The Clinical Utility of Vertebral Fracture Assessment in Predicting Fractures
Introduction
Osteoporosis is a systemic skeletal disease characterized by low bone mineral density (BMD) and poor bone quality, resulting in low bone strength and increased risk of fracture (1). It is estimated that osteoporotic fractures will increase by more than 3-fold over the next 50 years in women and in men because of the aging of the population (2). Vertebral fractures (VFs) are the most common type of osteoporotic fracture, especially in postmenopausal women. Most VFs are not clinically recognized and not diagnosed 3, 4, 5.
The prevalence of osteoporotic fractures is approximately 40% in postmenopausal women, and 25%–33% in elderly men (6). It is well documented that a previous osteoporotic VF increases the risk of subsequent fractures, both VFs, and fractures at other skeletal sites. History of prior fracture in the elderly population is an important risk factor for developing future fractures, independently of BMD 6, 7.
VFs have a negative impact on the quality of life compared with patients with osteoporosis without fractures (7). Chronic pain, physical limitations, loss of independence, institutionalization, and an increased morbidity and mortality are some of the consequences of VFs 8, 9.
VFs can be diagnosed by plain film X-rays, computed tomography (CT), magnetic resonance imaging, nuclear bone scanning, and vertebral fracture assessment (VFA) by dual-energy X-ray absorptiometry (DXA) (10). CT provides excellent image resolution but is less available, more costly, and exposes the patient to greater radiation than conventional radiography. Magnetic resonance imaging can be useful to evaluate malignancy, estimate the time when the fracture occurs and, unlike CT, no ionizing radiation is used; however, the cost is high, and availability is limited (11). Conventional X-ray images of the thoracic and lumbar spine with VF grading using the Genant semiquantitative technique is one of the most widely used methods to diagnose VFs (12). VFA has lower image resolution than these methods but can be conveniently performed along with BMD measurement by DXA, with lower cost than the other methods and less radiation than CT or conventional radiography. The aim of this review is to discuss the clinical utility of VFA as a tool for diagnosing VFs and managing patients with osteoporosis.
Section snippets
Vertebral Fracture Assessment
VFA is a fast low-radiation method performed during BMD measurement, using DXA technology, to identify moderate to severe VFs 13, 14.
The International Society for Clinical Densitometry (ISCD) Official Positions state that VFA is indicated when T-score is less than −1.0, and when 1 or more of the following conditions is present: women aged ≥70 years and men aged ≥80 years, historical height loss >4 cm (>1.5 inches), self-reported prior VF, or glucocorticoid therapy ≥5 mg of prednisolone or
VFA Compared With Conventional Radiography
Several studies have demonstrated good agreement between VFA and radiographs, with very good sensitivity and specificity, notably for moderate and severe fractures (23). A multicenter study compared VFA scans using modern DXA equipment with conventional radiographic using Genant's semiquantitative technique. There was good agreement between VFA and X-ray assessments for the diagnosis of moderate and severe VFs, with sensitivity and specificity ranging from 0.70 to 0.86 and from 0.99 to 0.998,
VFA in Postmenopausal Women
It has been demonstrated that VFA is a clinically useful method for detecting moderate and severe VFs in the mid- and lower thoracic spine and lumbar spine (11). A prospective study evaluated the sensitivity and specificity of VFA for the diagnosis of VFs in postmenopausal women compared with X-rays of the thoracic and lumbar spine. Sensitivity was 94.1%, and specificity was 83.0%. VFA had a high negative predictive value; it was determined that use of VFA could avoid 32% of spine X-rays in the
VFA in Men
Osteoporosis and VFs are more prevalent in postmenopausal women than in men, but men are at risk as well. The prevalence of VFs in men increases notably with age (p < 0.02), current smoking (p < 0.002), and low BMD (p < 0.001); however, VFA visualized a significant proportion of VFs in men with normal BMD (32.4%) (29). Some studies have demonstrated that VFA can be a useful tool for diagnosing VFs in men referred for BMD analysis 29, 30.
A cohort study was performed to investigate the utility of
VFA in Children
The number of pediatric patients diagnosed with secondary osteoporosis has been increasing, which raises concerns regarding the risk of VFs in this population. BMD is widely performed in the diagnostic assessment of children with fractures and suspected skeletal diseases. VFA is a practical, fast, and safe alternative to conventional radiography (32). A study showed the reliability of this method for diagnosis of VFs in children and adolescents with osteogenesis imperfecta, with favorable
VFA in Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a systematic inflammatory disease associated with osteoporosis and fragility fractures, especially in older individuals. VFA is a convenient technique for diagnosing VFs in these patients because it can be done at the same time as BMD measurement. A study enrolled 100 women with RA to evaluate the validity of VFA for the diagnosis of VFs. Most of them were postmenopausal (97%) and were using glucocorticoids. The prevalence of VFs was 50%. Sensitivity and specificity
VFA and the FRAX Algorithm
The World Health Organization fracture risk algorithm, FRAX, is a clinical tool that can be used to estimate the 10-year probability of developing a hip fracture and major osteoporotic fracture (hip, clinical spine, shoulder, forearm). This method combines femoral neck BMD with clinical risk factors, such as age, smoking, prior fracture, and chronic glucocorticoid treatment (35). Although there are limitations to the use of the FRAX algorithm because of the lack of inclusion of some risk
Conclusion
In conclusion, VFA is a convenient, low-radiation, low-cost, and highly effective method for diagnosing VFs. VFA can be performed at the same time as BMD measurement. The identification of previously unrecognized VFs with this technique may change the diagnostic classification, estimation of fracture risk, and treatment strategies. Treatment based on the identification of VFs may prevent new osteoporotic fractures and enhance the quality of life.
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2019, Journal of Clinical DensitometryCitation Excerpt :The Genant visual semiquantitative technique using VFA is the ISCD method of choice for diagnosing VFs because of good interobserver reliability and predictive validity, as well as its efficient use in clinical practice (7). Several studies have demonstrated good agreement between VFA and radiographs, with excellent sensitivity and specificity, especially for moderate and severe fractures (8,9). A multicenter study compared VFA scans using modern DXA equipment with conventional radiographic using the Genant semiquantitative technique (10).
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Conflicts of interest: The authors report no conflicts of interest.