Can you diagnose for vertebral fracture correctly by plain X-ray?

Radiological diagnosis of prevalent osteoporotic vertebral fracture on radiographs: an interim consensus from a group of experts of the ESSR osteoporosis and metabolism subcommittee

When a low-energy trauma induces an acute vertebral fracture (VF) with clinical symptoms, a definitive diagnosis of osteoporotic vertebral fracture (OVF) can be made. Beyond that, a "gold" radiographic standard to distinguish osteoporotic from non-osteoporotic VFs does not exist. Fracture-shaped vertebral deformity (FSVD) is defined as a deformity radiographically indistinguishable from vertebral fracture according to the best of the reading radiologist's knowledge. FSVD is not uncommon among young populations with normal bone strength. FSVD among an older population is called osteoporotic-like vertebral fracture (OLVF) when the FSVD is likely to be associated with compromised bone strength. In more severe grade deformities or when a vertebra is collapsed, OVF diagnosis can be made with a relatively high degree of certainty by experienced readers. In "milder" cases, OVF is often diagnosed based on a high probability rather than an absolute diagnosis. After excluding known mimickers, singular vertebral wedging in older women is statistically most likely an OLVF. For older women, three non-adjacent minimal grade OLVF (< 20% height loss), one minimal grade OLVF and one mild OLVF (20-25% height loss), or one OLVF with ≥ 25% height loss, meet the diagnosis of osteoporosis. For older men, a single OLVF with < 40% height loss may be insufficient to suggest the subject is osteoporotic. Common OLVF differential diagnoses include X-ray projection artifacts and scoliosis, acquired and developmental short vertebrae, osteoarthritic wedging, oncological deformities, deformity due to high-energy trauma VF, lateral hyperosteogeny of a vertebral body, Cupid's bow, and expansive endplate, among others.

Thoracic spine X-ray examination of patients with back pain using different breathing technique and exposure times - A diagnostic study

INTRODUCTION

The breathing and suspended inspiration techniques are often used interchangeably for spine X-ray examinations. However, these techniques are not always adequately supported by clinical evidence. This study aimed to determine the two techniques' diagnostic value and adverse image outcomes.

METHODS

A total of 400 participants were examined on a Siemens Ysio Max system and randomized into four examination groups: suspended inspiration or breathing techniques with exposure times of 1, 2, and 3.2 s, respectively. Two consultant radiologists conducted the evaluation of the X-ray images. If disagreement was present, the radiologists collaboratively reviewed the X-ray images until a consensus was reached.

RESULTS

The final 394 study population comprised 275 women and 119 men with a mean age of 64 years (range:18-96 years). The proportions of visually sharp reproduction of the endplates and trabecular structures did not differ significantly with regards to differences in exposure times between groups. The breathing technique groups had significantly higher proportions of blurring and motion artifacts (p < 0.001). However, adverse image outcomes (motions artifacts) were significantly lower in the 1-s exposure group.

CONCLUSIONS

The suspended inspiration and breathing techniques performed equally well regarding visually sharp reproduction. However, the suspended inspiration technique was superior to the breathing technique. regarding adverse image outcomes, although the latter could be improved by using a shorter exposure time.

IMPLICATIONS FOR PRACTICE

The suspended inspiration and breathing technique appeared to perform at equal diagnostic levels. The suspended inspiration technique should be preferred due to its reduced risk of adverse image outcomes. However, the risk could also be reduced using a short exposure time with the breathing technique.

Forward Bending in Supine Test: Diagnostic Accuracy for Acute Vertebral Fragility Fracture

Despite its high incidence rate, vertebral fragility fracture (VFF) is frequently underdiagnosed due to the absence of marked symptoms. This study evaluated the diagnostic accuracy of our suggested physical examinations and compared them with that of plain radiographs. Patients over 65 years of age with sudden back pain within the preceding 3 weeks were enrolled. Physical examinations in three different positions and a closed-fist percussion test were performed, and the presence of VFF was evaluated through confirmatory radiographic tools. We assessed the diagnostic accuracy of each physical examination and compared them with the interpretation of plain radiographs and examined the patient-reported pain locations based on the VFF level. A total of 179 patients were enrolled. The forward bending in supine (FB-SU) test demonstrated superior diagnostic values (sensitivity: 90.6%, specificity: 71.2%), which outperformed those of plain radiographs (sensitivity: 68.9%, specificity: 71.9%). The location of patient-reported pain was generally close to or lower than the index fracture level. FB-SU showed the highest diagnostic accuracy and was more valuable than plain radiographs in diagnosing acute VFF. FB-SU is a simple and affordable screening test. If positive, physicians should highly suspect VFF even when based on vague evidence of acute fracture provided by plain radiographs.

Osteoporotic Fractures of the Thoracic and Lumbar Vertebrae: Diagnosis and Conservative Treatment

BACKGROUND

The prevalence of osteoporotic vertebral body fractures in Europe is 18-26%. Although most of these injuries can be treated conservatively, the underlying concepts have not been defined clearly or uniformly. In this article, we present the current state of the evidence on the diagnosis and conservative treatment of osteoporotic fractures of the thoracic and lumbar vertebrae.

METHODS

A systematic review of the literature up to May 2020 was carried out in the PubMed and Web of Science Core Collection databases. 549 articles were identified, of which 36 were suitable for inclusion in the review. Articles were sought in the areas of diagnosis, provision of physical aids, pharmacotherapy, physiotherapy, and treatments from the realm of alternative medicine.

RESULTS

The primary diagnostic technique was conventional x-ray in two planes (with the patient standing, if possible), which had 51.3% sensitivity and 75% specificity. If a fracture was suspected, magnetic resonance imaging (MRI) of the entire spine and regional computed tomography (CT) were carried out. The overall state of the evidence on treatment is poor; the best available evidence is for exercise therapy and physiotherapy, which are supported by three level I and four level II studies. Improvements were seen mainly in mobility and a reduced fear of falling. The use of an active orthosis can be useful as well. No evidence was found on the use of drugs or alternative medicine exclusively in the conservative treatment of osteoporotic vertebral body fractures.

CONCLUSION

It is reasonable to evaluate instability with imaging repeatedly, at regular intervals, over a period of six months. There is still a lack of reliable data on the optimal intensity and duration of physiotherapy, and on the use of orthoses.

Using artificial intelligence to diagnose fresh osteoporotic vertebral fractures on magnetic resonance images

BACKGROUND CONTEXT

Accurate diagnosis of osteoporotic vertebral fracture (OVF) is important for improving treatment outcomes; however, the gold standard has not been established yet. A deep-learning approach based on convolutional neural network (CNN) has attracted attention in the medical imaging field.

PURPOSE

To construct a CNN to detect fresh OVF on magnetic resonance (MR) images.

STUDY DESIGN/SETTING

Retrospective analysis of MR images PATIENT SAMPLE: This retrospective study included 814 patients with fresh OVF. For CNN training and validation, 1624 slices of T1-weighted MR image were obtained and used.

OUTCOME MEASURE

We plotted the receiver operating characteristic (ROC) curve and calculated the area under the curve (AUC) in order to evaluate the performance of the CNN. Consequently, the sensitivity, specificity, and accuracy of the diagnosis by CNN and that of the two spine surgeons were compared.

METHODS

We constructed an optimal model using ensemble method by combining nine types of CNNs to detect fresh OVFs. Furthermore, two spine surgeons independently evaluated 100 vertebrae, which were randomly extracted from test data.

RESULTS

The ensemble method using VGG16, VGG19, DenseNet201, and ResNet50 was the combination with the highest AUC of ROC curves. The AUC was 0.949. The evaluation metrics of the diagnosis (CNN/surgeon 1/surgeon 2) for 100 vertebrae were as follows: sensitivity: 88.1%/88.1%/100%; specificity: 87.9%/86.2%/65.5%; accuracy: 88.0%/87.0%/80.0%.

CONCLUSIONS

In detecting fresh OVF using MR images, the performance of the CNN was comparable to that of two spine surgeons.

Variations in situational risk factors for fractures of the distal forearm, hip, and vertebrae in older women

Background

Situational factors during a fall among three common types of fractures of the distal forearm, hip, and vertebrae among older women in Taiwan were investigated.

Methods

In 2016 ~ 2017, study participants were identified from those aged ≥65 years who visited emergency departments due to a fall in two university-affiliated hospitals in Taipei. In addition to individual characteristics, situational factors during the fall (location, activity, change of center of mass, fall mode, fall direction, initiating a protective response, and being hit) were collected. A sample of 203 distal-forearm fractures, 189 vertebral fractures, and 375 hip fractures was recruited, while 717 women with a soft-tissue injury were used as a control group. The identification of situational risk factors for each type of fracture was validated by using those who sustained one of the other two types of fracture as a control group.

Results

After adjusting for age and other individual characteristics, compared to soft-tissue injuries, distal-forearm fractures were significantly more likely to occur with slips (odds ratio [OR] = 11.0; 95% confidence interval [CI] = 4.76 ~ 25.4), trips (OR = 3.40; 95% CI = 1.42 ~ 8.17), step-downs (OR = 4.95; 95% CI = 2.15 ~ 11.4), and from sideways falls (OR = 1.73; 95% CI = 1.12 ~ 2.67) and significantly less likely to occur indoors (OR = 0.62; 95% CI = 0.42 ~ 0.90) or from backwards falls (OR = 0.62; 95% CI = 0.41 ~ 0.95). Hip fractures were significantly more likely to occur with step-downs (OR = 1.76; 95% CI = 1.13 ~ 2.75) and from backwards (OR = 3.16; 95% CI = 2.15 ~ 4.64) or sideways falls (OR = 5.56; 95% CI = 3.67 ~ 8.41) and significantly less likely when hitting an object (OR = 0.26; 95% CI = 0.13 ~ 0.52) or initiating a protective response (OR = 0.58; 95% CI = 0.36 ~ 0.93). Vertebral fractures were significantly more likely to occur with slips (OR = 2.42; 95% CI = 1.30 ~ 4.50), step-downs (OR = 2.53; 95% CI = 1.43 ~ 4.48), and backwards falls (OR = 2.15; 95% CI = 1.39 ~ 3.32). Similar results were found in the validation analyses.

Conclusions

Large variations in situational risk factors for the three types of fracture in older women existed. A combination of individual and situational risk factors may display a more-comprehensive risk profile for the three types of fracture, and an intervention that adds training programs on safe landing strategies and effective compensatory reactions may be valuable in preventing serious injuries due to a fall.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02157-2.

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.

Diagnostic accuracy of MR, CT, and ECT in the differentiation of neoplastic from nonneoplastic spine lesions

AIM

To provide guidance for appropriate imaging examinations for diagnosing spinal tumors or tumor-like lesions.

METHODS

A total of 121 patients with suspected spinal tumors were included this retrospective study. Each patient underwent ≥2 imaging examinations, including computerized tomography (CT), magnetic resonance (MR), and/or emission computed tomography (ECT). All patients were diagnosed by pathology after core needle or surgical biopsies. The results were compared with those of pathological examinations using paired chi-squared tests, and compared with each other. Statistical indicators that tested the consistency of the results included McNemar's and kappa coefficients, as well as receiver operating characteristic curves.

RESULTS

The differences among MR, CT, ECT, and pathology were not significant. The kappa coefficient of MR, CT, and ECT was 46.1%, 36.0%, and 55.9%, respectively. The area under the curve of ECT, MR, and CT scans was 0.809, 0.705, and 0.704, respectively; and the differences among them were significant (P < .05). Post hoc multiple comparisons showed no significant differences among imaging examinations in terms of sensitivity, specificity, misdiagnosis rate, and coincidence rate (P > .05). However, significant differences were noted in the kappa coefficient and missed diagnosis rate (P < .05).

CONCLUSIONS

Although ECT was the most accurate imaging method, its high cost and large radiation dosage limit its widespread application. Furthermore, MR verified spinal tumors more effectively; however, CT excluded them more efficiently. In summary, when all factors are considered, MR is still the optimal modality for the diagnosis of spinal tumors, especially during the initial screening.

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.

[Modern radiological diagnostics in spine surgery]

BACKGROUND

Radiological imaging is important in the preoperative diagnosis of many forms of spinal pathology and plays a fundamental role in the assessment of p.o. effects, which can be verified on the spinal column as well as on the surrounding soft tissues, depending on the imaging method used.

AIM

The article provides an overview of the current status and possibilities of radiological diagnostic methods for the verification of possibly recommended spine surgery in the context of degenerative, inflammatory-infectious, post-traumatic or p.o. pathologies and changes in the spine: X‑rays, computed tomography (CT), magnetic resonance imaging (MRI). The supplementary nuclear medicine procedures (scintigraphy, PET[-CT], SPECT, etc.) which may be required for special questions are not discussed.

MATERIAL AND METHODS

The merits and limitations of the techniques used in the investigation of advanced degenerative spinal pathologies and post-traumatic conditions are discussed, with multidetector CT being the focus of attention in spinal clearance for traumatic injuries. In most cases of spinal infection, MRI images, as a central diagnostic tool, show typical findings such as destruction of adjacent endplates, bone marrow and intervertebral disc abnormalities, and paravertebral or epidural abscesses. However, it is not always easy to diagnose a spinal infection, especially if atypical MR patterns of infectious spondylitis are present. Knowledge of them means misdiagnosis and improper treatment can be avoided.

RESULTS

It is shown that high-quality modern radiological examinations are essential for diagnosis and p.o. management, as these provide answers to the main questions in the treatment: Is the entity/injury stable or unstable, acute or old, benign or malign; is there a myelopathy or p.o. complication?

DISCUSSION

The main indications for p.o. diagnostic imaging, difficulties such as metal artefact formation, and potential pitfalls are analyzed. Entity-specific radiological image patterns, imaging algorithms and differential diagnostic peculiarities are presented and discussed based on current literature and selected case studies.

A Clinical Prospective Observational Cohort Study on the Prevalence and Primary Diagnostic Accuracy of Occult Vertebral Fractures in Aged Women with Acute Lower Back Pain Using Magnetic Resonance Imaging

Background

Elderly female patients complaints of acute low back pain (LBP) may involve vertebral fracture (VF), among which occult VF (OVF: early-stage VF without any morphological change) is often missed to be detected by primary X-ray examination. The current study aimed to investigate the prevalence of VF and OVF and the diagnostic accuracy of the initial X-ray in detecting OVF.

Method

Subjects were elderly women (>70 years old) complaining of acute LBP with an accurate onset date. Subjects underwent lumbar X-ray, magnetic resonance imaging (MRI), and bone mineral density (BMD) measurement at their first visit. The distribution of radiological findings from X-ray and magnetic resonance imaging (MRI) as well as the calculation of the prevalence of VF and OVF are investigated.

Results

The prevalence of VF among elderly women with LBP was 76.5% and L1 was the most commonly injured level. Among VF cases, the prevalence of OVF was 33.3%. Furthermore, osteoporotic patients tend to show increased prevalence of VF (87.5%). The predictive values in detecting VF on the initial plain X-ray were as follows: sensitivity, 51.3%; specificity, 75.0%; and accuracy rate, 56.7%.

Conclusions

Acute LBP patients may suffer vertebral injury with almost no morphologic change in X-ray, which can be detected using MRI.

[Spinal fractures]

Osteoporotic spinal fractures are typical age-related fragility fractures. Their impact on the quality of life is often underestimated; therefore, anti-osteoporotic drug treatment according to the current guidelines is essential. Occult vertebral fractures may be difficult to detect and a differentiation between fresh and old fractures is often only possible with magnetic resonance imaging (MRI) to reveal cancellous bone edema. Treatment recommendations are predominantly based on traumatic fractures in younger adults and are thus not applicable in orthogeriatrics. A new classification currently under validation and presented in this article was developed in order to aid decision-making for operative interventions. Minimally invasive treatment options include vertebroplasty, kyphopasty and internal fixation. The application of cement provides additional stability but can be accompanied by cement-specific complications, such as extravasation and embolism.

A critical appraisal of vertebral fracture assessment in paediatrics

PURPOSE

There is a need to improve our understanding of the clinical utility of vertebral fracture assessment (VFA) in paediatrics and this requires a thorough evaluation of its readability, reproducibility, and accuracy for identifying VF.

METHODS

VFA was performed independently by two observers, in 165 children and adolescents with a median age of 13.4 years (range, 3.6, 18). In 20 of these subjects, VFA was compared to lateral vertebral morphometry assessment on lateral spine X-ray (LVM).

RESULTS

1528 (84%) of the vertebrae were adequately visualised by both observers for VFA. Interobserver agreement in vertebral readability was 94% (kappa, 0.73 [95% CI, 0.68, 0.73]). 93% of the non-readable vertebrae were located between T6 and T9. Interobserver agreement per-vertebra for the presence of VF was 99% (kappa, 0.85 [95% CI, 0.79, 0.91]). Interobserver agreement per-subject was 91% (kappa, 0.78 [95% CI, 0.66, 0.87]). Per-vertebra agreement between LVM and VFA was 95% (kappa 0.79 [95% CI, 0.62, 0.92]) and per-subject agreement was 95% (kappa, 0.88 [95% CI, 0.58, 1.0]). Accepting LVM as the gold standard, VFA had a positive predictive value (PPV) of 90% and a negative predictive value (NPV) of 95% in per-vertebra analysis and a PPV of 100% and NPV of 93% in per-subject analysis.

CONCLUSION

VFA reaches an excellent level of agreement between observers and a high level of accuracy in identifying VF in a paediatric population. The readability of vertebrae at the mid thoracic region is suboptimal and interpretation at this level should be exercised with caution.

Efficacy of the dynamic radiographs for diagnosing acute osteoporotic vertebral fractures

We investigated the efficacy of dynamic radiographs for diagnosing acute osteoporotic vertebral fractures (OVFs) compared with supine radiographs or sitting radiographs alone. Evaluation of the dynamic radiographs was superior to the other evaluations. Dynamic radiographs provide a convenient and useful method of diagnosing acute OVFs.

INTRODUCTION

Identifying acute OVFs on plain radiographs is difficult. We studied a new approach to identify acute OVFs on the basis of fracture mobility.

METHODS

We performed a retrospective radiographic analysis of 472 acute OVFs (<3 weeks after onset), which were diagnosed on the basis of magnetic resonance imaging of T5 through L5 (a total of 5,239 vertebrae). Supine lateral radiographs were compared with sitting lateral radiographs to determine the presence or absence of mobility. Vertebrae showing changes in the vertebral body height were diagnosed as acute OVFs. We analyzed the diagnostic accuracy on the basis of comparative supine and sitting lateral radiographs and compared it with that of radiographs obtained in the supine or the sitting position alone.

RESULTS

Of the 472 acute OVFs diagnosed, 313 (66 %) exhibited vertebral mobility on supine lateral and sitting lateral radiographs. Correct diagnoses of acute OVFs or no acute OVFs were made in 4,883 vertebrae. There were 159 unreadable OVFs (3 %), and 197 previous OVFs (4 %) were misdiagnosed as acute OVFs. The sensitivity was 66 % and the specificity was 96 %. Evaluation of the mobility of acute OVFs in the supine and the sitting position was superior to evaluation using radiographs in either the supine or the sitting position alone.

CONCLUSIONS

Dynamic radiographs provide a convenient way to identify acute OVFs.

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.

Quantitative vertebral morphometry based on parametric modeling of vertebral bodies in 3D

Quantitative vertebral morphometry (QVM) was performed by parametric modeling of vertebral bodies in three dimensions (3D).

INTRODUCTION

Identification of vertebral fractures in two dimensions is a challenging task due to the projective nature of radiographic images and variability in the vertebral shape. By generating detailed 3D anatomical images, computed tomography (CT) enables accurate measurement of vertebral deformations and fractures.

METHODS

A detailed 3D representation of the vertebral body shape is obtained by automatically aligning a parametric 3D model to vertebral bodies in CT images. The parameters of the 3D model describe clinically meaningful morphometric vertebral body features, and QVM in 3D is performed by comparing the parameters to their statistical values. Thresholds and parameters that best discriminate between normal and fractured vertebral bodies are determined by applying statistical classification analysis.

RESULTS

The proposed QVM in 3D was applied to 454 normal and 228 fractured vertebral bodies, yielding classification sensitivity of 92.5% at 7.5% specificity, with corresponding accuracy of 92.5% and precision of 86.1%. The 3D shape parameters that provided the best separation between normal and fractured vertebral bodies were the vertebral body height and the inclination and concavity of both vertebral endplates.

CONCLUSION

The described QVM in 3D is able to efficiently and objectively discriminate between normal and fractured vertebral bodies and identify morphological cases (wedge, (bi)concavity, or crush) and grades (1, 2, or 3) of vertebral body fractures. It may be therefore valuable for diagnosing and predicting vertebral fractures in patients who are at risk of osteoporosis.

[Osteoporosis diagnosis and therapy according to the 2010 guidelines]

Osteoporotic fractures are a frequent cause of disability and loss of quality of life in old age. Maintaining muscle function and balance, a daily calcium intake of 1000 mg, sufficient vitamin D and prudent use of drugs associated with falls and osteoporosis are key components to fracture prevention. The German guideline recommends that a specific long-term osteoporosis medication be initiated in individuals with a 30% 10-year risk for hip fractures and vertebral fractures.

Vertebral fracture assessment: impact of instrument and reader

PURPOSE

Many osteoporotic vertebral fractures are not clinically recognized but increase fracture risk. We hypothesized that a newer generation densitometer increases the number of evaluable vertebrae and vertebral fractures detected. We also explored the impact of reader experience on vertebral fracture assessment (VFA) interpretation.

METHODS

VFA images obtained using Prodigy and iDXA densitometers in 103 older adults were evaluated for vertebral visualization and fracture presence in the T4-L5 region. A "true" read for each densitometer was achieved by consensus. If readers disagreed, the evaluation of a third expert physician was taken as true. Main outcomes were evaluable vertebrae, vertebral fractures, and intrareader/interreader reproducibility.

RESULTS

Using the "true" reads, 92% of vertebrae were visualized on iDXA and 76% on Prodigy. Numerically, more fractures were identified with iDXA; the "true" reads found 43 fractures on iDXA and 21 on Prodigy. The experienced reader had better intrareader and interreader reproducibility than the inexperienced reader when compared with the "true" read.

CONCLUSIONS

Using the newer iDXA densitometer for VFA analysis improves vertebral body visualization and fracture detection. Training and experience enhance result reproducibility.

Nationwide survey of current medical practices for hospitalized elderly with spine fractures in Japan

BACKGROUND

The status of hip fracture incidence and treatment is well known through nationwide surveys in Japan. However, there have been no similar studies on spine fractures. Therefore, we investigated current medical practices for them.

METHODS

Altogether, 1200 hospitals were randomly selected for the survey with consideration of region and hospital characteristics. Questionnaire items included the number of hospitalized spine patients, imaging test implementation, type of conservative treatment, use of open surgery and vertebroplasty, and the number of these procedures performed in 2005.

RESULTS

Responses were received from 473 hospitals. On the day of response, there were 14 372 hospitalized orthopedic patients (average 32.8/hospital). Among them were 1403 spine fracture patients (3.1/hospital), accounting for 13.5% of orthopedic patients. Of them, 91.9% received conservative treatment. The mean percentage of spine fracture patients who were hospitalized was 39.5%. The most reliable imaging test was said to be magnetic resonance imaging. Casting or bracing was used in most of the institutions. The most common analgesic treatment was oral nonsteroidal antiinflammatory drugs. Open surgery and vertebroplasty were conducted for spine fractures in the elderly at 26.5% and 16.3% of hospitals, respectively. In these hospitals, 624 and 257 patients underwent open surgery and vertebroplasty, respectively, in 2005.

CONCLUSIONS

In Japan, more than 90% of elderly patients hospitalized with spine fractures received conservative treatment. Surgical treatment, either open surgery or vertebroplasty, was performed at 30% of the hospitals. This study provides basic data that will contribute to planning improvements in spinal fracture treatment in the elderly.

Trauma of the spine and spinal cord: imaging strategies

Traumatic injuries of the spine and spinal cord are common and potentially devastating lesions. We present a comprehensive overview of the classification of vertebral fractures, based on morphology (e.g., wedge, (bi)concave, or crush fractures) or on the mechanism of injury (flexion-compression, axial compression, flexion-distraction, or rotational fracture-dislocation lesions). The merits and limitations of different imaging techniques are discussed, including plain X-ray films, multi-detector computed tomography (MDCT), and magnetic resonance imaging (MRI) for the detection. There is growing evidence that state-of-the-art imaging techniques provide answers to some of the key questions in the management of patients with spine and spinal cord trauma: is the fracture stable or unstable? Is the fracture recent or old? Is the fracture benign or malignant? In summary, we show that high-quality radiological investigations are essential in the diagnosis and management of patients with spinal trauma.

[Osteoporosis--current diagnostics and therapy]

Osteoporotic fractures are a frequent cause of disability and a loss of quality of life in old age. Maintenance of muscle function and balance, a daily calcium intake of 1,000 mg, sufficient vitamin D, and a prudent use of fall- and osteoporosis-associated drugs are key components of fracture prevention. The German guideline recommends to initiate a specific long-term osteoporosis medication in individuals with a 30% 10-year risk for hip fractures and vertebral fractures.

Vertebral Fracture Assessment: the 2007 ISCD Official Positions

Vertebral fracture assessment (VFA) is an established, low radiation method for detection of prevalent vertebral fractures. Vertebral fractures are usually not recognized clinically at the time of their occurrence, but their presence indicates a substantial risk for subsequent fractures independent of bone mineral density. Significant evidence supporting VFA use for many post-menopausal women and older men has accumulated since the last ISCD Official Position Statement on VFA was published. The International Society for Clinical Densitometry considered the following issues at the 2007 Position Development Conference: (1) What are appropriate indications for Vertebral Fracture Assessment; (2) What is the most appropriate method of vertebral fracture detection with VFA; (3) What is the sensitivity and specificity for detection of vertebral fractures with this method; (4) When should additional spine imaging be performed following a VFA; and (5) What are the reporting obligations for those interpreting VFA images?