± 26.8 g/day, we found that 48.4% had low muscle mass; there was a frequency of 45.3% of osteoporosis; and vertebral fractures in 24.7% of them. The estimates of the logistic regression model with the outcome variable obesity and low muscle mass with reference to "low muscle mass" showed that the 80 years or older independent people who have a fracture are more likely to be obese with low muscle mass compared to those with only low muscle mass.

CONCLUSION

In the studied population of 80 years or older independent people, we observed that among all the nutrients studied, only dietary protein per g/kg/day was associated with body composition and bone mineral density, but not with fracture, although the elderly who have fracture are more likely to be obese with low muscle mass compared to those not obese with low muscle mass. More studies about nutrients intakes and its relationship with muscle and bone health in this population is necessary.

External validation of a convolutional neural network algorithm for opportunistically detecting vertebral fractures in routine CT scans

The Convolutional Neural Network algorithm achieved a sensitivity of 94% and specificity of 93% in identifying scans with vertebral fractures (VFs). The external validation results suggest that the algorithm provides an opportunity to aid radiologists with the early identification of VFs in routine CT scans of abdomen and chest.

PURPOSE

To evaluate the performance of a previously trained Convolutional Neural Network (CNN) model to automatically detect vertebral fractures (VFs) in CT scans in an external validation cohort.

METHODS

Two Chinese studies and clinical data were used to retrospectively select CT scans of the chest, abdomen and thoracolumbar spine in men and women aged ≥50 years. The CT scans were assessed using the semiquantitative (SQ) Genant classification for prevalent VFs in a process blinded to clinical information. The performance of the CNN model was evaluated against reference standard readings by the area under the receiver operating characteristics curve (AUROC), accuracy, Cohen's kappa, sensitivity, and specificity.

RESULTS

A total of 4,810 subjects were included, with a median age of 62 years (IQR 56-67), of which 2,654 (55.2%) were females. The scans were acquired between January 2013 and January 2019 on 16 different CT scanners from three different manufacturers. 2,773 (57.7%) were abdominal CTs. A total of 628 scans (13.1%) had ≥1 VF (grade 2-3), representing 899 fractured vertebrae out of a total of 48,584 (1.9%) visualized vertebral bodies. The CNN's performance in identifying scans with ≥1 moderate or severe fractures achieved an AUROC of 0.94 (95% CI: 0.93-0.95), accuracy of 93% (95% CI: 93%-94%), kappa of 0.75 (95% CI: 0.72-0.77), a sensitivity of 94% (95% CI: 92-96%) and a specificity of 93% (95% CI: 93-94%).

CONCLUSION

The algorithm demonstrated excellent performance in the identification of vertebral fractures in a cohort of chest and abdominal CT scans of Chinese patients ≥50 years.

Towards Improved Identification of Vertebral Fractures in Routine Computed Tomography (CT) Scans: Development and External Validation of a Machine Learning Algorithm

Vertebral fractures (VFs) are the hallmark of osteoporosis, being one of the most frequent types of fragility fracture and an early sign of the disease. They are associated with significant morbidity and mortality. VFs are incidentally found in one out of five imaging studies, however, more than half of the VFs are not identified nor reported in patient computed tomography (CT) scans. Our study aimed to develop a machine learning algorithm to identify VFs in abdominal/chest CT scans and evaluate its performance. We acquired two independent data sets of routine abdominal/chest CT scans of patients aged 50 years or older: a training set of 1011 scans from a non-interventional, prospective proof-of-concept study at the Universitair Ziekenhuis (UZ) Brussel and a validation set of 2000 subjects from an observational cohort study at the Hospital of Holbaek. Both data sets were externally reevaluated to identify reference standard VF readings using the Genant semiquantitative (SQ) grading. Four independent models have been trained in a cross-validation experiment using the training set and an ensemble of four models has been applied to the external validation set. The validation set contained 15.3% scans with one or more VF (SQ2-3), whereas 663 of 24,930 evaluable vertebrae (2.7%) were fractured (SQ2-3) as per reference standard readings. Comparison of the ensemble model with the reference standard readings in identifying subjects with one or more moderate or severe VF resulted in an area under the receiver operating characteristic curve (AUROC) of 0.88 (95% confidence interval [CI], 0.85-0.90), accuracy of 0.92 (95% CI, 0.91-0.93), kappa of 0.72 (95% CI, 0.67-0.76), sensitivity of 0.81 (95% CI, 0.76-0.85), and specificity of 0.95 (95% CI, 0.93-0.96). We demonstrated that a machine learning algorithm trained for VF detection achieved strong performance on an external validation set. It has the potential to support healthcare professionals with the early identification of VFs and prevention of future fragility fractures. © 2023 UCB S.A. and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Establishing national diagnostic reference levels in radiography, mammography, and dual-energy x-ray absorptiometry services in Ireland and comparing these with European diagnostic reference levels

OBJECTIVES

The aim of this work was to establish national diagnostic reference levels (DRLs) in Ireland and compare these to existing European DRLs where available. This work surveyed all radiological facilities providing radiography, mammography, and dual-energy x-ray absorptiometry (DXA) services in Ireland.

METHODS

A list of common procedures and clinical tasks was established. A national database of service providers was used to identify the appropriate medical radiological facilities providing these services. These facilities were issued with an online survey. National DRLs were set as the 75th percentile of the distribution of median values obtained. A national median dose was also established. The broad categorisation of equipment type was also considered. Where differences between DRLs established using different detector types were deemed statistically significant, equipment-specific national DRLs were established.

RESULTS

National DRLs were established for 12 adult radiography projections. Equipment-specific (computed radiography and digital radiography) adult DRLs were established for four radiography projections. Paediatric DRLs were established for 11 radiography projections, including two based on clinical indications, for a range of paediatric weight categories. National DRLs were established for unilateral two-view mammography and breast tomosynthesis as well as for four DXA clinical indications and projections. All but one Irish DRL figure was found to be below or equal to European data.

CONCLUSIONS

This work provided a unique opportunity to establish national DRLs based on census data for a range of procedures and clinical tasks across radiography, mammography and DXA and compare these with European levels.

CLINICAL RELEVANCE STATEMENT

This work established national diagnostic reference levels (DRLs) based on census data for a range of procedures and clinical tasks across radiography, mammography and dual-energy x-ray absorptiometry. The establishment of national DRLs is an essential component in the optimisation of patient radiation dose.

KEY POINTS

• Diagnostic reference levels are easily measured quantities intended for use as an aid to optimise patient dose and to identify when levels of patient dose are unusually high. • Data from all medical radiological facilities in Ireland was obtained to establish national diagnostic reference level (DRL) values and national median dose values in radiography, x-ray breast imaging and dual-energy x-ray absorptiometry (DXA) scanning and these were compared to existing European DRLs where available. • National DRL values were established for the first time in breast tomosynthesis, DXA scanning, and paediatric radiography.

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

EDITORIAL NOTE

See https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD014461.pub2/full for a more recent review that covers this topic and has superseded this review.

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.

First Ecuadorian statement consensus for the evaluation and treatment of osteoporosis

Osteoporosis management has become more relevant as the life expectancy increases. In Ecuador, approximately 19% of adults over 65 years of age have been diagnosed with osteoporosis. There is no national consensus for the management and prevention of the disease being this proposal the first Ecuadorian consensus.

INTRODUCTION

In Ecuador, it is estimated that around 19% of adults over 65 years of age have osteoporosis. Due to the increase in life expectancy in the world population, the evaluation and management of osteoporosis has become more relevant. Currently, there is no national consensus for the management and prevention of the disease. The Ecuadorian Society of Rheumatology presented the project for the elaboration of the first Ecuadorian consensus for the management and prevention of osteoporosis.

METHODS

A panel of experts in multiple areas and extensive experience was invited to participate. The consensus was carried out using the Delphi method. Six working dimensions were created: definition and epidemiology of osteoporosis, fracture risk prediction tools, non-pharmacological treatment, pharmacological treatment, calcium and vitamin D, and glucocorticoid-induced osteoporosis.

RESULTS

The first round was held in December 2021, followed by the second round in February 2022 and the third round in March 2022. The data was shared with the specialists at the end of each round. After three rounds of work, a consensus was reached for the management and prevention of osteoporosis.

CONCLUSION

This is the first Ecuadorian consensus for the management and treatment of postmenopausal osteoporosis.

Definition of normal vertebral morphometry using NHANES‐II radiographs

A robust definition of normal vertebral morphometry is required to confidently identify abnormalities such as fractures. The Second National Health and Nutrition Examination Survey (NHANES‐II) collected a nationwide probability sample to document the health status of the United States. Over 10,000 lateral cervical spine and 7,000 lateral lumbar spine X‐rays were collected. Demographic, anthropometric, health, and medical history data were also collected. The coordinates of the vertebral body corners were obtained for each lumbar and cervical vertebra using previously validated, automated technology consisting of a pipeline of neural networks and coded logic. These landmarks were used to calculate six vertebral body morphometry metrics. Descriptive statistics were generated and used to identify and trim outliers from the data. Descriptive statistics were tabulated using the trimmed data for use in quantifying deviation from average for each metric. The dependency of these metrics on sex, age, race, nation of origin, height, weight, and body mass index (BMI) was also assessed. There was low variation in vertebral morphometry after accounting for vertebrae (eg, L1, L2), and the R² was high for ANOVAs. Excluding outliers, age, sex, race, nation of origin, height, weight, and BMI were statistically significant for most of the variables, though the F‐statistic was very small compared to that for vertebral level. Excluding all variables except vertebra changed the ANOVA R² very little. Reference data were generated that could be used to produce standardized metrics in units of SD from mean. This allows for easy identification of abnormalities resulting from vertebral fractures, atypical vertebral body morphometries, and other congenital or degenerative conditions. Standardized metrics also remove the effect of vertebral level, facilitating easy interpretation and enabling data for all vertebrae to be pooled in research studies. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Health-related quality of life in men with osteoporosis: a systematic review and meta-analysis

PURPOSE

The increased social and economic burdens make osteoporosis in men an emerging public health issue. However, the quality of life among men with osteoporosis is still unclear. This systematic review and meta-analysis aimed to evaluate the health-related quality of life (HRQoL) among men with osteoporosis or osteoporotic fracture.

METHODS

PubMed, EMBASE, and the Cochrane Library database were systematically searched from inception to May 2021. Studies were included if they used validated questionnaires to measure HRQoL among osteoporotic men. A meta-analysis was performed using a random-effects model or fixed-effects model to calculate the standard mean difference (SMD) or mean difference (MD) with 95% confidential interval (95% CI).

RESULTS

14 studies involving 6338 male participants were chosen for systematic review, of which 10 were included in the meta-analysis. Men with osteoporosis had poorer global HRQoL and multiple dimensions of HRQoL than men without osteoporosis. Hip fracture, vertebral fractures, or wrist fractures dramatically impaired HRQoL of men, and physical function was declined even before hip fracture (SMD = -0.60, 95% CI, -0.82 to -0.39). Femoral and lumbar BMD was positively correlated with HRQoL, and a number of fragility fractures and time since fracture had negative effects on HRQoL. Effective anti-osteoporotic drugs could improve HRQoL of men.

CONCLUSION

The health-related life quality of men was significantly impaired by osteoporosis and fracture of the hip, vertebral, or wrist. We should pay more attention to the diagnosis and treatment of male osteoporosis to improve the life quality of men.

Vertebral fracture: epidemiology, impact and use of DXA vertebral fracture assessment in fracture liaison services

Vertebral fractures are independent risk factors for vertebral and nonvertebral fractures. Since vertebral fractures are often missed, the relatively new introduction of vertebral fracture assessment (VFA) for imaging of the lateral spine during DXA-measurement of the spine and hips may contribute to detect vertebral fractures. We advocate performing a VFA in all patients with a recent fracture visiting a fracture liaison service (FLS). Fracture liaison services (FLS) are important service models for delivering secondary fracture prevention for older adults presenting with a fragility fracture. While commonly age, clinical risk factors (including fracture site and number of prior fracture) and BMD play a crucial role in determining fracture risk and indications for treatment with antiosteoporosis medications, prevalent vertebral fractures usually remain undetected. However, vertebral fractures are important independent risk factors for future vertebral and nonvertebral fractures. A development of the DXA technology, vertebral fracture assessment (VFA), allows for assessment of the lateral spine during the regular DXA bone mineral density measurement of the lumbar spine and hips. Recent approaches to the stratification of antiosteoporosis medication type according to baseline fracture risk, and differences by age in the indication for treatment by prior fracture mean that additional information from VFA may influence initiation and type of treatment. Furthermore, knowledge of baseline vertebral fractures allows reliable definition of incident vertebral fracture events during treatment, which may modify the approach to therapy. In this manuscript, we will discuss the epidemiology and clinical significance of vertebral fractures, the different methods of detecting vertebral fractures, and the rationale for, and implications of, use of VFA routinely in FLS. • Vertebral fracture assessment is a tool available on modern DXA instruments and has proven ability to detect vertebral fractures, the majority of which occur without a fall and without the signs and symptoms of an acute fracture. • Most osteoporosis guidelines internationally suggest that treatment with antiosteoporosis medications should be considered for older individuals (e.g., 65 years +) with a recent low trauma fracture without the need for DXA. • Younger individuals postfracture may be risk-assessed on the basis of FRAX® probability including DXA and associated treatment thresholds. • Future fracture risk is markedly influenced by both site, number, severity, and recency of prior fracture; awareness of baseline vertebral fractures facilitates definition of true incident vertebral fracture events occurring during antiosteoporosis treatment. • Detection of previously clinically silent vertebral fractures, defining site of prior fracture, might alter treatment decisions in younger or older FLS patients, consistent with recent IOF-ESCEO guidance on baseline-risk-stratified therapy, and provides a reliable baseline from which to define new, potentially therapy-altering, vertebral fracture events.

Clinical and biochemical characteristics of adults with hypophosphatasia attending a metabolic bone clinic

OBJECTIVES

This study sought to identify the clinical and biochemical characteristics that would help distinguish hypophosphatasia (HPP) from other metabolic bone diseases in adult patients attending a metabolic bone clinic by comparing patients who have genetically confirmed HPP with a group of patients with low bone mineral density (BMD) in the osteoporotic or osteopenic range.

METHODS

Data were collected from February 2016 to October 2018 for 41 patients (n = 20 in the HPP group, n = 21 in the low-BMD group) attending the metabolic bone clinic at Sheffield, United Kingdom (UK) or who were recruited via the Rare UK Diseases Study (RUDY) platform during the same period. A study questionnaire was administered to all patients, and assessments were conducted for laboratory values, physical functions, BMD, and spine imaging.

RESULTS

Patients with HPP were characterized as being younger, more likely to have metatarsal or femoral shaft fractures, and less likely to have vertebral fractures compared with patients in the low-BMD group. The HPP group had lower total and bone-specific alkaline phosphatase, higher pyridoxal 5'-phosphate (PLP), and lower, albeit sufficient, 25-hydroxyvitamin D. Low-BMD group had lower C-terminal telopeptide and tartrate-resistant acid phosphatase 5b (61.9% were on bisphosphonates at enrollment). Dual X-ray absorptiometry (DXA) analysis found that the HPP group had higher total hip and lumbar BMD T- and Z-scores compared with the low-BMD group. There were no differences found between the two groups with physical functional assessments. Results of receiver operating characteristic analysis indicated strong diagnostic accuracy of these biomarkers for HPP. Thresholds of total alkaline phosphatase (ALP) activity of 43 IU/L or less and PLP level of 120 nmol/L or more were determined to be potentially clinically useful for distinguishing HPP from other metabolic bone diseases.

CONCLUSION

This study supported the use of ALP and PLP measurements as predictive of HPP diagnosis along with certain demographic and clinical characteristics (younger age, metatarsal or femoral fractures without low mean BMD T- and Z-scores on a DXA scan) that can aid in recognizing adults who should be further evaluated for HPP. The critical values identified need to be applied to an independent sample to be tested for diagnostic accuracy.

Osteoporotic vertebral fractures: A diagnostic challenge in the 21ST century

Vertebral fractures are the most prevalent osteoporotic fractures and are paradoxically the most underdiagnosed. While only one-third of patients have acute pain, they can present other associated chronic complications. Vertrebal fractures are associated with the onset of new fractures, both vertebral and nonvertebral. Radiography of the dorsal-lumbar spine is a useful tool for detecting them but depends on the subjective interpretation of the physician conducting the assessment. New techniques, such as vertebral morphometry, have recently demonstrated greater efficacy in detecting v vertebral fractures and are performed concomitantly with bone densitometry. Knowing how to identify vertebral fractures is essential for the secondary prevention of new fractures and improving our patients' quality of life.

Skin Autofluorescence, a Noninvasive Biomarker for Advanced Glycation End-Products, Is Associated With Prevalent Vertebral and Major Osteoporotic Fractures: The Rotterdam Study

Advanced glycation end-products (AGEs), which bind to type 1 collagen in bone and skin, have been implicated in reduced bone quality. The AGE reader™ measures skin autofluorescence (SAF), which might be regarded as a marker of long-term accumulation of AGEs in tissues. We investigated the association of SAF with bone mineral density (BMD) and fractures in the general population. We studied 2853 individuals from the Rotterdam Study with available SAF measurements (median age, 74.1 years) and with data on prevalent major osteoporotic (MOFs: hip, humerus, wrist, clinical vertebral) and vertebral fractures (VFs: clinical + radiographic Genant's grade 2 and 3). Radiographs were assessed 4 to 5 years before SAF. Multivariate regression models were performed adjusted for age, sex, BMI, creatinine, smoking status, and presence of diabetes and additionally for BMD with interaction terms to test for effect modification. Prevalence of MOFs was 8.5% and of VFs 7%. SAF had a curvilinear association with prevalent MOFs and VFs and therefore, age-adjusted, sex stratified SAF quartiles were used. The odds ratio (OR) (95% confidence interval [CI]) of the second, third and fourth quartiles of SAF for MOFs were as follows: OR 1.60 (95% CI, 1.08-2.35; p = .02); OR 1.30 (95% CI, 0.89-1.97; p = .20), and OR 1.40 (95% CI, 0.95-2.10; p = .09), respectively, with first (lowest) quartile as reference. For VFs the ORs were as follows: OR 1.69 (95% CI, 1.08-2.64; p = .02), OR 1.74(95% CI, 1.11-2.71; p = .01), and OR 1.73 (95% CI, 1.12-2.73; p = .02) for second, third, and fourth quartiles, respectively. When comparing the top three quartiles combined with the first quartile, the OR (95% CI) for MOFs was 1.43 (95% CI, 1.04-2.00; p = .03) and for VFs was 1.72 (95% CI, 1.18-2.53; p = .005). Additional adjustment for BMD did not change the associations. In conclusion, there is evidence of presence of a threshold of skin AGEs below which there is distinctly lower prevalence of fractures. Longitudinal analyses are needed to confirm our cross-sectional findings. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Radiographic osteoporotic vertebral fractures in elderly men: a brief review focusing on differences between the sexes

Bone loss occurs in both sexes as a result of ageing but is exacerbated in women by the hormonal changes associated with menopause. Unlike in women, secondary osteoporosis occurs in almost half of men diagnosed with osteoporosis. Moreover, vertebral fractures (VFs) seen in elderly men may more likely be the result of high energy trauma. The osteoporotic vertebral fracture (OVF) radiograph diagnosis criteria for women may not be directly applicable for men. Particular attention should be paid to the mid-thoracic level where over-diagnosis commonly occurs. For wedge-shaped vertebral deformities (VDs) or VDs with anterior height reduction only, a diagnosis of OVF requires great caution, as they are poorly correlated to bone mineral density (BMD). For age-matched subjects, it is likely that elderly men's prevalent radiographic OVFs are approximately half of the elderly women's. This male-female ratio is very similar to other clinical fractures such as those occurring at the hip. Even so, the clinical relevance of OVF in elderly men may be less than that of elderly women. On the other hand, for elderly men with hip BMD-based osteoporosis, the OVF risk is as high as that of osteoporotic women. Elderly Chinese men have a lower OVF prevalence than age-matched Caucasian men.

Dietary Advanced Glycation End-Products (dAGEs) Intake and Bone Health: A Cross-Sectional Analysis in the Rotterdam Study

Animal studies suggest a role for dietary advanced glycation end-products (dAGEs) in bone health, but human studies on dAGEs in relation to bone are lacking. We aimed to study whether dAGEs intake is associated with the parameters of bone strength namely, bone mineral density (BMD), prevalent vertebral (VFs), and major osteoporotic fractures (MOFs = hip, wrist, proximal humerus, and clinical VFs). 3949 participants (mean age 66.7 ± 10.5 years) were included from a Rotterdam study for whom Carboxymethyllysine (CML—a dietary AGE) was estimated from food frequency questionnaires combined with dAGEs databases. Multivariable linear and logistic regression models were performed adjusting for age, sex, energy intake, dietary quality, physical activity, diabetes, smoking, renal function, and cohort effect and for models on fractures, subsequently for BMD. We observed no association of CML with BMD at both femoral neck (β = −0.006; p = 0.70) and lumbar spine (β = −0.013; p = 0.38). A higher intake of CML was linearly associated with VFs (Odds ratio, OR = 1.16, 95% CI (1.02–1.32) and a similar but non-significant trend with MOFs (OR = 1.12 (0.98–1.27). Additional adjustment for BMD did not change the associations. Our results imply a positive association between dietary intake of CML and VFs independent of BMD. Future studies are needed in order to elucidate whether associations found are causal.

Prevalence of asymptomatic radiographic vertebral fracture in postmenopausal Thai women

We aim to investigate the nationwide prevalence of asymptomatic radiographic vertebral fracture in Thailand. We found 29% of postmenopausal women had at least one radiographic vertebral fracture. The prevalence was significantly higher among women with osteoporosis at the total hip (TH) region which implies that TH bone mineral density is a determinant of vertebral fracture risk.

INTRODUCTION

Radiographic vertebral fracture is associated with an increased risk of osteoporotic fracture and mortality in postmenopausal women. We designed a study to determine the prevalence of asymptomatic vertebral fractures in postmenopausal Thai women.

METHODS

The study was designed as a cross-sectional investigation at five university hospitals so as to achieve representation of the four main regions of Thailand. Radiographs were taken from 1062 postmenopausal women averaging 60 years of age. The presence of vertebral fracture was assessed by the Genant's semiquantitative method with three independent radiologists. Respective bone mineral density was measured by dual-energy X-ray absorptiometry (DEXA) at the lumbar spine (LS), femoral neck (FN), and total hip (TH).

RESULTS

Among the 1062 women, 311 were found to have at least one radiographic vertebral fracture-yielding a prevalence of 29% (95% CI 23.6-32.0%)-and 90 (8.5%, 95% CI 6.8-10.2%) had at least two fractures. The prevalence of vertebral fracture increased with advancing age. Most fractures occurred at one vertebra (71%) and only 29% at multiple vertebrae. The prevalence of vertebral fracture was significantly higher among women with osteoporosis compared with non-osteoporosis at the TH region. There was no significant difference in the prevalence among women with or without osteoporosis at the LS or FN.

CONCLUSIONS

Radiographic vertebral fractures were common among Thai postmenopausal women (~ 29%). These findings suggest that approximately one in three postmenopausal women has undiagnosed vertebral fracture. Radiographic diagnosis should therefore be an essential investigation for identifying and confirming the presence of vertebral fractures.

Osteoporotic vertebral fractures: A diagnostic challenge in the 21st century

Vertebral fractures are the most prevalent osteoporotic fractures and are paradoxically the most underdiagnosed. While only one-third of patients have acute pain, they can present other associated chronic complications. Vertrebal fractures are associated with the onset of new fractures, both vertebral and nonvertebral. Radiography of the dorsal-lumbar spine is a useful tool for detecting them but depends on the subjective interpretation of the physician conducting the assessment. New techniques, such as vertebral morphometry, have recently demonstrated greater efficacy in detecting v vertebral fractures and are performed concomitantly with bone densitometry. Knowing how to identify vertebral fractures is essential for the secondary prevention of new fractures and improving our patients' quality of life.

Semi-quantitative grading and extended semi-quantitative grading for osteoporotic vertebral deformity: a radiographic image database for education and calibration

The Genant’s semi-quantitative (GSQ) criteria is currently the most used approach in epidemiology studies and clinical trials for osteoporotic vertebral deformity (OVD) evaluation with radiograph. The qualitative diagnosis with radiological knowledge helps to minimize false positive readings. However, unless there is a face-to-face training with experienced readers, it can be difficult to apply GSQ criteria by only reading the text description of Genant et al. (in 1993), even for a musculoskeletal radiologist. We propose an expanded semi-quantitative (eSQ) OVD classification with the following features: (I) GSQ grade-0.5 is noted as minimal grade (eSQ grade-1) for OVDs with height loss <20%; (II) GSQ mild grade (grade-1) is the same as eSQ mild grade (grade-2); (III) GSQ moderate grade (grade-2) is subdivided into eSQ grade-3 (moderate, >25%–1/3 height loss) and eSQ grade-4 (moderately-severe, >1/3–40% height loss); (IV) GSQ severe grade is subdivided into eSQ grade-5 (severe, >40%–2/3 height loss) and eSQ grade-6 (collapsed, with >2/3 height loss). We advocate to estimate vertebral height loss with adjacent vertebral heights as the reference (rather than using individual vertebra’s posterior height as the reference). This article presents radiographs of 36 cases with OVD, together with gradings using GSQ criteria and eSQ criteria. The examples in this article can serve as teaching material or calibration database for readers who will use GSQ criteria or eSQ criteria. Our approach for quantitative measurement is explained graphically.

Elderly males with or without existing osteoporotic vertebral fracture have much lower future vertebral fracture risk than elderly females: the MrOS (Hong Kong) year-4 follow-up spine radiograph study

MrOS (Hong Kong)'s year-4 follow-up shows, for subjects at baseline without vertebral deformity (VD) and endplate or/and cortex fracture (ECF), the VD progression/new VD rate during follow-up in males was half of our paired MsOS (Hong Kong) study's results. For those with VD or ECF, the VD progression/new VD was less than one sixth of females' rate.

INTRODUCTION

This study documents MrOS (Hong Kong)'s year-4 follow-up, and the results are compared with the MsOS (Hong Kong) study. Of elderly females with Genant's grade-0, -1, -2, and -3 VD, at year-4 follow-up, 4.6%, 8%, 10.6%, and 28.9% had at least one VD progression or incident VD, respectively.

METHODS

Spine radiographs of 1500 Chinese males with baseline (mean age 71.7 years, range 65-91 years) and year-4 follow-up were evaluated according to Genant's VD criteria and ECF (non-existent, ECF0; or existent, ECF1). Grade-2 VDs were divided into mild (VD2m, 25-34% height loss) and severe (VD2s, 34-40% height loss) subgroups. Study subjects were graded into eight categories: VD0/ECF0, VD1/ECF0, VD2m/ECF0, VD0/ECF1, VD1/ECF1, VD2m/ECF1, VD2s/ECF1, and VD3/ECF1. With an existing VD, a further height loss of ≥ 15% was a VD progression. A new VD incident was a change from grade-0 to grade-2/3, or to grade-1 with ≥ 10% height loss.

RESULTS

Of subjects with Genant's grade-0, 2.05% (25/1219) developed at least one VD progression or/and new VD, while of subjects with Genant's grade-1, -2, and -3 VD, only 2% (3/149), 3.1% (3/96), and 2.8% (1/36) developed at least one VD progression/new VD, respectively. Among the three ECF0 groups, there was a significant difference in new ECF incidence, with VD0/ECF0 being the lowest and VD2m/ECF0 being the highest.

CONCLUSION

VD progression/new VD is much less common in elderly men than in elderly women. Vertebrae with VD had a higher risk of developing ECF.

Effect of medications and epidural steroid injections on fractures in postmenopausal women with osteoporosis

Osteoporosis is a common problem, especially among postmenopausal women. Postmenopausal women with osteoporosis have major risk factors for osteoporotic fractures. The abuse of epidural steroid injections (ESIs) or the misunderstanding of their proper use could cause osteoporotic fractures. Therefore, we aimed to investigate whether ESIs are associated with osteoporotic fractures in postmenopausal women with low back pain and osteoporosis. Furthermore, we aimed to provide evidence on whether ESIs could be used in postmenopausal women with osteoporosis who are at high risk for osteoporotic fractures.We reviewed the medical records of postmenopausal women with osteoporosis but no fractures. A total of 172 postmenopausal women were divided into 2 groups. Group 1 comprised patients receiving medications and Group 2 comprised patients receiving ESIs. All participants received medications for treating osteoporosis. Each patient's age, bone mineral density, body mass index, medical history, and status with respect to smoking, drinking, physical activity, and exercise were obtained using a questionnaire and medical records.The mean total number of ESIs was 6.2, and the mean cumulative administered dose of glucocorticoids (dexamethasone) was 31 mg. The incidences of fractures in the medication and ESI groups were 22% and 24%, respectively, in the thoracolumbar spine, and 2% and 5%, respectively, in the hip joint.There was no significant difference in the incidences of osteoporotic fractures at the thoraco-lumbar spine and hip joint in postmenopausal women with osteoporosis between those who received ESIs (a mean of 6.2 ESIs, a cumulative dexamethasone dose of 31 mg) and those who did not, with both groups taking anti-osteoporotic medications for low back pain. Our data suggest that ESI treatment using a mean of 6.2 ESIs to deliver a maximum cumulative dexamethasone dose of 31 mg could be safely used in postmenopausal women with osteoporosis, without any significant impact on the their risk for osteoporotic fractures.

Osteoporotic vertebral deformity with endplate/cortex fracture is associated with higher further vertebral fracture risk: the Ms. OS (Hong Kong) study results

Compared with vertebrae without deformity, vertebrae with mild/moderate deformity have a higher risk of endplate or/and cortex fracture (ecf). Compared with subjects without ecf, subjects with ecf are at a higher risk of short-term (4-year period) deformity progression and new incident deformity.

INTRODUCTION

The progression and incidence of osteoporotic vertebral deformity/fracture (VD/VF) in elderly Chinese females remain not well documented.

METHODS

Spine radiographs of 1533 Chinese females with baseline and year-4 follow-up (mean age 75.7 years) were evaluated according to Genant's VD criteria and endplate/cortex fracture (non-existent: ecf0 or existent: ecf1). Grade-2 VDs were divided into mild (vd2m, 25-34% height loss) and severe (vd2s, 34-40% height loss) subgroups. According to their VD/VF, subjects were graded into seven categories: vd0/ecf0, vd1/ecf0, vd2m/ecf0, vd1/ecf1, vd2m/ecf1, vd2s/ecf1, and vd3/ecf1. With an existing VD, a further height loss of ≥ 15% was a VD progression. A new incident VD was a change from grade-0 to grade-2/3 or to grade-1 with ≥ 10% height loss.

RESULTS

Of subjects with Genant's grades 0, - 1, - 2, and - 3 VD, at follow-up, 4.6%, 8%, 10.6%, and 28.9% had at least one VD progression or new incident VD respectively. Among the three ecf0 groups, there was no difference in VD progression or new VD; while there was a significant difference in new ecf incidence, with vd0/ecf0 being lowest and vd2m/ecf0 being highest. Vd1/ecf0 and vd2m/ecf0 vertebrae had a higher risk of turning to ecf1 than vd0/ecf0 vertebrae. If vd1/ecf0 and vd2m/ecf0 subjects were combined together (range 20-34% height loss) to compare with vd1/ecf1 and vd2m/ecf1 subjects, the latter had significantly higher VD progression and new VD rates.

CONCLUSION

Vertebrae with grade-1/2 VDs had a higher risk of developing ECF. Subjects with pre-existing ECFs had a higher risk of worsening or new vertebral deformities.

Diagnosis of osteoporotic vertebral fractures in children

Osteoporosis is a generalised disorder of the skeleton with reduced bone density and abnormal bone architecture. It increases bone fragility and renders the individual susceptible to fractures. Fractures of the vertebrae are common osteoporotic fractures. Vertebral fractures may result in scoliosis or kyphosis and, because they may be clinically silent, it is imperative that vertebral fractures are diagnosed in children accurately and at an early stage, so the necessary medical care can be implemented. Traditionally, diagnosis of osteoporotic vertebral fractures has been from lateral spine radiographs; however, a small number of studies have shown that dual energy x-ray absorptiometry is comparable to radiographs for identifying vertebral fractures in children, while allowing reduced radiation exposure. The diagnosis of vertebral fractures from dual energy x-ray absorptiometry is termed vertebral fracture assessment. Existing scoring systems for vertebral fracture assessment in adults have been assessed for use in children, but there is no standardisation and observer reliability is variable. This literature review suggests the need for a semiautomated tool that (compared to the subjective and semiquantitative methods available) will allow more reliable and precise detection of vertebral fractures in children.

A modification and validation of quantitative morphometry classification system for osteoporotic vertebral compressive fractures in mainland Chinese

This study described a modified quantitative morphometry (mQM) system adapted to specific reference values for Mainland Chinese population. The mQM system is validated using the Genant Semiquantative system and is sensitive for detecting vertebral height changes and predicting cement leakage after percutaneous kyphoplasty (PKP) in patients with osteoporotic vertebral compressive fracture (OVCF).

INTRODUCTION

OVCF is a manifestation of osteoporosis. To improve clinical management of osteoporosis, the quantitative morphometry (QM) system has been widely used for the early diagnosis and precise classification of OVCF in developed countries. Here, we present an mQM system and validated its use in detecting OVCF in Mainland Chinese.

METHODS

Using our mQM system, the pre- and post-operative values of vertebral heights were measured and evaluated in 309 Mainland Chinese who received percutaneous kyphoplasty (PKP) as OVCF treatment. Measurements and classification of fractures from the mQM system were validated by comparing to values obtained by the Genant semiquantative (SQ) method. Moreover, we evaluated the sensitivity of the mQM system by its ability to detect restoration of vertebral heights and predict cement leakage after PKP.

RESULTS

The five classification of fractures, No deformity (ND), anterior wedge (AW), posterior wedge (PW), biconcavity (BC), and compression (CP), evaluated by the mQM method shared similar distribution characteristics compared to those obtained by the SQ method. In addition, mQM evaluation showed that the vertebra height of all fracture types showed significant restoration after PKP. The incidence of cement leakage was most common in CP (37.5%), followed by AW (31.6%), BC (26.5%), ND (23.7%), and PW (0.0%).

CONCLUSIONS

Our mQM system is suitable for classification of fractures, detection of vertebral height restoration, and correlation of cement leakage after PKP in Mainland Chinese population.

Vertebral Fracture Identification as Part of a Comprehensive Risk Assessment in Patients with Osteoporosis

PURPOSE OF REVIEW

To review current evidence regarding the vertebral fracture prevalence, the accuracy of vertebral fracture identification on current imaging technologies, and the potential impact of vertebral fracture identification on fracture risk.

RECENT FINDINGS

Important new studies have clarified the features of prevalent vertebral fracture that most strongly predict incident fractures. Age- and sex-stratified estimates of vertebral fracture prevalence on densitometric lateral spine images in the US population are now available. The accuracy of densitometric vertebral fracture assessment, how computed tomography scans and other spinal images obtained for indications other than vertebral fracture assessment can be leveraged to detect prevalent vertebral fractures, and the potential impact of vertebral fracture assessment on patient and provider fracture risk management behavior have been clarified. Substantial progress has been made regarding screening strategies using lateral spine imaging to detect prevalent vertebral fracture in the older population. Further research regarding implementation of these strategies in clinical practice and their impact on clinical outcomes is needed.

Osteoporotic Vertebral Fracture Prevalence Varies Widely Between Qualitative and Quantitative Radiological Assessment Methods: The Rotterdam Study

Accurate diagnosis of vertebral osteoporotic fractures is crucial for the identification of individuals at high risk of future fractures. Different methods for radiological assessment of vertebral fractures exist, but a gold standard is lacking. The aim of our study was to estimate statistical measures of agreement and prevalence of osteoporotic vertebral fractures in the population-based Rotterdam Study, across two assessment methods. The quantitative morphometry assisted by SpineAnalyzer® (QM SA) method evaluates vertebral height loss that affects vertebral shape whereas the algorithm-based qualitative (ABQ) method judges endplate integrity and includes guidelines for the differentiation of vertebral fracture and nonfracture deformities. Cross-sectional radiographs were assessed for 7582 participants aged 45 to 95 years. With QM SA, the prevalence was 14.2% (95% CI, 13.4% to 15.0%), compared to 4.0% (95% CI, 3.6% to 4.5%) with ABQ. Inter-method agreement according to kappa (κ) was 0.24. The highest agreement between methods was among females (κ = 0.31), participants age >80 years (κ = 0.40), and at the L₁ level (κ = 0.40). With ABQ, most fractures were found at the thoracolumbar junction (T₁₂ -L₁ ) followed by the T₇ -T₈ level, whereas with QM SA, most deformities were in the mid thoracic (T₇ -T₈ ) and lower thoracic spine (T₁₁ -T₁₂ ), with similar number of fractures in both peaks. Excluding mild QM SA deformities (grade 1 with QM) from the analysis increased, the agreement between the methods from κ = 0.24 to 0.40, whereas reexamining mild deformities based on endplate depression increased agreement from κ = 0.24 to 0.50 (p <0.001). Vertebral fracture prevalence differs significantly between QM SA and ABQ; reexamining QM mild deformities based on endplate depression would increase the agreement between methods. More widespread and consistent application of an optimal method may improve clinical care. © 2017 American Society for Bone and Mineral Research.

[Prevalence of osteoporosis, estimation of probability of fracture and bone metabolism study in patients with newly diagnosed prostate cancer in the health area of Lugo]

OBJECTIVE

To study the prevalence of osteoporosis and fracture probability in patients diagnosed with prostate cancer.

DESIGN

Observational descriptive transversal study. SITE: Study performed from Primary Care of Lugo in collaboration with Rheumatology and Urology Services of our referral hospital.

PARTICIPANTS

Patients diagnosed with prostate cancer without bone metastatic disease from January to December 2012.

MAIN MEASUREMENTS

Epidemiologic, clinical, laboratory and densitometric variables involved in osteoporosis were collected. The likelihood of fracture was estimated by FRAX^® Tool.

RESULTS

Eighty-three patients met the inclusion criteria. None was excluded. The average age was 67 years. The Body Mass Index was 28.28. Twenty-five patients (30.1%) had previous osteoporotic fractures. Other prevalent risk factors were alcohol (26.5%) and smoking (22.9%). Eighty-two subjects had vitamin D below normal level (98.80%). Femoral Neck densitometry showed that 8.9% had osteoporosis and 54% osteopenia. The average fracture risk in this population, estimated by FRAX^®, was 2.63% for hip fracture and 5.28% for major fracture. Cut level for FRAX^® major fracture value without DXA >5% and ≥7.5% proposed by Azagra et al. showed 24 patients (28.92%) and 8 patients (9.64%) respectively.

CONCLUSIONS

The prevalence of osteoporosis in this population was very high. The more frequent risk factors associated with osteoporosis were: previous osteoporotic fracture, alcohol consumption, smoking and family history of previous fracture. The probability of fracture using femoral neck FRAX^® tool was low. Vitamin D deficiency was very common (98.8%).

Identification of a novel locus on chromosome 2q13, which predisposes to clinical vertebral fractures independently of bone density

OBJECTIVES

To identify genetic determinants of susceptibility to clinical vertebral fractures, which is an important complication of osteoporosis.

METHODS

Here we conduct a genome-wide association study in 1553 postmenopausal women with clinical vertebral fractures and 4340 controls, with a two-stage replication involving 1028 cases and 3762 controls. Potentially causal variants were identified using expression quantitative trait loci (eQTL) data from transiliac bone biopsies and bioinformatic studies.

RESULTS

A locus tagged by rs10190845 was identified on chromosome 2q13, which was significantly associated with clinical vertebral fracture (P=1.04×10-9) with a large effect size (OR 1.74, 95% CI 1.06 to 2.6). Bioinformatic analysis of this locus identified several potentially functional SNPs that are associated with expression of the positional candidate genes TTL (tubulin tyrosine ligase) and SLC20A1 (solute carrier family 20 member 1). Three other suggestive loci were identified on chromosomes 1p31, 11q12 and 15q11. All these loci were novel and had not previously been associated with bone mineral density or clinical fractures.

CONCLUSION

We have identified a novel genetic variant that is associated with clinical vertebral fractures by mechanisms that are independent of BMD. Further studies are now in progress to validate this association and evaluate the underlying mechanism.

Evaluation of high resolution thermal imaging to determine the effect of vertebral fractures on associated skin surface temperature in children with osteogenesis imperfecta

Vertebral fractures are common in children with osteogenesis imperfecta (OI). Current imaging methods for fracture detection (X-ray and DXA) use ionising radiation. This pilot study explored whether the alteration in blood flow in vertebral fractures results in skin temperature changes that may be detected using high resolution thermal imaging (HRTI) and thus assist diagnosis and monitoring of fractures in OI patients. Eleven participants aged 5-18 years with OI and known vertebral fractures were enrolled. Small metal discs were placed on the skin surface alongside the vertebrae before participants had DXA and X-ray scans and thermal imaging of their backs. Visibility of the discs on the DXA and X-ray scans and thermal images allowed the temperatures of the skin surface above vertebrae without (healthy) and with fractures to be compared to their respective adjacent skin surface regions (region of reference, ROR) by calculating the temperature percentage change (TPC). The TPC between the skin temperature over the fractured thoracic vertebrae (n = 11) and the ROR was significant (1.44%, p = 0.002, 95% confidence). TPC between the skin temperature over healthy thoracic vertebrae and ROR was not significant (0.97%, p = 0.15, 95% confidence). HRTI may provide a novel tool for assisting in detection of vertebral fractures in OI. Graphical abstract • Patients (aged 5-18) with osteogenesis imperfecta and known vertebral fractures. • Thermal imaging was performed alongside routine imaging (DXA scan and spinal X-ray). • The temperature above each vertebra was compared with its adjacent skin region to assist with diagnosis of the fracture.

Imaging of diabetic bone

Diabetes is an important concern in terms of medical and socioeconomic costs; a high risk for low-trauma fractures has been reported in patients with both type 1 and type 2 diabetes. The mechanism involved in the increased fracture risk from diabetes is highly complex and still not entirely understood; obesity could play an important role: recent evidence suggests that the influence of fat on bone is mainly dependent on the pattern of regional fat deposition and that an increased amount of visceral adipose tissue negatively affects skeletal health.Correct and timely individuation of people with high fracture risk is critical for both prevention and treatment: Dual-energy X-ray Absorptiometry (currently the "gold standard" for diagnosis of osteoporosis) underestimates fracture risk in diabetic patients and therefore is not sufficient by itself to investigate bone status. This paper is focused on imaging, covering different modalities involved in the evaluation of skeletal deterioration in diabetes, discussing the limitations of conventional methods and exploring the potential of new tools and recent high-resolution techniques, with the intent to provide interesting insight into pathophysiology and fracture risk.

Correlative Analysis of Vertebral Trabecular Bone Microarchitecture and Mechanical Properties: A Combined Ultra-high Field (7 Tesla) MRI and Biomechanical Investigation

STUDY DESIGN

High-resolution imaging and biomechanical investigation of ex-vivo vertebrae.

OBJECTIVE

The aim of this study was to assess bone microarchitecture of cadaveric vertebrae using ultra-high field (UHF) 7 Tesla magnetic resonance imaging (MRI) and to determine whether the corresponding microarchitecture parameters were related to bone mineral density (BMD) and bone strength assessed by dual-energy x-ray absorptiometry (DXA) and mechanical compression tests.

SUMMARY OF BACKGROUND DATA

Limitations of DXA for the assessment of bone fragility and osteoporosis have been recognized and criteria of microarchitecture alteration have been included in the definition of osteoporosis. Although vertebral fracture is the most common osteoporotic fracture, no study has assessed directly vertebral trabecular bone microarchitecture.

METHODS

BMD of 24 vertebrae (L2, L3, L4) from eight cadavers was investigated using DXA. The bone volume fraction (BVF), trabecular thickness (Tb.Th), and trabecular spacing (Tb.Sp) of each vertebra were quantified using UHF MRI. Measurements were performed by two operators to characterize the inter-rater reliability. The whole set of specimens underwent mechanical compression tests to failure and the corresponding failure stress was calculated.

RESULTS

The inter-rater reliability for bone microarchitecture parameters was good with intraclass correlation coefficients ranging from 0.82 to 0.94. Failure load and stress were significantly correlated with BVF, Tb.Sp, and BMD (P < 0.05). Tb.Th was only correlated with the failure stress (P < 0.05). Multiple regression analysis demonstrated that the combination of BVF and BMD improved the prediction of the failure stress from an adjusted R = 0.384 for BMD alone to an adjusted R = 0.414.

CONCLUSION

We demonstrated for the first time that the vertebral bone microarchitecture assessed with UHF MRI was significantly correlated with biomechanical parameters. Our data suggest that the multimodal assessment of BMD and trabecular bone microarchitecture with UHF MRI provides additional information on the risk of vertebral bone fracture and might be of interest for the future investigation of selected osteoporotic patients.

LEVEL OF EVIDENCE

N /A.

Vertebral heights and ratios are not only race-specific, but also gender- and region-specific: establishment of reference values for mainland Chinese

This study established gender-specific reference values in mainland Chinese (MC) and is important for quantitative morphometry for diagnosis and epidemiological study of osteoporotic vertebral compressive fracture. Comparisons of reference values among different racial populations are then performed to demonstrate the MC-specific characteristic.

PURPOSE

Osteoporotic vertebral compressive fracture (OVCF) is a common complication of osteoporosis in the elder population. Clinical diagnosis and epidemiological study of OVCF often employ quantitative morphometry, which relies heavily on the comparison of patients' vertebral parameters to existing reference values derived from the normal population. Thus, reference values are crucial in clinical diagnosis. To our knowledge, this is the first study to establish reference values of the mainland Chinese (MC) for quantitative morphometry.

METHODS

Vertebral heights including anterior (Ha), middle (Hm), posterior (Hp) heights, and predicted posterior height (pp) from T4 to L5 were obtained; and ratios of Ha/Hp, Hm/Hp and Hp/pp. were calculated from 585 MC (both female and male) for establishing reference values and subsequent comparisons with other studies.

RESULTS

Vertebral heights increased progressively from T4 to L3 but then decreased in L4 and L5. Both genders showed similar ratios of vertebral dimensions, but male vertebrae were statistically larger than those of female (P < 0.01). Vertebral size of MC population was smaller than that of US and UK population, but was surprisingly larger than that of Hong Kong Chinese, although these two are commonly considered as one race. Data from different racial populations showed similar dimensional ratios in all vertebrae.

CONCLUSIONS

We established gender-specific reference values for MC. Our results also indicated the necessity of establishing reference values that are not only race- and gender-specific, but also population- or region-specific for accurate quantitative morphometric assessment of OVCF.

DXA-Based Measurements in Diabetes: Can They Predict Fracture Risk?

In the absence of a fragility fracture, osteoporosis is usually diagnosed from bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA). Osteoporosis is an increasingly prevalent disease, as is diabetes [in particular type 2 diabetes (T2D)], in part due to aging populations worldwide. It has been suggested that an increased risk of fracture may be another complication ensuing from longstanding diabetes. The purpose of this review is to concentrate on skeletal parameters and techniques readily available from DXA scanning, and their utility in routine clinical practice for predicting fracture risk. In addition to BMD, other applications and measures from DXA include trabecular bone score (TBS), skeletal geometry and DXA-based finite-element analysis, vertebral fracture assessment, and body composition. In type 1 diabetes (T1D), BMD and FRAX^R (when secondary osteoporosis is included without BMD) only partially account for the excess risk of fracture in T1D. Consistent data exist to show that BMD and FRAX^R can be used to stratify fracture risk in T2D, but do not account for the increased risk of fracture. However, several adjustments to the FRAX score can be made as proxies for T2D to inform the use of FRAX by primary care practitioners. Examples include using the rheumatoid arthritis input (as a proxy for T2D), lumbar spine TBS (to adjust FRAX probability) or an altered hip T-score (lowered by 0.5 units). These adjustments can improve fracture risk prediction in T2D and help to avoid systematically underestimating the risk of osteoporosis-related fractures in those with diabetes.

Application of digital volume correlation to study the efficacy of prophylactic vertebral augmentation

BACKGROUND

Prophylactic augmentation is meant to reinforce the vertebral body, but in some cases it is suspected to actually weaken it. Past studies only investigated structural failure and the surface strain distribution. To elucidate the failure mechanism of the augmented vertebra, more information is needed about the internal strain distribution. This study aims to measure, for the first time, the full-field three-dimensional strain distribution inside augmented vertebrae in the elastic regime and to failure.

METHODS

Eight porcine vertebrae were prophylactically-augmented using two augmentation materials. They were scanned with a micro-computed tomography scanner (38.8μm voxel resolution) while undeformed, and loaded at 5%, 10%, and 15% compressions. Internal strains (axial, antero-posterior and lateral-lateral components) were computed using digital volume correlation.

FINDINGS

For both augmentation materials, the highest strains were measured in the regions adjacent to the injected cement mass, whereas the cement-interdigitated-bone was less strained. While this was already visible in the elastic regime (5%), it was a predictor of the localization of failure, which became visible at higher degrees of compression (10% and 15%), when failure propagated across the trabecular bone. Localization of high strains and failure was consistent between specimens, but different between the cement types.

INTERPRETATION

This study indicated the potential of digital volume correlation in measuring the internal strain (elastic regime) and failure in augmented vertebrae. While the cement-interdigitated region becomes stiffer (less strained), the adjacent non-augmented trabecular bone is affected by the stress concentration induced by the cement mass. This approach can help establish better criteria to improve vertebroplasty.

Vertebral fracture assessment by DXA is inferior to X-ray in clinical severe osteoporosis

Spine fractures are diagnosed by X-ray or vertebral fracture assessment (VFA) by dual-energy X-ray absorptiometry (DXA) scanning. The use of VFA evaluation by DXA is still debated. We demonstrate that VFA is inferior relative to X-ray in visualizing vertebrae properly in the upper spine and therefore with a reduced diagnostic performance in detecting fractures.

INTRODUCTION

Vertebral fracture assessment (VFA) by DXA has been evaluated for many years, and its use in clinical practice is still debated. In a cross-sectional setting, we aimed to compare VFA with traditional radiography in vertebral fracture (VF) diagnosis in severe osteoporotic patient.

METHODS

A total of 207 patients referred to the outpatient clinic for teriparatide treatment were screened, out of whom 35 (16.9 %) severe osteoporotic patients were identified (mean age 67.5 ± 11.3 years and median T-score -3.2 interquartile range (IQR) (-1.9 to -3.7). VF diagnosis was performed independently using VFA and X-ray in accordance with the semiquantitative (SQ) approach. The same technician performed the primary interpretation on both sets of images, after which a radiologist and an endocrinologist reviewed the evaluation for a conclusive judgement.

RESULTS

In total, 180 radiographic fractures were detected, corresponding to 5.1 fractures per individual. Using VFA, 18.5 % of vertebrae were considered unreadable, compared to 2.0 % on X-ray. The accuracy of VFA in VF detection using X-ray as a reference resulted in sensitivity and specificity of 75.5 and 86.7 %, respectively. Sensitivity decreased from the lumbar to thoracic level. Nevertheless, VFA only identified fractures consistently between Th11 and L3.

CONCLUSION

Our data, based on a severe osteoporotic population, demonstrate that VFA is inferior relative to X-ray in visualizing vertebrae properly in the upper spine, resulting in vertebrae not being assessable for analysis and a reduced diagnostic performance in detecting fractures. Improvements in DXA techniques are needed for it to be comparable with X-ray in VF diagnosis.

Vertebral Fractures: Clinical Importance and Management

Vertebral fractures are common and can result in acute and chronic pain, decreases in quality of life, and diminished lifespan. The identification of vertebral fractures is important because they are robust predictors of future fractures. The majority of vertebral fractures do not come to clinical attention. Numerous modalities exist for visualizing suspected vertebral fracture. Although differing definitions of vertebral fracture may present challenges in comparing data between different investigations, at least 1 in 5 men and women aged >50 years have one or more vertebral fractures. There is clinical guidance to target spine imaging to individuals with a high probability of vertebral fracture. Radiology reports of vertebral fracture need to clearly state that the patient has a "fracture," with further pertinent details such as the number, recency, and severity of vertebral fracture, each of which is associated with risk of future fractures. Patients with vertebral fracture should be considered for antifracture therapy. Physical and pharmacologic modalities of pain control and exercises or physiotherapy to maintain spinal movement and strength are important components in the care of vertebral fracture patients.

Osteoporotic Vertebral Fractures as Part of Systemic Disease

Our understanding of the genetic control of skeletogenesis and bone remodeling is expanding, and normally, bone resorption and bone formation are well balanced through regulation by hormones, growth factors, and cytokines. Osteoporosis is considered a systemic disease characterized by low bone mass and microarchitectural deterioration of bone tissue. Consequent increased bone fragility results in higher fracture risk. The most common osteoporotic fractures are located in the spine, and they form a significant health issue. A large variety of systemic diseases are associated with risk of osteoporotic vertebral fractures, illustrating its multifactorial etiology. Prevalences of these conditions vary from common to extremely rare, and incidence peaks differ according to etiology. This review appreciates different aspects of osteoporotic vertebral fractures as part of systemic disease, including genetic, immunologic, inflammatory, metabolic, and endocrine pathways. It seems impossible to be all-comprehensive on this topic; nevertheless, we hope to provide a reasonably thorough overview. Plenty remains to be elucidated in this field, identifying even more associated diseases and further exposing pathophysiological mechanisms underlying osteoporotic vertebral fractures.

Genetics of Osteoporotic Vertebral Fractures

Our understanding of the genetic control of skeletogenesis and bone remodeling is increasing, and in addition to various nongenetic risk factors, a positive family history confers an increased risk of fracture. Vertebral fractures are the most common osteoporotic fractures and they are often a first manifestation of osteoporosis. This review presents the current state of knowledge on the genetic basis of osteoporotic vertebral fractures and, additionally, of structural vertebral deformities resembling osteoporotic vertebral fractures but which may have their own genetic basis. We conclude that, apart from tentative screening for rare monogenic forms of osteoporosis in very unusual case presentations, not enough is currently known to encourage routine genetic screening in regular osteoporotic vertebral fracture cases.

The Radiology of Osteoporotic Vertebral Fractures Redux

When a low-energy fracture occurs, then osteoporosis has progressed to the point of bony structural failure. Because vertebral fractures are the commonest type of osteoporotic fracture, the correct identification of them becomes important for diagnosis, risk estimation, and management. However, there are no uniformly agreed criteria for their diagnosis. The purpose of this review was to examine the diagnostic radiological strategies available and suggest a coherent approach to diagnosis. Diagnosis had come to focus on comparative changes in vertebral dimensions. However, it has become apparent that mild reductions in vertebral height are of uncertain implication. The importance of structural damage in diagnosis has become recognized in parallel. Relative reductions in vertebral height may not be a necessary nor sufficient criterion by which to diagnose a fracture.

Diagnosis of vertebral fractures in children: is a simplified algorithm-based qualitative technique reliable?

BACKGROUND

Identification of osteoporotic vertebral fractures allows treatment opportunity reducing future risk. There is no agreed standardised method for diagnosing paediatric vertebral fractures.

OBJECTIVE

To evaluate the precision of a modified adult algorithm-based qualitative (ABQ) technique, applicable to children with primary or secondary osteoporosis.

MATERIALS AND METHODS

Three radiologists independently assessed lateral spine radiographs of 50 children with suspected reduction in bone mineral density using a modified ABQ scoring system and following simplification to include only clinically relevant parameters, a simplified ABQ score. A final consensus of all observers using simplified ABQ was performed as a reference standard for fracture characterisation. Kappa was calculated for interobserver agreement of the components of both scoring systems and intraobserver agreement of simplified ABQ based on a second read of 29 randomly selected images.

RESULTS

Interobserver Kappa for modified ABQ scoring for fracture detection, severity and shape ranged from 0.34 to 0.49 Kappa for abnormal endplate and position assessment was 0.27 to 0.38. Inter- and intraobserver Kappa for simplified ABQ scoring for fracture detection and grade ranged from 0.37 to 0.46 and 0.45 to 0.56, respectively. Inter- and intraobserver Kappa for affected endplate ranged from 0.31 to 0.41 and 0.45 to 0.51, respectively. Subjectively, observers' felt simplified ABQ was easier and less time-consuming.

CONCLUSION

Observer reliability of modified and simplified ABQ was similar, with slight to moderate agreement for fracture detection and grade/severity. Due to subjective preference for simplified ABQ, we suggest its use as a semi-objective measure of diagnosing paediatric vertebral fractures.

Epidemiology of Vertebral Fractures

Vertebral fractures are one of the most common fractures associated with skeletal fragility and can cause as much morbidity as hip fractures. However, the epidemiology of vertebral fractures differs from that of osteoporotic fractures at other skeletal sites in important ways, largely because only one quarter to one-third of vertebral fractures are recognized clinically at the time of their occurrence and otherwise require lateral spine imaging to be recognized. This article first reviews the prevalence and incidence of clinical and radiographic vertebral fractures in populations across the globe and secular trends in the incidence of vertebral fracture over time. Next, associations of vertebral fractures with measures of bone mineral density and bone microarchitecture are reviewed followed by associations of vertebral fracture with various textural measures of trabecular bone, including trabecular bone score. Finally, the article reviews clinical risk factors for vertebral fracture and the association of vertebral fractures with morbidity, mortality, and other subsequent adverse health outcomes.

High prevalence of undiagnosed vertebral fractures in patients suffering from hip fracture at their hospital admission: weak concordance among observers

BACKGROUND

Vertebral fracture is often underdiagnosed. Patients with hip fracture may suffer from vertebral fracture without knowing it. The diagnosis of vertebral fracture is sometimes difficult because there is no consensus regarding the definition of osteoporotic vertebral fracture, and several indexes may be used to diagnose it and the concordance between several observers may not be optimal.

OBJECTIVE

To study the concordance in the diagnosis of vertebral fracture done by three different doctors: an orthopedic surgeon, a radiologist, and a bone mineral metabolism expert.

METHODS

A lateral thoracic-lumbar spine X-Ray was performed in 177 patients suffering from hip fracture to assess the presence or absence of vertebral fractures. Three different observers applied Genant's criteria for it. Concordance between observers was measured using Cohen's kappa coefficient.

RESULTS

Patients suffering from hip fractures have undiagnosed vertebral fractures in a range that varies from 41.8 to 47.5% depending on the observer. The concordance in the diagnosis of vertebral fractures is quite low, ranging a Cohen's kappa coefficient from 0.43 to 0.55 and a percentage of concordance varying from 64 to 72%. The best concordance was found between observers 1 and 3.

DISCUSSION

Depending on the observer who made the diagnosis, the prevalence of previously undiagnosed vertebral fractures in patients with HF varied widely. We selected three different observers to assess the possible differences in the diagnosis of vertebral fractures among these patients and using the same method (Genant's semi-quantitative assessment), surprisingly, there was little concordance among the three of them.

CONCLUSION

Patients with hip fracture have high prevalence of undiagnosed vertebral fractures. The diagnosis of these fractures varies widely depending on the observers and the Cohen's kappa coefficient and percentage of concordance is rather low.

The association between genetic variants of RUNX2, ADIPOQ and vertebral fracture in Korean postmenopausal women

Contrary to the traditional belief that obesity acts as a protective factor for bone, recent epidemiologic studies have shown that body fat might be a risk factor for osteoporosis and bone fracture. Accordingly, we evaluated the association between the phenotypes of osteoporosis or vertebral fracture and variants of obesity-related genes, peroxisome proliferator-activated receptor-gamma (PPARG), runt-related transcription factor 2 (RUNX2), leptin receptor (LEPR), and adiponectin (ADIPOQ). In total, 907 postmenopausal healthy women, aged 60-79 years, were included in this study. BMD and biomarkers of bone health and adiposity were measured. We genotyped for four single nucleotide polymorphisms (SNPs) from four genes (PPARG, RUNX2, LEPR, ADIPOQ). A general linear model for continuous dependent variables and a logistic regression model for categorical dependent variables were used to analyze the statistical differences among genotype groups. Compared with the TT subjects at rs7771980 in RUNX2, C-carrier (TC + CC) subjects had a lower vertebral fracture risk after adjusting for age, smoking, alcohol, total calorie intake, total energy expenditure, total calcium intake, total fat intake, weight, body fat. Odds ratio (OR) and 95% interval (CI) for the vertebral fracture risk was 0.55 (95% CI 0.32-0.94). After adjusting for multiple variables, the prevalence of vertebral fracture was highest in GG subjects at rs1501299 in ADIPOQ (p = 0.0473). A high calcium intake (>1000 mg/day) contributed to a high bone mineral density (BMD) in GT + TT subjects at rs1501299 in ADIPOQ (p for interaction = 0.0295). Even if the mechanisms between obesity-related genes and bone health are not fully established, the results of our study revealed the association of certain SNPs from obesity-related genes with BMD or vertebral fracture risk in postmenopausal Korean women.

Diagnosis of vertebral fractures on lateral chest X-ray: intraobserver agreement of semi-quantitative vertebral fracture assessment

BACKGROUND

In clinical practice lateral images of the chest are performed for various reasons. As these lateral chest X rays show the vertebrae of the thoracic and thoraco-lumbar region, we wondered if these X-rays can be used for evaluation of vertebral fractures instead of separate thoracic spine X-rays.

METHODS

To evaluate the agreement and intraobserver reliability of the semi-quantitative method for vertebral fractures on the lateral chest X-ray (X-chest) in comparison to the lateral thoracic spine X-ray (X-Tspine), two observers scored vertebral fractures on X-Tspine and twice on X-chest, separately,blinded and in different time periods. Agreement and Cohens' kappa were calculated for a diagnosis of any fracture on patient level and on vertebral body level. The study was done in patients visiting an outpatient geriatric day clinic, with a high prevalence of vertebral fractures.

RESULTS

109 patients were included. The intraobserver agreement for X-chest versus X-Tspine was 95-98%for the two levels of fracturing, with a Cohen's kappa of 0.88-0.91. The intraobserver agreement and reliability of the re-test on the X-chest showed an agreement between 91 and 98% with a Cohen's kappa of 0.81-0.93. More vertebrae were visible on the X-chest, mean 10.2, SD 0.66 versus mean 9.8, SD 0.73 on the X-Tspine (p < 0.001).

CONCLUSION

The results show good agreement and intraobserver reliability on the X-chest compared to the X-Tspine for visualizing vertebral fractures. The results of this study emphasizes that the routinely performed X-chest is reliable in order to diagnose vertebral fractures.

Reconsideration of the relevance of mild wedge or short vertebral height deformities across a broad age distribution

Based on an evaluation of vertebral fracture prevalence on lateral radiographs across all age groups in a large cohort, mild or wedge-shaped vertebral body changes identified among adults should be managed as osteoporosis or at least considered as a risk factor for osteoporotic fracture, since they are rare among young subjects.

INTRODUCTION

Radiographic assessment of vertebral fractures is limited by the inability to distinguish mild fractures from congenital mild wedge deformities or vertebrae of short vertebral height. We attempted to quantify the expected background prevalence of these deformities by measuring vertebral fracture prevalence across all age groups in a large hospital-based retrospective Chinese cohort.

METHODS

We reviewed eligible lateral chest radiographs from patients admitted to Peking Union Medical College Hospital during 2011 using the Genant semiquantitative method for vertebral fracture assessment (T4-L2). We evaluated fracture prevalence among subjects by sex, 10-year age group, and fracture severity grades subjectively. We further analyzed characteristics of subjects with mild (grade I) fractures to estimate the relative contribution of congenital mild wedge deformities.

RESULTS

A total of 10,720 subjects (5,396 men and 5,324 women) with lateral chest radiographs were evaluated. Subjects ranged in age from 0.5 to 97 years with a mean of 51.8 ± 17.4 years (men 52.8 ± 17.6 years; women 50.8 ± 17.2 years). When stratified by 10-year age groups, the prevalence of vertebral fractures was relatively low until about 40 years of age, after which prevalence increased for both genders. Fractures (13 fractures for 9 males and 6 fractures for 5 females) seen in subjects younger than 40 years of age were almost exclusively mild grade fractures. No fractures were identified in subjects younger than 20 years of age.

CONCLUSIONS

Mild or wedge-shaped vertebral body changes on lateral radiographs are rare among young subjects, indicating that when mild vertebral deformities are found among adults, they are likely to be the product of aging and not congenital variation. Clinically, therefore, mild vertebral body changes should be managed as osteoporosis or at least considered as a risk factor for osteoporotic fracture.

Osteoporosis and fragility fractures: Vertebral fractures

The incidence of vertebral fragility fractures and deformity increase steeply with age. Every sixth woman and every twelfth man will sustain a symptomatic vertebral fracture. Vertebral fractures result in pain, functional disability and decreased quality of life, which may last for several years, and may also affect mortality. The patient with an acute fracture should be examined with radiology for diagnosis. In case of a low-energy fracture, osteoporosis should be suspected and investigated. If the pain management fails, vertebroplasty or kyphoplasty could be considered. Braces may be used, but evidence for its effect is lacking. In the rare event of neurological compromise, or unstable fractures, surgical treatment should be considered. After vertebral fragility fractures, the risk for new fractures is high and secondary preventive measures advocated. The best evidence for secondary prevention is currently on medical treatment of osteoporosis.

Prediction models of prevalent radiographic vertebral fractures among older women

It is unknown how well prediction models incorporating multiple risk factors identify women with radiographic prevalent vertebral fracture (PVFx) compared with simpler models and what their value might be in clinical practice to select older women for lateral spine imaging. We compared 4 regression models for predicting PVFx in women aged 68 y and older enrolled in the Study of Osteoporotic Fractures with a femoral neck T-score ≤ -1.0, using area under receiving operator characteristic curves (AUROC) and a net reclassification index. The AUROC for a model with age, femoral neck bone mineral density, historical height loss (HHL), prior nonspine fracture, body mass index, back pain, and grip strength was only minimally better than that of a more parsimonious model with age, femoral neck bone mineral density, and historical height loss (AUROC 0.689 vs 0.679, p values for difference in 5 bootstrapped samples <0.001-0.35). The prevalence of PVFx among this older population of Caucasian women remained more than 20% even when women with low probability of PVFx, as estimated by the prediction models, were included in the screened population. These results suggest that lateral spine imaging is appropriate to consider for all Caucasian women aged 70 y and older with low bone mass to identify those with PVFx.