Pharmaceutical treatment of symptomatic vertebral fractures in primary care

Determining the Incidence of Adult Fractures: How Accurate Are Emergency Department Data?

Various research methods have been used to obtain skeletal fracture data and report the incidence of fractures. A large number of British studies have used data collected in emergency departments, and not data derived from orthopaedic units. We hypothesised that fracture data will differ depending upon the methodology employed to capture it. Two commonly used sources of fracture data at our institution were compared, (the Emergency Department (ED) database and the Orthopaedic Trauma Unit (OTU) database), using a cohort of adult patients from our defined population as the study sample. We performed univariate analyses to identify differences between groups with accurate and inaccurate ED fracture diagnoses. We then performed a binary logistic regression analysis to determine the best predictors of diagnostic accuracy. In one year, 7,449 patients were referred to the OTU. Three-quarters were referred with fractures. The overall false positive fracture referral rate was 25%. Several fracture subtypes were commonly overdiagnosed in the ED. Regression analysis showed that patient age, patient gender, and the seniority of the referring clinician were independently predictive of an accurate fracture diagnosis. We suggest that studies making use of ED fracture data may potentially overestimate the incidence of adult fractures.

Intravenous pamidronate for pain relief in recent osteoporotic vertebral compression fracture: a randomized double-blind controlled study

INTRODUCTION

We performed a randomized, double-blind, controlled clinical trial comparing intravenous pamidronate and placebo for pain relief in recent osteoporotic vertebral compression fractures (VCF).

METHODS

Patients suffered from recent (<21 days), painful, osteoporosis-related VCF. They were randomized to receive daily intravenous infusions of either placebo or 30 mg pamidronate for three consecutive days (total pamidronate: 90 mg). The main criterion for efficacy was improvement in standing pain on a 100-mm visual analogical scale (VAS) at day 7. Secondary criteria were standing pain at days 3 and 30; supine pain at days 3, 7, and 30; patients' overall assessment of improvement; mobility index; and number of "20% responders" and "50% responders" (respectively, 20% and 50% improvement in standing pain at days 7 and 30). Statistical analysis with non-parametric tests was carried out on an intention to treat basis.

RESULTS

Thirty-two patients were enrolled in the study; 16 were given placebo and 16 pamidronate. Thirty-one patients were evaluated at day 7 and 26 patients at day 30. VAS pain decreased significantly in both groups at day 7 (placebo -23 mm, pamidronate -42 mm, p<0.01). The difference in pain scores between groups was -23.25 mm (confidence interval (CI) [-42.3; -4.2], p=0.018) at day 7 and -26 mm at day 30 (p=0.03), in favor of pamidronate. At day 7, there were 4 versus 12 "50% responders," respectively, in the placebo and in the pamidronate groups (likelihood ratio: 8.372; p=0.004) and 9 versus 14 "20% responders" (likelihood ratio: 4.038; p=0.044). At day 30, there were 5 versus 10 "50% responders," respectively, in the placebo and in the pamidronate groups, and 7 versus 11 "20% responders." Patients' overall assessment of improvement at day 7 was 37+/-26 mm in the placebo group and 59+/-30 mm in the pamidronate group (p=0.019), and 42+/-26 mm and 72+/-21 mm at day 30 (p=0.07). The two groups did not differ significantly at days 7 and 30 for supine pain, Schober index, or finger-ground distance. No significant adverse reaction related to treatment occurred.

CONCLUSION

Pamidronate provides rapid and sustained pain relief in patients with acute painful osteoporotic VCF and is well tolerated. Further investigations are needed to better define the place of pamidronate in the management of painful recent osteoporotic collapse.

Reporting of vertebral fractures on spine X-rays

Vertebral fractures are the hallmark of osteoporosis, responsible for increased morbidity and mortality in post-menopausal women. However, two-thirds of vertebral fractures do not come to clinical attention. The aim of this study was to compare the identification of vertebral fractures on spine X-rays among rheumatologists. Study subjects were women aged 60-80 years having potential signs of vertebral fracture and visiting a rheumatologist. X-rays were performed according to standardized procedures. In 629 patients (among 824 included) at least one vertebral fracture was diagnosed, and the X-rays were then sent to a central facility where a semi-quantitative assessment of vertebral fracture was performed by a single rheumatologist trained for this evaluation. According to the vertebral level, kappa scores were between 0.20 to 0.77, i.e., below 0.6 from T4 to T7, and between 0.6 and 0.77 from T8 to L4. The false-negative fractures rate was 25.8% (and 15.7% of them were related to a numbering discrepancy). The rate of false positive fractures was 6.3%. At the patient level 6.8% had actually no fracture. This study shows that 25% of overall vertebral fractures are not diagnosed among patients considered as having at least one fracture. As a consequence, patients who require treatment to reduce fracture risk are not being properly identified.