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      Vertebral fracture: epidemiology, impact and use of DXA vertebral fracture assessment in fracture liaison services


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          Vertebral fractures are independent risk factors for vertebral and nonvertebral fractures. Since vertebral fractures are often missed, the relatively new introduction of vertebral fracture assessment (VFA) for imaging of the lateral spine during DXA-measurement of the spine and hips may contribute to detect vertebral fractures. We advocate performing a VFA in all patients with a recent fracture visiting a fracture liaison service (FLS). Fracture liaison services (FLS) are important service models for delivering secondary fracture prevention for older adults presenting with a fragility fracture. While commonly age, clinical risk factors (including fracture site and number of prior fracture) and BMD play a crucial role in determining fracture risk and indications for treatment with antiosteoporosis medications, prevalent vertebral fractures usually remain undetected. However, vertebral fractures are important independent risk factors for future vertebral and nonvertebral fractures. A development of the DXA technology, vertebral fracture assessment (VFA), allows for assessment of the lateral spine during the regular DXA bone mineral density measurement of the lumbar spine and hips. Recent approaches to the stratification of antiosteoporosis medication type according to baseline fracture risk, and differences by age in the indication for treatment by prior fracture mean that additional information from VFA may influence initiation and type of treatment. Furthermore, knowledge of baseline vertebral fractures allows reliable definition of incident vertebral fracture events during treatment, which may modify the approach to therapy. In this manuscript, we will discuss the epidemiology and clinical significance of vertebral fractures, the different methods of detecting vertebral fractures, and the rationale for, and implications of, use of VFA routinely in FLS.

          Summary points

          Vertebral fracture assessment is a tool available on modern DXA instruments and has proven ability to detect vertebral fractures, the majority of which occur without a fall and without the signs and symptoms of an acute fracture.

          Most osteoporosis guidelines internationally suggest that treatment with antiosteoporosis medications should be considered for older individuals (e.g., 65 years +) with a recent low trauma fracture without the need for DXA.

          Younger individuals postfracture may be risk-assessed on the basis of FRAX® probability including DXA and associated treatment thresholds.

          Future fracture risk is markedly influenced by both site, number, severity, and recency of prior fracture; awareness of baseline vertebral fractures facilitates definition of true incident vertebral fracture events occurring during antiosteoporosis treatment.

          Detection of previously clinically silent vertebral fractures, defining site of prior fracture, might alter treatment decisions in younger or older FLS patients, consistent with recent IOF-ESCEO guidance on baseline-risk-stratified therapy, and provides a reliable baseline from which to define new, potentially therapy-altering, vertebral fracture events.

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          Most cited references126

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          Clinician’s Guide to Prevention and Treatment of Osteoporosis

          The Clinician’s Guide to Prevention and Treatment of Osteoporosis was developed by an expert committee of the National Osteoporosis Foundation (NOF) in collaboration with a multispecialty council of medical experts in the field of bone health convened by NOF. Readers are urged to consult current prescribing information on any drug, device, or procedure discussed in this publication.
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            Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis.

            Numerous studies have reported increased risks of hip, spine, and other fractures among people who had previous clinically diagnosed fractures, or who have radiographic evidence of vertebral fractures. However, there is some variability in the magnitudes of associations among studies. We summarized the literature and performed a statistical synthesis of the risk of future fracture, given a history of prior fracture. The strongest associations were observed between prior and subsequent vertebral fractures; women with preexisting vertebral fractures (identified at baseline by vertebral morphometry) had approximately 4 times greater risk of subsequent vertebral fractures than those without prior fractures. This risk increases with the number of prior vertebral fractures. Most studies reported relative risks of approximately 2 for other combinations of prior and future fracture sites (hip, spine, wrist, or any site). The confidence profile method was used to derive a single pooled estimate from the studies that provided sufficient data for other combinations of prior and subsequent fracture sites. Studies of peri- and postmenopausal women with prior fractures had 2.0 (95 % CI = 1.8, 2.1) times the risk of subsequent fracture compared with women without prior fractures. For other studies (including men and women of all ages), the risk was increased by 2.2 (1.9, 2.6) times. We conclude that history of prior fracture at any site is an important risk factor for future fractures. Patients with a history of prior fracture, therefore, should receive further evaluation for osteoporosis and fracture risk.
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              The Lancet, 367(9527), 2010-2018

                Author and article information

                Osteoporos Int
                Osteoporos Int
                Osteoporosis International
                Springer London (London )
                21 January 2021
                21 January 2021
                : 32
                : 3
                : 399-411
                [1 ]GRID grid.16872.3a, ISNI 0000 0004 0435 165X, Amsterdam UMC, , VU University Medical Center, ; Amsterdam, The Netherlands
                [2 ]Department of Rheumatology, Univ. Lille, CHU Lille, MABLab ULR 4490, 59000 Lille, France
                [3 ]GRID grid.5491.9, ISNI 0000 0004 1936 9297, MRC Lifecourse Epidemiology Unit, , University of Southampton, ; Southampton, UK
                [4 ]GRID grid.163555.1, ISNI 0000 0000 9486 5048, Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, , Singapore General Hospital, ; Singapore, Singapore
                [5 ]GRID grid.4991.5, ISNI 0000 0004 1936 8948, Nuffield Department of Orthopaedics, Rheumatology and Orthopaedic Sciences, , University of Oxford, ; Oxford, UK
                [6 ]GRID grid.150338.c, ISNI 0000 0001 0721 9812, Clinical Service and Research Laboratory of Bone Diseases, , Hôpitaux Universitaires de Genève, ; Geneva, Switzerland
                [7 ]GRID grid.4514.4, ISNI 0000 0001 0930 2361, Department of Clinical Sciences and Department of Orthopaedics, Skane University Hospital, , Lund University, ; Malmö, Sweden
                © The Author(s) 2021

                Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.

                Position Paper
                Custom metadata
                © International Osteoporosis Foundation and National Osteoporosis Foundation 2021

                vertebral fracture,fracture liaison service (fls),vertebral fracture assessment (vfa),osteoporosis,epidemiology,bone mineral density (bmd)


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