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