Osteoporotic Vertebral Fracture Prevalence in Elderly Chinese Men and Women: A Comparison of Endplate/Cortex Fracture-Based and Morphometrical Deformity-Based Methods

The observation that older men suffer from hip fracture at DXA T-scores higher than older women and a proposal of a new low BMD category, osteofrailia, for predicting fracture risk in older men

The clinical significance of osteoporosis lies in the occurrence of fragility fractures (FFx), and the most relevant fracture site is the hip. The T-score is defined as follows: (BMDpatient-BMDyoung adult mean)/SDyoung adult population, where BMD is bone mineral density and SD is the standard deviation. When the femoral neck (FN) is measured in adult Caucasian women, a cutpoint value of patient BMD of 2.5 SD below the young adult mean BMD results in a prevalence the same as the lifetime risk of hip FFx for Caucasian women. The FN T-score criterion for classifying osteoporosis in older Caucasian men has been provisionally recommended to be - 2.5, but debates remain. Based on a systematic literature review, we noted that older men suffer from hip FFx at a FN T-score approximately 0.5-0.6 higher than older women. While the mean hip FFx FN T-score of around - 2.9 for women lies below - 2.5, the mean hip FF FN T-score of around - 2.33 for men lies above - 2.5. This is likely associated with that older male populations have a higher mean T-score than older female populations. We propose a new category of low BMD status, osteofrailia, for older Caucasian men with T-score ≤  - 2 (T-score ≤  - 2.1 for older Chinese men) who are likely to suffer from hip FFx. The group with T-score ≤  - 2 for older Caucasian men is comparable in prevalence to the group with T-score ≤  - 2.5 for older Caucasian women. However, older men in such category on average have only half the FFx risk as that of older women with osteoporotic T-score.

Biomechanical Changes in Kyphotic Cervical Spine After Anterior Cervical Discectomy and Fusion with Different Degrees of Correction

Cervical kyphosis is a debilitating disease, and its surgical treatment involves correction to restore sagittal alignment. Few studies have explored the appropriate degree of correction, and the biomechanical impact of correction on the cervical spine is still unclear. This study aimed to compare the biomechanical changes in the cervical spine after different degrees of correction by two-level anterior cervical discectomy and fusion (ACDF). Three-dimensional finite element (FE) models of the intact cervical spine (C2-C7) with normal physiological lordosis and kyphosis were constructed. Based on the kyphotic model, three two-level ACDF in C4-6 surgical models were developed: (1) non-correction: only the intervertebral heights were restored; (2) partial correction: the cervical curvature was adjusted to straighten; (3) complete correction: the cervical curvature was adjusted to physiological lordosis. A pure moment of 1.0 Nm combined with a follower load of 73.6 N was applied to the C2 vertebra to simulate flexion, extension, lateral bending, and axial rotation. The stress of vertical bodies and facet joints, intradiscal pressure (IDP), and the overall ROMs of all models were computed. The peak von Mises stress on the upper (C4) and lower (C6) instrumented vertebral bodies in the kyphotic model was greater than that of the physiological lordosis model, with the exception of C6 under lateral bending. The maximum stress was observed in C4 during lateral bending after complete correction, which increased by 145% compared to preoperative von Mises stress. For the middle (C5) instrumented vertebral body, the peak von Mises stress increased after surgery. The maximum stress was observed in partial correction during flexion. Compared to physiological lordosis, the peak von Mises stress on the facet joints in kyphotic segments was lower; however, it was higher in the adjacent segments, except C4/5 in extension. The stress on the facet joints in kyphotic segments decreased, with the most significant decrease observed in partial correction. The IDPs in adjacent segments, except for C6/7 in flexion, showed no significant difference before and after surgery. Additionally, correction seemed to have little impact on IDPs in adjacent segments. In conclusion, for the treatment of cervical kyphosis with two-level ACDF, complete correction resulted in the highest peak von Mises stress on the upper instrumented vertebral body. Partial correction mitigated von Mises stress within the facet joints in kyphotic segments, albeit at the expense of high von Mises stress on the middle instrumented vertebral body.

Quantitative CT lumbar spine BMD cutpoint value for classifying osteoporosis among older Chinese men can be the same as that of older Chinese women, both much lower than the value for Caucasians

For older Caucasian women and men, the QCT (quantitative CT) lumbar spine (LS) bone mineral density (BMD) threshold for classifying osteoporosis is 80 mg/ml. It was recently proposed that, for older East Asian women, the QCT LS BMD value equivalent to the Caucasian women's threshold of 80 mg/mL is about 45∼50 mg/ml. For a data of 328 cases of Chinese men (age: 73.6 ± 4.4 years) who had QCT LS BMD and DXA LS BMD at the same time and with the DXA BMD value of ≤ 0.613 g/cm2 to classify osteoporosis, the corresponding QCT LS BMD threshold is 53 mg/ml. Osteoporotic-like vertebral fracture sum score (OLVFss) ≤ -2.5 has been proposed to diagnose osteoporosis. For 316 cases of Chinese men (age:73.7±4.5 years), OLVFss ≤ -2.5 defines an osteoporosis prevalence of 4.4%; to achieve this osteoporosis prevalence, the corresponding QCT LS BMD value is < 47.5 mg/ml. In the China Action on Spine and Hip Status study, a Genant grades 2/3 radiographic 'osteoporotic vertebral fracture' prevalence was 2.84% for Chinese men (total n = 1267, age: 62.77 ± 9.20 years); to achieve this osteoporosis prevalence, the corresponding BMD value was < 42.5 mg/ml. In a study of 357 Beijing older men, according to the clinical fragility fracture prevalence and femoral neck DXA T-score, the QCT LS BMD value to classify osteoporosis was between 39.45 mg/ml and 51.38 mg/ml. For older Chinese men (≥ 50 years), we recommend the cutpoint for the QCT LS BMD definition of osteoporosis to be 45∼50 mg/ml which is the same as the value for Chinese women.

Radiological diagnosis of prevalent osteoporotic vertebral fracture on radiographs: an interim consensus from a group of experts of the ESSR osteoporosis and metabolism subcommittee

When a low-energy trauma induces an acute vertebral fracture (VF) with clinical symptoms, a definitive diagnosis of osteoporotic vertebral fracture (OVF) can be made. Beyond that, a "gold" radiographic standard to distinguish osteoporotic from non-osteoporotic VFs does not exist. Fracture-shaped vertebral deformity (FSVD) is defined as a deformity radiographically indistinguishable from vertebral fracture according to the best of the reading radiologist's knowledge. FSVD is not uncommon among young populations with normal bone strength. FSVD among an older population is called osteoporotic-like vertebral fracture (OLVF) when the FSVD is likely to be associated with compromised bone strength. In more severe grade deformities or when a vertebra is collapsed, OVF diagnosis can be made with a relatively high degree of certainty by experienced readers. In "milder" cases, OVF is often diagnosed based on a high probability rather than an absolute diagnosis. After excluding known mimickers, singular vertebral wedging in older women is statistically most likely an OLVF. For older women, three non-adjacent minimal grade OLVF (< 20% height loss), one minimal grade OLVF and one mild OLVF (20-25% height loss), or one OLVF with ≥ 25% height loss, meet the diagnosis of osteoporosis. For older men, a single OLVF with < 40% height loss may be insufficient to suggest the subject is osteoporotic. Common OLVF differential diagnoses include X-ray projection artifacts and scoliosis, acquired and developmental short vertebrae, osteoarthritic wedging, oncological deformities, deformity due to high-energy trauma VF, lateral hyperosteogeny of a vertebral body, Cupid's bow, and expansive endplate, among others.

East Asians' T-scores for the diagnosis of osteoporosis should be calculated using ethnicity- and gender-specific BMD reference ranges: justifications

The 2013 ISCD consensus recommended a Caucasian female reference database for T-score calculation in men, which says "A uniform Caucasian (non-race adjusted) female reference database should be used to calculate T-scores for men of all ethnic groups." However, this statement was recommended for the US population, and no position was taken with respect to BMD reference data or ethnicity matching outside of the USA. In East Asia, currently, a Japanese BMD reference database is universally adopted in Japan for clinical DXA diagnosis, while both local BMD and Caucasian BMD reference databases are in use in Mainland China, South Korea, Taiwan, and Singapore. In this article, we argue that an ethnicity- and gender-specific BMD database should be used for T-score calculations for East Asians, and we list the justifications why we advocate so. Use of a Caucasian BMD reference database leads to systematically lower T-scores for East Asians and an overestimation of the prevalence of osteoporosis. Using a female BMD reference database to calculate T-scores for male patients leads to higher T-score values and an underestimation of the prevalence of osteoporosis. Epidemiological evidence does not support using a female BMD reference database to calculate T-scores for men. We also note that BMD reference databases collected in Asia should be critically evaluated for their quality.

Overloaded vertebral body: a unique radiographic phenomenon following multilevel anterior cervical discectomy and fusion

PURPOSE

Because previous studies have not focused on postoperative cervical collapse, the purpose of the present study was to introduce the overloaded vertebral body (OVB) phenomenon following multilevel zero-profile anterior cervical discectomy and fusion (ACDF) as well as to investigate its effects on radiographic outcomes.

METHODS

We conducted a retrospective study involving patients who underwent ACDF. A total of 55 patients were included in the analysis, including 110 OVB and 110 non-OVB. The evaluated vertebral parameters included the vertebral cross-sectional area (CSA), wedge angle (WA), vertebral height [anterior (AH) and posterior (PH)] and anterior-posterior vertebral diameter [upper (UD) and lower (LD)].

RESULTS

The CSA and WA were significantly lower in the OVB group than in the non-OVB group at 3, 6, and 12 months after surgery as well as at the final follow-up (p < 0.01). The AH of the OVB group was significantly lower at 3, 6, and 12 months after surgery as well as at the final follow-up compared to 1 week after surgery (p < 0.01).

CONCLUSIONS

OVB, a new phenomenon following multilevel ACDF, is defined as the cervical vertebral body located in the middle of the surgical segments in multilevel anterior cervical spine surgery. Statistical analysis of vertebral parameters, including CSA, WA, AH, PH, UD, and LD, showed that OVB occurs mainly at the anterior edge of the vertebra and that its largest radiographic manifestation is the loss of height at the anterior edge of the vertebra in the early postoperative period.

Conversion of osteoporotic-like vertebral fracture severity score to osteoporosis T-score equivalent status: A framework study for older Chinese men

Objectives

To define what portion of older community men with what severity of radiographic osteoporotic-like vertebral fracture (OLVF) correspond to what low T-score status.

Methods

There were 755 community Chinese men (age: 76.4 ± 6.7 years) with thoracic and lumbar spine radiographs, and hip and lumbar spine bone mineral density measures. For each vertebra in a subject, a score of 0, -0.5, -1, -1.5, -2, -2.5, and -3 was assigned for no OLVF or OLVF of <20%, ≥ 20-25%, ≥ 2 5%-1/3, ≥ 1/3-40%, ≥ 40%-2/3, and ≥ 2/3 vertebral height loss, respectively. OLVFss was defined as the summed score of vertebrae T4 to L5. OLVFss and T-scores were ranked from the smallest to the largest values.

Results

OLVFss of -2, -2.5, -3, corresponded to a mean femoral neck T-score of -2.297 (range: -2.355∼-2.247), -2.494 (range: -2.637∼ -2.363), and -2.773 (range: -2.898∼-2.643), a mean hip T-score of-2.311 (range: -2.420∼-2.234), -2.572 (range: -2.708∼-2.432), -2.911 (range: -3.134∼-2.708), a mean lumbar spine T-score of -2.495 (range: -2.656∼-2.403), -2.931 (range: -3.255∼-2.664), and -3.369 (range: -3.525∼-3.258). The Pearson correlation value of OLVFss and T-score of femoral neck, hip and lumbar spine was r = 0.21, 0.26, and 0.22 (all P < 0.0001).

Conclusions

A single severe grade radiological OLVF (≥ 40% height loss) or OLVFss ≤ -2.5 suggest the subject is osteoporotic, and a single collapse grade (≥ 2/3 height loss) OLVF or OLVFss ≤ -3 meets osteoporosis diagnosis criterion. The results highlight the difficulty of diagnosing osteoporotic vertebral fractures among Chinese older men.

Prevalence of osteoporosis and incidence of related fractures in developed economies in the Asia Pacific region: a systematic review

Robust data on osteoporosis in the Asia Pacific region could improve healthcare decision-making. Osteoporosis affects 10-30% of women aged 40 + , and up to 10% of men in 7 developed economies in Asia Pacific. Fractures affect 500-1000 adults aged 50 + per 100,000 person-years. Policymakers and clinicians must address this problem.

PURPOSE

Osteoporosis and associated fractures result in considerable morbidity, loss of productivity, early mortality, and increased healthcare expenses. Many countries in the Asia Pacific (AP) region, especially middle- and higher-income economies, are faced with aging and increasingly sedentary populations. It is critical to consolidate and analyze the available information on the prevalence and incidence of the disease in these countries.

METHODS

We systematically reviewed articles and gray literature for Australia, China, Hong Kong, Japan, Singapore, South Korea, and Taiwan. We searched PubMed, ScienceDirect, JSTOR, Cochrane, Google Scholar, and other databases for data published 2009-2018. We included articles with prevalence or incidence estimates for adults with osteoporosis or related fractures.

RESULTS

All locations had data available, but of widely varying quantity and quality. Most estimates for osteoporosis prevalence ranged from 10 to 30% for women ages 40 and older, and up to 10% for men. Osteoporotic fracture incidence typically ranged between 500 and 1000 per 100,000 person-years among adults aged 50 and older. Both outcomes typically increased with age and were more common among women.

CONCLUSION

Osteoporosis and associated fractures affect significant portions of the adult population in developed economies in the AP region. Governments and healthcare systems must consider how best to prevent and diagnose osteoporosis, and manage affected individuals, to reduce healthcare costs and mortality associated with fractures.

CT detects more osteoporotic endplate depressions than radiograph: a descriptive comparison of 76 vertebrae

This study analyzed elderly women who had chest radiograph and chest CT with indications other than spine disorders. Using CT images as reference, the study demonstrates that radiograph can miss a high portion of mild endplate depression. Detection of endplate depression is confounded by the limitation of projectional overlay for radiograph.

INTRODUCTION

The definition of radiographic OVF (osteoporotic vertebral fracture) remains controversial. Some authors suggest all OVFs should demonstrate endplate fracture/depression on radiograph. Using CT image as the reference, our study tests the hypothesis that a considerable portion of endplate depressions not seen on radiograph can be detected on CT.

METHODS

We retrospectively analyzed 46 female cases (age: 67-94 years) who had both chest radiography and chest CT with indications other than spine disorders. Sixty-six "vertebrae of interest" were identified on radiograph; then, CT images were read side-by-side with lateral chest radiograph.

RESULTS

Thirty-eight vertebrae (38/66) had anterior wedging deformity with height loss of < 20% while without radiographic endplate depression. Among them, 28 vertebrae had endplate depression and 8 vertebrae had no endplate depression on CT, while 2 vertebrae with "very" minimal deformity were read as normal on CT. In 9 vertebrae (9/66) with anterior wedging and height loss of ≥ 20%, all had additional endplate depression seen on CT. Five vertebrae (5/66) had ambiguous endplate depression on radiograph, 3 had endplate depression on CT while the other 2 vertebrae in one patient were false positive due to X-ray projection. There were 14 short height vertebrae (14/66) where middle and anterior heights were reduced to the same extent while did not show apparent anterior wedging or bi-concaving. Four cases each had one short height vertebra, and all had endplate depression on CT. Another 4 cases had 2, 2, 3, and 3 adjacent short height vertebrae, respectively, and all did not show endplate depression on CT. In addition, inspection of spine CT showed 10 vertebrae in 9 cases appeared normal on radiograph while demonstrated endplate depression on CT.

CONCLUSION

With CT images as reference, radiograph can miss a high portion of mild endplate depressions.

Prevalence of Vertebral Fractures in Adults With Type 1 Diabetes: DenSiFy Study (Diabetes Spine Fractures)

CONTEXT

Vertebral fracture (VF) prevalence up to 24% has been reported among young people with type 1 diabetes (T1D). If this high prevalence is confirmed, individuals with T1D could benefit from preventative VF screening.

OBJECTIVE

We compared the prevalence of VFs between adults with T1D and nondiabetic controls.

METHODS

This cross-sectional study included 127 adults with T1D, and 65 controls with a similar age, sex, and BMI distribution, from outpatient clinics of 2 tertiary care centers. Vertebral fracture assessment (VFA) by dual-energy x-ray absorptiometry (DXA) was used for prevalent VFs. The modified algorithm-based qualitative (mABQ) method was applied. Bone mineral density (BMD) and trabecular bone score (TBS) were assessed by DXA. Serum bone turnover markers and sclerostin were measured in a subgroup of participants.

RESULTS

Participants with T1D (70 women, 57 men) had a mean age of 42.8 ± 14.8 years, median diabetes duration of 25.8 (15.8-34.4) years, mean BMI of 26.6 ± 5.4 kg/m2 and mean HbA1c over the past 3 years of 7.5 ± 0.9%. Controls (35 women, 30 men) had mean age of 42.2 ± 15.9 years and mean BMI of 26.1 ± 5.1 kg/m2. VF prevalence was comparable between groups (2.4% vs 3.1%, P = 0.99). TBS, BMD at the total hip and femoral neck, and bone formation and resorption markers were lower while sclerostin levels were similar in participants with T1D vs controls.

CONCLUSION

Our VFA results using the mABQ method do not confirm increased prevalence of VFs in men and women with relatively well-controlled T1D.

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.

'Healthier Chinese spine': an update of osteoporotic fractures in men (MrOS) and in women (MsOS) Hong Kong spine radiograph studies

For the MrOS (Hong Kong) and MsOS (Hong Kong) baseline (BL) studies, community-dwelling 2,000 Chinese men (mean age: 72.3 years) and 2,000 Chinese women (mean age: 72.5 years) were recruited from 2001 to 2003. These two studies have spanned two decades till now. This review summarizes our spine radiograph results. Senile and post-menopausal osteoporosis were associated with intervertebral disc volume reduction; and in women, menopause accelerates disc degeneration. Elderly women's osteoporotic vertebral fracture (OVF) prevalence was double of that of elderly men. For year-4 follow-up (FU), male participants with BL OVF had little increased risk for further OVF. In our study comparing OVF rates in age-matched Hong Kong Chinese women and Italian Caucasian women (mean age: 74.1 years), endplate and/or cortex fracture (ECF) prevalence was 26% for Chinese and 47% for Italian. OVF with ≥40% vertebral height loss was recorded among 9.5% of the Chinese subjects while among 26% of the Italian subjects. OVFs in Italian subjects were more likely to be multiple and generally severer. Clinical spine fractures were recorded 133 cases/100,000 person-years in MrOS (Hong Kong) participants and 273 cases/100,000 person-years in MsOS (Hong Kong) participants. Literature review suggests the clinical vertebral fracture rates among elderly Hong Kong Chinese subjects are approximately half of those of American, Australian, and Canadian subjects. Data synthesis suggests elderly Caucasians have a higher degenerative spondylolisthesis prevalence, being approximately 70% higher than that of elderly Hong Kong Chinese. Literature review of other authors' publications shows, compared with Caucasians, Chinese have a much lower incident rate of back pain. We conclude that elderly Chinese have a generally healthier spine relative to elderly Caucasians.

High prevalence of osteoporosis in patients undergoing spine surgery in China

Background

With the increase in life expectancy, a large number of patients with osteoporosis (OP) are undergoing spine surgery, which may adversely affect the surgical success rate. The prevalence of OP varies in different regions, and no data are available that represent the prevalence of OP among Chinese patients over 50 years of age who are undergoing spine surgery. It was the first multicenter study to assess OP in these patients. Aiming to obtain comprehensive data, this study combined bone mineral density (BMD) measurements and visual radiography assessment (VRA) to analyze the prevalence of OP in patients aged > 50 years who underwent spine surgery.

Methods

Data from 1,856 patients aged over 50 years undergoing spine surgery who resided in northern, central, and southern China were reviewed between 2018 and 2019. Based on the perioperative BMD and X-ray data, we calculated the prevalence of OP in this special population according to sex, age, and spine degenerative disease.

Results

A total of 1,245 patients (678 females and 567 males) were included in the study. The prevalence of OP diagnosed by BMD was 52.8 % in females and 18.7 % in males. When we combined with BMD and VRA, the prevalence of OP increased from 52.8 to 65.9 % in females and from 18.7 to 40.6 % in males. Although OP was more severe in females than in males, a significant difference in the rate of vertebral fracture (VF) was not observed between females and males with a normal BMD and osteopenia (females vs. males: aged 50–59 years, P = 0.977; 60–69 years, P = 0.302; >70 years, P = 0.172). Similarly, no significant difference in the vertebral fracture rate was observed within different age groups of patients with a normal BMD and osteopenia (females: P = 0.210; males, P = 0.895). The incidence of OP in patients with degenerative scoliosis was higher than that in the remaining patients (females: 63.6 % vs. 42.4 %, P = 0.018; males: 38.9 % vs. 13.8 %, P = 0.004).

Conclusions

A high prevalence of OP was identified in patients aged > 50 years undergoing spine surgery, especially in patients whose primary diagnosis was degenerative scoliosis. BMD and VRA evaluations should be included in the clinical routine for these patients prior to surgery.

Radiological features of traumatic vertebral endplate fracture: an analysis of 194 cases with 263 vertebral fractures

BACKGROUND

The importance of identifying osteoporotic vertebral endplate or/and cortex fracture (ECF), which primarily includes endplate fracture (EPF) and vertebral anterior cortex buckling, has been recognized. However, some old traumatic ECFs with healing process in the elderly may be mistaken as osteoporotic. This study analyzes the radiological features of traumatic EPF.

METHODS

This was a retrospective analysis of 194 spine trauma patients with 263 vertebral fractures (mean age: 42.11 ± 9.82 years, 118 males and 76 females). All patients had traumatic EPF identified by X-ray/CT/MRI.

RESULTS

The involved vertebra was mostly L1 (29.7%), followed by T12 and L2. Except EPFs involved both superior and inferior endplates (12.6%), only 1.9% involved inferior endplate alone, with the majority involved superior endplate. If each endplate was divided into five segments of equal lengths (from anterior to posterior: a1, a2, m, p2, p1), the most depressed point of superior EPFs was mostly at segment-a2 (approximately 45%), followed by segment-a1 (approximately 20%) or segment-m (approximately 20%), and very rarely at segment-p1. The upper 1/3 of anterior vertebral wall was more likely to fracture, followed by middle 1/3 of anterior wall. For posterior vertebral wall fracture, 68.5% broke the bony wall surrounding the basivertebral vain. 58.6%, 30.0%, and 11.4% of vertebral fractures had <1/5, 1/5-1/3, and >1/3 vertebral body height loss. As the extent of vertebral height loss increased, the chance of having both superior and inferior EPFs also increased; however, the chance of having inferior EPF alone did not increase.

CONCLUSION

Traumatic EPF features are characterized, which may help the differentiation of traumatic and osteoporotic EPFs.

Improving osteoporotic vertebral deformity detection on chest frontal view radiograph by adjusted X-ray beam positioning

Purpose

In clinics, chest frontal view radiograph (CFR) is often taken for patients suspected of respiratory diseases and for assessing the heart and big vessels. CFR can be utilised to opportunistically detect osteoporotic vertebral fracture (OVF). However, for standard CFR, the site of highest OVF prevalence, i.e., the thoracolumbar junction, is usually 'off-centre' to the X-ray beam focus. This study tested the hypothesis that, if a CRF is taken with approximately two vertebrae lower than the standard X-ray beam positioning, the visualization of thoraco-lumbar junction can be much improved.

Materials

Four hospitals (A, B, C, D) provided 101 elderly women's digital CFRs with standard filming (28, 20, 24, and 21 cases respectively). Eighty four elderly female patients were prospectively recruited from hospitals-A and B, who were consecutive patients referred for chest radiograph with indications other than spine disorders. For theses prospective CFRs, the focus of X-ray beam was adjusted from towards vertebra T6 to towards T8, and standard lateral radiographs were obtained for reference. Visibility of spine and detectability of OVF were assessed on the CFRs. OVF was diagnosed based on chest lateral radiograph (CLR) after excluding other potential causes both radiographically and clinically.

Results

For standardly filmed CFR, spine readability was similar among those from Hospitals-A, B, and C, while performed less well for those from Hospital-D. With the prospective cases from Hospitals-A and B, spines readable to vertebra L1 level or lower increased from 48.2% for standard filming to 80.7% for adjusted filming. Spines with 'blurry' labelling decreased from 35.7% for standard filming to 15.7% for adjusted filming. For the 84 prospective cases, 42.9% (36/84) of the patients had OVF, and 26 cases of CLR positive cases were detected as having vertebral deformity on CFR. For minimal OVF cases (<20% height loss), 38% (5/13) were detected on CFR. Among 22 cases with apparent OVF (≥20% height loss), two cases were missed on CFR. False positivity was labelled in five cases, among them four cases had 'burry' spines.

Conclusion

CFR can help opportunistically detect OVF, which can be further improved if X-ray beam is adjusted to towards vertebra T8 instead of towards vertebra T6.

The translational potential of this article

This study confirms that CFR can help detect OVF opportunistically, and the visibility of the mid/lower thoracic spine and thoracolumbar junction can be much improved after minor adjustment of X-ray beam positioning. This study also suggests high positive rate of OVF in elderly Chinese female patients indicated for chest radiograph. Radiologists should be trained and sensitized in vertebral deformity identification on CFR as the clinical management can be improved by opportunistic detection of OVF.

Vertebral fracture: epidemiology, impact and use of DXA vertebral fracture assessment in fracture liaison services

Vertebral fractures are independent risk factors for vertebral and nonvertebral fractures. Since vertebral fractures are often missed, the relatively new introduction of vertebral fracture assessment (VFA) for imaging of the lateral spine during DXA-measurement of the spine and hips may contribute to detect vertebral fractures. We advocate performing a VFA in all patients with a recent fracture visiting a fracture liaison service (FLS). Fracture liaison services (FLS) are important service models for delivering secondary fracture prevention for older adults presenting with a fragility fracture. While commonly age, clinical risk factors (including fracture site and number of prior fracture) and BMD play a crucial role in determining fracture risk and indications for treatment with antiosteoporosis medications, prevalent vertebral fractures usually remain undetected. However, vertebral fractures are important independent risk factors for future vertebral and nonvertebral fractures. A development of the DXA technology, vertebral fracture assessment (VFA), allows for assessment of the lateral spine during the regular DXA bone mineral density measurement of the lumbar spine and hips. Recent approaches to the stratification of antiosteoporosis medication type according to baseline fracture risk, and differences by age in the indication for treatment by prior fracture mean that additional information from VFA may influence initiation and type of treatment. Furthermore, knowledge of baseline vertebral fractures allows reliable definition of incident vertebral fracture events during treatment, which may modify the approach to therapy. In this manuscript, we will discuss the epidemiology and clinical significance of vertebral fractures, the different methods of detecting vertebral fractures, and the rationale for, and implications of, use of VFA routinely in FLS. • Vertebral fracture assessment is a tool available on modern DXA instruments and has proven ability to detect vertebral fractures, the majority of which occur without a fall and without the signs and symptoms of an acute fracture. • Most osteoporosis guidelines internationally suggest that treatment with antiosteoporosis medications should be considered for older individuals (e.g., 65 years +) with a recent low trauma fracture without the need for DXA. • Younger individuals postfracture may be risk-assessed on the basis of FRAX® probability including DXA and associated treatment thresholds. • Future fracture risk is markedly influenced by both site, number, severity, and recency of prior fracture; awareness of baseline vertebral fractures facilitates definition of true incident vertebral fracture events occurring during antiosteoporosis treatment. • Detection of previously clinically silent vertebral fractures, defining site of prior fracture, might alter treatment decisions in younger or older FLS patients, consistent with recent IOF-ESCEO guidance on baseline-risk-stratified therapy, and provides a reliable baseline from which to define new, potentially therapy-altering, vertebral fracture events.

Interpretation of osteoporotic vertebral deformity on frontal view radiographs of the chest and abdomen: a pictorial review

Osteoporotic vertebral fracture (OVF) has high prevalence in the elderly population. It affects at least one-fourth of all postmenopausal women and is commonly seen among women approximately one decade after menopause. A vertebral fracture, after minor trauma, is a hallmark of osteoporosis. Many fractures and associated complications, including secondary fractures and mortality, can be prevented by routine osteoporosis screening in older people and timely treatment initiation in at-risk individuals. Depending on the technical condition of the radiographs, a substantial portion of moderate to severe grades OVFs in mid-thoracic and lower thoracic spine as well as lumbar spine can be detected on a frontal view digital radiograph of the chest or abdomen. Radiologists should pay attention to the potential existence of an OVF while reading chest and abdominal radiographs of elderly female subjects. In this pictorial review, we describe our experience in evaluating the normal shaped and deformed vertebrae on chest and abdominal radiographs.

Elderly men have much lower vertebral fracture risk than elderly women even at advanced age: the MrOS and MsOS (Hong Kong) year 14 follow-up radiology results

MrOS MsOS (Hong Kong) studies year 14 follow-up shows for subjects without baseline osteoporotic vertebral deformity, women's incident vertebral fracture (VF) rate was twice that of men. For subjects with vertebral deformity of baseline ≥ 20% height loss, counting subject, women's incident VF rate was three times higher than that of men.

INTRODUCTION

For MrOS MsOS (Hong Kong) baseline (BL) studies, 2000 men and 2000 women ≥ 65 years were recruited during 2001 to 2003. This study presents the year 14 follow-up (FU).

MATERIALS

Whole spine MRI was performed in 271 males (mean, 82.8 ± 3.6 years) and 150 females (mean, 82.0 ± 4.29 years). Osteoporotic vertebral deformity (OVD) classification included no OVD (grade 0), and OVDs with < 20%, 20~25%, > 25%~1/3, > 1/3~40%, > 40%~2/3, and > 2/3 height loss (grade 1~6). With an existing VD, a further height loss of ≥ 15% was a VD progression. A new incident VD was a change from grade 0 to ≥ grade 2 or to grade 1 with ≥ 10% height loss. OVD progression and new incident OVD were considered incident VF.

RESULTS

The proportion of osteoporotic subjects only slightly increased during FU for men but doubled for women. Groupwise, OVD was not associated with back pain in men; but OVD with > 1/3 height loss was associated with back pain in women. For subjects without BL OVD, 7.9% of men and 14.6% of women had incident VF. For subjects with BL OVD of ≥ 20% height loss, men's and women's incident VF were 17.6% and 52.6%, respectively, counting subject and 1.68% and 7.89%, respectively, counting vertebra.

CONCLUSION

Elderly men with or without existing osteoporotic VD have much lower future VF risk than elderly women.

Radiographic osteoporotic vertebral fractures in elderly men: a brief review focusing on differences between the sexes

Bone loss occurs in both sexes as a result of ageing but is exacerbated in women by the hormonal changes associated with menopause. Unlike in women, secondary osteoporosis occurs in almost half of men diagnosed with osteoporosis. Moreover, vertebral fractures (VFs) seen in elderly men may more likely be the result of high energy trauma. The osteoporotic vertebral fracture (OVF) radiograph diagnosis criteria for women may not be directly applicable for men. Particular attention should be paid to the mid-thoracic level where over-diagnosis commonly occurs. For wedge-shaped vertebral deformities (VDs) or VDs with anterior height reduction only, a diagnosis of OVF requires great caution, as they are poorly correlated to bone mineral density (BMD). For age-matched subjects, it is likely that elderly men's prevalent radiographic OVFs are approximately half of the elderly women's. This male-female ratio is very similar to other clinical fractures such as those occurring at the hip. Even so, the clinical relevance of OVF in elderly men may be less than that of elderly women. On the other hand, for elderly men with hip BMD-based osteoporosis, the OVF risk is as high as that of osteoporotic women. Elderly Chinese men have a lower OVF prevalence than age-matched Caucasian men.

Traumatic vertebral fractures involve the anterior end plate more than the posterior end plate: A retrospective study

Traumatic end plate fractures (EPFs) refers to the EPF caused by trauma, rather than the pathological status of the end plate (EP). However, some old traumatic EPFs may be mistaken as osteoporotic in the elderly. The objective of this study is to describe the radiological features of traumatic EPF in different traumatic fracture type patients presenting in the Emergency department setting. And to compare the result with osteoporotic vertebral fracture (VF).This study retrospectively analyzed the anatomical location of acute thoracolumbar vertebral traumatic EPFs in males (age≤55 years) and females (age≤50 years). The anatomic distribution of EPFs, the anterior and posterior wall fracture were analyzed in patients, who were scanned with 1 or more of the following methods: radiography, CT, and magnetic resonance imaging.There were 194 cases of acute spine trauma involving at least 1 EPF, including 118 males and 76 females. The involved vertebra was mostly at L1 (29.7%), followed by T12 (18.3%), and then by L2 (12.9%). Excluding those with both upper and lower EP involvements, the ratio of superior EPF to inferior EPF was 33.5 for males and 45.5 for females. With the EP divided into 5 segments of equal length in the anteroposterior direction in different fracture types, fractures occurred mostly at a2 segment (71.48% for superior EPs and 7.60% for inferior EPs), followed by a1 segment (66.16% for superior EPs). The upper third of the anterior and posterior walls were most prone to fracture in traumatic vertebral fracture.Traumatic EPFs more likely involve the anterior EP more than the posterior EP and is correlated with fracture type. These characteristics may help radiologist differential diagnosis between traumatic and osteoporotic EPF.

Vertebral Fractures: Which Radiological Criteria Are Better Associated With the Clinical Course of Osteoporosis?

STUDY PURPOSE

Morphometric methods categorize potential osteoporotic vertebral fractures (OVF) on the basis of loss of vertebral height. A particular example is the widely used semiquantitative morphometric tool proposed by Genant (GSQ). A newer morphologic algorithm-based qualitative (mABQ) tool focuses on vertebral end-plate damage in recognizing OVF. We used data from both sexes in the Canadian Multicentre Osteoporosis Study (CaMos) to compare the 2 methods in identifying OVF at baseline and during 10 years of follow-up.

MATERIALS AND METHODS

We obtained lateral thoracic and lumbar spinal radiographs (T4-L4) 3 times, at 5-year intervals, in 828 participants of the population-based CaMos. Logistic regressions were used to study the association of 10-year changes in bone mineral density (BMD) with incident fractures.

RESULTS

At baseline, 161 participants had grade 1 and 32 had grade 2 GSQ OVF; over the next 10 years, only 9 of these participants had sustained incident GSQ OVF. Contrastingly, 21 participants at baseline had grade 1 and 48 grade 2 mABQ events; over the next 10 years, 79 subjects experienced incident grade 1 or grade 2 mABQ events. Thus, incident grades 1 and 2 morphologic fractures were 8 times more common than morphometric deformities alone. Each 10-year decrease of 0.01 g/cm² in total hip BMD was associated with a 4.1% (95% CI: 0.7-7.3) higher odds of having an incident vertebral fracture.

CONCLUSIONS

This analysis further suggests that morphometric deformities and morphologic fractures constitute distinct entities; morphologic fractures conform more closely to the expected epidemiology of OVF.

Recognizing osteoporotic vertebral deformity on frontal view radiograph: a cohort analysis and a pictorial review

PURPOSE

Opportunities exist to detect osteoporotic vertebral deformities (VDs) on frontal radiograph (FR) indicated for lung or abdominal diseases, while literature have been mostly based on lateral radiograph (LR). This study analyzed the detectability of moderate and severe grades VD on FR.

METHODS

There were 105 female cases (mean 72 years, range 55~93 year), who were referred for digital spine FR and LR with back and/or leg pain. The LR and FR were read, osteoporotic VDs with < 20%, 20-25%, 25-40%, and > 40% vertebral body height loss were recorded as minimal, mild, moderate, and severe grades, respectively. After a 10-month interval, only FRs were read again, and each vertebra was classified as (1) no notable VD, (2) with notable VD, and (3) ambiguous. The first reading was the reference, while the second reading was allowed to miss minimal/mild VCD and endplate/cortex fracture.

RESULTS

Counting by subjects, for 98 cases, the two reading sessions had agreement, including 43 "true negative" cases and 55 true positive cases. There were two false positive cases, and five ambiguous cases. In total, 1286 vertebra were assessed, FR reading had 1126 vertebrae "true negative," 130 vertebrae true positive, one vertebra false negative, 3 vertebrae false positive, and 26 ambiguous vertebrae (65.4% being true negative and 34.6% being true positive). Most of the disagreements were associated with kyphosis or poor X-ray projection. Nineteen illustrative cases are presented graphically.

CONCLUSION

Moderate and severe grades of VD are identifiable on FR as long as the involved vertebrae are clearly filmed.

Semi-quantitative grading and extended semi-quantitative grading for osteoporotic vertebral deformity: a radiographic image database for education and calibration

The Genant’s semi-quantitative (GSQ) criteria is currently the most used approach in epidemiology studies and clinical trials for osteoporotic vertebral deformity (OVD) evaluation with radiograph. The qualitative diagnosis with radiological knowledge helps to minimize false positive readings. However, unless there is a face-to-face training with experienced readers, it can be difficult to apply GSQ criteria by only reading the text description of Genant et al. (in 1993), even for a musculoskeletal radiologist. We propose an expanded semi-quantitative (eSQ) OVD classification with the following features: (I) GSQ grade-0.5 is noted as minimal grade (eSQ grade-1) for OVDs with height loss <20%; (II) GSQ mild grade (grade-1) is the same as eSQ mild grade (grade-2); (III) GSQ moderate grade (grade-2) is subdivided into eSQ grade-3 (moderate, >25%–1/3 height loss) and eSQ grade-4 (moderately-severe, >1/3–40% height loss); (IV) GSQ severe grade is subdivided into eSQ grade-5 (severe, >40%–2/3 height loss) and eSQ grade-6 (collapsed, with >2/3 height loss). We advocate to estimate vertebral height loss with adjacent vertebral heights as the reference (rather than using individual vertebra’s posterior height as the reference). This article presents radiographs of 36 cases with OVD, together with gradings using GSQ criteria and eSQ criteria. The examples in this article can serve as teaching material or calibration database for readers who will use GSQ criteria or eSQ criteria. Our approach for quantitative measurement is explained graphically.

Corrigendum to how to define an osteoporotic vertebral fracture

[This corrects the article DOI: 10.21037/qims.2019.09.10.].

Elderly males with or without existing osteoporotic vertebral fracture have much lower future vertebral fracture risk than elderly females: the MrOS (Hong Kong) year-4 follow-up spine radiograph study

MrOS (Hong Kong)'s year-4 follow-up shows, for subjects at baseline without vertebral deformity (VD) and endplate or/and cortex fracture (ECF), the VD progression/new VD rate during follow-up in males was half of our paired MsOS (Hong Kong) study's results. For those with VD or ECF, the VD progression/new VD was less than one sixth of females' rate.

INTRODUCTION

This study documents MrOS (Hong Kong)'s year-4 follow-up, and the results are compared with the MsOS (Hong Kong) study. Of elderly females with Genant's grade-0, -1, -2, and -3 VD, at year-4 follow-up, 4.6%, 8%, 10.6%, and 28.9% had at least one VD progression or incident VD, respectively.

METHODS

Spine radiographs of 1500 Chinese males with baseline (mean age 71.7 years, range 65-91 years) and year-4 follow-up were evaluated according to Genant's VD criteria and ECF (non-existent, ECF0; or existent, ECF1). Grade-2 VDs were divided into mild (VD2m, 25-34% height loss) and severe (VD2s, 34-40% height loss) subgroups. Study subjects were graded into eight categories: VD0/ECF0, VD1/ECF0, VD2m/ECF0, VD0/ECF1, VD1/ECF1, VD2m/ECF1, VD2s/ECF1, and VD3/ECF1. With an existing VD, a further height loss of ≥ 15% was a VD progression. A new VD incident was a change from grade-0 to grade-2/3, or to grade-1 with ≥ 10% height loss.

RESULTS

Of subjects with Genant's grade-0, 2.05% (25/1219) developed at least one VD progression or/and new VD, while of subjects with Genant's grade-1, -2, and -3 VD, only 2% (3/149), 3.1% (3/96), and 2.8% (1/36) developed at least one VD progression/new VD, respectively. Among the three ECF0 groups, there was a significant difference in new ECF incidence, with VD0/ECF0 being the lowest and VD2m/ECF0 being the highest.

CONCLUSION

VD progression/new VD is much less common in elderly men than in elderly women. Vertebrae with VD had a higher risk of developing ECF.

Underreporting characteristics of osteoporotic vertebral fracture in back pain clinic patients of a tertiary hospital in China

Aim

Osteoporotic vertebral compressive fractures (VCFs) ​are known to be commonly missed in X-rays indicated for pulmonary or heart diseases. In this study, we investigated the underreporting status of VCF in back pain clinic patients when the spine was the focus of interest.

Materials and methods

This is a retrospective analysis of 105 female cases (mean: 72 years, range: 55–93 years) from a tertiary hospital in China (facility A, FA). The patients with back and/or leg pain were referred for a spine X-ray. The images were retrieved and transferred to a central reading facility (facility B, FB), where images were double-read by two readers experienced in evaluating osteoporotic vertebral compressive deformity (VCD)/VCF. A qualitative VCD with <20%, 20–25%, 25–40%, and >40% vertebral body height loss was recorded as minimal, mild, moderate, and severe grades, respectively. A ​VCD coexisted with endplate/cortex fracture (ECF) was VCF. FB readings were considered as the reference.

Results

There were 34 true negative cases where FA and FB had a consensus. In 7 cases with minimal VCD, 3 cases with ECF, and 7 cases with minimal or mild VCFs, the FA readings were false negative. No standalone singular moderate or severe VCD/VCF in a patient was missed in FA's reports. In 25 FA reading positive cases with multiple VCFs, one VCF was missed in 8 cases, more than one VCF was missed in 15 cases, and one additional ECF was missed in 2 cases. In 14 cases, FA and FB had VCF number agreement, with the term ‘vertebral fracture’ was used appropriately in FA reports. In 15 cases, FA and FB had agreement in VCF number; however, the appropriate term ‘vertebral fracture’ was not used in FA reports; instead the terms of ‘compressive change’ or ‘wedging change’ were used. In most VCFs, severity grading was not given in FA. In 13 VCFs where grading was reported, all were marked as ‘mild’, including seven mild VCFs, five moderate VCFs, and even one severe VCF.

Conclusion

Among the patients with VCD/VCF, the false negative rate among was 23.9% (17/71), but the missed cases were all minimal or mild grades. One or more VCFs were missed in 32.4% (23/71) of the cases with multiple VCFs. Appropriate severity grading was not reported for most cases.

The translational potential of this article

The underreporting rate of osteoporotic vertebral compressive fracture in back pain clinic patients in a typical tertiary hospital setting in China compared favorably with literature reports. However, there is a general lack of awareness of vertebral endplate/cortex fracture sign and vertebral fracture severity grading, while minimal and mild VCD with endplate/cortex fracture may have clinical significance. Moreover, after one VCF is spotted in a patient, it is highly advisable to carefully check the whole spine so that multiple VCFs will not be missed.

How to define an osteoporotic vertebral fracture?

A vertebral deformity (VD) is not always a vertebral fracture (VF). Because of lack of a completely satisfactory "gold standard", there is no consensus on the exact definition of a VF. Therefore, it may sometimes be difficult, especially in mild cases, to discriminate the prevalent VF from a non-fracture deformity or short vertebral height (SVH). A combined standardized approach based on qualitative and semiquantitative (SQ) vertebral assessment may be the most option to correctly identify a VD as a VF. However this visual approach for VF identification is subjective, therefore it is mandatory an adequate training and experience of radiologist to reach a good sensitivity and specificity. Vertebral morphometry, objective and reproducible method, could be used only to evaluate the severity of VFs but requires the availability of reference values of vertebral height ratios. There is actually an evidentiary basis for suggesting that a qualitative approach by expert radiologists to morphological vertebral assessment, combined SQ and morphometric methods seem to be the preferred option for the correct diagnosis of VF as endplate or/and cortex fracture (ECF) or severe vertebral height loss.

Osteoporotic vertebral deformity with endplate/cortex fracture is associated with higher further vertebral fracture risk: the Ms. OS (Hong Kong) study results

Compared with vertebrae without deformity, vertebrae with mild/moderate deformity have a higher risk of endplate or/and cortex fracture (ecf). Compared with subjects without ecf, subjects with ecf are at a higher risk of short-term (4-year period) deformity progression and new incident deformity.

INTRODUCTION

The progression and incidence of osteoporotic vertebral deformity/fracture (VD/VF) in elderly Chinese females remain not well documented.

METHODS

Spine radiographs of 1533 Chinese females with baseline and year-4 follow-up (mean age 75.7 years) were evaluated according to Genant's VD criteria and endplate/cortex fracture (non-existent: ecf0 or existent: ecf1). Grade-2 VDs were divided into mild (vd2m, 25-34% height loss) and severe (vd2s, 34-40% height loss) subgroups. According to their VD/VF, subjects were graded into seven categories: vd0/ecf0, vd1/ecf0, vd2m/ecf0, vd1/ecf1, vd2m/ecf1, vd2s/ecf1, and vd3/ecf1. With an existing VD, a further height loss of ≥ 15% was a VD progression. A new incident VD was a change from grade-0 to grade-2/3 or to grade-1 with ≥ 10% height loss.

RESULTS

Of subjects with Genant's grades 0, - 1, - 2, and - 3 VD, at follow-up, 4.6%, 8%, 10.6%, and 28.9% had at least one VD progression or new incident VD respectively. Among the three ecf0 groups, there was no difference in VD progression or new VD; while there was a significant difference in new ecf incidence, with vd0/ecf0 being lowest and vd2m/ecf0 being highest. Vd1/ecf0 and vd2m/ecf0 vertebrae had a higher risk of turning to ecf1 than vd0/ecf0 vertebrae. If vd1/ecf0 and vd2m/ecf0 subjects were combined together (range 20-34% height loss) to compare with vd1/ecf1 and vd2m/ecf1 subjects, the latter had significantly higher VD progression and new VD rates.

CONCLUSION

Vertebrae with grade-1/2 VDs had a higher risk of developing ECF. Subjects with pre-existing ECFs had a higher risk of worsening or new vertebral deformities.

The Radiology of Osteoporotic Vertebral Fractures Revisited

Until recently there has been little evidence available to validate any method by which to make an accurate diagnosis of an osteoporotic vertebral fractures (OVFs) from plain radiographs. In part this reflects a lack of a completely satisfactory "gold standard," but primarily it relates to the absence of well-designed prospective studies in this context. Historically, OVFs were recognized by evidence of macroscopic structural failure in vertebrae using the criteria applied elsewhere in the skeleton. This comprised altered alignment, fragmentation, cortical disruptions, and breaks, among other changes. However, these morphological criteria were replaced by vertebral morphometry, referring to the use of quantitative or quasi-quantitative measurement tools for fracture diagnosis. Vertebral morphometry emerged as an understanding of and treatment for osteoporosis evolved, mainly in response to the need for expeditious assessments of large numbers of spine images for epidemiological and pharmaceutical purposes. Although most of the descriptions of such morphometric tools have stressed that they were not to be applied to clinical diagnosis with respect to individual patients, this constraint has been widely disregarded. Here we review the major attempts to develop a diagnostic strategy for OVF and describe their characteristics in adults and children. Recent evidence suggests that morphometric (quantitative; ie, based on measurement of dimensions and shape description) criteria are inferior to morphologic (qualitative; ie, based on structural integrity) vertebral damage assessment in identifying people with low bone density and at an increased risk of future fracture. Thus there is now an evidentiary basis for suggesting that morphological assessment is the preferred strategy for use in diagnosing OVF from radiographs. © 2019 American Society for Bone and Mineral Research.

Prevalent osteoporotic vertebral fractures more likely involve the upper endplate than the lower endplate and even more so in males

Background

While the importance of identifying osteoporotic vertebral endplate fracture (EPF) is being recognized; the pathophysiological understanding of EPF till now remain insufficient. In this population-based cross-sectional radiograph study, we aim to investigate the anatomic location characteristics of osteoporotic EPF.

Methods

This study analyzed the anatomical location of osteoporotic EPFs in elderly Chinese population (age ≥65 years). The T4-L4 radiographs of 1,954 elderly Chinese men (mean: 72.3 years) and 1,953 elderly Chinese women (mean: 72.5 years) were evaluated to identify EPF, and vertebral bodies were graded according to Genant's vertebral deformity criteria.

Results

Of the 101,582 endplates analyzed, there were 505 EPFs (males: 27.7%; females: 72.3%). Excluding those with both upper endplate and lower endplate involvements, the ratio of upper EPF to lower EPF was 9.63 for males and 4.3 for females (P<0.05). Thoracolumbar junction, particularly L1 (26.4% for males and 24.1% for females) and followed by T12 (20.7% for males and 19.7% for females), had highest prevalence of EPF. With an endplate divided into 5 segments of equal length in the anteroposterior direction and grade 0.5 & 1, grade 2 vertebral deformities analyzed, fractures occurred mostly at the middle segment (70.1% for upper endplates in males and 78.6% for upper endplates in females), followed by second anterior segment (20.9% for upper endplates in males and 14.4% for upper endplates in females). The most anterior and most posterior segments were not primarily involved in EPF.

Conclusions

Osteoporotic EPFs more likely involve the upper endplate rather than lower endplate, with a trend for this effect to be greater in men than in women. These characteristics may help radiographic differential diagnosis for osteoporotic EPF.

Osteoporotic vertebral endplate and cortex fractures: A pictorial review

Despite years' research, the radiographic criteria for osteoporotic vertebral fracture and its grading remain debated. The importance of identifying vertebral endplate/cortex fracture (ECF) is being recognised; however, evaluation of osteoporotic ECF requires training and experience. This article aims to serve as a teaching material for radiologists/physicians or researchers to evaluate osteoporotic ECF. Emphasis is particularly dedicated to identifying ECF that may not be associated with apparent vertebral body collapse. We suggest a combined approach based on standardised radiologic evaluation by experts and morphometry measurement is the most appropriate approach to detect and classify osteoporotic vertebral fractures.

The translational potential

A good understanding of radiologic anatomy of vertebrae and fracture signs of endplate/cortex are essential for spine fragility fracture assessment.