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      Opportunistic diagnosis of osteoporotic vertebral fractures on standard imaging performed for alternative indications

      review-article
      , MB, BCH, BAO, MSc 1 , , MB, BCH, BAO, MRCPI, FRCR, FFR, RCSI 1 ,
      BJR Open
      The British Institute of Radiology.

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          Abstract

          Osteoporotic vertebral fractures (VFs) are the most common type of osteoporotic fracture. Patients with VF are at increased risk of hip fractures or additional VFs, both of which contribute to patient morbidity and mortality. Early diagnosis of VFs is essential so patients can be prescribed appropriate medical therapy.

          Most patients with clinical suspicion for VF have an X-ray of the spine. Many VFs are invisible on X-ray and require further imaging. CT can provide excellent bony detail but uses high doses of ionising radiation. MRI provides excellent soft tissue detail and can distinguish old from new fractures in addition to differentiating osteoporotic VFs from other causes of back pain. Bone scans have a limited role due to poor specificity.

          The literature suggests that radiologists frequently miss or do not report VFs when imaging is requested for an alternative clinical indication and when there is no clinical suspicion of VF. Common examples include failure to identify VFs on lateral chest X-rays, sagittal reformats of CT thorax and abdomen, lateral localizers on MRI and scout views on CT.

          Failure to diagnose a VF is a missed opportunity to improve management of osteoporosis and reduce risk of further fractures. This article discusses the role of radiographs, CT, MRI and bone scintigraphy in the assessment and recognition of osteoporotic fractures. This article focuses on opportunistic diagnosis of VFs on imaging studies that are performed for other clinical indications. It does not discuss use of dual energy X-ray absorptiometry which is a specific imaging modality for osteoporosis.

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          Most cited references39

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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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            Vertebral fracture assessment using a semiquantitative technique.

            The assessment of vertebral fracture by conventional radiography has been refined and improved using either semiquantitative or quantitative criteria. The inter- and intraobserver variability was determined for a semiquantitative visual approach that we routinely use in clinical studies for assessing prevalent and incident vertebral fractures. In addition, the semiquantitative approach was compared with a quantitative morphometric approach. The incidence and prevalence of vertebral fractures were determined in 57 postmenopausal women (age 65-75 years) by three independent observers. The radiographic basis for fracture definitions and the source of interobserver agreement for the semiquantitative technique. We conclude that the semiquantitative approach can be applied reliably in vertebral fracture assessment when performed using well-defined criteria.
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              Perspective. How many women have osteoporosis?

              Osteoporosis is widely viewed as a major public health concern, but the exact magnitude of the problem is uncertain and likely to depend on how the condition is defined. Noninvasive bone mineral measurements can be used to define a state of heightened fracture risk (osteopenia), or the ultimate clinical manifestation of fracture can be assessed (established osteoporosis). If bone mineral measurements more than 2 standard deviations below the mean of young normal women represent osteopenia, then 45% of white women aged 50 years and over have the condition at one or more sites in the hip, spine, or forearm on the basis of population-based data from Rochester, Minnesota. A smaller proportion is affected at each specific skeletal site: 32% have bone mineral values this low in the lumbar spine, 29% in either of two regions in the proximal femur, and 26% in the midradius. Although this overall estimate is substantial, some other serious chronic diseases are almost as common. More importantly, low bone mass is associated with adverse health outcomes, especially fractures. The lifetime risk of any fracture of the hip, spine, or distal forearm is almost 40% in white women and 13% in white men from age 50 years onward. If the enormous costs associated with these fractures are to be reduced, increased attention must be given to the design and implementation of control programs directed at this major health problem.
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                Author and article information

                Contributors
                Journal
                BJR Open
                BJR Open
                bjro
                BJR Open
                The British Institute of Radiology.
                2513-9878
                2021
                17 December 2021
                : 3
                : 1
                Affiliations
                [1 ]org-divisionDepartment of Radiology, University Hospital Galway , Galway, Ireland
                Author notes
                Address correspondence to: Professor Diane Bergin. E-mail: dianebergin@ 123456yahoo.com diane.bergin@ 123456hse.ie
                Article
                BJRO-D-21-00053
                10.1259/bjro.20210053
                9185849
                eeccbc60-d316-4010-95f3-d242b3233a43
                © 2021 The Authors. Published by the British Institute of Radiology

                This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 6, Tables: 0, Equations: 0, References: 40, Pages: 8, Words: 4524
                Product
                Categories
                Review Article
                bjro, BJRO
                musc, Musculoskeletal
                nuc-med, Nuclear medicine
                ct, CT
                mri, MRI

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