www.osteoporosis.ca a powerful tool to reduce the risk of future osteoporotic fractures the...

www.osteoporosis.ca

a powerful tool to reduce the risk of future osteoporotic fractures

The recognition and reporting

of vertebral fractures:

B Lentle, J Brown, A Khan, Leslie WD, Levesque J, Lyons DJ, Siminoski K, Tarulli G

Osteoporosis Canada

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Vertebral fracture prevalence:

0

10

20

30

40

50

60

T4 T6 T8 T10 T12 L2 L4

Number

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Mortality rates by number of vertebral fractures:

0

5

10

15

20

25

30

35

40

0 1 2 3 4 5+

Mor

talit

y/10

00 P

erso

n-ye

ars

Number of Vertebral FracturesKado D. Arch Intern Med 1999; 159: 1215

p for trend < 0.001

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1

1.5

2

2.5

3

3.5

4

Melton '99 Gunnes '98 Black '99 Lauritzen '93

Rel

ativ

e R

isk

Vertebral fractures predict hip fracture:

RR = RR = Prevalent Vertebral FracturesPrevalent Vertebral Fractures No Prevalent FractureNo Prevalent Fracture

2.32.3 2.42.4 2.82.8

3.83.8

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Survival Rates after Fracture:

Cooper C. Am J Epidemiol 1993; 137: 1001

Years after Fracture

Surv

ival

%

100806040200

100806040200

100806040200

0 1 2 3 45

Vertebral

Hip

Distal forearm

ObservedExpected

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All vertebral fractures are clinically important:

Nevitt M. Arch Intern Med 2000; 160: 77

ClinicalFracture

0

20

40

60

80

100

120

140

160

180

Severe Back Pain

No IncidentFracture

0

5

10

15

20

25

30

35

40

45

Bed Rest

Mea

n #

of D

ays

RadiographicFracture

Mea

n #

of D

ays

No IncidentFracture

RadiographicFracture

Days of pain, or bed rest due to pain, over 3 years

ClinicalFracture

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Radiological fracture recognition (1):

Review of chest radiographs on 934 women aged >60 years, admitted to hospital

On review 132 had 1 or more spinal fractures

Of these: 65 (49%) were reported23 (17%) were noted in the

medical record25 (19%) were treatedGehlbach SH et al. Osteoporosis Int 2000;11:577 - 582

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Radiological fracture recognition (2):

In a Canadian study of emergency room radiography the following were the chief findings in relation to the thoracic spine:

• Mean age of the population was 75 years, • 47% were women, and 46% were admitted to the

hospital. • According to the reference radiologist, prevalence of

moderate to severe vertebral fractures was 22%. • Simple agreement was about 88% among reviewers;

kappa values were moderate (0.56-0.58). • Only 55% (12/22) of the vertebral fractures identified

were mentioned in the radiology reports.Kim N, Rowe BH, Raymond G, Jen H, Colman I, Jackson SA et al.Underreporting of vertebral fractures on routine chest radiography. Am J Roentgenol. 2004;182:297 - 300.

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Role of CT & MRI

CT = Clarify radiographic findings

MRI = Useful for recognizing fracture acuity and

incidental disease (e.g. tumours)

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Osteoporotic fracturing –

the pathological

view:

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Risk prediction and prevalent fractures:

Ross PD et al. Pre–existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med 1991; 114: 919 – 923.

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Vertebral body fractures as a special case:

Vertebral fractures may occur incrementally and not catastrophically

Mechanism of injury: axial cf. transverse loading (crush)

Vertebral fractures may be associated with a vaccuum phenomenon

Vertebral fractures may only be evident under load-bearing

The definition of vertebral fractures is subject to debate (and varies by practitioner and country)

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Vertebral deformities:

All fractures cause deformities

Not all deformities are due to fracturing

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Spinal fracturing:

• Low trauma spinal fractures:

• 60% are asymptomatic

Hajcsar EE, Hawker G, Bogoch ER. Investigation and treatment of osteoporosis in patients with fragility fractures. Canad Med Ass J 2000; 163: 819 - 822.

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Spinal osteoporosis:

1. Spinal deformities (fractures)

2. Prominent vertical trabeculae (loss of secondary trabeculation)

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Normal (Grading 0)

Gd. 1: <25 %deformity

Gd. 2 25 – 40 %deformity

Gd. 3: >40 %deformity

WedgeBiconcavityCrush

Genant Grading: Vertebral fracture assessment

using a semiquantitative technique

Genant HK et al. J Bone Miner Res. 1993; 8: 1137-1148

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Problematical aspects of the Genant paradigm:

• It proposes a quantitative classification• It makes unrealistic distinctions between fracture types • Morphometry cf. radiological “signs” of fracture• Both projected area (“volume”) and vertical dimensions are

invoked• The reference dimensions are subject to variation and

interpretation• The “grades” overlap

– Grade 1: 20 – 25%– Grade 2: 25 – 40%– Grade 3: > 40%

• The classification has suffered mutation or “creep”

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Spinal morphometry:

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Osteoporotic fractures are nearly always end-plate fractures:

Jiang G, Eastell R, Barrington NA, Ferrar L. Comparison of methods for the visual identification of prevalent vertebral fracture in osteoporosis. Osteoporos Int 2004; 15: 887 - 896

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Grade 1 anterior wedge and crush (superior end plate) fracture:

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A Grade 2 anterior wedge and superior end-plate fracture:

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A Grade 2 anterior wedge and end-plate fracture:

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A Grade 3 crush (superior end plate) fracture (arrow)

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Glucocorticoid-induced osteoporosis:

These fractures induce sub-cortical schlorisis

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Tc-99m MDP bone scan:

Low trauma fractures of the sacrum,

sacral ala and coccyx are best

recognized by radionuclear bone scans

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Differential diagnosis:

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The lower pole of scapula (larger arrow) projected over T 7:

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Congenital abnormalities:

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Orthogonal views of the lower thoracic spine in a patient with

a T 10 “butterfly” (bifid) vertebra:

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Cupid’s bow (“notochordal”) defects (L3-5):

Dietz GW, Christenson EE.; Vertebrae 1976; 121: 577-579; Chan KK, Sartoris DJ, Haghighi P, Sledge P, et al.; Radiology 1997; 202: 253-256

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Acquired abnormalities:

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Scheuermann disease

Juvenile disc disease

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Scheuermann disease mimics:

Hereditary progressive arthro-ophthalmopathy

(Stickler syndrome)

Acrodysostosis (peripheral dysostosis)

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Intervertebral

Disc Herniation

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Schmorl’s nodes and limbus defects:

Disc herniation into the vertebral body (Schmorl node)

Disc herniation through the secondary ring ossification centre (limbus defect)

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Schmorl’s nodes:

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Spectrum of Intervertebral Disc Herniation

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A limbus defect at the antero-superior margin of L3.

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Secondary ossification centres:

Lumbar spine –5-year old

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Disc disease and vertebral remodelling:

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Summary:

The old:– About ten systems

varying between subjective and objective; quantitative and qualitative

– Summarised in: Genant H et al. Monograph on vertebral fractures

– Eastell et al: two grades, JBMR, 1991

The new:– Jiang G. et al.

Prevalence SQ (24%) > Qual (11%) > ABQ (7%); BMD α Qual/ABQ OI 2004

– Increasingly, European studies (ISCD) focus on end-plate changes

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Inter-observer variability: semiquantitative visual

assessment of prevalent fractures

0

10

20

30

40

50

60

70

80

90

100

First reading(%)

Secondreading (%)

% Agree

Experienced obs.Inexperienced obs.

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Incident fracturing:

Brian C Lentle, MD, FRCPC; Jacques P Brown, MD, FRCPC; Aliya Khan, MD, FRCPC; William D Leslie, MD, FRCPC; Jacques Levesques, MD, FRCPC; David J Lyons, MD, FRCPC; Kerry Siminoski, MD, FRCPC; Giuseppe Tarulli, MD,

FRCPC; Robert G Josse, MD, MBBS, FRCPC; Anthony Hodsman, MD, FRCPC; CARJ Vol 58, No 1, February 2007; 27-36