Prevention Of Osteoporotic Vertebral Fractures Research Articles

Comparison of the Clinical Efficacy of Anabolic Agents and Bisphosphonates in the Patients With Osteoporotic Vertebral Fracture: Systematic Review and Meta-analysis of Randomized Controlled Trials.

We investigated the clinical efficacy of anabolic agents compared with bisphosphonates (BPs) for the incidence of new osteoporotic vertebral fracture (OVF) and fracture healing of OVF in the patients with OVF via meta-analyses of randomized controlled trials (RCTs). Electronic databases, including PubMed, Embase, and Cochrane Library were searched for published RCTs till December 2022. The RCTs that recruited participants with osteoporosis at high-/very high-risk of fracture (a history of osteoporotic vertebral or hip fracture) or fresh OVF were included in this study. We assessed the risk of bias on every included RCTs, estimated relative risk (RR) for the incidence of new OVF and fracture healing of OVF, and overall certainty of evidence. Meta-analyses were performed by Cochrane review manager (RevMan) ver. 5.3. Cochrane risk of bias 2.0 and GRADEpro/GDT were applied for evaluating methodological quality and overall certainty of evidence, respectively. Five hundred eighteen studies were screened, and finally 6 eligible RCTs were included in the analysis. In the patients with prevalent OVF, anabolic agents significantly reduced the incidence of new OVF (teriparatide and romosozumab vs. alendronate and risedronate [RR, 0.57; 95% confidence interval, 0.45-0.71; p < 0.00001; high-certainty of evidence]; teriparatide vs. risedronate [RR, 0.50; 95% confidence interval, 0.37-0.68; p < 0.0001; high-certainty of evidence]). However, there was no evidence of teriparatide compared to alendronate in fracture healing of OVF (RR, 1.23; 95% confidence interval, 0.95-1.60; p = 0.12; low-certainty of evidence). In the patients with prevalent OVF, anabolic agents showed a significant superiority for preventing new OVF than BPs, with no significant evidence for promoting fracture healing of OVF. However, considering small number of RCTs in this study, additional studies with large-scale data are required to obtain more robust evidences.

Radiological diagnosis of prevalent osteoporotic vertebral fracture on radiographs: an interim consensus from a group of experts of the ESSR osteoporosis and metabolism subcommittee.

When a low-energy trauma induces an acute vertebral fracture (VF) with clinical symptoms, a definitive diagnosis of osteoporotic vertebral fracture (OVF) can be made. Beyond that, a "gold" radiographic standard to distinguish osteoporotic from non-osteoporotic VFs does not exist. Fracture-shaped vertebral deformity (FSVD) is defined as a deformity radiographically indistinguishable from vertebral fracture according to the best of the reading radiologist's knowledge. FSVD is not uncommon among young populations with normal bone strength. FSVD among an older population is called osteoporotic-like vertebral fracture (OLVF) when the FSVD is likely to be associated with compromised bone strength. In more severe grade deformities or when a vertebra is collapsed, OVF diagnosis can be made with a relatively high degree of certainty by experienced readers. In "milder" cases, OVF is often diagnosed based on a high probability rather than an absolute diagnosis. After excluding known mimickers, singular vertebral wedging in older women is statistically most likely an OLVF. For older women, three non-adjacent minimal grade OLVF (< 20% height loss), one minimal grade OLVF and one mild OLVF (20-25% height loss), or one OLVF with ≥ 25% height loss, meet the diagnosis of osteoporosis. For older men, a single OLVF with < 40% height loss may be insufficient to suggest the subject is osteoporotic. Common OLVF differential diagnoses include X-ray projection artifacts and scoliosis, acquired and developmental short vertebrae, osteoarthritic wedging, oncological deformities, deformity due to high-energy trauma VF, lateral hyperosteogeny of a vertebral body, Cupid's bow, and expansive endplate, among others.

Schmorl's nodes are associated with prevalent osteoporotic vertebral fracture and low bone mineral density: a population-based thoracic spine MRI study in older men and women.

Schmorl's node (SN) corresponds to nucleus pulposus herniation into the vertebral spongy bone with thickened trabeculae around the formed node. We hypothesize that a pathway may exist that: osteoporosis → weakened endplate → SN development ↔ endplate fracture of an osteoporotic vertebra. For osteoporotic fractures in men (MrOS) and in women (MsOS) Hong Kong studies, at 14-year follow-up, thoracic spine magnetic resonance imaging (MRI) was sampled in 270 males (mean: 82.9±3.7 years) and 150 females (mean: 81.5±4.3 years). SN and Modic change were assessed as existed or not existed. For posterior disc protrusion, ligamentum flavum ossification, and spinal canal stenosis, semi-quantitative gradings were applied. For each vertebra in women, a score of 0, 0.5, 1, 1.5, 2, 2.5, 3 was assigned for no osteoporotic vertebral fracture (OVF) or OVF of <1/5, ≥1/5-1/4, ≥1/4-1/3, ≥1/3-2/5, ≥2/5-2/3, and ≥2/3 vertebral height loss, respectively, and a summed score was calculated by summing up the scores of vertebrae T1 to T12. For men, those of minimal grade were not considered as OVF and assigned a '0' score. SN prevalence in women (55.5%) almost doubled that in men (25.9%). SN was statistically significantly correlated with lower bone mineral density (BMD) derived femoral neck T-score, while the other four spine degeneration changes were not statistically significantly correlated with the T-score. SN were statistically significantly correlated with OVF score. Subjects with SN were more likely to have OVF, with odds ratio for men of 4.32 [95% confidence interval (CI): 1.70-11.00, P=0.002] and odds ratio for women of 3.28 (95% CI: 1.23-8.74, P=0.018). Among older population, many features of SN parallel those of OVF.

Efficacy and safety of pharmacologic therapies for prevention of osteoporotic vertebral fractures in postmenopausal women

BackgroundThere are many pharmaceutical interventions available to prevent osteoporotic vertebral fractures in postmenopausal women, but the efficacy and safety of these drugs are unknown. This study aimed to investigate the efficacy and safety of drugs in the prevention of osteoporotic vertebral fractures. MethodsPubMed, Embase, and the Cochrane Library were comprehensively searched for randomized controlled trials (RCTs) published up to February 15, 2020, including postmenopausal women with osteoporosis. Network meta-analysis was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The relative risk (RR) and 95% confidence interval (CI) were used to report the results. This study was registered with PROSPERO, number CRD42020201167. Main Outcomes were incidences of new vertebral fracture and serious adverse events. ResultsFifty-five RCTs (n = 104 580) evaluating vertebral fractures of sixteen kinds of pharmacologic therapies were included in the network meta-analysis. Abaloparatide (RR, 0.21; [95% CI, 0.09 to 0.51]), alendronate (RR, 0.55; [95% CI, 0.38 to 0.81]), calcitonin (RR, 0.44; [95% CI, 0.25 to 0.78]), denosumab (RR, 0.33; [95% CI, 0.14 to 0.61]), parathyroid hormone (PTH) (RR, 0.32; [95% CI, 0.10 to 0.97]), risedronate (RR, 0.65; [95% CI, 0.42 to 1.00]), romosozumab (RR, 0.31; [95% CI, 0.16 to 0.61]), strontium ranelate (RR, 0.62; [95% CI, 0.42 to 0.93]), teriparatide (RR, 0.27; [95% CI, 0.17 to 0.43]), and zoledronate (RR, 0.41; [95% CI, 0.93]) were associated with lower vertebral fracture risk compared to placebo. PTH was associated with more adverse event rates. For any two drug treatments, the RR of serious adverse events was not statistically significant. Hormone replacement therapy (HRT) and calcitonin may be slower to work because they have only been shown to reduce the risk of vertebral fractures in long-term (>18 months) follow-up. ConclusionsA variety of drugs are safe and effective in preventing osteoporotic vertebral fractures. HRT and calcitonin only reduced the risk of vertebral fractures during a follow-up of 21–72 months.

Prevalence of Osteoporosis in Myelodysplastic Syndrome Patients and Association with Cytopenias

Background :Perturbations of the osteo-hematopoietic niche architecture disrupt tissue homeostasis and can promote malignant diseases such as myelodysplastic syndromes (MDS). Recently an increased risk of osteoporosis in patients with CHIP has been observed after adjusting on usual risk factors for osteoporosis and in mouse models DnmT3a mutation cause a reduction in bone mass. However, little is known on the clinical presentation of osteoporosis in MDS patients. Here we report the results of a prospective cohort study of bone mass evaluation in newly diagnosed MDS patients. Methods : All patients with newly-diagnosed MDS or CMML (proved by bone marrow aspirate) were prospectively enrolled since January 2020 after informed consent. Bone mass evaluation was performed by conventional radiography of dorsal and lumbar rachis and bone mineral density was measured by a HOLOGIC® device at the upper extremity of the femur and the rachis. Osteoporosis risk factor were collected by a rheumatologist. After analysis of osteoporosis biomarker and biological MDS evaluation, if the diagnosis of osteoporosis was established, specific treatment were proposed. Avaible bone marrow biopsies were analysed by RAMAN microspectrosopy and compared to healthy bone marrow analysis specimens. Results : At data cut off (06/06/2022)108 pts were enrolled and evaluable for bone mineral density. Median age was 77 years [55-99] and 45.4% were female. WHO classification included MDS-MLD, MDS-MLD, MDS-RS-SLD, MDS-RS-MLD, 5Q-, MDS-EB1, MDS-EB2, CMML and AML (with 20-30% blast) in 10.2%,16.7%, 10.7%, 5.6%, 10.2%, 14.8%, 5.6%, 23.2% and 2.6% respectively. IPSS-R was very low, low, intermediate, high and very high in 20.4%, 51%, 19.4%, 8.3%, 1% respectively. Prior to the bone assessment, 15 pts had already a diagnosis of osteoporosis and among them 10 had previously received bisphosphonates. At the time of the bone assessment, 57 additional pts (52.8%) were diagnosed with osteoporosis including 22 males et 35 females and 30 pts (27.8%) had a prevalent osteoporotic vertebral fracture. In our cohort, prevalence of osteoporosis seem to increase with R-IPSS score with 49.4 %, 57.1% and 70% in low, intermediate, and high-risk, pts respectively, near significativity (p=0.052). After univariate analysis neither age (p=0.46) , 25 OH -vitamine D (p=0.07), ferritine (p=0.53), EPO (p=0.45), nor R-IPSS score (p=0.2) were associated with osteoporosis. However osteoporotic pts had significantly lower hemoglobin levels (9.7 vs 10.3 g/dL, p=0.04) and platelet counts (215 vs 170 G/L, p=0.05). After multivariate analysis, only female gender remained statistically associated with osteoporosis (p=0.01). After initial evaluation among the 57 pts with ostoporosis, 53 pts (49% of the cohort) were treated with intravenous bisphosphonates (2 pts refused and 2 had a contraindication). Analysis of avaible bone marrow biopsies (n=8) by Raman microspectoscopy at the center of trabecula showed defects in the bone marrow matrix in MDS pts in comparison to healthy specimens (n=18) with an increase in the hydoxylation of proline suggesting degradation of collagen type I in MDS bone. (figure 1) Conclusion :We found a high prevalence of osteoporosis in 52.3% of prospective, newly diagnosed MDS pts with 27.8% of pts with osteoporotic vertebral fracture. More profound cytopenias seem to be associated with an increased risk of osteoporosis prevalence underlying the impact of the osteo-hematopoietic niche in the physiopathology of MDS. An update of this study will be presented Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Automatic opportunistic osteoporosis screening in routine CT: improved prediction of patients with prevalent vertebral fractures compared to DXA

ObjectivesTo compare spinal bone measures derived from automatic and manual assessment in routine CT with dual energy X-ray absorptiometry (DXA) in their association with prevalent osteoporotic vertebral fractures using our fully automated framework (https://anduin.bonescreen.de) to assess various bone measures in clinical CT.MethodsWe included 192 patients (141 women, 51 men; age 70.2 ± 9.7 years) who had lumbar DXA and CT available (within 1 year). Automatic assessment of spinal bone measures in CT included segmentation of vertebrae using a convolutional neural network (CNN), reduction to the vertebral body, and extraction of bone mineral content (BMC), trabecular and integral volumetric bone mineral density (vBMD), and CT-based areal BMD (aBMD) using asynchronous calibration. Moreover, trabecular bone was manually sampled (manual vBMD).ResultsA total of 148 patients (77%) had vertebral fractures and significantly lower values in all bone measures compared to patients without fractures (p ≤ 0.001). Except for BMC, all CT-based measures performed significantly better as predictors for vertebral fractures compared to DXA (e.g., AUC = 0.885 for trabecular vBMD and AUC = 0.86 for integral vBMD vs. AUC = 0.668 for DXA aBMD, respectively; both p < 0.001). Age- and sex-adjusted associations with fracture status were strongest for manual vBMD (OR = 7.3, [95%] CI 3.8–14.3) followed by automatically assessed trabecular vBMD (OR = 6.9, CI 3.5–13.4) and integral vBMD (OR = 4.3, CI 2.5–7.6). Diagnostic cutoffs of integral vBMD for osteoporosis (< 160 mg/cm3) or low bone mass (160 ≤ BMD < 190 mg/cm3) had sensitivity (84%/41%) and specificity (78%/95%) similar to trabecular vBMD.ConclusionsFully automatic osteoporosis screening in routine CT of the spine is feasible. CT-based measures can better identify individuals with reduced bone mass who suffered from vertebral fractures than DXA.Key Points• Opportunistic osteoporosis screening of spinal bone measures derived from clinical routine CT is feasible in a fully automatic fashion using a deep learning-driven framework (https://anduin.bonescreen.de).• Manually sampled volumetric BMD (vBMD) and automatically assessed trabecular and integral vBMD were the best predictors for prevalent vertebral fractures.• Except for bone mineral content, all CT-based bone measures performed significantly better than DXA-based measures.• We introduce diagnostic thresholds of integral vBMD for osteoporosis (< 160 mg/cm3) and low bone mass (160 ≤ BMD < 190 mg/cm3) with almost equal sensitivity and specificity compared to conventional thresholds of quantitative CT as proposed by the American College of Radiology (osteoporosis < 80 mg/cm3).

Pentosidine and carboxymethyl-lysine associate differently with prevalent osteoporotic vertebral fracture and various bone markers

Pentosidine (PEN) and carboxymethyl-lysine (CML) are well-recognized advanced glycation end products (AGEs). However, how these AGEs affect the pathophysiology of osteoporosis and osteoporotic fractures remains controversial. This cross-sectional study aimed to investigate the associations of PEN and CML with bone markers, bone mineral density (BMD), and osteoporotic fractures in postmenopausal women from the Nagano Cohort Study. A total of 444 Japanese postmenopausal outpatients (mean ± standard deviation age: 69.8 ± 10.2 years) were enrolled after the exclusion of patients with acute or severe illness or secondary osteoporosis. The relationships among urinary PEN and serum CML levels, various bone markers, lumbar and hip BMD, and prevalent vertebral and long-bone fractures were evaluated. PEN associated significantly with prevalent vertebral fracture after adjustment for other confounders (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.22–2.07; P < 0.001), but not with lumbar BMD. In contrast, a significant negative correlation was found between CML and lumbar BMD (r = − 0.180; P < 0.001), and this relationship was significant after adjustment for confounders (OR 0.84, 95% CI 0.76–0.93; P < 0.01). Although patients with prevalent vertebral fracture had significantly higher CML levels, the association between CML and prevalent vertebral fracture did not reach significance in the multivariate regression model. Both PEN and CML may play important roles in bone health for postmenopausal women, possibly via different mechanisms.

Pharmacologic intervention for prevention of fractures in osteopenic and osteoporotic postmenopausal women: Systemic review and meta-analysis

ObjectivesEmerging evidence has indicated a role for pharmacologic agents in the primary prevention of osteoporotic fracture, but have not yet been systematically reviewed for meta-analysis. We conducted a meta-analysis to evaluate the efficacy of pharmacologic interventions in reducing fracture risk and increasing bone mineral density (BMD) in postmenopausal women with osteopenia or osteoporosis but without prevalent fragility fracture. MethodThe Medline, EMBASE, and CENTRAL databases were searched from inception to September 30, 2019. Only randomized placebo-controlled trials evaluating postmenopausal women with −1.0 > bone mineral density (BMD) T-score > −2.5 (low bone mass) and those with BMD T-score ≤ −2.5 (osteoporosis) but without baseline fractures, who were receiving anti-osteoporotic agents, providing quantitative outcomes data and evaluating risk of vertebral and/or non-vertebral fragility fracture at follow-up. The PRISMA guidelines were followed, applying a random-effects model. The primary endpoint was the effect of anti-osteoporotic regimens in reducing the incidence of vertebral fractures. Secondary endpoints were percentage changes in baseline BMD at the lumbar spine and total hip at 1 and 2 years follow up. ResultsFull-text review of 144 articles yielded, 20 for meta-analysis. Bisphosphonates reduced the risk of vertebral fracture (pooled OR = 0.50, 95%CIs = 0.36–0.71) and significantly increased lumbar spine BMD after 1 year, by 4.42% vs placebo (95%CIs = 3.70%–5.14%). At the hip, this value was 2.94% (95%CIs = 2.13%–3.75%). Overall results of limited studies for non-bisphosphonate drugs showed increased BMD and raloxifene significantly decreases the risk of subsequent clinical vertebral fractures. ConclusionThe bisphosphonates are efficacious and most evident for the primary prevention of osteoporotic vertebral fractures, reducing their incidence and improving BMD in postmenopausal women with osteopenia or osteoporosis.

Opportunistic osteoporosis screening in multi-detector CT images via local classification of textures

SummaryOur study proposed an automatic pipeline for opportunistic osteoporosis screening using 3D texture features and regional vBMD using multi-detector CT images. A combination of different local and global texture features outperformed the global vBMD and showed high discriminative power to identify patients with vertebral fractures.IntroductionMany patients at risk for osteoporosis undergo computed tomography (CT) scans, usable for opportunistic (non-dedicated) screening. We compared the performance of global volumetric bone mineral density (vBMD) with a random forest classifier based on regional vBMD and 3D texture features to separate patients with and without osteoporotic fractures.MethodsIn total, 154 patients (mean age 64 ± 8.5, male; n = 103) were included in this retrospective single-center analysis, who underwent contrast-enhanced CT for other reasons than osteoporosis screening. Patients were dichotomized regarding prevalent vertebral osteoporotic fractures (noFX, n = 101; FX, n = 53). Vertebral bodies were automatically segmented, and trabecular vBMD was calculated with a dedicated phantom. For 3D texture analysis, we extracted gray-level co-occurrence matrix Haralick features (HAR), histogram of gradients (HoG), local binary patterns (LBP), and wavelets (WL). Fractured vertebrae were excluded for texture-feature and vBMD data extraction. The performance to identify patients with prevalent osteoporotic vertebral fractures was evaluated in a fourfold cross-validation.ResultsThe random forest classifier showed a high discriminatory power (AUC = 0.88). Parameters of all vertebral levels significantly contributed to this classification. Importantly, the AUC of the proposed algorithm was significantly higher than that of volumetric global BMD alone (AUC = 0.64).ConclusionThe presented classifier combining 3D texture features and regional vBMD including the complete thoracolumbar spine showed high discriminatory power to identify patients with vertebral fractures and had a better diagnostic performance than vBMD alone.

Prevalent osteoporotic vertebral fractures more likely involve the upper endplate than the lower endplate and even more so in males.

While the importance of identifying osteoporotic vertebral endplate fracture (EPF) is being recognized; the pathophysiological understanding of EPF till now remain insufficient. In this population-based cross-sectional radiograph study, we aim to investigate the anatomic location characteristics of osteoporotic EPF. This study analyzed the anatomical location of osteoporotic EPFs in elderly Chinese population (age ≥65 years). The T4-L4 radiographs of 1,954 elderly Chinese men (mean: 72.3 years) and 1,953 elderly Chinese women (mean: 72.5 years) were evaluated to identify EPF, and vertebral bodies were graded according to Genant's vertebral deformity criteria. Of the 101,582 endplates analyzed, there were 505 EPFs (males: 27.7%; females: 72.3%). Excluding those with both upper endplate and lower endplate involvements, the ratio of upper EPF to lower EPF was 9.63 for males and 4.3 for females (P<0.05). Thoracolumbar junction, particularly L1 (26.4% for males and 24.1% for females) and followed by T12 (20.7% for males and 19.7% for females), had highest prevalence of EPF. With an endplate divided into 5 segments of equal length in the anteroposterior direction and grade 0.5 & 1, grade 2 vertebral deformities analyzed, fractures occurred mostly at the middle segment (70.1% for upper endplates in males and 78.6% for upper endplates in females), followed by second anterior segment (20.9% for upper endplates in males and 14.4% for upper endplates in females). The most anterior and most posterior segments were not primarily involved in EPF. Osteoporotic EPFs more likely involve the upper endplate rather than lower endplate, with a trend for this effect to be greater in men than in women. These characteristics may help radiographic differential diagnosis for osteoporotic EPF.

Vertebroplasty using bisphosphonate-loaded calcium phosphate cement in a standardized vertebral body bone defect in an osteoporotic sheep model

In the context of bone regeneration in an osteoporotic environment, the present study describes the development of an approach based on the use of calcium phosphate (CaP) bone substitutes that can promote new bone formation and locally deliver in situ bisphosphonate (BP) directly at the implantation site. The formulation of a CaP material has been optimized by designing an injectable apatitic cement that (i) hardens in situ despite the presence of BP and (ii) provides immediate mechanical properties adapted to clinical applications in an osteoporotic environment. We developed a large animal model for simulating lumbar vertebroplasty through a two-level lateral corpectomy on L3 and L4 vertebrae presenting a standardized osteopenic bone defect that was filled with cements. Both 2-D and 3-D analysis of microarchitectural parameters demonstrated that implantation of BP-loaded cement in such vertebral defects positively influenced the microarchitecture of the adjacent trabecular bone. This biological effect was dependent on the distance from the implant, emphasizing the in situ effect of the BP and its release from the cement. As a drug device combination, this BP-containing apatitic cement shows good promise as a local approach for the prevention of osteoporotic vertebral fractures through percutaneous vertebroplasty procedures.

EMAS position statement: The management of postmenopausal women with vertebral osteoporotic fracture

IntroductionOsteoporotic vertebral fractures are associated with significant morbidity, excess mortality as well as health and social service expenditure. Additionally, women with a prevalent osteoporotic vertebral fracture have a high risk of experiencing a further one within one year. It is therefore important for the physician to use a diagnostic and therapeutic algorithm for early detection and effective treatment of vertebral fractures. AimsThe aim of this position statement is to provide and critically appraise evidence on the management of women with a vertebral osteoporotic fracture. Materials and methodsLiterature review and consensus of expert opinion. Results and conclusionsThe management of women with osteoporotic vertebral fractures includes measures to reduce pain providing early mobility, to support the affected spine ensuring fracture healing, as well as starting treatment for osteoporosis itself. Any other underlying pathology should be sought and treated. Early detection and treatment is essential as there is an increased risk of further fractures in patients with vertebral fractures. Treatment will depend on the underlying causes of bone loss, efficacy in any particular situation, cost and patient preference.

Frequency, distribution and severity of prevalent osteoporotic vertebral fractures in postmenopausal women

Assessment of previous vertebral fractures provides useful information to predict future fracture risk. This study aimed to determine the frequency, distribution and severity of prevalent osteoporotic vertebral fractures in postmenopausal women. Data on patient characteristics, bone densitometry values, and spine radiographs (T2-L5) were reviewed in 232 postmenopausal women admitted to our osteoporosis clinic. Prevalent vertebral fractures were detected in 28 (12.1%) women (95%CI: 7.8 16.3). Fifteen women (6.5%) had mild fractures and 13 (5.6%) had moderate or severe fractures according to Genant's semi-quantitative technique. The T-score was associated with the presence of prevalent vertebral fractures (OR= 0.61; 95%CI: 0.38-0.96, P= 0.034). The most frequently fractured vertebrae were T11 and T12, followed by T7 and T9. Sixty percent of fractures were wedge-type while 40% were biconcave. The frequency of wedge-type fractures at the T11-T12 levels (93.8%) was higher compared to that at all other levels (44.1%) (P= 0.001). We determined the frequency, distribution, and severity of prevalent fractures and identified certain distribution patterns of fracture locations and types. To verify our results and detect possible predictive factors for fracture risk, population-based larger trials are needed.

Randomized controlled trial of a primary care–based screening program to identify older women with prevalent osteoporotic vertebral fractures: Cohort for skeletal health in Bristol and Avon (COSHIBA)

Approximately 12% of postmenopausal women have osteoporotic vertebral fractures (VFs); these are associated with excess morbidity and mortality and a high risk of future osteoporotic fractures. Despite this, less than one-third come to clinical attention, partly due to lack of clear clinical triggers for referral for spinal radiographs. The aim of this study was to investigate whether a novel primary care–based screening tool could be used to identify postmenopausal women with osteoporotic VFs and increase appropriate management of osteoporosis. A randomized controlled trial was undertaken in 15 general practices within the Bristol area of the UK. A total of 3200 women aged 65 to 80 years were enrolled, with no exclusion criteria. A simple screening tool was carried out by a nurse in primary care to identify women at high risk of osteoporotic VFs. All identified high-risk women were offered a diagnostic thoracolumbar radiograph. Radiographs were reported using standard National Health Service (NHS) reporting, with results sent back to each participant's general practitioner (GP). Participants in the control arm did not receive the screening tool or radiographs. The main outcome measure was self-reported prescription of medication for osteoporosis at 6 months with a random 5% subsample verified against electronic GP records. Secondary outcome was self-reported incidence of new fractures. Results showed that allocation to screening increased prescription of osteoporosis medications by 124% (odds ratio [OR] for prescription 2.24 at 6 months; 95% confidence interval [CI], 1.16 to 4.33). Allocation to screening also reduced fracture incidence at 12-month follow-up (OR for new fracture 0.60; 95% CI, 0.35–1.03; p = 0.063), although this did not reach statistical significance. This study supports the use of a simple screening tool administered in primary care to increase appropriate prescription of medications for osteoporosis in postmenopausal women in the UK. © 2012 American Society for Bone and Mineral Research

In search of the perfect SERM—a 5-year study of bazedoxifene

Selective estrogen receptor modulators (SERMs) hold the promise of an ideal estrogenic compound. Moderate efficacy for the prevention of osteoporotic vertebral fractures has now been found after 5 years of treatment with the SERM bazedoxifene; however, expectations for one SERM to provide multiple benefits for postmenopausal women might be a pipe dream.

Psychometric properties evaluation of the quality of life Questionnaire of the European foundation for Osteoporosis in Arabic population

We aimed to validate QUALEFFO-41 in Arabic language and to examine the use of QUALEFFO-41 in clinical practice for assessing quality of life in patients with vertebral fractures (VF). A total of 201 women were included in the study: 106 (53%) cases with at least one vertebral fracture which had been defined morphometrically and 95 (47%) women with OP or osteopenia and no fractures as a control group. The QUALEFFO was translated into Arabic and applied to case-control pairs with prevalent osteoporotic vertebral fractures to evaluate its reliability, validity, and discriminatory ability. It was also used to evaluate the quality of life (QOL) of case-control with prevalent morphometric fractures. The QOL of all subjects was concurrently assessed using SF-36 for comparison. QUALEFFO-41 had good reliability with adequate convergent and discriminatory validity. There were good correlations between QUALEFFO-41 and SF-36. Subjects with clinical osteoporotic vertebral fractures showed significant impairment of HRQoL on the QUALEFFO compared with controls. Similar results were also observed using the SF-36. ROC curve analysis revealed that QUALEFFO-41 had significant ability to discriminate between morphometric fracture subjects versus and controls. The QUALEFFO discriminates for pain (P = 0.002), physical function (P < 0.0001), social function (P = 0.04), general health (P = 0.001), and mental function (P = 0.01), whereas the SF-36 discriminates exclusively for physical function (P = 0.01) and social function (P = 0.02). The Moroccan Arabic version of the QUALEFFO is a reliable and valid instrument that can be administered to Arabic patients suffering from vertebral fracture osteoporosis to evaluate their quality of life. Its measurement properties were comparable with versions in other languages. In addition, the quality of life measured by QUALEFFO is decreased in patients with vertebral fracture due to OP.

Impact of osteoporosis and vertebral fractures on quality-of-life. a population-based study in Valencia, Spain (The FRAVO Study)

BackgroundTo describe the health related quality of life in a population sample of postmenopausal women over the age of 50 and resident in the city of Valencia (Spain), according to the presence/absence of osteoporosis and the severity of prevalent morphometric vertebral fractures.MethodsA cross-sectional age-stratified population-based sample of 804 postmenopausal women of 50 years of age and older were assessed with the SF-12 questionnaire. Information about demographic features, lifestyle, clinical features, educational level, anti-osteoporotic and other treatments, comorbidities and risk factors for osteoporosis were collected using an interviewer-administered questionnaire and densitometric evaluation of spine and hip and spine x-rays were carried out.ResultsIn the non-adjusted analysis, mild and moderate-severe vertebral fractures were associated with decreased scores in the SF-12 Physical Component Summary (PCS) but not in the Mental Component Summary (MCS), while densitometric osteoporosis with no accompanying fracture was not associated with a worse health related quality of life. In multivariate analysis worse PCS scores were associated to the age groups over 70 (-2.43 for 70-74 group and -2.97 for 75 and older), chronic conditions (-4.66, -6.79 and -11.8 according to the presence of 1, 2 or at least 3 conditions), obesity (-5.35), peripheral fracture antecedents (-3.28), hypoestrogenism antecedents (-2.61) and the presence of vertebral fracture (-2.05).ConclusionsAfter adjusting for confounding factors, the physical components of health related quality of life were significantly lower in women with prevalent osteoporotic vertebral fractures than in women -osteoporotic or not- without vertebral fractures.

Validation of the quality of life questionnaire of the European foundation for osteoporosis (QUALEFFO-31) in Chinese

QUALEFFO-31 is a recently developed disease-specific instrument derived from QUALEFFO-41 and intended to have improved efficacy and response rates. We aimed to validate QUALEFFO-31 in Chinese and examine the use of QUALEFFO-31 in clinical practice. This questionnaire was translated into Chinese and applied to 118 case–control pairs aged between 50 and 85 years with prevalent osteoporotic vertebral fractures to evaluate its validity, repeatability, and discriminatory ability. It was also used to evaluate the quality of life (QOL) of 69 case–control trios with prevalent clinical and morphometric fractures. The QOL of all subjects was concurrently assessed using SF-36 for comparison. QUALEFFO-31 had good internal consistency with adequate convergent and discriminatory validity. The median test–retest repeatability ranged from 0.65–0.85. In general, there were good correlations between QUALEFFO-31 and SF-36. ROC curve analysis revealed that QUALEFFO-31 had significant ability to discriminate between clinical fracture subjects versus morphometric fracture subjects and controls. QUALEFFO-31 also demonstrated higher discriminatory capacity for pain. Subjects with clinical vertebral fractures (CVFs) had a significant reduction in QOL compared with other subjects. The QUALEFFO-31 is a useful tool for assessing QOL in Chinese. It was well accepted and significantly predictive of subjects with CVFs.

Under-reporting of osteoporotic vertebral fractures on computed tomography

Purpose Osteoporotic vertebral fractures are frequently asymptomatic. They are often not diagnosed clinically or radiologically. Despite this, prevalent osteoporotic vertebral fractures predict future osteoporotic fractures and are associated with increased mortality and morbidity. Appropriate management of osteoporosis can reduce future fracture risk. Fractures on lateral chest radiographs taken for other conditions are frequently overlooked by radiologists. Our aim was to assess the value of computed tomography (CT) in the diagnosis of vertebral fracture and identify the frequency with which significant fractures are missed. Materials and methods The thoracic CT scans of 100 consecutive male and 100 consecutive female patients over 55 years were reviewed. CT images were acquired on General Electric Lightspeed multi-detector (MD) CT scanners (16 or 32 row) using 1.25 mm slice thickness. Midline sagittal images were reconstructed from the 3D volume images. The presence of moderate (25–40% height loss) or severe (>40% height loss) vertebral fractures between T1 and L1 was determined using an established semi-quantitative method and confirmed by morphological measurement. Results were compared with the formal CT report. Results Scans of 192 patients were analysed (95 female; 97 male); mean age 70.1 years. Thirty-eight (19.8%) patients had one or more moderate to severe vertebral fractures. Only 5 (13%) were correctly reported as having osteoporotic fractures in the official report. The sensitivity of axial CT images to vertebral fracture was 0.35. Conclusion Incidental osteoporotic vertebral fractures are under-reported on CT. The sensitivity of axial images in detecting these fractures is poor. Sagittal reformations are strongly recommended to improve the detection rate.

Is short vertebral height always an osteoporotic fracture? The Osteoporosis and Ultrasound Study (OPUS)

Introduction and hypothesis: Diagnosis of prevalent osteoporotic vertebral fracture is complicated by normal or developmental variation in vertebral shape or size and non-osteoporotic deformities that appear to have ‘reduced’ height. Using our visual approach, the algorithm-based qualitative method (ABQ) a vertebra with apparent “reduced” height without evidence of osteoporotic endplate depression is classified as non-osteoporotic short vertebral height (SVH). We aimed to determine whether ABQ classification of SVH represents true or false negative diagnosis of osteoporotic vertebral fracture, by testing the associations with clinical outcomes of osteoporosis or vertebral fracture. Methods: The ABQ method was used to assess spinal radiographs acquired at baseline for a subset of 904 postmenopausal women participating in the Osteoporosis and Ultrasound Study (OPUS). The sample was enriched with vertebral fracture cases. Subjects were categorized by ABQ diagnosis as (i) normal, (ii) non-osteoporotic short vertebral height (SVH) or (iii) osteoporotic vertebral fracture. Results: Women were classified by ABQ as follows: osteoporotic vertebral fracture, n = 231; SVH, n = 376 and normal, n = 297. Women with vertebral fracture were older, with lower height, weight and height loss than those classified as SVH or normal. Women with SVH were heavier and older, with greater historical height loss than normal women. Age-adjusted SD units ( z-scores) for BMD were lower than expected among women with osteoporotic vertebral fracture, but not among those with SVH. There was a significant association between diagnosis of osteoporotic vertebral fracture and history of low-trauma non-vertebral and vertebral fracture ( p < 0.001, odds ratios = 3.2 and 20.6, respectively). There was also an association between diagnosis of SVH and previous low-trauma non-vertebral fracture ( p < 0.05, odds ratio = 1.7). Conclusions: Short vertebral height without evidence of central endplate fracture in postmenopausal women is largely unrelated to osteoporosis. Quantitative morphometry should not be used alone for the assessment of vertebral fracture in clinical decision making: we recommend differential diagnosis of morphometric vertebral deformities by an expert reader to rule out non-osteoporotic deformities with short vertebral height.