Diagnosis of Osteoporotic Vertebral Fractures: Importance of Recognition and Description by Radiologists

Leon Lenchik; Lee F. Rogers; Pierre D. Delmas; Harry K. Genant

Disclosures

Am J Roentgenol. 2004;183(4) 

In This Article

Treatment of Patients With Vertebral Fractures

The clinical treatment of patients with vertebral fracture is largely determined by the presence of signs and symptoms, in particular pain. The management of pain may include physical modalities (i.e., heat, cold, ultrasound, or electrical stimulation), physical rehabilitation and exercise programs, pharmacologic therapy, nerve blocks, vertebroplasty and kyphoplasty, or surgery. Pharmacologic therapy aimed at prevention of future osteoporotic fractures is vital for patients with vertebral fractures and is applicable to both symptomatic and asymptomatic fractures.

It is in the accurate diagnosis of asymptomatic vertebral fractures that radiologists make perhaps the most significant contribution to patient care. More specifically, the diagnosis of vertebral fracture by radiologists impacts patient treatment by enabling the diagnosis of osteoporosis, helping select patients for pharmacologic therapy, improving the ability to assess risk of future fracture, and providing rationale for bone mineral density (BMD) measurement.

Diagnosis of Osteoporosis

Many clinicians consider the presence of a fragility fracture as sufficient for diagnosis of osteoporosis regardless of the patient's BMD. Although bone densitometry is useful for assessing disease severity and monitoring therapy in patients with fractures, densitometry is not essential for the diagnosis of osteoporosis in this setting. Exclusion of malignancy and trauma as the cause of fracture and biochemical evaluation of serum or urine or both to exclude secondary causes for bone fragility are required. After the diagnosis of osteoporosis is made, most patients are offered pharmacologic therapy aimed at preventing future fractures. Thus, the ability to make the diagnosis of osteoporosis on the basis of the presence of vertebral fracture is not trivial.

Selection of Patients for Therapy

Increasing evidence[36–42] justifies offering pharmacologic therapy for osteoporosis to patients with vertebral fracture after nonosteoporotic causes (e.g., malignancy and trauma) have been excluded.

The presence of vertebral fractures has been one of the most common criteria for selecting individuals for clinical trials on osteoporosis therapy.[36–42] Individuals with existing vertebral fractures have a much higher incidence of subsequent fractures than those without fractures and have been used in most clinical trials on osteoporosis therapy.[36–42] Pharmacologic therapy for osteoporosis is effective in patients with vertebral fractures: trials with alendronate, calcitonin, raloxifene, risedronate, and teriparatide have shown 30–50% reductions in fracture incidence.[36–42] Although these agents also reduce the risk of vertebral fracture in patients with low BMD but without prevalent fractures, the absolute risk reduction is greater in those with prevalent vertebral fractures.[36–42] Thus, the decision as to whether a patient is a candidate for therapeutic intervention is based not only on the results of a bone densitometry examination but also on the presence of a vertebral fracture.

Improving the Ability to Predict Fracture Risk

The presence of vertebral fracture is an important factor in predicting the risk of future fractures. Clinical guidelines, including those from the National Osteoporosis Foundation[43] and the International Osteoporosis Foundation (IOF),[44] state that vertebral fractures are the key risk factor, other than low BMD, in the assessment of future fracture risk. The importance of vertebral fractures is also recognized in the World Health Organization (WHO) classification criteria for osteoporosis.[45] The WHO criteria define "severe osteoporosis" as low bone mass "in the presence of one or more fragility fractures."

Risk assessment for individual patients can be improved by combining BMD results and vertebral fracture assessment. For example, a woman with low BMD and one vertebral fracture has 25 times the risk of a patient with normal BMD and no fracture.[46] Thus, the diagnosis of vertebral fractures by radiologists helps clinicians and their patients to be better informed about the overall fracture risk.

Indication for Bone Densitometry

Many insurance carriers (including the Centers for Medicare and Medicaid Services) consider vertebral fractures as one of the indications for bone densitometry. Practically, the approach of measuring BMD even in patients with vertebral fractures has merit because patients with low bone density and vertebral fractures are not only at the highest risk for future fractures but are also most likely to benefit from pharmacologic therapy.

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