Vertebral Fractures & the Elderly

The Under Diagnosis of Osteoporotic Vertebral Fractures

According to the National Osteoporosis Foundation, 30
million American women and 14 million men are
affected by osteopenia or osteoporosis. All are at an
increased risk for fracture, and some have already
experienced fracture. In the United Sates, the lifetime
risk of osteoporotic fracture is 40% in white women and
13% in white men. Patients with osteoporosis commonly
fracture their vertebrae, proximal femur, distal radius,
or proximal humerus; the most common site is the
vertebral body. With approximately 700,000 cases each
year in the United States, vertebral fractures account
for nearly half of all osteoporotic fractures and are at
least twice as common as hip fractures.

Although vertebral fractures are common in
postmenopausal women and older men, they are often
difficult to identify clinically; i.e., without radiographs.
Only about one in four vertebral fractures is clinically
recognized. The lack of recognition is due to both the
absence of symptoms and the difficulty in determining
the cause of symptoms. Because most episodes of back
pain are not related to vertebral fractures, vertebral
fractures are not commonly suspected in patients
reporting back pain, unless the back pain is associated
with trauma.

Height loss, another indicator of vertebral
fractures, is also difficult to assess clinically. Some
height loss is expected with aging, because of
compression of the intervertebral disks. Studies have
concluded that height loss is an unreliable indicator of
fracture status until it exceeds 4 cm. Kyphosis in the
elderly is associated with vertebral fracture but is
difficult to measure in a clinical setting without the use
of radiography.

For these reasons, vertebral fractures are not commonly
considered in the clinical evaluation of patients. Even
when patients are being evaluated for the presence of
osteoporosis, it is far less common for them to be
referred for spine radiographs than for bone
densitometry.

Radiologic Diagnosis

Vertebral fractures suspected at clinical evaluation
require radiologic confirmation. Most radiologists make
the diagnosis of vertebral fracture on the basis of a
qualitative impression. In contrast, those who conduct
research typically make that diagnosis on the basis of a
semiquantitative assessment or a quantitative
measurement of vertebral dimensions (e.g., vertebral
morphometry).

Radiologists qualitatively analyze radiographs of the
thoracolumbar spine to identify vertebral fractures in
patients whose clinical indications suggest trauma,
osteoporosis, malignancy, or acute back pain. While
diagnosing the vertebral fracture in question, the
observer also considers the potential differential
diagnoses of this deformity. The radiologist's decision
can be aided by additional radiographic projections or by
complementary examinations.

In a research setting, many different approaches have
been used to diagnose and characterize vertebral
fractures. The most widely used have been those
initially described by Fletcher, Barnett and Nordin,
Hurxthal, Smith et al., Minne et al., Melton et al., Black
et al., Eastell et al., McCloskey et al., and Genant et al.
Typically, the approaches involve quantitative
assessment of vertebral dimensions. Unfortunately,
little standardization exists in both the quantitative and
qualitative approaches to vertebral fracture diagnosis.
This may, in part, explain why a substantial proportion
of vertebral fractures remains undetected.

Under Diagnosis of Vertebral Fractures

Vertebral fractures often go undetected by clinicians and
undiagnosed by radiologists. According to data from the
National Ambulatory Medical Care Survey from 1993 to
1997, primary care physicians diagnosed vertebral
fracture (or osteoporosis) in 2-13% of white women age
60 years and older, whereas the estimated prevalence
in this age group was 20-30%. A recent retrospective
study of 934 women 60 years old and older found
radiographic evidence for 132 moderate or severe
vertebral fractures (14%) and showed that only 50% of
contemporaneous radiology reports mentioned these
fractures. A multinational study of 2,000
postmenopausal women with osteoporosis was
conducted, in part, to assess the accuracy of
radiographic diagnosis of vertebral fractures by
comparing results of local radiographic reports with
those of subsequent central readings. This study
reported false-negative rates from 27% to 45%, despite
a strict radiographic protocol that minimized
underdiagnosis due to inadequate film quality. The
investigators concluded that the failure to diagnose
vertebral fracture is a worldwide problem due in part to
the lack of fracture recognition by radiologists and the
use of ambiguous terminology in radiology reports.

Excellent Article on Non-Surgical Treatment of Osteoporotic Fractures...
http://www.emedicine.com/pmr/topic238.htm