Vertebral morphometry: a comparison of long-term precision of morphometric X-ray absorptiometry and morphometric radiography in normal and osteoporotic subjects

Definition of normal vertebral morphometry using NHANES‐II radiographs

A robust definition of normal vertebral morphometry is required to confidently identify abnormalities such as fractures. The Second National Health and Nutrition Examination Survey (NHANES‐II) collected a nationwide probability sample to document the health status of the United States. Over 10,000 lateral cervical spine and 7,000 lateral lumbar spine X‐rays were collected. Demographic, anthropometric, health, and medical history data were also collected. The coordinates of the vertebral body corners were obtained for each lumbar and cervical vertebra using previously validated, automated technology consisting of a pipeline of neural networks and coded logic. These landmarks were used to calculate six vertebral body morphometry metrics. Descriptive statistics were generated and used to identify and trim outliers from the data. Descriptive statistics were tabulated using the trimmed data for use in quantifying deviation from average for each metric. The dependency of these metrics on sex, age, race, nation of origin, height, weight, and body mass index (BMI) was also assessed. There was low variation in vertebral morphometry after accounting for vertebrae (eg, L1, L2), and the R² was high for ANOVAs. Excluding outliers, age, sex, race, nation of origin, height, weight, and BMI were statistically significant for most of the variables, though the F‐statistic was very small compared to that for vertebral level. Excluding all variables except vertebra changed the ANOVA R² very little. Reference data were generated that could be used to produce standardized metrics in units of SD from mean. This allows for easy identification of abnormalities resulting from vertebral fractures, atypical vertebral body morphometries, and other congenital or degenerative conditions. Standardized metrics also remove the effect of vertebral level, facilitating easy interpretation and enabling data for all vertebrae to be pooled in research studies. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Osteoporotic vertebral fractures: radiologic diagnosis, clinical and radiologic factors affecting surgical decision making: WFNS Spine Committee Recommendations

With the varied literature on osteoporotic vertebral fracture that may predispose to diagnostic and management dilemma, it is timely to evaluate and streamline the evidence. The aim of this review is to create recommendations on osteoporotic vertebral fractures regarding radiologic diagnosis, and clinical and radiological factors affecting surgical decision making. A computerized literature search was done using PubMed, Google scholar and Cochrane Database of Systematic Reviews from 2010 to 2020. For radiologic diagnosis, the keywords "osteoporotic vertebral fractures" and "radiologic diagnosis" were used yielding 394 articles (19 relevant articles). For clinical and radiological factors affecting surgical decision making, the keywords "osteoporotic vertebral fractures", "radiologic diagnosis", and "surgery" were used yielding 568 articles (25 relevant articles). All pertinent data were reviewed, and consensus statements were obtained in two virtual separate consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine committee. The statements were voted and yielded positive or negative consensus using the Delphi method. This review summarizes the WFNS Spine Committee recommendations on the radiologic diagnosis, and clinical and radiological factors affecting surgical decision making of osteoporotic vertebral fractures.

Comparison of DXA Scans and Conventional X-rays for Spine Morphometry and Bone Age Determination in Children

Conventional lateral spine and hand radiographs are the standard tools to evaluate vertebral morphometry and bone age in children. Beside bone mineral density analyses, dual-energy X-ray absorptiometry (DXA) measurements with lower radiation exposure provide high-resolution scans which are not approved for diagnostic purposes. Data about the comparability of conventional radiographs and DXA in children are missing yet. The purpose of the trial was to evaluate whether conventional hand and spine radiographs can be replaced by DXA scans to diminish radiation exposure. Thirty-eight children with osteogenesis imperfecta or secondary osteoporosis or short stature (male, n=20; age, 5.0-17.0 yr) were included and assessed once by additional DXA (GE iDXA) of the spine or the left hand. Intraclass correlation coefficients (ICCs) were used to express agreement between X-ray and iDXA assessment. Evaluation of the spine morphometry showed reasonable agreement between iDXA and radiography (ICC for fish-shape, 0.75; for wedge-shape, 0.65; and for compression fractures, 0.70). Bone age determination showed excellent agreement between iDXA and radiography (ICC, 0.97). IDXA-scans of the spine in a pediatric population should be used not only to assess bone mineral density but also to evaluate anatomic structures and vertebral morphometry. Therefore, iDXA can replace some radiographs in children with skeletal diseases.

Management of severe osteoporosis

INTRODUCTION

Severe osteoporosis represents a disease of high mortality and morbidity. Recognition of what constitutes and causes severe osteoporosis and aggressive intervention with pharmacological agents with evidence to reduce fracture risk are outlined in this review.

AREAS COVERED

This review is a blend of evidence obtained from literature searches from PubMed and The National Library of Medicine (USA), clinical experience and the author's opinions. The review covers the recognition of what constitutes severe osteoporosis, and provides up-to-date references on this sub-set of high risk patients.

EXPERT OPINION

Severe osteoporosis can be classified by using measurements of bone densitometry, identification of prevalent fractures, and, knowledge of what additional risk factors contribute to high fracture risk. Once recognized, the potential consequences of severe osteoporosis can be mitigated by appropriate selection of pharmacological therapies and modalities to reduce the risk for falling.

Vertebral fracture assessment: Current research status and application in patients with kyphoplasty

Imaging of the spine is of paramount importance for the recognition of osteoporotic vertebral fractures (VFs), and standard radiography (SR) of the spine is the suggested diagnostic method but is not routinely used because of the cost and radiation exposure considerations. VF assessment (VFA) is an efficient, low radiation method for identifying VFs at the time of bone mineral density (BMD) measurement. Prediction models used to indicate the need for VFA may have little predictive power in subspecialty referral populations such as rheumatologic patients or patients who underwent kyphoplasty. Rheumatologic patients are frequently at increased risk for VFs, and VFA should be performed on an individual basis, also taking in account the guidelines for the general population. Kyphoplasty is a new minimal invasive procedure for the treatment of VFs and is being performed with increasing frequency. Following kyphoplasty, there may be a risk of new VFs in adjacent vertebrae. The assessment and follow-up of patients who underwent kyphoplasty requires repetitive X-ray imaging with the known limitations of SR. Thus, VFA may facilitate the evaluation of VFs in these patients because most of the kyphoplasty patients would fulfill the criteria. In a pilot study, we measured the BMD and performed VFA in 28 patients treated with kyphoplasty. Ratios of anterior to posterior (A/P) and middle to posterior (M/P) height were measured, and Genant’s method was used to classify vertebrae accordingly. Intraobserver and interobserver reliability for A/P, M/P and the Genant’s method were determined. Only 1 patient did not meet the criteria for VFA. Of the 364 available vertebrae, 295 could be analyzed. Most missing data (concerning 69 vertebrae) occurred in the upper thoracic region. Three of the 69 non-eligible vertebrae were lumbar vertebrae with cement leakage from the kyphoplasty procedure. In our hands, VFA was highly reproducible, demonstrating very good agreement in terms of intraobserver and interobserver reliability. Agreement was very good on the vertebral level, “vertebrae with kyphoplasty” level and “2 above and 1 below the kyphoplasty vertebrae” level. The application of Genant’s method to these patients also resulted in perfect agreement. We believe that the potential value of VFA in patients treated with kyphoplasty requires further evaluation, particularly comparing VFA with SR and performing a longitudinal follow-up. More research will help to adopt care processes that determine which patients require VFA and how often VFA should be performed, while also considering the impact of this technique on the cost of healthcare organizations.

Outcome of percutaneous balloon kyphoplasty in vertebral compression fractures

BACKGROUND

Incidence of vertebral compression fractures (VCFs) is increasing due to increase in human life expectancy and prevalence of osteoporosis. Vertebroplasty had been traditional treatment for pain, but it neither attempts to restore vertebral body height nor eliminates spinal deformity and is associated with a high rate of cement leakage. Balloon kyphoplasty involves introduction of inflatable balloon into the fractured body of vertebra for elevation of the end-plates prior to fixation of the fracture with bone cement. This study evaluates short term functional and radiological outcomes of balloon kyphoplasty. The secondary aim is to explore short-term complications of the procedure.

MATERIALS AND METHODS

A retrospective study of 199 kyphoplasty procedures in 135 patients from March 2009 to March 2012 were evaluated with short form-36 (SF-36) score, visual analogue scale (VAS), detailed neurological and radiological evaluations. The mean followup was 18 months (range 12-20 months). Statistical analysis including paired sample t-test was done with statistical package for social sciences.

RESULTS

Statistically significant improvements in SF-36 (from 34.29 to 48.53, an improvement of 14.24, standard deviation (SD) - 20.08 P < 0.0001), VAS (drop of 4.49, from 6.74 to 2.24, SD - 1.44, P < 0.0001), percentage restoration of lost vertebral height (from 30.62% to 16.19%, improvement of 14.43%, SD - 15.37, P < 0.0001) and kyphotic angle correction (from 17.41° to 10.59°, improvement of 6.82, SD - 7.26°, P < 0.0001) were noted postoperatively. Six patients had cement embolism, 65 had cement leak and three had adjacent level fracture which required repeat kyphoplasty later. One patient with history of ischemic heart disease had cardiac arrest during the procedure. No patients had neurological deterioration in the followup period.

CONCLUSIONS

Kyphoplasty is a safe and effective treatment for VCFs. It improves physical function, reduces pain and corrects kyphotic deformity.

Comprehensive vertebral deformity and vertebral fracture assessment in clinical practice: intra- and inter-reader agreement of a clinical workflow tool

STUDY DESIGN

Study design randomized intra- and inter-reader reproducibility study.

OBJECTIVE

To evaluate reproducibility of quantitative morphometry (QM) and agreement of dichotomous fracture/no-fracture status on lateral spinal radiographs acquired during routine clinical practice using a clinical workflow tool.

SUMMARY OF BACKGROUND DATA

Several recent guidelines have underlined the importance of Genant semi-quantitative scoring and selective QM to confirm and grade suspected vertebral fractures in clinical practice.

METHODS

Thoracic and lumbar spine radiographs were acquired from 98 consecutive subjects (mean age, 60.1 ± 11.7 yr) attending the clinic for osteoporosis evaluation. For each subject, QM and Genant semi-quantitative scoring were performed on all evaluable vertebrae from L4 to T4 using a software workflow tool. A radiologist and an experienced radiographical technician performed 2 repeat reading sessions of the radiographs 12 months apart, blinded to each other's results; for the second read, the cases were anonymized and the order was randomized.

RESULTS

Inter-reader reproducibility results were 3.1% and 3.2% coefficient of variation (%) for heights, 0.030 and 0.031 root mean square standard deviation for height ratios. For intrareader reproducibility, these values were 2.2% and 3.5% coefficient of variation %; 0.023 and 0.034 root mean square standard deviation. Kappa score results for agreement of dichotomous fracture/no-fracture status were 0.67 and 0.72 (inter-rater) and 0.50 and 0.67 (intrarater).

CONCLUSION

The software assessed in this study is a reliable clinical tool that facilitates QM and Genant semi-quantitative scoring of the spine in routine clinical practice.

LEVEL OF EVIDENCE

3.

Intrarater reliability of dual-energy X-ray absorptiometry-based measures of vertebral height in postmenopausal women

The primary purpose was to estimate intrarater reliability of vertebral body height (VH) measures in postmenopausal women based on duplicate analyses of vertebral fracture assessment (VFA) images. The secondary purpose was to determine the consistency in classification of vertebral deformity on duplicate analyses. Thirty-two VFA were randomly selected from a database of 464 scans acquired in postmenopausal women using dual-energy X-ray absorptiometry (Discovery A; Hologic Inc., Waltham, MA). Visible endplates were marked on each image on 2 occasions (4 wk apart) by a single rater; the semiautomated software derived measures of anterior, middle, and posterior VH and classified severity of vertebral deformity. Intrarater reliability was assessed using the intraclass correlation coefficient (with 95% confidence interval [CI]) when ≥ 22 VFA could be analyzed. Reliability of grading deformity of 267 vertebrae was assessed using Cohen's unweighted kappa (with 95% CI). Reliability of anterior, middle, and posterior height measures from T8 to L4 was 0.85 and greater except for T8 anterior VH and T9 posterior VH (0.76 [0.43, 0.90] and 0.62 [0.15, 0.83], respectively). Chance-corrected agreement for 4 grades of vertebral deformity was 0.48 (0.30, 0.66) and for 2 categories (normal/mild and moderate/severe) was 0.70 (50, 0.90). Intrarater reliability was acceptable for VH measures from T10 to L4. Reliability in grading severity of deformity was improved by classifying as <25% deformity (nonfracture) and as >25% deformity (fracture).

Combined vertebral fracture assessment and bone mineral density measurement: a new standard in the diagnosis of osteoporosis in academic populations

Vertebral Fracture Analysis enables the detection of vertebral fractures in the same session as bone mineral density testing. Using this method in 2,424 patients, we found unknown vertebral fractures in approximately one out of each six patients with significant impact on management.

INTRODUCTION

The presence of osteoporotic vertebral fractures (VF) is an important risk factor for all future fractures independent of BMD. Yet, determination of the VF status has not become standard practice. Vertebral Fracture Assessment (VFA) is a new feature available on modern densitometers. In this study we aimed to determine the prevalence of VF using VFA in all patients referred for BMD testing in a university medical center and to evaluate its added clinical value.

METHODS

Prospective diagnostic evaluation study in 2,500 consecutive patients referred for BMD. Patients underwent VFA in supine position after BMD testing. Questionnaires were used to assess perceived added value of VFA.

RESULTS

In 2,424 patients (1,573 women), results were evaluable. In 541 patients (22%), VFA detected a prevalent VF that was unknown in 69%. In women, the prevalence was 20% versus 27% found in men (p < 0.0001). The prevalence of VF was 14% in patients with normal BMD (97/678), increased to 21% (229/1,100) in osteopenia and to 26% in those with osteoporosis (215/646) by WHO criteria. After excluding mild fractures VF prevalence was 13% (322/2,424). In 468 of 942 questionnaires (50% response rate), 27% of the referring physicians reported VFA results to impact on patient management.

CONCLUSIONS

VFA is a patient friendly new tool with a high diagnostic yield, as it detected unknown VF in one out of each six patients, with significant impact on management. We believe these findings justify considering VFA in all new patients referred for osteoporosis assessment in similar populations.

Vulnerability of healthy vertebrae in patients with and without previous vertebral fracture

Vertebral deformities are associated with a marked increase in morbidity, mortality, and burden in terms of sanitary expenditures. Patients with vertebral fractures have a negative impact in their health, less quality of life, and loss of functional capacity and independence. The purpose of this study was to explore the vulnerability of healthy vertebrae in patients who have sustained already a compression fracture and in patients who do not have prevalent fractures in the thoracic spine; and to explore the association of the deformity in healthy vertebrae with different variables, such as bone mineral density (BMD), body mass index, age, loss of height, presence of clinical kyphosis, history of other osteoporotic fractures, and falls occurring during the last year. Clinical data and complementary studies from 175 postmenopausal outpatients were analyzed. These women (age: 69.7±11.1 years) had not received any treatment for osteoporosis. Anteroposterior and lateral radiographs of the thoracic spine and bone densitometry of the hip were obtained; morphometry was performed in 1575 thoracic vertebrae from T4 to T12. The angle of wedging of each vertebral body was calculated using a trigonometric formula. Then, the sum of wedge angles of vertebral bodies (SWA) was determined, and Cobb angle was measured. In patients with vertebral fractures, after excluding the angles of fractured vertebral bodies, the mean wedge angle of the remaining vertebrae (MWAhealthy) was calculated. The same procedure was followed in patients without vertebral fractures. MWAhealthy was considered as an indicator of the structural vulnerability of non-fractured vertebrae. Patients with prevalent fractures had lower BMD, wider Cobb angle, and higher sum of wedge angles than patients without vertebral fractures. The proportion of patients with accentuation of clinical kyphosis was higher in the group with prevalent vertebral fractures. A highly significant difference was found in the MWAhealthy, which was higher in patients with prevalent fractures (4.1±1.3° vs. 3.0±1.1°; p<0.001). Patients showing vertebral fractures had 7.1±4.2 cm height loss in average, significantly superior than that found among non-fractured women (3.6±3.2 cm; p<0.01). In multivariate analysis, the increase of MWAhealthy was associated with advancing age (p<0.02), lower femoral neck BMD (p<0.005), presence of clinical kyphosis (p<0.01) and vertebral fractures (p<0.02). This study presents evidence that a series of factors independently influence the increase in wedging deformity of vertebral bodies that are not fractured yet. These factors could contribute to an increased vulnerability of the vertebrae, making them more susceptible to fracture.

Combined vertebral fracture assessment and bone mineral density measurement: a patient-friendly new tool with an important impact on the Canadian Risk Fracture Classification

PURPOSE

Vertebral fractures often go unnoticed, while they constitute a significant risk factor for new fractures, independent of the bone density. Vertebral Fracture Assessment (VFA) is a new feature on DXA bone densitometry equipment. Our purpose was to determine the added value of VFA and its impact on the Canadian fracture risk classification using data from a Dutch academic cohort.

METHODS

All 958 consecutive patients (64% female, mean age 53 [20-94], mean weight 75 kg [32-150]) who underwent BMD measurement at the University Medical Center Groningen, The Netherlands also underwent VFA in the same session.

RESULTS

The prevalence of vertebral fractures was 26%. In 68% of these patients this fracture was unknown. The severity was "mild" (20%-25% height loss) in 43%, "moderate" (25%-35%) in 44% and "severe" (>35% height loss) in 13%. Even after excluding mild fractures, the prevalence of vertebral fractures was 17%. In the 28% with normal BMD the vertebral fracture prevalence was still 18%, in the 43% with osteopenia 23%, and in the 29% with osteoporosis 36%. The Canadian risk classification was "low fracture risk" in 68%, "moderate" in 19%, and "high" in 13%. Adding VFA altered the classification in 20% of the patients, to become 54%, 27%, and 19%, respectively.

CONCLUSIONS

VFA added to BMD is a patient friendly diagnostic tool with a high diagnostic yield, as it detected unknown vertebral fractures and altered diagnostic classification in approximately 1 out of every 5 patients. These results suggest that BMD plus VFA may become the new standard in osteoporosis testing.

Vertebral fracture assessment in supine position: comparison by using conventional semiquantitative radiography and visual radiography

PURPOSE

To retrospectively evaluate the accuracy of vertebral fracture assessment (VFA) performed with the patient in the supine position and conventional semiquantitative radiography of the spine by using conventional visual radiography of the spine as the reference standard.

MATERIALS AND METHODS

This retrospective study was approved by the institutional ethics review board; informed consent was obtained from the patients. A total of 250 consecutive patients (mean age, 62.0 years; range, 25-89 years) consisting of 190 women (mean age, 64 years; range, 25-89 years) and 60 men (mean age, 57.0 years; range, 27-83 years) who were suspected of having osteoporosis and who underwent VFA in the supine position and radiography of the spine were evaluated. VFA and semiquantitative radiography were analyzed by using a six-marker point method to describe the shape and deformity of each vertebra. Visual radiography of the lateral spine was performed by an experienced radiologist. The agreement between VFA, visual radiography, and semiquantitative radiography of semiquantitative graded fractures was assessed by using weighted kappa statistics.

RESULTS

Visual radiography helped identify 92 (36.8%) patients with at least one vertebral fracture (mean, 1.8 per patient). Most fractures were present in T7, T12, and L1. Excellent agreement was found between VFA and visual radiography, with 97.5% concordance and kappa = 0.82; VFA and semiquantitative radiography were in agreement in 97.4% of patients, with kappa = 0.83; and visual radiography and semiquantitative radiography were in agreement in 98.1%, with kappa = 0.87. Sensitivity, specificity, and positive and negative predictive values calculated by lesion level for VFA compared with visual assessment were 83.6%, 99.1%, 84.1%, and 99.1%, respectively.

CONCLUSION

VFA performed with patients in the supine position is an accurate method to help detect vertebral fractures when compared with conventional spine radiography. VFA permits combination of fracture assessment with bone mineral density measurement in a single session.

Local topological analysis of densitometer-generated scan images of the proximal femur for differentiation between patients with hip fracture and age-matched controls

SUMMARY

We evaluate densitometer-generated scan images of the proximal femur with respect to topological properties of bone mineral distribution patterns in selected regions of interest. In a population of 100 post-menopausal women, the method has a highly discriminative potential with a performance superior to standard densitometry. Results vary with anatomical location within the proximal femur.

INTRODUCTION

The objectives of the study were to evaluate densitometer-generated scan images of the proximal femur with respect to topological properties of bone mineral distribution patterns in selected regions of interest, to test the ability for differentiation between post-menopausal women hip fracture and controls, and to compare results with standard bone densitometry.

MATERIALS AND METHODS

We used dual-energy X-ray absorptiometry (DXA) to measure the femoral bone mineral density (BMD) of 100 post-menopausal women (73.4 +/- 12.2), 50 of whom had a recent hip fracture. Local bone mineral distribution in the scanner-generated images was analyzed in the standard DXA-regions of interest (ROIs; femoral neck, the shaft, the trochanteric area; and the total hip) using an optimized, local topological parameter MF2D. Performance of topological analysis and BMD was tested by receiver-operator characteristic and discriminant analysis.

RESULTS

Area under the curve (AUC) for correct differentiation between patients with and without fractures by BMD in the different ROIs ranged from 0.64 to 0.71; AUC of regional density-pattern analysis varied between 0.79 and 0.84. Using multivariate statistical models, between 71% and 84% of patients were correctly identified as fracture/non-fracture cases by regional topological analysis, whereas BMD reached levels from 58% to 68%.

CONCLUSION

Our analysis indicates that identification of patients with hip fracture by regional evaluation of density patterns varies with anatomical location within the proximal femur. In our study population, performance of the novel parameter was superior to densitometry.

Vertebral Fracture Assessment: the 2007 ISCD Official Positions

Vertebral fracture assessment (VFA) is an established, low radiation method for detection of prevalent vertebral fractures. Vertebral fractures are usually not recognized clinically at the time of their occurrence, but their presence indicates a substantial risk for subsequent fractures independent of bone mineral density. Significant evidence supporting VFA use for many post-menopausal women and older men has accumulated since the last ISCD Official Position Statement on VFA was published. The International Society for Clinical Densitometry considered the following issues at the 2007 Position Development Conference: (1) What are appropriate indications for Vertebral Fracture Assessment; (2) What is the most appropriate method of vertebral fracture detection with VFA; (3) What is the sensitivity and specificity for detection of vertebral fractures with this method; (4) When should additional spine imaging be performed following a VFA; and (5) What are the reporting obligations for those interpreting VFA images?

The spinal curvature irregularity index independently identifies vertebral fractures

INTRODUCTION AND HYPOTHESIS

The spinal curvature irregularity index (SCII) is a quantitative measure of the irregularity of the spinal curvature. We evaluated the predictive ability of SCII to identify subjects with vertebral fractures (VF).

METHODS

Vertebral heights were measured by quantitative vertebral morphometry in 461 Lebanese women 20-89 years of age and VFs were ascertained by the grade 1 Eastell method. SCII scores were log-transformed and expressed as Z-SCII, the number of standard deviations above or below the mean ln(SCII) of young patients without VF. Univariate and multivariate binary logistic regression models were used to identify clinical predictors of VF.

RESULTS

Women with a higher SCII were more likely to have prevalent VF. A higher SCII was associated with a greater prevalence of VF within each category of femoral neck BMD (normal, osteopenia, osteoporosis). In univariate analysis, predictors of VF included Z-SCII (odds ratio, OR: 2.21, 95% CI: 1.80-2.71) and femoral neck T-score (OR: 1.35, 95% CI: 1.12-1.63). In multivariate analysis, predictors of VF were: Z-SCII (OR: 1.54, 95% CI: 1.02-2.32), femoral neck T-score (OR: 1.41, 95% CI: 1.11-1.78) and age(3) (OR: 1.40, 95% CI 1.10-1.82). At a cutoff SCII of 9.5%, the sensitivity and specificity of SCII for VF were 71 and 64% respectively, and higher SCII cutoffs identified VFs with greater specificity.

CONCLUSION

The SCII is a robust, simple and independent indicator of the presence of VFs.

Clinical review: Clinical applications of vertebral fracture assessment by dual-energy x-ray absorptiometry

CONTEXT

Vertebral fracture (VF) is the most common type of fragility fracture, yet most VFs are not clinically apparent. VFs are associated with a significant increase in morbidity, mortality, and risk of future fracture. Many patients with VFs do not have T-scores classified as osteoporosis. Knowledge of VFs may change diagnostic classification, estimation of future fracture risk, and clinical management. VF assessment (VFA) by dual-energy x-ray absorptiometry is a method for imaging the spine to diagnose VFs.

EVIDENCE ACQUISITION

Background information and medical evidence on the technology and clinical applications of VFA was acquired by electronic searching of PubMed for appropriate terms that included vertebral fracture, imaging, diagnosis, dual-energy x-ray absorptiometry, and cost effectiveness. Matches with the highest levels of medical evidence were selected for review, recognizing that the new and evolving nature of the field required inclusion of some material that relied partly on expert opinion.

EVIDENCE SYNTHESIS

The sensitivity and specificity of VFA compare favorably with spine radiographs in the ability to diagnose grade 2 and 3 VFs. VFA involves less radiation, lower cost, and often greater patient convenience than spine radiography. Cost effectiveness modeling suggests that imaging of the spine in selected patients provides essential diagnostic and therapeutic information at a nominal cost. Patients with T-scores that are classified as low bone mass (osteopenia) who are selected for pharmacological therapy based on the presence of a VF benefit by reduction in fracture risk. Guidelines for the clinical application of VFA have been developed by the International Society for Clinical Densitometry.

CONCLUSIONS

VFA is a technology for diagnosing VFs that may alter diagnostic classification, improve fracture risk stratification, and identify patients likely to benefit from pharmacological therapy who otherwise might not be treated.

Calcaneus ultrasonometry and dual-energy X-ray absorptiometry for the evaluation of vertebral fracture risk

The aim of this retrospective, cross-sectional, controlled, non-population-based study was to evaluate the specificity and sensitivity of quantitative ultrasonometry (QUS) of the heel and of dual-energy X-ray absorptiometry (DXA) in the prediction of morphometric vertebral fracture in postmenopausal women and to establish whether the combination of the two devices could improve the capacity to identify the presence of vertebral fracture. Also, we tried to identify the best T-score threshold for high risk of vertebral fracture for both QUS and DXA, highlighting the discrepancies between the two methodologies and between the various sites examined with DXA. From 6,300 patients examined by DXA (total body, lumbar spine, total femur, femoral neck), QUS and DXA vertebral morphometry (MXA), we selected 764 postmenopausal women with nontraumatic vertebral fractures; 770 postmenopausal women with normal morphometry were chosen as a control group. Logistic regression analysis yielded odds ratios (ORs) for bone mineral density (BMD) measurements and QUS that were comparable: BMD-total body 4.16, BMD-lumbar spine 4.80, BMD-total femur 3.77, BMD-femoral neck 3.86, and QUS 4.41, without statistical differences even after correction for different confounding variables (menopausal years, weight, height, body mass index, and age). The ORs obtained from different combinations of QUS and DXA results did not show statistically significant differences compared to those from a single method alone. The sensitivity and specificity of all measurements were determined by area using the receiver operating characteristic curve; these were 0.94 for total body, 0.95 for lumbar spine, 0.86 for total femur, 0.89 for femoral neck, and 0.93 for QUS, without statistical difference. The areas under the curve obtained from the combination of QUS and DXA were higher but without statistical significance compared to QUS alone. In conclusion, both QUS and DXA were able to discriminate women with fracture from women without fracture and independently contributed to determining the association with fracture. The combination of QUS and BMD did not improve the diagnostic ability of either individual technique. We found different diagnostic thresholds for QUS and DXA.

Vertebral morphometry by DXA: a comparison of supine lateral and decubitus lateral densitometers

Identification of vertebral fracture has become increasingly important in the diagnosis and management of osteoporosis. This study compares the morphometric techniques on a fan beam dual-energy X-ray absorptiometry (DXA) GE-Lunar Expert system (Expert) using a supine lateral position and a narrow fan beam GE-Lunar Prodigy system (Prodigy; GE Lunar, Madison, WI) that requires lateral decubitus positioning. Patient acceptability, image quality, observer, and equipment variability were determined. Study subjects were recruited from clinical referrals sent for a routine DXA study that included vertebral morphometry. Twenty-five patients underwent lateral vertebral assessment on both machines and completed a questionnaire on comfort and tolerability. Analysis was undertaken by two trained observers. Vertebral height, anterior/posterior height (A/P) and mid/posterior height (M/P) ratios, image quality, and prevalent fractures were assessed. There were no significant differences in patient comfort or image quality scores. More upper thoracic vertebrae could be assessed on the Expert, and good radiographic positioning was easier to achieve on the Expert. Inter-observer coefficients of variance percentage (CV%) of vertebral height was lower on the Prodigy (3.5% in the lumbar spine rising to 12.8% in the thoracic spine) than the Expert (4.2% to 16.9%). Inter-observer CV% for A/P and M/P ratios varied from 2.5% to 10.5% on the Prodigy compared with 3.5% to 12.3% on the Expert, depending on vertebral level. The variation between instruments was similar to the inter-observer CV% (anterior height: -0.11+/-1.65 mm; mid height: 0.54+/-1.51 mm; posterior height: 0.43+/-1.46 mm). There was good agreement between observers and between the Expert and Prodigy in identifying severe fractures, but lack of agreement in identifying moderate fractures. In conclusion, there was no clinically significant difference in patient comfort and image quality between the Expert and the Prodigy. The inter-observer variations in vertebral height and A/P and M/P ratios are similar to the variations between instruments. In making the change from the supine lateral to the decubitus lateral positioning, measurements of vertebral height are reproducible and patient comfort is not compromised.

Vertebral fracture assessment: the 2005 ISCD Official Positions

Vertebral Fracture Assessment (VFA) is a low radiation method for imaging the thoraco-lumbar spine using bone densitometers. VFA can easily be performed at the time of bone mineral density (BMD) measurement, allowing integration of BMD and vertebral fracture information into clinical patient care. As VFA is a relatively new procedure, it has received limited study and heretofore has not had widespread clinical application. Consequently, the International Society for Clinical Densitometry (ISCD) considered the following VFA issues at the 2005 Position Development Conference: (1) indications for VFA; (2) methodology for the diagnosis of vertebral fractures using VFA; and (3) indications for additional imaging after VFA. The ISCD Official Positions with respect to the above issues, as well as the rationale and evidence used to derive these positions, are presented here.

Reduction of pain and fracture incidence after kyphoplasty: 1-year outcomes of a prospective controlled trial of patients with primary osteoporosis

Previously, we reported significantly reduced pain and improved mobility persisting for 6 months after kyphoplasty of chronically painful osteoporotic vertebral fractures in the first prospective controlled trial. Since improvement of spinal biomechanics by restoration of vertebral morphology may affect the incidence of fracture, long-term clinical benefit and thereby cost-effectiveness, here we extend our previous work to assess occurrence of new vertebral fractures and clinical parameters 1 year after kyphoplasty compared with a conservatively treated control group. Sixty patients with osteoporotic vertebral fractures due to primary osteoporosis were included: 40 patients were treated with kyphoplasty, 20 served as controls. All patients received standard medical treatment. Morphological characteristics, new vertebral fractures, pain (visual analog scale), physical function [European Vertebral Osteoporosis Study (EVOS) score] (range 0-100 each) and back-pain-related doctors' visits were re-assessed 12 months after kyphoplasty. There were significantly fewer patients with new vertebral fractures of the thoracic and lumbar spine, after 12-months, in the kyphoplasty group than in the control group (P=0.0084). Pain scores improved from 26.2 to 44.4 in the kyphoplasty group and changed from 33.6 to 34.3 in the control group (P=0.008). Kyphoplasty treated patients required a mean of 5.3 back-pain-related doctors' visits per patient compared with 11.6 in the control group during 12 months follow-up (P=0.006). Kyphoplasty as an addition to medical treatment and when performed in appropriately selected patients by an interdisciplinary team persistently improves pain and reduces occurrence of new vertebral fractures and healthcare utilization for at least 12 months in individuals with primary osteoporosis.

Lateral vertebral assessment: a valuable technique to detect clinically significant vertebral fractures

Although many vertebral fractures are clinically silent, they are associated with increased risk for subsequent osteoporotic fractures. A substantial number of these fractures are demonstrable using instant vertebral assessment with Hologic densitometers. Whether similar recognition is possible using dual-energy lateral vertebral assessment (LVA) with GE Lunar densitometers remains uncertain. Thus, we evaluated the ability of clinicians using LVA to detect prevalent vertebral fractures. Dual-energy LVA and conventional thoracic and lumbar spine radiographs were concurrently obtained in 80 postmenopausal women. Using an established visual semiquantitative system, vertebral fractures were identified individually by two non-radiologist clinicians on LVA images, and the results were compared with spinal radiograph evaluation by an expert radiologist. Using LVA, 95% of vertebral bodies from T7 through L4 were evaluable, but a majority (66%) of vertebrae from T4 to T6 were not adequately visualized. In the LVA-evaluable vertebrae, prevalent fractures were identified in 40 vertebral bodies by radiography. In this regard, the clinicians using LVA detected 17 of 18 radiographically evident vertebral fractures of grade 2 or 3, a false negative rate of 6%. They identified 50% (11/22) of grade 1 fractures. Additionally, the vast majority of evaluable non-fractured vertebrae, (764/794, 96.2%) were correctly classified as normal by LVA. Thus, clinicians utilizing LVA correctly identified the vast majority of grade 2 or 3 vertebral compression fractures and normal vertebral bodies, although detection of grade 1 fractures was less effective. In conclusion, the low-radiation, dual-energy LVA technique provides a rapid and convenient way for clinicians to identify patients with, and without, grade 2 or 3 vertebral fractures, thereby enhancing care of osteoporotic patients.

Identification of vertebral fractures: an update

Osteoporotic vertebral fracture is associated with increased morbidity and mortality. As a powerful predictor of future fracture risk, the identification of vertebral fracture helps target individuals who will benefit from anti-fracture therapy. The identification of vertebral fractures is problematic because (1) "normal" radiological appearances in the spine vary greatly both among and within individuals; (2) "normal" vertebrae may exhibit misleading radiological appearances due to radiographic projection error; and (3) "abnormal" appearances due to non-fracture deformities and normal variants are common, but can be difficult to differentiate from true vertebral fracture. Various methods of vertebral fracture definition have been proposed, but there is no agreed gold standard. Quantitative methods of vertebral fracture definition are objective and reproducible, but the major limitation of these methods is their inability to differentiate between vertebral deformity and vertebral fracture. The qualitative visual approach draws on the expertise of the reader, but it is a subjective method with poor interobserver agreement. Semiquantitative assessment of vertebral fracture is a standardized visual method, which is commonly applied in research studies as a surrogate gold standard. This method is more objective and reproducible than a purely qualitative approach, but can be difficult to apply. The established methods focus primarily on the identification of "reduced" or short vertebral height as an indication of vertebral fracture, but this is also a feature of some non-fracture deformities and normal variants. A modified visual approach known as algorithm-based qualitative assessment of vertebral fracture (ABQ) has recently been introduced, and this focuses on radiological evidence of change at the vertebral endplate as the primary indicator of fracture. Preliminary testing of the ABQ method has produced promising results, but the method requires further evaluation. Vertebral imaging by means of dual energy X-ray absorptiometry (DXA) scanner produces images of near-radiographic quality at a fraction of the radiation dose incurred by conventional radiography. There is growing interest in vertebral fracture assessment using this technique as a means of assessing a patient's fracture risk. Given the increasing availability of new technology and the importance of accurate diagnosis of vertebral fracture, there is an urgent need for better awareness of and training in the definition of vertebral fracture. Methods of vertebral fracture definition should be validated by testing the association with clinical outcomes of vertebral fracture, in particular the prediction of incident fractures.

Treatment of painful vertebral fractures by kyphoplasty in patients with primary osteoporosis: a prospective nonrandomized controlled study

This study investigates the effects of kyphoplasty on pain and mobility in patients with osteoporosis and painful vertebral fractures compared with conventional medical management.

INTRODUCTION

Pharmacological treatment of patients with primary osteoporosis does not prevent pain and impaired activity of patients with painful vertebral fractures. Therefore, we evaluated the clinical outcome after kyphoplasty in patients with vertebral fractures and associated chronic pain for >12 months.

MATERIALS AND METHODS

Sixty patients with primary osteoporosis and painful vertebral fractures presenting for >12 months were included in this prospective, nonrandomized controlled study. Twenty-four hours before performing kyphoplasty, the patients self-determined their inclusion into the kyphoplasty or control group so that 40 patients were treated with kyphoplasty, whereas 20 served as controls. This study assessed changes in radiomorphology, pain visual analog scale (VAS) score, daily activities (European Vertebral Osteoporosis Study [EVOS] score), number of new vertebral fractures, and health care use. Outcomes were assessed before treatment and at 3 and 6 months of follow-up. All patients received standard medical treatment (1g calcium, 1000 IE vitamin D(3), standard dose of oral aminobisphosphonate, pain medication, physical therapy).

RESULTS

Kyphoplasty increased midline vertebral height of the treated vertebral bodies by 12.1%, whereas in the control group, vertebral height decreased by 8.2% (p = 0.001). Augmentation and internal stabilization by kyphoplasty resulted in a reduction of back pain. VAS pain scores improved in the kyphoplasty group from 26.2 +/- 2 to 44.2 +/- 3.3 (SD; p = 0.007) and in the control group from 33.6 +/- 4.1 to 35.6 +/- 4.1 (not significant), whereas the EVOS score increased in the kyphoplasty group from 43.8 +/- 2.4 to 54.5 +/- 2.7 (p = 0.031) and in the control group from 39.8 +/- 4.5 to 43.8 +/- 4.6 (not significant). The number of back pain-related doctor visits within the 6-month follow-up period decreased significantly after kyphoplasty compared with controls: mean of 3.3 visits/patient in the kyphoplasty group and a mean of 8.6 visits/patient in the control group (p = 0.0147).

CONCLUSIONS

The results of this study show significantly increased vertebral height, reduced pain, and improved mobility in patients after kyphoplasty. Kyphoplasty performed in appropriately selected osteoporotic patients with painful vertebral fractures is a promising addition to current medical treatment.

Assessment of vertebral fracture using densitometric morphometry

Diagnosis of vertebral fracture is critical for management of osteoporosis, as existence of such deformities substantially increases the risk of subsequent fracture. Thus, accurate and precise techniques allowing detection of such deformities are essential to clinicians. So far, this detection has been performed by spinal lateral X-rays. More advanced techniques have recently been developed, based on dual energy X-ray absorptiometry (DXA). This review describes these different techniques and discusses the effectiveness of the DXA technique to assess vertebral deformities compared to X-ray. The use of DXA detection of vertebral fracture for clinical practice and clinical trials is discussed. Specifically, vertebral morphometry using DXA provides an excellent specificity, with moderate sensitivity. The major limitation of the DXA vertebral assessment is the poor quality of images of thoracic vertebrae. The clinical utility of vertebral morphometry using densitometry may help screening patients with vertebral fracture, but technological improvements are necessary to improve image quality.

Incidence of vertebral deformities in 255 female rheumatoid arthritis patients measured by morphometric X-ray absorptiometry

To date, no studies have been published on incident deformities in patients with rheumatoid arthritis (RA). Morphometric X-ray absorptiometry (MXA) is an alternative to conventional X-rays for identifying vertebral deformities. The aim of the present study was to describe the incidence of vertebral deformities in 255 female RA patients measured by MXA, and the relationship between incident deformities and clinical and demographic variables. MXA is still under evaluation for its ability to identify deformities, so we explored four different cut-off thresholds including fixed percentage reduction and the principle of least significant change (LSC). MXA (T4-L4) and BMD (L2-L4 and total hip; Lunar Expert) were performed on 255 patients (mean age 54.3, range 29.2-70.8 years) at baseline and after a mean period of 2.3 years. MXA scans were analyzed pairwise by the same trained technician, and incident deformities calculated applying LSC with a 99.9% and 99.99% confidence limit, and a fixed reduction of 20% and 25% for anterior, middle or posterior heights. Long term precision (%CV) of height measurements for all vertebrae combined (T4-L4) were 4.8, 4.8 and 4.4, respectively. Frequency and distribution of incident deformities varied from 39 deformities in 33 patients (fixed 20% reduction) to 17 deformities in 15 patients (fixed 25% reduction), and quality control analyses revealed a high number of presumed false deformities. Incidence per 100 patient years varied from 2.9 to 6.7 deformities according to method, and was comparable to those obtained from intervention studies in corticosteroid-induced osteoporosis. Patients with incident deformities were significantly older, had lower BMD, higher disability and more often a previous non-vertebral fractures than those without incident deformities Incident deformities by MXA need further evaluation in secondary osteoporosis. It seems, however, that older patients with previous limb fractures and low BMD are especially prone to this complication.

When should the doctor order a spine X-ray? Identifying vertebral fractures for osteoporosis care: results from the European Prospective Osteoporosis Study (EPOS)

Vertebral fractures are common but usually remain unrecognized in primary care. Data from 2908 women and 2653 men in the EPOS study were used to derive algorithms to indicate the need for a spine X-ray to identify a fracture using easily elicited determinants. At a sensitivity of 50% for identifying cases, the specificity was increased from 50% to 78% in women and from 50% to 72% in men compared with a random allocation of X-rays. Use of X-rays can be optimized by selecting patients at high risk using a short screening procedure.

INTRODUCTION

Previous osteoporotic fracture is an independent risk factor for further fractures and an indication for treatment. Vertebral fractures are the most common osteoporotic fractures before age 75, accounting for 48% of all fractures in men and 39% in women over 50. They usually remain unrecognized, so many patients requiring treatment are denied it, doubling their risk of a further fracture. Our objective was to develop an efficient algorithm indicating the need for an X-ray.

MATERIALS AND METHODS

Data from 2908 women and 2653 men >or=50 years of age in the European Prospective Osteoporosis Study (EPOS) were analyzed. Lateral thoracic and lumbar spine radiographs were taken at baseline and at an average of 3.8 years later. Prevalent fractures were qualitatively diagnosed by an experienced radiologist. Fracture risk was modeled as a function of age, statural height loss since age 25, gender, and fracture history including limb fractures in the last 3 years using negative binomial regression. Receiver operating characteristic (ROC) curves were used to summarize a model's predictive ability, and a prediction algorithm was devised to identify those most likely to have a fracture.

RESULTS

In a multivariate model for women, the risk of prevalent vertebral fracture significantly increased with age (RR, 1.67 [95% CI, 1.46, 1.93] per decade), statural height loss (1.06, [1.03, 1.10] per centimeter decrease), self-reported history of spine fracture (7.52 [5.52, 10.23]), and history of other major fracture (1.83 [1.46, 2.28]). Higher body weight reduced risk (0.86 [0.79, 0.95] per 10-kg increase). In men, the respective RR estimates were as follows: age (1.32 [1.18, 1.49]); height loss (1.06 [1.04, 1.09]); self-reported spine fracture (5.05 [3.69, 6.90]); other major fracture (1.42 [1.12, 1.81]); and weight (0.86 [0.79, 0.94]). Using algorithms based on these easily elicited determinants, specificity was increased from 50% to 78% in women and from 50% to 72% in men at a sensitivity of 50% compared with a random allocation of X-rays. At a sensitivity of 75%, the specificity was 50% in women and 40% in men. Inclusion of hip BMD (femoral neck or trochanter), measured in 1360 women and 1046 men, significantly improved the area under the ROC curves by 4% in women (p < 0.002) but not in men (p > 0.350). Spine BMD, measured in 982 women and 847 men, produced a significant 5% AUC improvement in women (p = 0.007) but not in men (p = 0.554).

CONCLUSION

A woman 65 years of age with one vertebral fracture has a one in four chance of another fracture over 5 years, which can be reduced to one in eight by treatment. Positive treatment decisions are often contingent on identifying a vertebral fracture. Selective use of lateral vertebral X-rays can be optimized using a 2-minute screening procedure administered by a nurse.

The aging spine: new technologies and therapeutics for the osteoporotic spine

Osteoporosis results in low-energy fractures of the spine. The load necessary to cause a vertebral fracture is determined by the characteristics related to the vertebral body structure, mineral content, and quality of bone. Radiographic techniques centered on dual X-ray absorptiometry (DXA) permit a determination of bone mass and fracture risk. Current medical therapies principally using bisphosphonate and pulsatile PTH profoundly decrease the risk of fracture (50+%). Fall prevention strategies can further decrease the possibility of fracture. A comprehensive approach to osteoporosis can favorably alter the disease.

A 6-mo home-based exercise program may slow vertebral height loss

Twenty-one of 46 postmenopausal women were assigned to a home-based exercise program consisting of 60 min of exercise, 3 d/wk. The 25 nonexercisers continued usual daily activities. Each woman had at least one prevalent vertebral fracture and suffered from osteoporosis as defined by the application of WHO criteria to lumbar spine bone mineral density. Vertebral heights were measured using bone densitometry at baseline and 12 mo later. Vertebrae T9 to L4 were all identified for each of the 46 subjects in both the baseline and end-of-study lateral scans. The change in mean vertebral height over the course of the study was -0.3 mm anteriorly, -0.7 mm at the mid-location, and -0.4 mm posteriorly for the nonexercisers. For the exercisers, the corresponding changes were +0.1 mm anteriorly, -0.3 mm at the mid-location, and +0.2 mm posteriorly. The benefit of exercise in preserving vertebral morphometry in patients with osteoporosis deserves further investigation.

Vertebral morphometric X-ray absorptiometry in women with Colles' fracture

Colles' fracture (CF) in younger postmenopausal women is associated with low bone mineral density (BMD) and with an increased risk of other osteoporotic fractures; however, the prevalence of vertebral deformities has been not studied in CF patients. Vertebral morphometry (MXA) using dual-energy X-ray absorptiometry (DXA) is a research tool developed to evaluate the presence of vertebral deformities, but its clinical use is still limited. The goals of this work were to know the prevalence of vertebral deformities in women with CF, to study the morphometric characteristics of height ratios, and to determine the correlation between MXA findings and BMD. MXA was evaluated within an incident case-control study in which 58 women with a recent CF and 83 population-based control women were enrolled. Anterior (Ha), middle (Hm), and posterior (Hp) heights were measured, and wedge (Ha/Hp) and mid-wedge (Hm/Hp) ratios were calculated. A vertebral deformity was defined when at least one ratio fell 3 SD below the reference mean of that ratio at any vertebral level. The mean age of cases was 65.8 yr and in controls 58.7 (p < 0.05). Morphometric vertebral deformities were found in 19% of cases against 11% of controls (nonsignificant). The cases had a lower mid-wedge ratio than controls at each vertebral level (p < 0.05), while wedge ratio results did not show significant results. When the sample was stratified by age, CF showed a trend to be associated with vertebral deformity only in the younger (<65 yr) group. A low but significant coefficient of correlation was found between mid-wedge ratio and BMD, mainly at hip level. By using MXA we found that younger Colles' fracture cases were likely to have more vertebral deformities than healthy controls of the same age range.

Error rates in dental microwear quantification using scanning electron microscopy

There is a degree of correlation between dietary habits and dental microwear in extant primates, and this has enabled inferences to be made about prehistoric diets. Several techniques have been used to quantify microwear, but the comparability of results derived from each has not been demonstrated. Moreover, neither intra- nor interobserver error rates in microwear quantification have been documented to date. We here assess intra- and interobserver error using Microware 4.0, and evaluate intertechnique comparability using the three methods that have been most widely employed in the field. This study documents an overall intraobserver error rate of about 7%, and an overall interobserver error rate of some 9%. Both intra- and interobserver error appears to be influenced substantially by the nature of the micrograph being measured. In no instance did the results obtained by different observers using Microware 4.0 differ significantly, and there was a reasonable degree of interobserver consistency in the rank ordering of micrographs in relation to any given parameter. The results obtained through the use of different quantitative techniques differed significantly, with an overall intertechnique error rate of approximately 19%. Several variables, including differences in magnification factor, scanning electron microscope kV settings, and specimen-detector relationships undoubtedly contribute to the differences among the three methods, but we were not able to assess their relative importance. Microwear quantification permits distinctions between broad dietary categories, but the margin of intra- and interobserver error should be taken into account when defining pattern differences between populations (or species) or when documenting seasonally mitigated differences within a taxon. In view of the error introduced by the use of different methods, we suggest that a consistent technique, such as offered by the Microware software package, be adopted by current researchers to establish a common microwear database.

Prevalence of vertebral compression fracture deformity by X-ray absorptiometry of lateral thoracic and lumbar spines in a population referred for bone densitometry

The presence of a vertebral compression fracture has been demonstrated to be a predictor of future fracture independent of bone mineral density in prospective cohort studies. Fan-beam densitometers are now available that can image the thoracic and lumbar spines and detect deformities consistent with fracture. We report a pilot study of 342 patients referred for bone densitometry who had lateral vertebral imaging performed. Fifty patients (14.6%) of the entire cohort had one or more vertebral deformities identified on lateral vertebral imaging. Seventy-three patients (21.3%) of the entire cohort were 60 or more years of age and had osteopenia by World Health Organization (WHO) criteria (T-score: -1.0 to -2.4 at the spine, total hip, or femoral neck). Twenty of these patients (27.4%) had one or more vertebral deformities. Without identifying prevalent vertebral deformities, these individuals at high risk for fracture may not be offered pharmacologic therapy to reduce fracture risk. Therefore, it may be reasonable to obtain lateral vertebral imaging at least for individuals age > or =60 yr who have mild to moderate bone loss at the spine or hip.