High Incidence of Vertebral Fractures in Children With Acute Lymphoblastic Leukemia 12 Months After the Initiation of Therapy

Abstract

Purpose-Vertebral fractures due to osteoporosis are a potential complication of childhood acute lymphoblastic leukemia (ALL). To date, the incidence of vertebral fractures during ALL treatment has not been reported. CIHR Author ManuscriptCIHR Author Manuscript CIHR Author ManuscriptPatient and Methods-We prospectively evaluated 155 children with ALL during the first 12 months of leukemia therapy. Lateral thoracolumbar spine radiographs were obtained at baseline and 12 months. Vertebral bodies were assessed for incident vertebral fractures using the Genant semi-quantitative method, and relevant clinical indices such as spine bone mineral density (BMD), back pain and the presence of vertebral fractures at baseline were analyzed for association with incident vertebral fractures.Results-Of the 155 children, 25 (16%, 95% Confidence Interval (CI) 11% to 23%) had a total of 61 incident vertebral fractures, of which 32 (52%) were moderate or severe. Thirteen of the 25 children with incident vertebral fractures (52%) also had fractures at baseline. Vertebral fractures at baseline increased the odds of an incident fracture at 12 months by an odds ratio of 7.3 (95% CI 2.3 to 23.1, p = 0.001). In addition, for every one standard deviation reduction in spine BMD Zscore at baseline, there was 1.8-fold increased odds of incident vertebral fracture at 12 months (95% CI 1.2 to 2.7, p = 0.006).Conclusion-Children with ALL have a high incidence of vertebral fractures after 12 months of chemotherapy, and the presence of vertebral fractures and reductions in spine BMD Z-scores at baseline are highly associated clinical features.

Observer agreement in pediatric semiquantitative vertebral fracture diagnosis

“…Solid data on normal height ratios in children is limited to the lower thoracic spine and lumbar area, where values are similar to those of adults and do not exceed 20% [37]. Since we have previously shown that GSQ-method defined fractures in our ALL population correlate with clinical variables like bone density, metacarpal cortical area, back pain, and risk of future fractures, it is likely that the vast majority of the vertebral deformities meeting the GSQ method definition of fracture do, in fact, represent true fractures [17,18,38]. Further information is needed on normal vertebral body height ratios in the upper and middle thoracic spine of children and adolescents, however, in order to determine the likelihood of false positives in this region.…”

Skeletal findings in the first 12 months following initiation of glucocorticoid therapy for pediatric nephrotic syndrome

“…In pediatric leukemia, we have shown that Grade 1 prevalent VF diagnosed around the time of leukemia presentation were independently associated with increased odds of incident (i.e. new) VF at 12 months post-chemotherapy initiation [34]. Furthermore, Gaca et al [30] showed that 95% of healthy children had an anterior:posterior vertebral height ratio loss of 11% or less, with no child exceeding a 14% loss in height ratio.…”

“…Previously, it has been shown that the risk of vertebral and forearm fractures in children increases for every 1.0 SD below the healthy average in LS BMD Z-score [33,34]. Given these observations, we sought to differentiate children with LS BMD Z-scores ≤ −1.0 at 12 months from those without.…”

ENDOCRINOLOGY AND ADOLESCENCE: Osteoporosis in children: diagnosis and management

“…VFs in children can present with backache but are often asymptomatic. They are a significant cause of morbidity and an indicator of future incident VFs in children (18,19) and adults (20). Children also have the unique ability of bone reshaping due to their growth potential.…”

“…The Canadian Steroid-Associated Osteoporosis in the Pediatric Population (STOPP) study prospectively studies GC treated conditions and reported a VF prevalence of 16% in children with ALL at diagnosis (69) with another 16% of new VFs following 12 months of ALL treatment (18). BMD correlated well with VFs, with an 80% increase in VF risk with every one S.D.…”