Progress in Osteoporosis and Fracture Prevention: Focus on Postmenopausal Women

Kenneth G Saag; Piet Geusens


Arthritis Res Ther. 2009;11(5):251 

In This Article

Assessment of Vertebral Fractures: An Opportunity to Identify High-risk Patients

Vertebral fractures are a special group of fractures. Morphometric vertebral fractures are the most frequent fractures in women and men older than 50 years[17] and their presence is a strong predictor of future vertebral, non-vertebral, and hip fracture risk.[18] Clinical vertebral fractures represent one out of three to four morphometric vertebral fractures and represent less than 10% of all fractures in patients presenting with a fracture to the emergency department.[1] Most morphometric vertebral fractures are not diagnosed until clinically suspected (for example, significant height loss, hyperkyphosis, protruding abdomen, rib-iliac crest distance of less than 2 cm, and acute or chronic back pain) and imaging by x-ray is performed. But even when lateral x-rays of the spine are available, vertebral fractures are often missed.[18,19]

Vertebral fracture assessment (VFA) is a new method to evaluate the presence of morphometric vertebral fractures and deformities using x-ray absorptiometry (Figure 4).[19] With appropriate DXA devices, VFA can be performed at the occasion of a bone densitometry. Advantages are its low irradiation, the availability of semiautomatic image analysis tools to assist in measuring vertebral shapes of the individual vertebrae, its plan-parallel projection, and its high negative predictive value. Disadvantages include difficulties in measuring upper thoracic vertebrae due to overlying soft tissue and ribs.

Figure 4.

Example of using dual-energy x-ray absorptiometry technology for vertebral fracture assessment.

The prevalence of previously unknown morphometric vertebral fractures has been studied in various at-risk populations. In a recent study of women and men presenting with a nonvertebral fracture, one out of four had a prevalent morphometric vertebral fracture on VFA that was not recognized previously.[14] In one other study, the prevalence of morphometric vertebral fractures was 21% in postmenopausal women with osteopenia.[20] The authors concluded that the use of VFA contributed to better define the fracture risk in patients presenting with a nonvertebral fracture and in women with osteopenia and contributed to treatment decisions by identifying patients at high risk of fractures in the absence of BMD osteoporosis. VFA also helps to select patients in whom x-rays of the spine are indicated to differentiate changes in shape from normal variations and diseases such as Scheuermann disease, pathologic fractures, bone remodeling in the context of osteoarthritis, and developmental short vertebral height.[19] According to the International Society of Clinical Densitometry (ISCD), additional x-ray imaging is needed in cases of two or more mild (grade 1) deformities without any moderate or severe (grade 2 or 3) deformities, when lesions in vertebrae cannot be ascribed to benign causes, or when vertebral deformities are found in a patient with a known history of a relevant malignancy.[19] In patients with BMD-diagnosed osteoporosis, a baseline VFA is not necessary for treatment decisions but can be helpful to identify during follow-up whether a vertebral fracture is new or old.[15] Indications for VFA according to the ISCD are shown in Table 3.[19]


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