The Accuracy of Incident Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches

Abstract

Vertebral fractures are clinically important sequelae of a wide array of pediatric diseases. In this study, we examined the accuracy of case-finding strategies for detecting incident vertebral fractures (IVF) over 2 years in glucocorticoid-treated children (n = 343) with leukemia, rheumatic disorders, or nephrotic syndrome. Two clinical situations were addressed: the prevalent vertebral fracture (PVF) scenario (when baseline PVF status was known), which assessed the utility of PVF and low lumbar spine bone mineral density (LS BMD; Z-score <−1.4), and the non-PVF scenario (when PVF status was unknown), which evaluated low LS BMD and back pain. LS BMD was measured by dual-energy X-ray absorptiometry, vertebral fractures were quantified on spine radiographs using the modified Genant semiquantitative method, and back pain was assessed by patient report. Forty-four patients (12.8%) had IVF. In the PVF scenario, both low LS BMD and PVF were significant predictors of IVF. Using PVF to determine which patients should have radiographs, 11% would undergo radiography (95% confidence interval [CI] 8-15) with 46% of IVF (95% CI 30-61) detected. Sensitivity would be higher with a strategy of PVF or low LS BMD at baseline (73%; 95% CI 57-85) but would require radiographs in 37% of children (95% CI 32-42). In the non-PVF scenario, the strategy of low LS BMD and back pain produced the highest specificity of any non-PVF model at 87% (95% CI 83-91), the greatest overall accuracy at 82% (95% CI 78-86), and the lowest radiography rate at 17% (95% CI 14-22). Low LS BMD or back pain in the non-PVF scenario produced the highest sensitivity at 82% (95% CI 67-92), but required radiographs in 65% (95% CI 60-70). These results provide guidance for targeting spine radiography in children at risk for IVF.

Skeletal Outcomes in Children and Young Adults with Glomerular Disease

“…In the absence of high energy trauma or falls from a significant height, these fracture sites also indicate underlying bone fragility. 53,54 Furthermore, vertebral fractures may be asymptomatic, and their incidence is likely underestimated. Two prior studies have examined vertebral fractures in children with nephrotic syndrome.…”

“…We focused on these fracture sites in particular because they are rare but associated with significant morbidity. In the absence of high energy trauma or falls from a significant height, these fracture sites also indicate underlying bone fragility 53 , 54 . Furthermore, vertebral fractures may be asymptomatic, and their incidence is likely underestimated.…”

Vertebral Body Reshaping after Fractures: An Important Index of Recovery in Glucocorticoid-Treated Children

“…Left-hand and wrist radiographs were obtained to determine bone age ( 20 ). Lumbar spine bone mineral density (LS BMD) was assessed by dual-energy x-ray absorptiometry using either Hologic (QDR 4500, 3 centers; Discovery, 2 centers; Delphi, 1 center; Hologic, Inc., Marlborough, MA, USA) or Lunar (Prodigy, 4 centers; GE Healthcare, Chicago, IL, USA) systems at baseline and every 6 months in the first 4 years and annually thereafter, with details about the scan mode, cross-calibration, and analysis software programs described previously ( 21 ). Raw LS BMD results were converted to Hologic units, and age- and sex-matched Z-scores were generated using the Hologic 12.3 normative database ( 22 ).…”

Prevalence of osteopathologies in a single center cohort of survivors of childhood primary brain tumor

“…To date the onset of osteopathologies in survivors of childhood malignancies is not yet well characterized. Recent studies in ALL indicate that impaired bone health may be observed as early as at the time of manifestation of the malignancy ( 18 , 19 ) and is present in many survivors during follow-up ( 15 ).…”