The prevalence of vertebral fracture amongst patients presenting with non-vertebral fractures

Abstract

Introduction Despite vertebral fracture being a significant risk factor for further fracture, vertebral fractures are often unrecognised. A study was therefore conducted to determine the proportion of patients presenting with a nonvertebral fracture who also have an unrecognised vertebral fracture. Methods Prospective study of patients presenting with a non-vertebral fracture in South Glasgow who underwent DXA evaluation with vertebral morphometry (MXA) from DV5/6 to LV4/5. Vertebral deformities (consistent with fracture) were identified by direct visualisation using the Genant semi-quantitative grading scale. Results Data were available for 337 patients presenting with low trauma non-vertebral fracture; 261 were female. Of all patients, 10.4% were aged 50-64 years, 53.2% were aged 65-74 years and 36.2% were aged 75 years or over. According to WHO definitions, 35.0% of patients had normal lumbar spine BMD (T-score j1 or above), 37.4% were osteopenic (T-score j1.1 to j2.4) and 27.6% osteoporotic (Tscore j2.5 or lower). Humerus (n=103, 31%), radius-ulna (n=90, 27%) and hand/foot (n=53, 16%) were the most common fractures. For 72% of patients (n=241) the presenting fracture was the first low trauma fracture to come to clinical attention. The overall prevalence of vertebral deformity established by MXA was 25% (n=83); 45% (n=37) of patients with vertebral deformity had deformities of more than one vertebra. Of the patients with vertebral deformity and readable scans for grading, 72.5% (58/80) had deformities of grade 2 or 3. Patients presenting with hip fracture, or spine T-score ej2.5, or low BMI, or with more than one prior non-vertebral fracture were all significantly more likely to have evidence of a prevalent vertebral deformity (p<0.05). However, 19.8% of patients with an osteopenic T-score had a vertebral deformity (48% of which were multiple), and 16.1% of patients with a normal T-score had a vertebral deformity (26.3% of which were multiple). Following non-vertebral fracture, some guidelines suggest that anti-resorptive therapy should be reserved for patients with DXA-proven osteoporosis. However, patients who have one or more prior vertebral fractures (prevalent at the time of their non-vertebral fracture) would also become candidates for anti-resorptive therapy-which would have not been the case had their vertebral fracture status not been known. Overall in this study, 8.9% of patients are likely to have had a change in management by virtue of their underlying vertebral deformity status. In other words, 11 patients who present with a non-vertebral fracture would need to undergo vertebral morphometry in order to identify one patient who ought to be managed differently. Conclusions Our results support the recommendation to perform vertebral morphometry in patients who are

Vertebral fracture and cause-specific mortality: a prospective population study of 3,210 men and 3,730 women with 30 years of follow-up

“…Other weaknesses of this study include the fact that our analysis for practical reasons could be concentrated only on the thoracic spine, and corresponding information concerning the lumbar and cervical spine was missed. However, the thoracic spine and the thoracolumbar junction are considered the principal sites of osteoporotic vertebral fractures [24,25]. The severity of vertebral fracture was not assessed.…”

Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures

“…VFA identified a substantial burden of prevalent vertebral fractures that had not been previously documented. The proportion of non-vertebral fracture patients that would be managed differently as a result of conducting VFA was relatively small (9% [53] and 3% [54]). This is perhaps not surprising given that the patients investigated had a non-vertebral fracture which triggered FLS assessment.…”

“…This approach has been explored in the FLS setting [53,54]. Amongst patients presenting with nonvertebral fractures that were assessed by a FLS, the overall prevalence of vertebral deformity was of the order of a quarter to a fifth (25% [53] and 20% [54]). VFA identified a substantial burden of prevalent vertebral fractures that had not been previously documented.…”

“…Given that an increasing number of clinical guidelines make reference to intervention thresholds based upon a FRAX ® score, the decision to treat or not may be influenced by knowledge of vertebral fracture status. Another conclusion of the FLS VFA work was that VFA should ideally be conducted on all patients that are referred for DXA who do not have a clinical fracture history, in order to improve case-finding of vertebral fractures [53].…”

Does a History of Non-Vertebral Fracture Identify Women Without Osteoporosis for Treatment?

“…31 It is unclear why our study finding were different from this study; possible explanations include the greater potency of zoledronic acid; or the likely high prevalence of undiagnosed prevalent vertebral fracture associated with incident hip fracture. 32 Finally, the measurement of bone turnover is an effective and possibly cost-effective tool to identify women without osteoporosis for treatment with alendronate. This approach is ideal as biomarker measurement can be performed in the outpatient setting.…”