Abstract
ObjectivesTo assess whether diagnostic accuracy of morphometric vertebral fracture (VF) diagnosis in children can be improved using AVERT™ (a 33-point semi-automated program developed for VF diagnosis in adults) compared with SpineAnalyzer™ (a 6-point program), which has previously been shown to be of insufficient accuracy.Materials and methodsLateral spine radiographs (XR) and dual-energy X-ray absorptiometry (DXA) scans of 50 children and young people were analysed by two observers using two different programs (AVERT™ and SpineAnalyzer™). Diagnostic accuracy (sensitivity, specificity, false-negative (FN) and false-positive rates (FP)) was calculated by comparing with a previously established consensus arrived at by three experienced paediatric musculoskeletal radiologists, using a simplified algorithm-based qualitative scoring system. Observer agreement was calculated using Cohen’s kappa.ResultsFor XR, overall sensitivity, specificity, FP and FN rates using AVERT™ were 36%, 95%, 5% and 64% respectively and 26%, 98%, 2% and 75% respectively, using SpineAnalyzer™. For DXA, overall sensitivity, specificity, FP and FN rates using AVERT™ were 41%, 91%, 9% and 59% respectively and 31%, 96%, 4% and 69% respectively, using SpineAnalyzer. Reliability (kappa) ranged from 0.34 to 0.37 (95%CI, 0.26–0.46) for AVERT™ and from 0.26 to 0.31 (95%CI, 0.16–0.44) for SpineAnalyzer™. Inter- and intra-observer agreement ranged from 0.41 to 0.47 for AVERT™ and from 0.50 to 0.79 for SpineAnalyzer™.ConclusionAVERT™ has slightly higher accuracy but lower observer reliability for the representation of vertebral morphometry in children when compared with SpineAnalyzer™. However, neither software program is satisfactorily reliable for VF diagnosis in children.Key Points• SpineAnalyzer™ and AVERT™ have low diagnostic accuracy and observer agreement when compared to three paediatric radiologists’ readings for the diagnosis of vertebral fractures (VF) in children.• Neither AVERT™ nor SpineAnalyzer™ is satisfactorily reliable for VF diagnosis in children.• Development of specific paediatric software and normative values (incorporating age-related physiological variation in children) is required.
Highlights
Low bone mass is characterised by structural deterioration of bone tissue, leading to bone fragility and increased susceptibility to fractures, especially of the spine and long bones
Neither AVERTTM nor SpineAnalyzerTM is satisfactorily reliable for vertebral fractures (VF) diagnosis in children
A total of 2600 individual vertebral bodies (T4–L4) collated from both radiographs and vertebral fracture assessment (VFA) were assessed by each observer using SpineAnalyzerTM and AVERTTM
Summary
Low bone mass is characterised by structural deterioration of bone tissue, leading to bone fragility and increased susceptibility to fractures, especially of the spine and long bones. Osteoporotic VFs are increasingly recognised in children as a vital sign of low bone mineral density (BMD) whether primary, e.g. osteogenesis imperfecta [2], or secondary, e.g. acute lymphoblastic leukaemia, rheumatological conditions, Duchenne muscular dystrophy and glucocorticoid use [1, 3]. Children who have been identified with VFs, especially those with osteogenesis imperfecta and Duchenne muscular dystrophy, are more likely to have multiple VFs [4, 5]. The gold standard for identifying VFs in children is the lateral spine radiograph. The diagnosis of VFs from DXA is termed vertebral fracture assessment (VFA)
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