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Recognition and Reporting of Vertebral Fractures

International Osteoporosis Foundation & European Society of Musculoskeletal Radiology. VERTEBRAL FRACTURE INITIATIVE Slide Kit Part 2:. Recognition and Reporting of Vertebral Fractures. What is the vertebral fracture initiative?.

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Recognition and Reporting of Vertebral Fractures

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  1. International Osteoporosis Foundation&European Society of Musculoskeletal Radiology VERTEBRAL FRACTURE INITIATIVESlide Kit Part 2: Recognition and Reporting of Vertebral Fractures

  2. What is the vertebral fracture initiative? • An educational initiative to improve recognition and reporting of vertebral fractures. Pilot phase in five European countries. • Initiative leaders:Pierre D Delmas & Harry K Genant • France: Jean-Denis Larédo & Pierre D Delmas • Germany: Helmut Minne & Michael Jergas / Dieter Felsenberg • Italy: Silvano Adami & Giuseppe Guglielmi • Spain: Jorge Cannata & FranciscoAparisi • UK: David Reid & Judith Adams • A clinician and radiologist team taking the lead in each country

  3. What does the Vertebral Fracture Initiative include? 1. Presentations at Radiology Conferences 2. Articles in radiology and related publications 3. A resource document and a slide kit including: Part 1. Osteoporosis and Related Fractures: Clinical Perspectives Part 2. Recognition and Reporting of Vertebral Fractures 4. Summary handout 5. Interactive teaching program on CD-Rom Teaching tools available from: www.osteofound.org

  4. Osteoporosis Educational Program for Radiologists • Improve the understanding of the importance and nature of osteoporosis • Improve the recognition and reporting of vertebral fractures • Improve the economic pathways to wider access for radiologic services in osteoporosis

  5. Background Worldwide, a substantial percentage of vertebral fractures are not diagnosed by radiologists or clinicians It is likely that this contributes to unnecessary pain and suffering and to the under treatment of osteoporosis Identification of patients with a vertebral fracture is important because the presence of prevalent fracture greatly increases the risk of future fracture Recent widespread approval of effective treatments for patients with osteoporotic vertebral fractures

  6. High Prevalence of Vertebral Deformities 80 60 25% of women over age 50 have Vertebral Deformities Prevalence of 40 Deformities* (%) 20 0 55 65 75 86 95 Age (yrs) Melton, 1993

  7. High Rate of Repeat Fractures 30 25 20% of women with new vert fx will re-fracture within one year 20 % of Patients Fracturing Again within 1 Year 15 10 5 0 1 Multiple Number of Spine Fractures at Start of Year Lindsay, 2000

  8. Prevalent Vertebral Fractures Predict Incident Fracture RR = Incident fractures in patients with / without prevalent fxs 7.4 8 5.0 7 4.5 6 4.0 5 Relative Risk 4 3 2 1 0 Black '99 Ettinger '99 Ross '93 Harris '99, Reginster '00 3.7 years 3 years 3 years 3 years

  9. 40 30 20 10 Baseline Fracture Severity (SQ Grade) Predicts Risk of New Vertebral Fractures MORE Trial – Placebo Group at 3 years 38.1 *23.6 % of Women With >1 New Fracture *7.2 *4.3 SQ0 SQ1 SQ2 SQ3 Baseline SQ Grade Genant et al., Endocrine Soc 2002 *p<0.05 compared to SQ3

  10. Baseline Fracture Severity (SQ Grade) Predicts Risk of New Non-Vert Fractures 18 MORE Trial – Placebo Group at 3 years 16 13.8 14 12 *7.7 10 *7.2 % of Women With >1 New Fracture 8 *5.5 6 4 2 0 SQ0 SQ1 SQ2 SQ3 Baseline SQ Grade *p<0.05 compared to SQ3 Includes clavicle, humerus and wrist, pelvis, hip, and leg Genant et al., Endocrine Soc 2002

  11. Unrecognized Vertebral Fractures On X-Ray 934 women age 60 and older, hospitalized for various reasons Chest x-rays reviewed for fracture 140 120 100 Number of Subjects 52% 80 60 23% 40 17% 7% 20 0 Fracture Treatment for Mentioned in Mentioned in Osteoporosis Present Report Summary in Med Record Osteoporosis Gehlbach SH et al, Osteoporos Int 2000;11:577-582

  12. Prevalent Vertebral Fracture Severity Predicts Subsequent Vertebral and Nonvertebral Fracture Risk in Postmenopausal Women with Osteoporosis - Indication of Bone Fragility - - Indication for Treatment -

  13. Prevent Vertebral Fracture Cascade 10YR 20YR B/L

  14. Problem: Vertebral Fracture Assessment by Radiologists Vertebral Fractures are: • Not being identified • Not being reported • Not being acted upon

  15. Vertebral Fracture Assessment Shape Recognition …The Challenge Vertebral Fracture in Osteoporosis, eds, Genant et. al (1995)

  16. Vertebral Fracture:Semiquantitative Assessment (Visual) • Meunier ‘76 • Jensen ’84 • Epstein ’86 • Genant ’90 • Nielsen ’91 • Jergas ’94 • Felsenberg ’94 • Wu ‘95

  17. SQ T spine L spine Semiquantitative: Visually normal spine

  18. Orthograde Oblique

  19. Under-Penetrated Over-Penetrated

  20. Under-Penetrated Over-Penetrated

  21. Radiographic Osteopenia

  22. Radiographic Osteopenia

  23. Osteoporosis – RadiographicDifferential Diagnosis • Post Menopausal • Osteomalacia • Hyperparathyroidism • Hypercortisolism • Hyperthyroidism • Renal insufficiency • Chronic immobilization

  24. Osteoporosis – RadiographicDifferential Diagnosis • Osteogenesis imperfecta • Hepatic insufficiency • Diabetes mellitus • Multiple myeloma • Metastatic disease • Drug induced

  25. Post-Menop Osteoporotic Fx

  26. Post-Menop Osteoporotic Fx: Variations

  27. Osteomalacia

  28. Cushings Steroids

  29. Multiple Myeloma

  30. Congenital Anomalies

  31. Congenital Anomalies - Fusion

  32. Acquired Deformities – Scheurmann’s

  33. Acquired Deformities - Hyperostosis

  34. Remote Trauma Hemangioma

  35. Normal (Grade 0) Wedge fracture Biconcave fracture Crush fracture Mild fracture (Grade 1, ~20-25%) Moderate fracture (Grade 2, ~25-40%) Severe fracture (Grade 3, ~40%) Semiquantitative visual grading of vertebral fractures Genant & Wu

  36. Mild Fxs: loss of adjacent continuity

  37. SQ Mild Fx SQ Severe FX 3 1 1 3

  38. SQ Incident Mild Fx 0 1

  39. SQ Incident Moderate Fx 0 2

  40. SQ Incident Severe & Moderate Fxs 1 3 2 0

  41. Vertebral FractureDevelopments in Morphometry Barnett, Nordin ’60 Raymakers, Duursma ’90 Hurxthal ’68 Genant ’90 Kleerekoper, Parfitt ’84 Smith-Bindman, Genant ’91 Minne, Leidig’88 Black, Cummings, Nevitt ’91 Hedlung, Gallagher ’88 Eastell, Melton ’91 Davies, Recker, Heaney ’89 Ross, Wasnich ’93 Melton, Riggs ’89 McCloskey, Kanis ’93

  42. Morphometry: Placement of six digitizing points for different projections of the vertebrae

  43. Electronic Cursor for Morphometry

  44. QM with Six-Point Placements

  45. Six-Point Video-Assisted Verterbal Morphometry OARG/UCSF

  46. Vertebral Fracture Assessment (VFA) Point of Care • BMD • VFA

  47. Lateral Vertebral Assessment:Lateral Decubitus and Point-of-Care tools. Qualitative and quantitative!

  48. VFA Quality image choices… Single Dual Single Dual Dual or single energy. It’s the operators choice!

  49. Visual Assessment of Vertebral Fracture Using Lateral DXA Scan • VFA showed good sensitivity (>80%) in identifying moderate/severe XSQ deformities and excellent negative predictive value (>90%) in distinguishing subjects without from those with vertebral deformities on a per subject basis. J. Rea et al Osteoporos Int 2000 • Poor sensitivity to detect mild vertebral fractures, especially at the upper thoracic spine.

  50. Multi-Slice Computed Tomography in Diagnosis and Characterization of Vertebral Fracture

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