Value and potential limitations of vertebral fracture assessment (VFA) compared to conventional spine radiography: experience from a fracture liaison service (FLS) and a meta-analysis

Risk of Subsequent Hip Fractures across Varying Treatment Patterns for Index Vertebral Compression Fractures

Introduction: Vertebral compression fractures (VCFs) pose a considerable healthcare burden and are linked to elevated morbidity and mortality. Despite available anti-osteoporotic treatments (AOTs), guideline adherence is lacking. This study aims to evaluate subsequent hip fracture incidence after index VCF and to elucidate AOT prescribing patterns in VCF patients, further assessing the impact of surgical interventions on these patterns. Materials and Methods: Patients with index VCFs between 2010 and 2021 were identified using the PearlDiver database. Diagnostic and procedural data were recorded using International Classification of Diseases (ICD-9, ICD-10) and Current Procedural Terminology (CPT) codes. Patients under age 50 and follow-up Collapse

Key Words

• anti-osteoporotic treatment
• bisphosphonates
• fragility fracture
• hip fracture
• osteoporosis
• vertebral compression fracture

Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s)

Andy Ton Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Jennifer A. Bell Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
William J. Karakash Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Thomas D. Alter Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
Mary Kate Erdman Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.) Department of Orthopaedic Surgery, University of Chicago Medical Center, Chicago, IL 60612, USA
Hyunwoo Paco Kang Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Emily S. Mills Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Jonathan Mina Ragheb Department of Orthopaedic Surgery, Kaiser Permanente Bernard J. Tyson School of Medicine, Los Angeles, CA 91101, USA
Mirbahador Athari Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Jeffrey C. Wang Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Ram K. Alluri Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Raymond J. Hah Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)

Collapse

Geriatric spine fractures - Demography, changing trends, challenges and special considerations: A narrative review

The aim of this manuscript was to summarize the demography and changing trends of geriatric spinal injuries and to enumerate the challenges and special considerations in the care of geriatric spinal injuries. PubMed, Scopus and Embase databases were searched for literature on geriatric spine fractures using MeSH terms 'aged', 'aged, 80 and over', 'elderly', 'spinal fracture/epidemiology', spinal fracture/therapy∗' and keywords pertaining to the same. The search results were screened for appropriate articles and reviewed. There is a high community prevalence of elderly vertebral fractures ranging from 18% to as high as 51%. The proportion of older patients among the spinal injured is rising as well. There is a higher chance of missing spinal injuries in the elderly and clinical guidelines may not be applicable to this patient group. Classification and surgical treatment are different from younger adult counterparts as the elderly osteoporotic spine behaves differently biomechanically. There is a high incidence of respiratory complications both for surgically and conservatively managed groups. Older age generally is associated with a higher complication rate including mortality.

Bone mineral density, vertebral fractures and trabecular bone score in primary ovarian insufficiency

PURPOSE

Bone health in primary ovarian insufficiency (POI) is under-investigated. We assessed patients with spontaneous POI for vertebral fractures (VFs) and related parameters of bone health.

METHODS

70 cases with spontaneous POI (age 32.5 ± 7.0 years) and an equal number of controls were assessed for BMD, TBS, and VFs. BMD at the lumbar-spine (L1-L4), left hip, non-dominant forearm, and TBS (iNsight software) were measured on a dual-energy X-ray absorptiometry (DXA) machine. VFs were assessed by Genant's classification. Serum FSH, LH, estradiol, T4, TSH, iPTH, serum 25(OH)D, total calcium, and inorganic phosphorus were measured.

RESULTS

BMD at the lumbar-spine, hip and forearm was reduced by 11.5%, 11.4% and 9.1% in POI as compared to controls (P < 0.001). Degraded or partially degraded microarchitecture on TBS was observed in 66.7% of patients and 38.2% of controls (P = 0.001). 15.7% of the POI patients had VFs, compared to 4.3% of controls (P = 0.045). Age, duration of amenorrhea and duration of HRT use were the significant predictors of TBS (P < 0.01). Serum 25(OH)D was the significant determinant of VFs. TBS abnormalities were higher in patients with POI and VFs. BMD was not significantly different in patients with and without VFs.

CONCLUSION

Thus, lumbar-spine osteoporosis, impaired TBS and VFs were present in 35.7%, 66.7% and 15.7% of patients with spontaneous POI in their early third decade. This indicates need for rigorous investigations for impaired bone health in these young patients and management with HRT, vitamin-D, and possible need for bisphosphonate therapy.

Interpretable vertebral fracture quantification via anchor-free landmarks localization

Vertebral body compression fractures are early signs of osteoporosis. Though these fractures are visible on Computed Tomography (CT) images, they are frequently missed by radiologists in clinical settings. Prior research on automatic methods of vertebral fracture classification proves its reliable quality; however, existing methods provide hard-to-interpret outputs and sometimes fail to process cases with severe abnormalities such as highly pathological vertebrae or scoliosis. We propose a new two-step algorithm to localize the vertebral column in 3D CT images and then detect individual vertebrae and quantify fractures in 2D simultaneously. We train neural networks for both steps using a simple 6-keypoints based annotation scheme, which corresponds precisely to the current clinical recommendation. Our algorithm has no exclusion criteria, processes 3D CT in 2 seconds on a single GPU, and provides an interpretable and verifiable output. The method approaches expert-level performance and demonstrates state-of-the-art results in vertebrae 3D localization (the average error is 1mm), vertebrae 2D detection (precision and recall are 0.99), and fracture identification (ROC AUC at the patient level is up to 0.96). Our anchor-free vertebra detection network shows excellent generalizability on a new domain by achieving ROC AUC 0.95, sensitivity 0.85, specificity 0.9 on a challenging VerSe dataset with many unseen vertebra types.

Bone Texture Assessment on Lateral VFAs Using the Texture Research Investigational Platform (TRIP) and its Fracture Discrimination Ability

Texture Research Imaging Platform applies trabecular bone score (TBS) measurement principles to images acquired with multiple modalities to assess bone texture at various skeletal sites. This study aimed to assess the bone texture score in dual-energy X-ray absorptiometry-acquired lateral vertebral fracture assessment (VFA) images (BTS_VFA), evaluate its reproducibility, and vertebral fracture discrimination ability. Subjects included 178 VF cases and 178 non-VF controls, 136 women and 42 men in each group, age 55-92 years, from two research centers. Cases and controls were matched for age (±5 years), body mass index (±5 kg/m²) and TBS. All participants underwent dual-energy X-ray absorptiometry TBS assessment from standard posterior-anterior lumbar spine scans and BTS_VFA assessment. VF presence was determined using VFA images applying the Genant's method. BTS_VFA was lower among fractured women compared to non-fractured (0.626 ± 0.109 vs 0.675 ± 0.099, p < 0.01), but not among men. In a binary logistic regression adjusted for study center and sex, for each SD lower BTS_VFA, there was a 40% increase (OR 1.40, 95% CI (1.13-1.74)) in the risk of having a prevalent VF; area under the curve (95% CI) 0.616 (0.557-0.675). Inter-assessor and inter-centers ICCs for BTS_VFA measurements were very good; 0.96 (0.64-0.99) and 0.98 (0.95-0.99), respectively. The BTS_VFA precision (coefficient of variation) was 2.42%. This feasibility study demonstrates the potential to assess trabecular bone texture in lateral VFA images with good reproducibility. BTS_VFA can discriminate between fractured and non-fractured women independent of their age, body mass index and TBS. In conclusion, BTS_VFA, a potential trabecular texture assessment that excludes the posterior elements, may have value in fracture prediction or as a novel approach to be further investigated in spine surgery planning.

Vertebral Fractures Assessed by Dual-Energy X-Ray Absorptiometry and All-Cause Mortality: The Tromsø Study, 2007-2020

Vertebral fractures have been associated with increased mortality, but findings are inconclusive, and many vertebral fractures avoid clinical attention. We investigated this association in a general population of 2,476 older adults aged ≥55 years from Tromsø, Norway, who were followed over 2007-2020, using dual-energy x-ray absorptiometry (DXA) at baseline to evaluate vertebral fractures (mild, moderate, or severe). We used multiple Cox regression models to estimate hazard ratios (HRs) for all-cause mortality, adjusted for age, sex, body mass index, education, smoking, alcohol intake, cardiovascular disease, and respiratory disease. Mean follow-up in the cohort was 11.2 (standard deviation, 2.7) years; 341 participants (13.8%) had ≥1 vertebral fracture at baseline, and 636 participants (25.7%) died between baseline and follow-up. Full-adjustment models showed a nonsignificant association between vertebral fracture status (yes/no) and mortality. Participants with ≥3 vertebral fractures (HR = 2.43, 95% confidence interval: 1.57, 3.78) or ≥1 severe vertebral fracture (HR = 1.65, 95% confidence interval: 1.26, 2.15) had increased mortality compared with those with no vertebral fractures. Dual-energy x-ray absorptiometry-based screening could be a potent and feasible tool in detecting vertebral fractures that are often clinically silent yet independently associated with premature death. Our data indicated that detailed vertebral assessment could be warranted for a more accurate survival estimation.

Vertebral fractures, trabecular bone score and their determinants in chronic hypoparathyroidism

PURPOSE

Patients with hypoparathyroidism are at risk of vertebral fractures (VFs) despite high bone mineral density (BMD). We investigated this paradox by assessing trabecular bone score (TBS) and hip structural analysis (HSA) in non-surgical chronic hypoparathyroidism (cHypoPT) with and without VFs.

METHODS

152 cHypoPT patients (age 40.2 ± 13.4 years, M: F = 81:71) with a median follow-up of 8 (2-13) years were assessed for BMD, VFs, TBS, and HSA and compared with 152 healthy controls. VFs at T₇-L₄ were assessed by Genant's method. Average serum total calcium and phosphorus during follow-up were assessed.

RESULTS

The lumbar spine and hip BMD were higher by 25.4 and 13.4% in cHypoPT than controls (P < 0.001). Paradoxically, VFs (30.9 vs.7.9%), including multiple (12.5 vs. 2.6%) were higher in cHypoPT (P < 0.001). Though overall average TBS (1.411 ± 0.091) was normal in cHypoPT, 25.4% of the females had subnormal TBS, more in post than pre-menopausal women (52.3 vs. 14%, P = 0.002) and as compared to males (6.1%, P = 0.001). TBS correlated with menopausal status and follow-up serum calcium-phosphorus product. For every gm/cm² rise in BMD, TBS increase was only 0.227 in cHypoPT compared to 0.513 in controls. Frequency of VFs increased with declining TBS (P = 0.004). HSA was comparable between cHypoPT with and without VFs. 23.4% of cHypoPT with VFs had subnormal TBS.

CONCLUSION

31% of cHypoPT patients had VFs. TBS indicated degraded bone microarchitecture in 50% of the post-menopausal cHypoPT women. However, TBS has limitations to detect abnormal bone microarchitecture in cHypoPT as only one-fourth of patients with VFs showed low TBS.

Prevalence of Vertebral Fractures in Adults With Type 1 Diabetes: DenSiFy Study (Diabetes Spine Fractures)

CONTEXT

Vertebral fracture (VF) prevalence up to 24% has been reported among young people with type 1 diabetes (T1D). If this high prevalence is confirmed, individuals with T1D could benefit from preventative VF screening.

OBJECTIVE

We compared the prevalence of VFs between adults with T1D and nondiabetic controls.

METHODS

This cross-sectional study included 127 adults with T1D, and 65 controls with a similar age, sex, and BMI distribution, from outpatient clinics of 2 tertiary care centers. Vertebral fracture assessment (VFA) by dual-energy x-ray absorptiometry (DXA) was used for prevalent VFs. The modified algorithm-based qualitative (mABQ) method was applied. Bone mineral density (BMD) and trabecular bone score (TBS) were assessed by DXA. Serum bone turnover markers and sclerostin were measured in a subgroup of participants.

RESULTS

Participants with T1D (70 women, 57 men) had a mean age of 42.8 ± 14.8 years, median diabetes duration of 25.8 (15.8-34.4) years, mean BMI of 26.6 ± 5.4 kg/m2 and mean HbA1c over the past 3 years of 7.5 ± 0.9%. Controls (35 women, 30 men) had mean age of 42.2 ± 15.9 years and mean BMI of 26.1 ± 5.1 kg/m2. VF prevalence was comparable between groups (2.4% vs 3.1%, P = 0.99). TBS, BMD at the total hip and femoral neck, and bone formation and resorption markers were lower while sclerostin levels were similar in participants with T1D vs controls.

CONCLUSION

Our VFA results using the mABQ method do not confirm increased prevalence of VFs in men and women with relatively well-controlled T1D.

Osteoporotic vertebral fractures: radiologic diagnosis, clinical and radiologic factors affecting surgical decision making: WFNS Spine Committee Recommendations

With the varied literature on osteoporotic vertebral fracture that may predispose to diagnostic and management dilemma, it is timely to evaluate and streamline the evidence. The aim of this review is to create recommendations on osteoporotic vertebral fractures regarding radiologic diagnosis, and clinical and radiological factors affecting surgical decision making. A computerized literature search was done using PubMed, Google scholar and Cochrane Database of Systematic Reviews from 2010 to 2020. For radiologic diagnosis, the keywords "osteoporotic vertebral fractures" and "radiologic diagnosis" were used yielding 394 articles (19 relevant articles). For clinical and radiological factors affecting surgical decision making, the keywords "osteoporotic vertebral fractures", "radiologic diagnosis", and "surgery" were used yielding 568 articles (25 relevant articles). All pertinent data were reviewed, and consensus statements were obtained in two virtual separate consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine committee. The statements were voted and yielded positive or negative consensus using the Delphi method. This review summarizes the WFNS Spine Committee recommendations on the radiologic diagnosis, and clinical and radiological factors affecting surgical decision making of osteoporotic vertebral fractures.

Osteoporosis in children and adolescents: when to suspect and how to diagnose it

Early recognition of osteoporosis in children and adolescents is important in order to establish an appropriate diagnosis of the underlying condition and to initiate treatment if necessary. In this review, we present the diagnostic work-up, and its pitfalls, of pediatric patients suspected of osteoporosis including a careful collection of the medical and personal history, a complete physical examination, biochemical data, molecular genetics, and imaging techniques. The most recent and relevant literature has been reviewed to offer a broad overview on the topic. Genetic and acquired pediatric bone disorders are relatively common and cause substantial morbidity. In recent years, there has been significant progress in the understanding of the genetic and molecular mechanistic basis of bone fragility and in the identification of acquired causes of osteoporosis in children. Specifically, drugs that can negatively impact bone health (e.g. steroids) and immobilization related to acute and chronic diseases (e.g. Duchenne muscular dystrophy) represent major risk factors for the development of secondary osteoporosis and therefore an indication to screen for bone mineral density and vertebral fractures. Long-term studies in children chronically treated with steroids have resulted in the development of systematic approaches to diagnose and manage pediatric osteoporosis.

CONCLUSIONS

Osteoporosis in children requires consultation with and/or referral to a pediatric bone specialist. This is particularly relevant since children possess the unique ability for spontaneous and medication-assisted recovery, including reshaping of vertebral fractures. As such, pediatricians have an opportunity to improve bone mass accrual and musculoskeletal health in osteoporotic children.

WHAT IS KNOWN

• Both genetic and acquired pediatric disorders can compromise bone health and predispose to fractures early in life. • The identification of children at risk of osteoporosis is essential to make a timely diagnosis and start the treatment, if necessary.

WHAT IS NEW

• Pediatricians have an opportunity to improve bone mass accrual and musculoskeletal health in osteoporotic children and children at risk of osteoporosis. • We offer an extensive but concise overview about the risk factors for osteoporosis and the diagnostic work-up (and its pitfalls) of pediatric patients suspected of osteoporosis.

Bone Mineral Density, Bone Microarchitecture and Vertebral Fractures in Male Patients with Alcohol Use Disorders

AIM

To investigate abnormalities in bone mineral density, trabecular bone score and vertebral fractures in male patients with alcohol use disorder to understand the impact on bone health.

METHODS

The study subjects included 134 male patients. Controls were 134 age matched healthy males. Assessments were made of the bone mineral density (BMD), trabecular bone score (TBS) and vertebral morphometry (VFA) for vertebral fractures. Biochemical measurements included serum total T4, thyroid stimulating hormone (TSH), parathyroid hormone (PTH) and 25- Hydroxyvitamin D 25(OH) D.

RESULTS

The mean BMD at total forearm, proximal forearm (or distal 1/3) and mid forearm was significantly higher in the alcohol use disorders (AUD) group than the controls (P < 0.01). Around 15% of patients with AUD had VFs compared with 9.0% of the healthy controls (P = 0.19). For each kg/m2 gain in body mass index (BMI), lumbar spine and total hip BMD increased by 0.009 and 0.014 g/cm2, respectively. Lumbar and hip BMD decreased by 0.002 and 0.003 g/cm2 per year increase in duration of alcohol used. For every 5 years increase in age of the patients the odds of having VFs increased by 39% (odds ratio 1.393 [95% confidence interval = 1.031-1.881, P = 0.03]).

CONCLUSION

The findings of the current study suggest that persons with AUD in third and fourth decades of life, with BMI in normal range and with alcohol use disorder duration of around one decade might have no major alteration in BMD and TBS. Impact of alcohol use in this population was manifest by marginal increase in the prevalence of mild grade of vertebral fractures, mostly in the thoracic region.

Inter-observer agreement of vertebral fracture assessment with dual-energy x-ray absorptiometry equipment

PURPOSE

To investigate the time and effort needed to perform vertebral morphometry, as well as inter-observer agreement for identification of vertebral fractures on vertebral fracture assessment (VFA) images.

METHODS

Ninety-six images were retrospectively selected, and three radiographers independently performed semi-automatic 6-point morphometry. Fractures were identified and graded using the Genant classification. Time needed to annotate each image was recorded, and reader fatigue was assessed using a modified Simulator Sickness Questionnaire (SSQ). Inter-observer agreement was assessed per-patient and per-vertebra for detecting fractures of all grades (grades 1-3) and for grade 2 and 3 fractures using the kappa statistic. Variability in measured vertebral height was evaluated using the intraclass correlation coefficient (ICC).

RESULTS

Per-patient agreement was 0.59 for grades 1-3 fracture detection, and 0.65 for grades 2-3 only. Agreement for per-vertebra fracture classification was 0.92. Vertebral height measurements had an ICC of 0.96. Time needed to annotate VFA images ranged between 91 and 540 s, with a mean annotation time of 259 s. Mean SSQ scores were significantly lower at the start of a reading session (1.29; 95% CI: 0.81-1.77) compared to the end of a session (3.25; 95% CI: 2.60-3.90; p < 0.001).

CONCLUSION

Agreement for detection of patients with vertebral fractures was only moderate, and vertebral morphometry requires substantial time investment. This indicates that there is a potential benefit for automating VFA, both in improving inter-observer agreement and in decreasing reading time and burden on readers.

Asymptomatic vertebral fracture in Tunisian post-menopausal women at risk: prevalence and risk factors

Data are still scarce regarding the prevalence and the associated factors of vertebral fractures (VF) in the North Africa and the Middle East region. In this study, VF were common in at risk Tunisian women with a prevalence of 26.19%. Lower total hip T-score, having severe back pain, and being physically inactive were independently associated with VF.

INTRODUCTION

Vertebral fractures are related to a marked increase in morbidity and mortality and they are associated with a definite risk of subsequent fracture. Nevertheless, they remain underdiagnosed and little is known about their epidemiology in the African countries. In this first Tunisian study, we aimed to assess the prevalence and the associated factors of asymptomatic VF among at risk Tunisian post-menopausal women.

METHODS

In this cross-sectional study, we included post-menopausal women without a previous diagnosis of VF and who were referred for bone mineral density (BMD) measurement. Each participant had had an extensive medical history investigation, a BMD assessment, and a vertebral fracture assessment (VFA) scan using a dual energy X-ray absorptiometry. VF were defined using Genant semi-quantitative method.

RESULTS

Two hundred and ten post-menopausal women were included. The overall prevalence of VF was 26.19% and 9.52% of our participants had multiple VF. The prevalence of VF was significantly higher in older participants, those having a history of prior severe fragility fracture, or having at least one intrinsic fall. The percentage of low bone mineral density and osteoporosis were significantly higher in women with VF. After binary logistic regression analysis, severe back pain (OR = 3.016; 95% CI 1.304-6.974), regular physical activity (OR = 0.065; 95% CI 0.02-0.213), and total hip T-score (OR = 0.56; 95% CI 0.383-0.820) were independently associated with VF.

CONCLUSION

VF are very prevalent among at risk Tunisian post-menopausal women and their incorporation in a clinical and densitometric tool might identify more effectively subsequent fracture.

Current Applications and Selected Technical Details of Dual-Energy X-Ray Absorptiometry

The application of dual-energy X-ray absorptiometry (DXA) examinations in the assessment of bone mineral density (BMD) in the lumbar spine, hip, and forearm is the basic diagnostic method for recognition of osteoporosis. The constant development of DXA technique is due to the aging of societies and the increasing importance of osteoporosis as a public health problem. In order to assess the degree of bone demineralization in patients with hyperparathyroidism, forearm DXA examination is recommended. The vertebral fracture assessment (VFA) of the thoracic and lumbar spine, performed by a highly-skilled technician, is an interesting alternative to the X-ray examination. The DXA total body examination can be useful in the evaluation of fat redistribution among patients after bariatric surgery, in patients infected with HIV and receiving antiretroviral therapy, and in patients with metabolic diseases and suspected to have sarcopenia. The assessment of visceral adipose tissue (VAT) and detection of abdominal aortic calcifications may be useful in the prediction of cardiovascular events. The positive effect of anti-resorptive therapy may affect some parameters of DXA hip structure analysis (HSA). Long-term anti-resorptive therapy, especially with the use of bisphosphonates, may result in changes in the DXA image, which may herald atypical femur fractures (AFF). Reduction of the periprosthetic BMD in the DXA measurements can be used to estimate the likelihood of loosening the prosthesis and periprosthetic fractures. The present review aims to present current applications and selected technical details of DXA.

Vertebral compression fractures: Still an unpredictable aspect of osteoporosis

Vertebral compression fracture is a hallmark of osteoporosis (OP) and by far the most prevalent fragility fracture. It is well proven that patients who develop a vertebral compression fracture are at substantial risk for additional fractures. Diagnosis is based on adequate clinical evaluation, imaging, and laboratory tests. The imaging of OP and fragility fractures includes conventional radiology to evaluate spinal fractures, bone mineral density (BMD) testing by dual energy x-ray densitometry, quantitative computerized tomography, magnetic resonance imaging, bone scintigraphy (if necessary), and ultrasound. Screening and treatment of individuals with high risk of osteoporotic fracture are cost-effective, but approximately two-thirds of the vertebral compression fractures (VCF) that occur each year are not accurately diagnosed and, therefore, not treated. Evaluation of VCFs, even though they may be asymptomatic, seems essential to health-related and/or clinical research on OP.

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

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

The Belgian Bone Club 2020 guidelines for the management of osteoporosis in postmenopausal women

PURPOSE

To provide updated evidence-based guidelines for the management of osteoporosis in postmenopausal women in Belgium.

METHODS

The Belgian Bone Club (BBC) gathered a guideline developer group. Nine "Population, Intervention, Comparator, Outcome" (PICO) questions covering screening, diagnosis, non-pharmacological and pharmacological treatments, and monitoring were formulated. A systematic search of MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus was performed to find network meta-analyses, meta-analyses, systematic reviews, guidelines, and recommendations from scientific societies published in the last 10 years. Manual searches were also performed. Summaries of evidence were provided, and recommendations were further validated by the BBC board members and other national scientific societies' experts.

RESULTS

Of the 3840 references in the search, 333 full texts were assessed for eligibility, and 129 met the inclusion criteria. Osteoporosis screening using clinical risk factors should be considered. Patients with a recent (<2 years) major osteoporotic fracture were considered at very high and imminent risk of future fracture. The combination of bone mineral density measured by dual-energy X-ray absorptiometry and 10-year fracture risk was used to categorize patients as low or high risk. Patient education, the combination of weight-bearing and resistance training, and optimal calcium intake and vitamin D status were recommended. Antiresorptive and anabolic osteoporosis treatment should be considered for patients at high and very high fracture risk, respectively. Follow-up should focus on compliance, and patient-tailored monitoring should be considered.

CONCLUSION

BBC guidelines and 25 guideline recommendations bridge the gap between research and clinical practice for the screening, diagnosis, and management of osteoporosis.

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

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

Bone Mineral Density and Risk of Osteoporotic Fractures in Women with Parkinson's Disease

Osteoporosis and Parkinson's disease (PD) are two important age-related diseases, which have an influence on pain, physical activity, disability, and mortality. The aim of this research was to study the parameters of bone mineral density (BMD), frequency, and 10-year probability of osteoporotic fractures (OFs) in females with Parkinson's disease (PD). We have examined 113 postmenopausal women aged 50-74 years old which were divided into 2 groups (I, control group (CG), n = 53 and II, subjects with PD, n = 60). Bone mineral density of lumbar spine, femoral neck, distal radius, and total body were measured, and quantity and localization of vertebral deformities were performed by the vertebral fracture assessment (VFA). Ten-year probability of OFs was assessed by Ukrainian version of FRAX®. It was established that BMD of lumbar spine, femoral neck, distal radius, and total body in PD women was reliably lower compared to CG. The frequency of OFs in PD subjects was higher compared to CG (51.7 and 11.3%, respectively) with prevalence of vertebral fractures (VFs) in women with PD (52.6% among all fractures). 47.4% of the females had combined VFs: 74.2% of VFs were in thoracic part of the spine and 73.7% were wedge ones. Ten-year probability of major OFs and hip fracture were higher in PD women compared to CG with and without BMD measurements. Inclusion of PD in the FRAX calculation increased the requirement of antiosteoporotic treatment from 5 to 28% (without additional examination) and increased the need of additional BMD measurement from 50 to 68%. Anterior/posterior vertebral height ratios (Th₈-Th₁₁) measured by VFA in PD females without confirmed vertebral deformities were lower compared to indices of CG. In conclusion, women with PD have lower BMD indices, higher rate of osteoporosis, and risk of future low-energy fractures that should be taken into account in the assessment of their osteoporosis risk and clinical management.

Vertebral Fracture Assessment Increases Use of Pharmacologic Therapy for Fracture Prevention in Clinical Practice

The impact of vertebral fracture assessment (VFA) on lateral spine images in clinical practice on subsequent patient use of fracture prevention medication is unknown. Our objective was to determine the association of prevalent vertebral fracture identified on bone density lateral spine images (positive VFA) with subsequent use of fracture prevention therapy in usual clinical practice, using the Manitoba Bone Density Program database prospective observational cohort. Since 2010, targeted VFA imaging has been done at the time of bone densitometry in Manitoba for 21% of women and men meeting criteria based on age, bone mineral density (BMD), height loss, and glucocorticoid use. Among 6652 treatment-naive individuals with at least 90 days follow-up who had VFA imaging, 923 (13.9%) had one or more definite vertebral fractures identified using a modified algorithm-based qualitative (ABQ) method. For those with a positive VFA, their bone density reports stated the patient was at high risk of subsequent fracture and qualified for fracture prevention therapy. Subsequent osteoporosis treatment initiated within the next 12 months was identified using population-based pharmacy data. Logistic regression models were used to estimate the association of positive VFA with subsequent prescription (Rx), compared to negative VFA. Fracture prevention medication was started by 2127 (32%) individuals, 52.3% with positive versus 28.4% with negative VFA (p value <0.001). This association was substantially stronger in those designated (before VFA results were known) to have low or moderate fracture risk compared to high fracture risk (interaction p value <0.001), and in those with osteopenia (OR 4.51; 95% CI, 3.48 to 5.85) compared to those with osteoporosis by BMD criteria (OR 1.72; 95% CI, 1.43 to 2.08, interaction p value <0.001). Targeted VFA imaging at the time of bone densitometry substantially improves identification of those at high fracture risk and fracture prevention medication use among those with prevalent vertebral fracture. © 2019 American Society for Bone and Mineral Research. © 2019 American Society for Bone and Mineral Research.

Prevalent vertebral fracture on bone density lateral spine (VFA) images in routine clinical practice predict incident fractures

PURPOSE

The predictive validity of vertebral fracture assessment (VFA) on bone density lateral spine images to identify prevalent vertebral fractures in routine clinical practice has not been established. Our objective was to estimate the associations of prevalent vertebral fracture identified on VFA images in routine practice with incident hip, all non-vertebral, major osteoporotic, and clinical vertebral fractures, using the Manitoba Bone Density database.

METHODS

From 2010 onward, 9972 men and women (mean age [SD] 76 [6.9] years) had VFA images obtained at the time of bone densitometry that were interpreted for vertebral fracture by the clinicians reading the bone density tests. Definite and possible prevalent vertebral fractures, respectively, were identified in 1575 (15.8%) and 293 (2.9%) using a modified Algorithm Based Qualitative method. We ascertained incident fractures using Manitoba provincial health databases over a mean 2.8 (SD 1.7) years and used Cox proportional hazards models to estimate the associations of prevalent vertebral fractures with incident fractures.

RESULTS

Compared to no prevalent vertebral fracture, those with definite prevalent vertebral fracture had higher hazard ratios for incident hip (HR 1.95, 95% C.I. 1.45 to 2.62), non-vertebral (HR 1.99, 95% C.I. 1.68 to 2.35), and clinical vertebral fracture (HR 2.68, 95% C.I. 1.69 to 4.23) adjusted for age, bone mineral density, body mass index, prior fracture, parental hip fracture, glucocorticoid use, alcohol use, smoking, and rheumatoid arthritis. These associations did not vary by FRAX fracture risk estimates or bone mineral density category.

CONCLUSION

Prevalent vertebral fractures identified on densitometric VFA images in routine clinical practice are strongly associated with incident fractures, and this study is the first to show this using any lateral spine imaging modality outside of research settings. These findings are strong evidence supporting the targeted use of densitometric VFA imaging among post-menopausal women and older men referred for bone densitometry.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Propofol and sevoflurane combined with remifentanil on the pain index, inflammatory factors and postoperative cognitive function of spine fracture patients

The effects of propofol vs. sevoflurane combined with remifentanil on the pain index, inflammatory factors and postoperative cognitive function in spine fracture patients were studied and analyzed. A total of 62 patients with vertebral fracture were randomly divided into the propofol group (P group, n=41) and the sevoflurane group (S group, n=41). P group used induction anesthesia with propofol, and maintained anesthesia via intravenous injection of remifentanil. While patients in S group received induction anesthesia with sevoflurane, and also remifentanil as the maintained anesthesia. Results showed that extubation time, eye-opening time and response time of P group were lower than S group (p<0.05). The VAS score 48 h after surgery in P group was significantly lower than the S group (p<0.05). Levels of IL-6, IL-1β, ICAM-1 and MMP-9 in serum in P group were lower than those in S group (p<0.05). Mini-mental state examination (MMSE) score 24 h after surgery in P group was higher than that in S group (p<0.01). Compared with sevoflurane anesthesia, propofol combined with remifentanil anesthesia on spine fracture patients can significantly decrease the pain index and inflammatory reaction, shorten the postoperative recovery time.