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

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


Am J Roentgenol. 2004;183(4) 

In This Article

Diagnosis of Vertebral Fracture

The diagnosis of a vertebral fracture may be suspected on clinical evaluation and confirmed with radiography. However, unlike other fractures, vertebral fractures are commonly present on radiographs obtained for other reasons in patients who may not show signs or symptoms suggestive of fracture.

Clinical Diagnosis

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.[47] 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.[48,49] Some height loss is expected with aging, because of compression of the intervertebral disks. Studies[48,49] 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.[50]

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 (i.e., oblique views) or by complementary examinations (i.e., bone scintigraphy, CT, or MRI).

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,[51] Barnett and Nordin,[52] Hurxthal,[53] Smith et al.,[54] Minne et al.,[55] Melton et al.,[56] Black et al.,[57] Eastell et al.,[58] McCloskey et al.,[59] and Genant et al..[60] 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.

Underdiagnosis of Vertebral Fractures

Vertebral fractures often go undetected by clinicians and undiagnosed by radiologists.[17–20] 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%.[17–18] 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.[19] A multinational study[20] 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[20] 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.

It would seem that the detection of vertebral fractures should pose no great difficulty. Why then, are so many vertebral fractures being missed? One explanation may relate to the lack of standardization in the radiologic interpretation of vertebral fractures, especially when attention is not focused specifically on the issue of fracture. In this setting, radiologists often fail to recognize or mention many mild and some moderate fractures, or they use terminology that is nonspecific and does not adequately alert the referring clinician to the presence of a vertebral fracture. The diagnosis of vertebral fracture is often unsuspected clinically; this oversight makes accurate radiologic diagnosis essential for proper patient management.

Thus, we propose a call to action, in which radiologists begin to use a simple but standardized approach to diagnosis of vertebral fracture.


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