Vertebral fractures – epidemiology
It is estimated that one in twelve men and one in six women will suffer a symptomatic vertebral fracture during their lifetime27
fractures will also be realised28
, and with the prevalence of osteoporosis predicted to increase by 2021, a rise in .
Vertebral fractures (figure 1) pose a significant public health burden with 8% of these patients requiring hospitalisation and 2% requiring long-term nursing care29 morbidity and mortality30,31
. They are associated with both increased symptoms, height loss, depression, breathing difficulties and an increased risk of further fractures27,32,33
, with significant pain, functional disability, reduced quality of life, gastro-intestinal .
Peri- and postmenopausal women who have prevalent vertebral fractures have double the risk of sustaining subsequent fractures34
. The risk of incident vertebral fractures also increases with the number of prevalent
vertebral fractures; the relative risk increasing from 3.2 to 23.3 for one to three or more prevalent vertebral fractures respectively35 fracture within a year36
. One in five women with an incident vertebral fracture will suffer a further vertebral . These risks can be mitigated through treatment. For example, a 65 year old female
with one vertebral fracture has a 25% chance of sustaining a further fracture within five years, but this can be reduced by half with bone-sparing therapies37
and therefore methods are required to identify those with sub-clinical and missed vertebral fractures38 Vertebral fracture diagnosis
The severity of the negative outcomes associated with vertebral fracture means they are clinically important to detect and report, in order for appropriate treatment to commence. Schousboe et al reported a vertebral fracture prevalence of 20% in an elderly population, leading to their recommendation that lateral spine imaging should be considered in all Caucasian women over the age of 70 years who have low bone density39
.
Many fractures are clinically silent, whereby patients either do not present to their general practitioner, or are not referred for imaging; other patients have vertebral fractures that are not detected from radiographs or are reported using ambiguous terminology; all of which result in under-diagnosis of vertebral fractures38,40,41
.
In 2000, it was estimated that less than 30% of vertebral fractures are diagnosed, thus improved strategies to identify those with vertebral fractures are of particular importance42
. Exploratory imaging in women over
70 to identify prevalent vertebral fractures could therefore be argued as appropriate. However, the use of routine radiographs for the diagnosis of vertebral fractures is associated with a significant radiation burden and is therefore only appropriate for those in whom there is a high level of clinical suspicion. DXA scanners can be utilised to obtain a single lateral or a lateral and a postero-anterior image of the spine from T4 to L4 for VFA. VFA has a significantly reduced dose when compared to a thoracolumbar projection radiography series43
and reportedly has a high degree of accuracy with regard to fracture diagnosis. In practice, this can allow for the identification of vertebral fractures in those with previously unknown fractures and thus alter management26,44
vertebral fractures in community dwelling older adults, particularly if mild fractures are excluded45,46
. VFA has been reported to have comparable performance to radiographs for identifying .
Vertebral fractures from VFA can be graded using one of a number of scales based on ratios of vertebral height and the pattern of height loss within the vertebrae46,47
. From these scales, fractures can be generally -49-
. However, not all fractures will come to clinical attention .
Figure 1: Projection radiograph of typical osteoporotic vertebral fractures and demonstrating x-ray osteopenia.
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