Reporting of vertebral fractures on spine X-rays

Conventional X-rays in the diagnosis and follow-up of vertebral fractures in patients with acromegaly: a real-life study

OBJECTIVES

To explore the role of conventional X-ray imaging in detecting vertebral fractures (VFs) in patients with acromegaly, both at diagnosis of disease and at the last clinical visit. The risk factors for VFs were also evaluated.

DESIGN AND METHODS

A retrospective cohort study was conducted on 60 consecutive patients with acromegaly, in a tertiary referral centre. Thoracolumbar spine radiography (X-spine) was performed at the last clinical visit during the follow-up in order to detect VFs. Routine chest radiograph, performed as a part of the general evaluation at diagnosis of acromegaly, were retrospectively analysed to screen for baseline VFs.

RESULTS

At diagnosis of acromegaly, chest X-ray revealed that 10 (17%) patients had VFs. Of the 50 patients without VFs at diagnosis of acromegaly, 33 (66%) remained unfractured at the last clinical visit (median [IQR] time, 144 [96-192] months after the diagnosis of acromegaly), whereas 17 (34%) had VFs. Overall, 22 patients (37%) had novel VFs detected on X-spine including five patients with previous VFs. Risk factor for incident VFs was the presence of hypogonadism at diagnosis of acromegaly (p = 0.016).

CONCLUSIONS

In acromegaly patients, conventional X-rays can detect vertebral fractures early at diagnosis of acromegaly. They can also reveal incident VFs, which may occur several years later even in patients without VFs at diagnosis, above all in relation to hypogonadism.

Characterization of neuropathic component of back pain in patients with osteoporotic vertebral fractures

BACKGROUND:

Osteoporotic vertebral fractures (OVFs) are often followed by chronic back pain which may have a nociceptive, neuropathic, or mixed component. However, literature on this topic is lacking.

OBJECTIVE:

The objective of this cross-sectional study is to characterize the neuropathic component of chronic back pain in patients with OVFs.

METHODS:

Spine fractures were detected by morphometric examination. Pain severity and its impact on activities of daily living (ADL) were evaluated through the Brief Pain Inventory (BPI). Neuropathic pain was investigated through the Italian versions of the Leeds Assessment of Neuropathic Symptoms and Signs pain scale (LANSS) and the painDETECT questionnaire (PD-Q).

RESULTS:

We included 72 patients, mainly women (88.8%), with mean age of 69.2 years. The 70.8% of patients had multiple OVFs, of which 47% located at the thoracic spine, 43.1% at the thoracic and at lumbar spine, and 9.8% at the lumbar spine. The BPI showed moderate back pain in 23.6% of cases and severe in 8.3% of cases, with high interference with ADL in 38.9% of patients. The PD-Q revealed the presence of neuropathic pain in 5.5% of cases, while the LANSS in 23.6% of cases.

CONCLUSIONS:

In our study, the prevalence of neuropathic component of chronic back pain ranged from 5.5% to 23.6%, according to PD-Q and LANSS respectively, in patients with OVFs. Further studies should investigate if the characterization of chronic back pain might contribute to appropriateness of interventions for this population.

Vertebral fracture assessment (VFA) for osteoporosis screening in US postmenopausal women: is it cost-effective?

Vertebral fracture assessment (VFA) is cost-effective when it was incorporated in the routine screening for osteoporosis in community-dwelling women aged ≥ 65 years, which support guidelines, such as the National Osteoporosis Foundation (NOF) for the diagnostic use of VFA as an important addition to fracture risk assessment.

INTRODUCTION

To evaluate the cost-effectiveness of VFA as a screening tool to reduce future fracture risk in US community-dwelling women aged ≥ 65 years.

METHODS

An individual-level state-transition cost-effectiveness model from a healthcare perspective was constructed using derived data from published literature. The time horizon was lifetime. Five screening strategies were compared, including no screening at all, central dual-energy X-ray absorptiometry (DXA) only, VFA only, central DXA followed by VFA if the femoral neck T-score (FN-T) ≤ - 1.5, or if the FN-T ≤ - 1.0. Various initiation ages and rescreening intervals were evaluated. Oral bisphosphonate treatment for 5-year periods was assumed. Incremental cost-effectiveness ratios (2017 US dollars per quality-adjusted life-year (QALY) gained) were used as the outcome measure.

RESULTS

The incorporation of VFA slightly increased life expectancy by 0.1 years and reduced the number of subsequent osteoporotic fractures by 3.7% and 7.7% compared with using DXA alone and no screening, respectively, leading to approximately 30 billion dollars saved. Regardless of initiation ages and rescreening intervals, central DXA followed by VFA if the FN-T ≤ - 1.0 was most cost-effective ($40,792 per QALY when the screening is initiated at age 65 years and with rescreening every 5 years). Results were robust to change in VF incidence and medication costs.

CONCLUSION

In women aged ≥ 65 years, VFA is cost-effective when it was incorporated in routine screening for osteoporosis. Our findings support the National Osteoporosis Foundation (NOF) guidelines for the diagnostic use of VFA as an important addition to fracture risk assessment.

Artificial intelligence for the detection of vertebral fractures on plain spinal radiography

Vertebral fractures (VFs) cause serious problems, such as substantial functional loss and a high mortality rate, and a delayed diagnosis may further worsen the prognosis. Plain thoracolumbar radiography (PTLR) is an essential method for the evaluation of VFs. Therefore, minimizing the diagnostic errors of VFs on PTLR is crucial. Image identification based on a deep convolutional neural network (DCNN) has been recognized to be potentially effective as a diagnostic strategy; however, the accuracy for detecting VFs has not been fully investigated. A DCNN was trained with PTLR images of 300 patients (150 patients with and 150 without VFs). The accuracy, sensitivity, and specificity of diagnosis of the model were calculated and compared with those of orthopedic residents, orthopedic surgeons, and spine surgeons. The DCNN achieved accuracy, sensitivity, and specificity rates of 86.0% [95% confidence interval (CI) 82.0-90.0%], 84.7% (95% CI 78.8-90.5%), and 87.3% (95% CI 81.9-92.7%), respectively. Both the accuracy and sensitivity of the model were suggested to be noninferior to those of orthopedic surgeons. The DCNN can assist clinicians in the early identification of VFs and in managing patients, to prevent further invasive interventions and a decreased quality of life.

Identification of prevalent vertebral fractures using Vertebral Fracture Assessment (VFA) in asymptomatic postmenopausal women: A systematic review and meta-analysis

BACKGROUND

Vertebral fracture (VF) is the most common osteoporotic fracture in postmenopausal women, although most VFs are subclinical. Prevalent VFs are a significant predictor of subsequent fracture and therefore, identification of VF improves the identification of those with high fracture risk. The aim of present study was to systematically review the literature that assessed the prevalence of VF in asymptomatic postmenopausal women, using Vertebral Fracture Assessment (VFA) by dual-energy X-ray absorptiometry.

METHOD

Medline, Web of Science and Cochrane databases were searched between Jan 1st, 2000 and Jan 31st, 2018, for publications in English that reported the prevalence of VFA-detected VF in asymptomatic postmenopausal women. We also searched for reports, conference papers and grey literature. Reviewers screened studies for eligibility and extracted data for included studies. Random effects meta-analyses were performed to calculate the prevalence of VF. The presence of publication bias was assessed using funnel plots by precision and Egger's Test of the Intercept.

RESULTS

A total of 1777 articles were identified, 94 studies were fully reviewed and 28 studies (n = 25,418) met the inclusion criteria and were analyzed. More than two thirds of the studies were cross-sectional and the sample size varied widely across the studies (from 63 to 5156). The mean age ranged from 59.5 to 86.2 years old. The prevalence of osteoporosis and osteopenia varied between 6-57.0% and 25.1-58.9%, respectively. However, among women who had prevalent VFs, up to 43% had osteopenia and as many as 32% had normal bone density. The weighted pooled prevalence of VFA-detected VF in asymptomatic women was 28% (95% CI: 23%-32%).

CONCLUSION

VFA is able to identify prevalent VF in asymptomatic postmenopausal women. The use of VFA identified an average of 28% of asymptomatic women with VFs, many of whom did not have a diagnosis of osteoporosis. Implementation of VFA as a routine screening tool may detect high risk women. Detection of VF might lead to pharmacological treatment in individuals who may not otherwise be treated.

The Effect of 1 Year of Romosozumab on the Incidence of Clinical Vertebral Fractures in Postmenopausal Women With Osteoporosis: Results From the FRAME Study

Radiographic vertebral fractures (VFxs) are the most common fractures in osteoporosis and are associated with increased morbidity, mortality, and costs. A subset of VFxs manifest clinically, usually with a sudden onset of severe back pain. Romosozumab is a monoclonal antibody that binds and inhibits sclerostin, increasing bone formation and decreasing bone resorption, leading to rapid and large increases in bone density and strength and reduction in fracture risk. The FRAME (Fracture Study in Postmenopausal Women with Osteoporosis) study of postmenopausal women with osteoporosis demonstrated a significant reduction in new VFxs with romosozumab versus placebo. Here, we report the effect of romosozumab versus placebo on clinical VFx incidence over 12 months in women reporting back pain suggestive of VFxs. FRAME enrolled 7180 postmenopausal women with osteoporosis, mean age 70.9 years (hip T‐score −2.5 to −3.5). In the first year of the study, women received monthly romosozumab 210 mg (n = 3589) or placebo (n = 3591). At regular monthly visits, women reporting back pain suggestive of a clinical VFx had a confirmatory spine X‐ray. Clinical VFx risk in the romosozumab group versus the placebo group was calculated by Cox‐proportional hazards model. Of 119 women in FRAME with back pain suggestive of a clinical VFx over 12 months, 20 were confirmed to have experienced a new/worsening VFx. Three women receiving romosozumab had a clinical VFx (<0.1% of 3589 women) versus 17 (0.5% of 3591 women) receiving placebo resulting in a reduction in clinical VFx risk of 83% in the romosozumab group versus placebo through 12 months (HR 0.17; 95% CI, 0.05 to 0.58; p = 0.001). In the three romosozumab‐treated women, clinical VFxs occurred within the first 2 months of the study with no further clinical VFxs throughout the year. Romosozumab treatment for 12 months was associated with rapid and large reductions in clinical VFx risk versus placebo. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Delay in diagnosis of thoracolumbar fractures

The time interval between the date of trauma and the diagnosis of vertebral column fractures hinders management and increases liability. We have examined the features and implications of this delay. 585 consecutive thoracolumbar fractures (2005-2016), were considered; 382 (65.30%) were males and 203 (34.70%) females. Mean age was 51 yr. Fall from a height (187; 31.97%), simple fall (147; 25.13%) and road accidents (111; 18.97%) were the most frequent causes of trauma. Physical exertion caused 8.38% (N=49). 142 patients (24.27%) were not diagnosed on the injury day (mean = 3.2 days). Delay was longer in females (mean = 5.5 vs. 2.7 days) and shorter in falls from a height (mean = 2.3) or road accidents (2.8). Mean age of diagnosed on the injury day differed from those diagnosed in the first month (49.2 vs 60.1). Plain X-ray signs were found in 7 misdiagnosed cases (46.6%). Delay was more frequent in low mineralization cases. Diagnostic delay of spine fractures is frequent. Some risk profiles can help to reduce it. Careful emergency X-ray examination is encouraged, as well as early magnetic resonance imaging in risk profiles.

Usefulness of antero-posterior radiograph and variability of management in non-major thoracolumbar injuries: a single centre pilot study and review of literature

Background

Most adult trauma protocols suggest that where there has been a dangerous mechanism of injury or the patient exhibits abnormal physiology, CT scan is the primary radiological investigation. Other patients who may have suffered thoraco-lumbar (T-L) trauma initially have antero-posterior (AP) and lateral plain X-rays performed. Our clinical experience suggests AP views are not particularly useful in the management of these relatively low-velocity injuries. This is the first study intended to determine the contribution made by AP X-rays in these cases.

Methods

Adults with a history of T-L trauma referred to our tertiary spinal service over 20 weeks were reviewed. Those with a CT scan performed prior to X-rays were excluded. Four spine surgeons and four neuroradiologists were independently shown lateral X-rays along with the clinical details and asked to provide a management plan. Then they were shown the AP X-rays and asked if they would like to change their advice.

Results

Fifty-two patients were identified. Thirty-four sets of supine and 40 sets of erect X-rays were included (four people only had lateral X-rays performed), yielding 1152 film views. Average patient age was 58.3 years with 30 (58%) males. Forty-five (87%) were AO type A (compression-type) fractures. Seven (13%) had been erroneously referred with a diagnosis of acute fracture, which on review was not considered to be the case. Fifty-four percent of fractures were between T11 and L2. Forty-six percent appeared osteoporotic.

In no instance did evaluation of the AP X-ray change the management plan which had been suggested following the evaluation of the lateral X-ray alone. However, there was significant variation in advice on further management between consultants.

Conclusions

Our results suggest AP X-rays do not contribute to the management of low-velocity thoraco-lumbar traumas. Larger studies are required to support these findings, but there appears to be a potential to reduce both cost and radiation exposure. More importantly, it demonstrates there is large variability in the management of such patients due to the lack of evidence-based protocols.

Percutaneous Vertebral Augmentation Techniques in Osteoporotic and Traumatic Fractures

Percutaneous vertebral augmentation/consolidation techniques are varied. These are vertebroplasty, kyphoplasty, and several methods with percutaneous introduction of an implant (associated or not with cement injection). They are proposed in painful osteoporotic vertebral fractures and traumatic fractures. The objectives are to consolidate the fracture and, if possible, to restore the height of the vertebral body to reduce vertebral and regional kyphosis. Stabilization of the fracture leads to a reduction in pain and thus restores the spinal support function as quickly as possible, which is particularly important in the elderly. The effectiveness of these interventions on fracture pain was challenged once by two randomized trials comparing vertebroplasty to a sham intervention. Since then, many other randomized studies in support of vertebroplasty efficacy have been published. International recommendations reserve vertebroplasty for medical treatment failures on pain, but earlier positioning may be debatable if the objective is to limit kyphotic deformity or even reexpand the vertebral body. Recent data suggest that in osteoporotic fracture, the degree of kyphosis reduction achieved by kyphoplasty and percutaneous implant techniques, compared with vertebroplasty, is not sufficient to justify the additional cost and the use of a somewhat longer and traumatic procedure. In young patients with acute traumatic fractures and a significant kyphotic angle, kyphoplasty and percutaneous implant techniques are preferred to vertebroplasty, as in these cases a deformity reduction has a significant positive impact on the clinical outcome.

ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density

Osteoporosis is a considerable public health risk, with 50% of women and 20% of men >50 years of age experiencing fracture, with mortality rates of 20% within the first year. Dual x-ray absorptiometry (DXA) is the primary diagnostic modality by which to screen women >65 years of age and men >70 years of age for osteoporosis. In postmenopausal women <65 years of age with additional risk factors for fracture, DXA is recommended. Some patients with bone mineral density above the threshold for treatment may qualify for treatment on the basis of vertebral body fractures detected through a vertebral fracture assessment scan, a lateral spine equivalent generated from a commercial DXA machine. Quantitative CT is useful in patients with advanced degenerative bony changes in their spines. New technologies such as trabecular bone score represent an emerging role for qualitative assessment of bone in clinical practice. It is critical that both radiologists and referring providers consider osteoporosis in their patients, thereby reducing substantial morbidity, mortality, and cost to the health care system. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Hearing impairment increases the risk of distal radius, hip, and spine fractures: A longitudinal follow-up study using a national sample cohort

Objective

Hearing impairment has been suggested to increase the risk of falls. However, most previous studies were conducted in an older population without classification of the fracture regions. This study aimed to delineate the risk of each fracture type in all age populations.

Methods

The Korean National Health Insurance Service-National Sample Cohort was collected from 2002 to 2013. A total of 4,854 severe hearing-impaired and 1,354 profound hearing-impaired participants were matched for age, group, sex, income group, and region of residence with 19,416 and 5,416 control participants, respectively. The fracture diagnosis was based on the International Classification of Disease (ICD-10) codes as follows: distal radius fracture (S525), hip fracture (S720, S721, S722), and spine fracture (S220, S32). Crude (simple) and adjusted hazard ratios (HRs) for each fracture associated with severe or profound hearing impairment were analyzed using the Cox proportional hazard model.

Results

The severe hearing-impaired group had an increased risk of distal radius fracture, hip fracture, and spine fracture compared with the control group (adjusted HR = 1.67, 95% CI = 1.38–2.03, P < 0.001 for hip fracture). The profound hearing-impaired group had an increased risk of hip and spine fracture (adjusted HR = 2.21, 95% CI = 1.44–3.39, P < 0.001 for hip fracture).

Conclusion

The risk of distal radius fracture, hip fracture, and spine fracture was increased in the severe hearing-impaired group compared with the control group.

Misdiagnosis of vertebral fractures on local radiographic readings of the multicentre POINT (Prevalence of Osteoporosis in INTernal medicine) study

BACKGROUND

Osteoporotic vertebral fractures (VFs) are often misdiagnosed because asymptomatic and occurring in the absence of specific trauma. Further, diagnostic assessment of VFs may be suboptimal.

AIM OF THE STUDY

To assess the misdiagnosis of vertebral fractures on local radiographic readings in the cohort of patients enrolled in the POINT study.

METHODS

We enrolled hospitalised patients, admitted for any cause to the Internal Medicine Units of 37 hospitals participating to the cross-sectional previously published POINT study. The assessment of VFs was performed both by local radiologists and by two expert skeletal radiologists, by using semiquantitative method (SQ). To better evaluate mild vertebral deformities, the two central radiologists also used the algorithm-based qualitative assessment (ABQ).

RESULTS

The radiographs of 661 patients (401 females; mean age 75.8±8.0) were evaluated. The inter-reader percent agreement between two central expert radiologists per-vertebra assessment was excellent (99.78%; k=0.984; 95% CI, 0.977-0.991). Central reading identified 318/661 (48.1%) patients with at least one VF. Local and central readings agreed in 502/661 (75.9%) patients, resulting in a fair reproducibility (k=0.52; 95% confidence interval 0.44-0.59). Diagnostic performance parameters of local readings were: sensitivity 76.1%; specificity 75.8%; PPV 74.46%; NPV 77.38%). By examining 9254 vertebrae, central and local readers diagnosed 665 (7.2%) and 562 (6.1%) VFs respectively. Misdiagnosis (102 false positives and 205 false negatives) mainly occurred for mild VFs. Local readings identified correctly 460 out 665 VFs diagnosed by central readings, resulting in sensitivity of 69.2% and PPV of 81.8%.

CONCLUSIONS

Following a standardized protocol of acquisition techniques and of interpretation criteria, an excellent agreement between local and central readings for moderate and severe vertebral fractures resulted. However a significant amount of mild vertebral fractures, that are the most of VFs, were misdiagnosed by local radiologists. In order to improve VFs assessment, the radiologists should be trained and sensitized in relation to the relevant clinical significance of osteoporotic VFs identification.

Spinal radiographs in those with back pain-when are they appropriate to diagnose vertebral fractures?

The presence of an osteoporotic vertebral fracture improves fracture risk assessment and may change management, so it is vital for healthcare professionals to assess patients for the presence or absence of these fractures. This may be particularly important in the presence of back pain. However, the correlation between low back symptoms and spinal imaging results is poor and the pathophysiology of most low back pain is not known, leading to a common conclusion that spinal radiographs are not appropriate for the assessment of back pain. For individual patients with back pain, spinal radiographs should be considered if they have certain features in the history and examination. As well as the traditional risk factors for osteoporosis, self-reported descriptives of back pain and novel physical examination findings have been shown to make the presence of vertebral fractures more likely. Systematic approaches have the potential to improve bone health across the population but need to be targeted to be cost-effective. Spinal radiographs should be considered for individual older patients with back pain if they have certain additional features in the history and examination.

Association of vertebral compression fractures with physical performance measures among community-dwelling Japanese women aged 40 years and older

BACKGROUND

Numerous reported studies have shown that vertebral compression fractures are associated with impaired function or disability; however, few examined their association with objective measures of physical performance or functioning.

METHODS

We examined the association of vertebral compression fractures with physical performance measures in 556 Japanese women aged 40-89 years. Lateral spine radiographs were obtained and radiographic vertebral compression fractures were assessed by quantitative morphometry, defined as vertebral heights more than 3 SD below the normal mean. Measures of physical performance included walking speed, chair stand time and functional reach. Adjusted means of performance-based measures according to the number and severity of vertebral compression fractures were calculated using general linear modeling methods.

RESULTS

After adjusting for age, body mass index, back pain, number of painful joints, number of comorbidities and regular physical activities, the walking speed of women with two or more compression fractures (1.17 m/s) was significantly slower than that of women without compression fracture (1.24 m/s) (p = 0.03). Compared with women without compression fracture, chair stand time was longer in women with two or more compression fractures (p = 0.01), and functional reach was shorter (p = 0.01). No significant differences were observed in walking speed, chair stand time, or functional reach between women with one compression fracture and those without compression fracture.

CONCLUSIONS

Having multiple vertebral compression fractures affects physical performance in community-dwelling Japanese women. Poor physical functioning may lead to functional dependence, accelerated bone loss, and increased risk for falls, injuries, and fractures. Preventing vertebral compression fracture is considered important for preserving the independence of older adults.

Quantitative imaging methods in osteoporosis

Osteoporosis is characterized by a decreased bone mass and quality resulting in an increased fracture risk. Quantitative imaging methods are critical in the diagnosis and follow-up of treatment effects in osteoporosis. Prior radiographic vertebral fractures and bone mineral density (BMD) as a quantitative parameter derived from dual-energy X-ray absorptiometry (DXA) are among the strongest known predictors of future osteoporotic fractures. Therefore, current clinical decision making relies heavily on accurate assessment of these imaging features. Further, novel quantitative techniques are being developed to appraise additional characteristics of osteoporosis including three-dimensional bone architecture with quantitative computed tomography (QCT). Dedicated high-resolution (HR) CT equipment is available to enhance image quality. At the other end of the spectrum, by utilizing post-processing techniques such as the trabecular bone score (TBS) information on three-dimensional architecture can be derived from DXA images. Further developments in magnetic resonance imaging (MRI) seem promising to not only capture bone micro-architecture but also characterize processes at the molecular level. This review provides an overview of various quantitative imaging techniques based on different radiological modalities utilized in clinical osteoporosis care and research.

Underdiagnosis of osteoporotic vertebral fractures in patients with fragility fractures: retrospective analysis of over 300 patients

Osteoporosis (OP) is a silent disease unless a fracture occurs; it is a major health problem, mainly due to fragility fractures, that occur at vertebral and peripheral sites. Vertebral fractures (VF) are probably the most common fragility fractures, but they go often unrecognized. The main clinical symptoms of VF are acute and chronic back pain, spinal deformity, reduced mobility and impaired quality of life. They are frequently associated with other fragility fractures. We examined 478 patients at our outpatient clinic, who were referred for fragility fracture occurrence. The most common fragility fractures was hip fractures. However, after execution of spine X-rays in patients who had sustained hip fracture, we found that a large proportion of them had VF, which had not been reported in their medical history.

Back pain-related disability and quality of life in patients affected by vertebral fractures: data from baseline characteristics of population enrolled in Denosumab In Real Practice (DIRP)

BACKGROUND

Spine fragility fractures lead to a significant acute and/or chronic pain and worsening of quality of life. Denosumab is effective in reducing the risk of new vertebral fractures, but its effectiveness on pain relief and improvement of the quality of life in patients with spine fractures are not well known.

AIM

The aim of this paper is to describe the baseline demographic and clinical characteristics, back pain-related disability and quality of life of the Denosumab In Real Practice (DIRP) study population.

METHODS

DIRP is a multicenter prospective observational study evaluating the effectiveness of denosumab in reducing back pain-related disability and Health-Related Quality of Life (HRQoL) of women with postmenopausal osteoporosis who had already experienced at least one vertebral fragility fracture. Our evaluation protocol includes history of fractures, Spine Pain Index (SPI), HRQoL, bone mineral density (BMD) and radiological assessment of vertebral fragility fractures.

RESULTS

Two hundred and twenty-three post-menopausal women, who received a prescription for denosumab, were enrolled. The mean SPI score was 58.6 ± 21.4 SD, and 187 (83.86%) women experienced a moderate-severe pain. The mean HRQoL health state value was 0.54 ± 0.27 SD using EQ-5D index, whereas the mean Physical and Mental Health Composite Scale scores derived from the SF-12 were 31.06 ± 7.77 SD and 39.20 ± 11.03 SD.

DISCUSSION AND CONCLUSIONS

Baseline characteristics of DIRP study cohort indicate that patients who received a prescription of denosumab in Campania region are affected by severe osteoporosis with highly prevalent vertebral fractures, disabling back pain and poor health-related quality of life. This is in contradiction with what it is expected by a front-line drug for osteoporosis.

The risks of major osteoporotic fractures in patients with schizophrenia: a population-based 10-year follow-up study

OBJECTIVE

The aim of the study is to explore the incidence and the risks associated with major osteoporotic fractures, all-cause mortality with osteoporotic fractures and the effect of the psychiatric drug exposure in patients with schizophrenia during a 10-year follow-up period.

METHODS

Two nationwide cohorts were selected from the Taiwan National Health Insurance Research Database (NHIRD) consisting of 30,335 patients with schizophrenia (age ≥ 40 years) and 121,340 age- and sex-matched control participants without schizophrenia. The psychiatric proportion of days covered (PDC) is an indicator of the intensity of drug exposure in patients with schizophrenia. The incidence and risk factors of major osteoporotic fractures were calculated for both cohorts. Additionally, the patient survival rate after major osteoporotic fractures was also calculated.

RESULTS

During a 10-year follow-up period, 1677 (5.53%) schizophrenia and 4257 (3.51%) control subjects had major osteoporotic fractures (P < 0.001). The schizophrenia patients with a PDC > 0.1 showed a significantly higher incidence of major osteoporotic fractures than did the non-schizophrenia controls; however, those with a psychiatric PDC ≤ 0.1 did not. After adjustment, the psychiatric PDC was significantly and independently associated with the risk of major osteoporotic fractures except some medical morbidities but the schizophrenia diagnosis was not. In addition, among all 5934 patients with major osteoporotic fracture, the adjusted mortality hazard ratio for psychiatric PDC was 1.92 (95% CI = 1.63-2.26).

CONCLUSIONS

Patients with schizophrenia are at a higher risk for major osteoporotic fractures than the general population and also have a higher mortality rate due to major osteoporotic fractures. These findings may be caused by psychiatric drug use rather than schizophrenia, which suggests that directions can be taken in future studies.

Accuracy of spinal curvature assessed by a computer-assisted device and anthropometric indicators in discriminating vertebral fractures among individuals with back pain

This study examined the accuracy of thoracic and lumbar kyphotic angles as well as anthropometric indicators for discriminating patients with vertebral fracture among Japanese women >50 years old with back pain. Along with region-specific kyphotic angles and anthropometric indicators, the combination of thoracic and lumbar kyphotic angles offered the highest accuracy.

INTRODUCTION

Vertebral fractures have been associated with thoracic kyphosis. However, reports on lumbar kyphotic changes in association with vertebral fracture are scarce. This study investigated the accuracy of thoracic kyphotic angle (TKA) and lumbar kyphotic angle (LKA) measurements as well as anthropometric indicators (wall-occiput distance (WOD) and rib-pelvis distance (RPD)) in discriminating patients with vertebral fracture.

METHODS

Lateral radiographs of the spine were obtained in 70 postmenopausal Japanese women who visited an orthopedic clinic with low back pain (mean age, 76.2 ± 9.0 years). Radiographic vertebral fracture was diagnosed using quantitative measurement according to Japanese criteria. Osteoarthritis (OA) was defined as Kellgren-Lawrence (KL) grade 3 or higher. TKA and LKA were measured using SpinalMouse®. WOD and RPD were also measured.

RESULTS

At least one vertebral fracture was present in 49 subjects (70 %). Women with vertebral fractures showed significant increases in LKA, TKA + LKA, and WOD and decreases in RPD. Logistic regression analysis showed significant association between TKA + LKA and vertebral fracture independent of the presence of OA. Receiver operating characteristic analysis revealed that TKA was useful for discriminating thoracic fractures (area under the curve (AUC), 0.730) and LKA was useful for lumbar fractures (AUC, 0.691). The combination of TKA + LKA offered the highest accuracy for detecting thoracic, lumbar, and any vertebral fractures, with AUCs of 0.779, 0.728, and 0.783, respectively. WOD and RPD showed low-to-moderate accuracies for thoracic, lumbar, and any vertebral fractures.

CONCLUSIONS

Assessment of spinal kyphosis by SpinalMouse® as well as anthropometric indicators proved useful in discriminating subjects with vertebral fractures. These convenient and radiation-free methods could contribute to early diagnosis of vertebral fractures and subsequent appropriate treatment, thus preventing additional osteoporotic fractures.

Observer agreement in pediatric semiquantitative vertebral fracture diagnosis

BACKGROUND

The Genant semiquantitative (GSQ) method has been a standard procedure for diagnosis of vertebral fractures in adults but has only recently been shown to be of clinical utility in children. Observer agreement using the GSQ method in this age group has not been described.

OBJECTIVE

To evaluate observer agreement on vertebral readability and vertebral fracture diagnosis using the GSQ method in pediatric vertebral morphometry.

MATERIALS AND METHODS

Spine radiographs of 186 children with acute lymphoblastic leukemia were evaluated independently by three radiologists using the same GSQ methodology as in adults. A subset of 100 radiographs was evaluated on two occasions.

RESULTS

An average of 4.7% of vertebrae were unreadable for the three radiologists. Intraobserver Cohen's kappa (κ) on readability ranged from 0.434 to 0.648 at the vertebral level and from 0.416 to 0.611 at the patient level, while interobserver κ for readability had a range of 0.330 to 0.504 at the vertebral level and 0.295 to 0.467 at the patient level. Intraobserver κ for the presence of vertebral fracture had a range of 0.529 to 0.726 at the vertebral level and was 0.528 to 0.767 at the patient level. Interobserver κ for fracture at the vertebral level ranged from 0.455 to 0.548 and from 0.433 to 0.486 at the patient level.

CONCLUSION

Most κ values for both intra- and interobserver agreement in applying the GSQ method to pediatric spine radiographs were in the moderate to substantial range, comparable to the performance of the technique in adult studies. The GSQ method should be considered for use in pediatric research and clinical practice.

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.

Lumbar Disc Degeneration in Osteoporotic Men: Prevalence and Assessment of the Relation with Presence of Vertebral Fracture

Objective.

The relationship between osteoarthritis (OA) and osteoporosis (OP) remains controversial. An inverse relationship between spine OA and the presence of prevalent vertebral fractures has been shown in osteoporotic women. Our objective was to assess this relationship in osteoporotic men.

Methods.

All the patients had OP based on densitometric data and were aged ≥ 65 years. Spine radiographs were performed according to a standardized procedure. Vertebral fractures were assessed from T4 to L4 by a semiquantitative method. Disc degenerative changes were assessed by the presence and severity of osteophytes and disc narrowing at levels T12–L1 to L5–S1. Logistic regression was used to study the relationship between the presence of vertebral fracture and lumbar disc degeneration.

Results.

The study included 261 osteoporotic men. The prevalence of vertebral fractures was 26.4% (69/261). At least 1 osteophyte was found in 91.6% (239/261) of patients, and at least 1 disc space narrowing in 63.5% (165/260). The prevalence of at least 1 osteophyte and/or at least 1 disc space narrowing was similar in patients with and those without vertebral fracture. No relationship was found between the presence and/or the severity of osteophytes and disc narrowings and the presence of prevalent vertebral radiographic fractures.

Conclusion.

In osteoporotic men, the prevalence of lumbar spine degeneration is high. There is no relationship between lumbar disc degeneration and the presence of vertebral fracture in osteoporotic men.

Associations of vertebral deformities and osteoarthritis with back pain among Japanese women: the Hizen-Oshima study

We examined the spinal distribution of the types of vertebral deformities and the associations of vertebral deformities and osteoarthritis with back pain in Japanese women. Midthoracic and upper lumbar vertebrae were more susceptible to deformity. Vertebral deformity and osteoarthritis were frequent and were associated with back pain.

INTRODUCTION

Vertebral fractures due to osteoporosis and osteoarthritis are both common and significant health problems in aged people. However, little is known about the descriptive epidemiology of the individual deformity types and the relative clinical impact in women in Japan.

METHODS

Lateral radiographs were obtained from 584 Japanese women ages 40 to 89 years old. Deformities were defined as vertebral heights of more than 3 standard deviations (SDs) below the normal mean. Osteoarthritis was defined as Kellgren-Lawrence (KL) grade 2 or higher. Information on upper or low back pain during the previous month was collected by questionnaire. We compared the spinal distribution of the three types of vertebral deformities (wedge, endplate, and crush) typical of fractures and examined the associations of number and type of vertebral deformities and osteoarthritis with back pain.

RESULTS

Fifteen percent of women had at least one vertebral deformity and 74% had vertebral osteoarthritis. The prevalence of upper or low back pain was 30.1%. Deformities were most common in the midthoracic and upper lumbar regions and wedge was the frequent type, followed by endplate and crush. Multiple logistic regression analysis showed that the odds of back pain was 3.0 (95% CI 1.5-6.3) times higher for women with a single wedge deformity and 3.2 (95% CI 1.0--0.6) times higher for women with two or more wedge deformities, compared to women with no wedge deformity. Vertebral osteoarthritis was associated with back pain (OR 1.8, 95% CI 1.1-2.9), independent of other covariates including age and deformities.

CONCLUSION

Our results in this group of Japanese women are similar to and consistent with results reported previously in other populations of Japanese and Caucasians.

Anatomical distribution of vertebral fractures: comparison of pediatric and adult spines

SUMMARY

We compared the distribution of vertebral fractures in adults and children and found that fractures occurred in different locations in the two age groups. This likely relates to the different shape of the immature spine.

INTRODUCTION

We hypothesized that the anatomical distribution of vertebral fractures (VF) would be different in children compared to adults.

METHODS

We compared the distribution of VF defined using the Genant semi-quantitative method (GSQ method) in adults (N = 221; 545 fractures) and in children early in the course of glucocorticoid therapy (N = 44; 94 fractures).

RESULTS

The average age in the adult cohort was 62.9 years (standard deviation (SD), 13.4 years), 26% was male, the mean lumbar spine Z-score was -1.0 (SD, 1.5), and the corresponding T-score was -2.4 (SD, 1.4). The pediatric cohort median age was 7.7 years (range, 2.1-16.6 years), the mean lumbar spine Z-score was -1.7 (SD, 1.5), 52% was male, and disease categories were acute lymphoblastic leukemia (66%), rheumatological conditions (21%), and nephrotic syndrome (14%). The VF distribution was biphasic in both populations, but the peaks differed in location. In adults, the peaks were at T7/T8 and at T12/L1. In children, the focus was higher in the thoracic spine, at T6/T7, and lower in the lumbar spine, at L1/L2. When children were assessed in two age-defined sub-groups, a biphasic VF distribution was seen in both, but the upward shift of the thoracic focus to T6 was observed only in the older group, with the highest rates of fracture present between ages 7 and 10 years.

CONCLUSIONS

These results suggest that the anatomical distribution of VF differs between children and adults, perhaps relating to the different shape of the immature spine, notably the changing ratio of kyphosis to lordosis.

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.

Prevalence of vertebral fractures in patients with rheumatoid arthritis: revisiting the role of glucocorticoids

SUMMARY

Vertebral fracture assessment (VFA) is a convenient tool for the diagnosis of vertebral fracture in RA. Optimal control of inflammation may be an effective means to protect against vertebral fractures.

INTRODUCTION

The aim of this case-control study was to assess the prevalence of vertebral fractures (VFs) in patients with RA using VFA technology.

METHODS

Consecutive women (N = 101, 56.1 ± 14.2 years) with RA (mean disease duration, 14.9 ± 10 years) were recruited in the study. Clinical and biological statuses and treatments including glucocorticoids were assessed. Controls (N = 303), randomly selected from the general population, were individually matched to each case for age.

RESULTS

The prevalences of osteoporosis were 55.4% and 10.5% in patients and controls, respectively. Among the subjects, 21.7% and 4.2% had a vertebral fracture in the RA and control groups, respectively. Compared with controls, patients with RA had an increased risk of VFs: odds ratio (OR) (CI 95%) adjusted on body mass index was 6.5 (3.1, 13.9). In a multiple logistic regression analysis, VFs were independently associated with presence of non-vertebral fractures (OR = 9.2 [2.5-33.5]), presence of a fall in the previous year (OR = 4.6 [1.2-18.3]), current use of disease-modifying anti-rheumatic drugs (DMARDs) (OR = 0.05 [0.004, 0.51]) and current use of steroids (OR = 0.17 [0.04, 0.67]).

CONCLUSION

Rheumatoid arthritis is a risk factor of VF (OR = 6.5). VFA is a convenient tool for this diagnosis. Presence of VF is inversely related to the use of DMARD and glucocorticoids, enhancing the hypothesis that an appropriate control of the disease may be a protective factor against bone fragility.

Vertebral morphometry by X-ray absorptiometry: which reference data for vertebral heights?

INTRODUCTION

The recent improvement in the resolution of dual-energy X-ray absorptiometry (DXA) images enables most vertebral levels to be seen adequately and thus DXA may be a worthwhile alternative to radiologic morphometry for the identification of vertebral fractures (VF). In this multicenter study, we have derived reference data for vertebral heights and their ratios in Italian women using morphometric X-ray absorptiometry (MXA).

METHODS

DXA scans were acquired in 1254 consecutive pre- and postmenopausal women, (mean age 63.7 ± 11.3, range 26-88 yrs), referred to six osteoporosis centers. MXA analysis of these images was performed by the same operator measuring vertebral heights and height ratios from L4 to T4. We calculated measures of central tendency and dispersion of vertebral heights and vertebral ratios using different approaches (mean and standard deviation as well as median and interquartile range of raw data, mean and standard deviation of trimmed data using an iterative algorithm, and mean and standard deviation of not fractured vertebrae).

RESULTS

Independently of the approach that we used, all the measures of central tendency were similar, while significant differences were found when compared with reference ranges in other populations. The vertebral heights of our sample at every vertebral level were significantly smaller than both Rea population and the Lunar reference values, even after normalization. Splitting data according to age groups, there was a decrease in the vertebral heights and ratios between the younger and older women.

CONCLUSIONS

This study demonstrates that reference data for MXA should be population specific and age matched.

The incidence of hip, forearm, humeral, ankle, and vertebral fragility fractures in Italy: results from a 3-year multicenter study

Introduction

We aimed to assess the incidence and hospitalization rate of hip and "minor" fragility fractures in the Italian population.

Methods

We carried out a 3-year survey at 10 major Italian emergency departments to evaluate the hospitalization rate of hip, forearm, humeral, ankle, and vertebral fragility fractures in people 45 years or older between 2004 and 2006, both men and women. These data were compared with those recorded in the national hospitalizations database (SDO) to assess the overall incidence of fragility fractures occurring at hip and other sites, including also those events not resulting in hospital admissions.

Results

We observed 29,017 fractures across 3 years, with hospitalization rates of 93.0% for hip fractures, 36.3% for humeral fractures, 31.3% for ankle fractures, 22.6% for forearm/wrist fractures, and 27.6% for clinical vertebral fractures. According to the analyses performed with the Italian hospitalization database in year 2006, we estimated an annual incidence of 87,000 hip, 48,000 humeral, 36,000 ankle, 85,000 wrist, and 155,000 vertebral fragility fractures in people aged 45 years or older (thus resulting in almost 410,000 new fractures per year). Clinical vertebral fractures were recorded in 47,000 events per year.

Conclusions

The burden of fragility fractures in the Italian population is very high and calls for effective preventive strategies.

Spinal deformity index (SDI) is a good predictor of incident vertebral fractures

The spinal deformity index is a convenient tool to quantify the number and the severity of prevalent vertebral fractures. It is a predictor of the risk of sustaining incident vertebral fracture. This quantification must be taken into account to improve management of patients.

INTRODUCTION

Prevalent fractures are strong risk factors for subsequent fractures.

METHODS

The study subjects were women from the placebo groups of two studies of strontium ranelate in postmenopausal osteoporosis (N = 723 and 637 patients, respectively). Three lateral radiographs of the spine were obtained at baseline and annually over 3 years, according to standardized procedures. The semiquantitative visual assessment of each vertebra from T4 to L4 was performed by the same reader throughout the study. A spinal deformity index (SDI) was calculated by summing for each patient the grade of each vertebra from T4 to L4.

RESULTS

There was a linear relationship between baseline SDI and the 3-year incidence of vertebral fracture (adjusted R(2) = 0.76). The 3-year incidence of vertebral fractures was different among the tertiles of baseline SDI: 17.3 +/- 3.6%, 25.4 +/- 2.6%, and 47.6 +/- 3.1% from the lowest to the highest, respectively. There was no relationship between SDI and non-vertebral fractures incidence.

CONCLUSION

SDI is a good predictor of incident vertebral fractures. Patients with highest SDI should receive highest priority to treatment.

Oral nitrogen-containing bisphosphonates: a systematic review of randomized clinical trials and vertebral fractures

BACKGROUND

Vertebral fractures are the most common osteoporotic fracture. They are associated with increased morbidity and mortality, and also predict future vertebral and non-vertebral fracture risk. Bisphosphonates are the current mainstay for the treatment of postmenopausal osteoporosis. Health authority guidelines request that assessment of vertebral fracture risk reduction is part of the evaluation of bisphosphonate efficacy. In this review, we compare the published evidence for the efficacy of the nitrogen-containing oral bisphosphonates in reducing the risk of vertebral fractures.

METHODS

A review of publications in the treatment of postmenopausal osteoporosis and the most frequently prescribed oral bisphosphonate therapies (alendronate, ibandronate and risedronate) was carried out using the Dialog (Embase and Medline) and Cochrane online scientific citation databases. Eligible publications were those reporting randomized, placebo-controlled trials that included vertebral fracture as the primary or secondary endpoint (any time-point).

RESULTS

Of 159 publications identified, six studies assessing alendronate, ibandronate and risedronate met the pre-defined eligibility criteria. In total, 14,083 women were included in the studies, with 8182 patients receiving active treatment. Most studies were 3 years in duration. Discontinuation rates varied from 11 to 45%, being highest in those studies that specified one or more vertebral fracture as part of the inclusion criteria. Across these studies, the reduction in the risk of vertebral fractures ranged from 41 to 62% (44-48% for alendronate; 41-49% for risedronate; 62% for ibandronate).

CONCLUSIONS

Nitrogen-containing oral bisphosphonates effectively reduce the risk of osteoporotic vertebral fracture, with the magnitude of effect ranging from 41 to 62%.

Mild prevalent and incident vertebral fractures are risk factors for new fractures

This prospective four-year study indicates that post-menopausal osteoporotic women with mild prevalent and incident vertebral fractures have an increased risk of incident fractures.

INTRODUCTION

Mild vertebral fractures are under diagnosed as there is disagreement about their clinical significance. Our aim was to assess the risk of subsequent fractures induced by both prevalent and incident mild vertebral fractures in osteoporotic post-menopausal women.

PATIENTS AND METHODS

Three thousand three hundred and fifty-eight patients, aged 74 +/- 6 years, with post-menopausal osteoporosis included in the placebo groups of two clinical trials of strontium ranelate were followed for 4 years. A Cox regression model adjusted on age, body mass index and bone mineral density was used to calculate the relative risk (RR) of fracture in subjects with only mild fractures as compared to patients without fracture, and to patients with at least one grade >or= 2 fracture. These calculations were made for prevalent and then incident fractures.

RESULTS

The RR of vertebral fracture in 4 years was 1.8 (1.3-2.4) p < 0.001, and 2.7 (2.3-3.3) p < 0.001 for patients having only mild vertebral fractures and at least one grade >or= 2 fracture at baseline respectively. The RR of vertebral fracture in the 3rd and 4th years of follow-up was 1.7 (1.1-2.6) p = 0.01, and 1.9 (1.3-2.6) p < 0.001 for patients having during the first 2 years incident mild fractures only, and for patients having at least one grade >or= 2 incident fracture respectively. The RR of non-vertebral fracture in 4 years was 1.3 (0.9-1.9) p = 0.15 and 1.7 (1.4-2.1) p < 0.001 for patients having only mild or at least one grade >or= 2 vertebral fracture at baseline respectively. For patients aged more than 70 years, these RR were 1.45 (0.99-2.11) (p = 0.06), and 1.72 (1.36-2.18) p < 0.001 respectively. The RR of non-vertebral fracture in the 3rd and 4th years was 1.68 (1.36-2.09) p < 0.001 for patients having at least one grade >or= 2 incident fracture during the 2 first years of follow-up.

CONCLUSION

Mild vertebral fractures are a risk factor for subsequent vertebral and non-vertebral fracture in postmenopausal women with osteoporosis; 1 out of 4 patients with an incident mild vertebral fracture in 2 years will fracture again within the 2 next years.

Risk of vertebral osteoporosis in post-menopausal women with alterations of the mandible

BACKGROUND

Previous studies have suggested that a thin or eroded cortex of the mandible detected on dental panoramic radiographs is associated with low vertebral bone mineral density (BMD) or osteoporosis. However, those studies did not estimate the multivariate-adjusted risk for low vertebral BMD or osteoporosis associated with alterations of the mandible.

METHODS

BMD of the lumbar vertebrae (L2-L4) was compared among quartiles of cortical width and among three cortical shape categories in 450 post-menopausal women (mean age, 57.2 years), adjusted for potential confounders. The odds ratios for low BMD or osteoporosis according to cortical width and shape were also calculated.

RESULTS

Significant associations were found between cortical width and shape, and vertebral BMD. The odds ratios for low vertebral BMD associated with the second, third and lowermost quartiles of cortical width were 1.71 (95% confidence interval (CI), 0.96-3.05), 2.30 (95% CI, 1.29-4.11) and 5.43 (95% CI, 2.16-10.71), respectively, compared with the uppermost quartile. The odds ratios for osteoporosis according to cortical width category were similar to those for low BMD. The odds ratios for low BMD associated with mildly to moderately and severely eroded cortices were 3.85 (95% CI, 2.37-6.25) and 7.84 (95% CI, 2.57-23.90), respectively, compared with normal cortex. The odds ratios for osteoporosis associated with mildly to moderately and severely eroded cortices were 4.73 (95% CI, 2.54-8.80) and 14.73 (95% CI, 6.14-35.47), respectively.

CONCLUSIONS

Post-menopausal women with alterations of the mandible may have an increased risk for low vertebral BMD or osteoporosis.

Vertebral Fracture Assessment by dual-energy X-ray absorptiometry: insurance coverage issues in the United States. A White Paper of the International Society for Clinical Densitometry

Clinical trial data and fracture risk prediction models unequivocally demonstrate the utility of identifying prevalent vertebral fractures to predict future fractures of all types. Knowledge of prevalent vertebral fractures can alter patient management decisions and result in initiation of therapy to reduce fracture risk in some patients who would not otherwise be treated. Cost-benefit analysis demonstrates that identifying and treating patients with vertebral fractures, even those with a densitometric classification of osteopenia, is cost effective. Vertebral fractures can be readily identified in the office setting using standard radiography or Vertebral Fracture Assessment (VFA), a software addition to a central dual-energy X-ray absorptiometry (DXA) machine. In the United States, VFA was assigned a Current Procedural Terminology (CPT) code in January 2005. Nevertheless, coverage of VFA has not been uniformly embraced by Medicare carriers, companies that contract with the federal government to administer Medicare coverage and process claims for a region of the United States. Unlike DXA, for which uniform national coverage of qualified Medicare beneficiaries is mandated by the Balanced Budget Act of 1997, VFA coverage policies are determined by the local Medicare carriers. Third-party insurers are also variable in their coverage of VFA. This International Society for Clinical Densitometry (ISCD) White Paper documents the role of VFA in the evaluation and treatment of women with postmenopausal osteoporosis and compares it with standard spine radiography. Arguments used by some Medicare carriers and insurers to deny coverage of VFA in the United States are analyzed and critiqued. For health care providers within the United States, this White Paper may serve as a resource to respond to insurers who deny coverage of VFA. For health care providers regardless of their country, this article underscores the value of VFA as an alternative to spine radiography in the evaluation and management of postmenopausal women with suspected osteoporosis.