Measurement of Trabecular Bone Score of the Spine by Low-Dose Imaging System (EOS®): A Feasibility Study.

Purpose/Introduction: Measurement of trabecular bone score (TBS®) of the lumbar spine on dual energy X-ray absorptiometry (DXA) devices improves fracture risk prediction. We conducted a proof of concept study to assess the feasibility of TBS® measured on the low-dose imaging system EOS®. METHODS: TBS was assessed on both DXA and EOS® in 122 patients aged ≥ 50 yr, receiving no anti-osteoporotic treatment. The TBS® was computed on full-body EOS® images, focusing on the lumbar spine region. The patients were also scanned with a DXA bone densitometer (Hologic) and the spine and hip bone mineral density (g/cm²) were computed. RESULTS: TBS® measurement on EOS® was not possible in 34 patients due to technical problems. It could be measured on both DXA and EOS® in 88 patients (28 with severe low-trauma fracture and 60 without fracture). TBS-EOS values were significantly lower in fractured patients compared to nonfractured patients. TBS-EOS was associated with the presence of fractures as reported by an AUC of 0.70. Odds ratio of TBS-EOS for the presence of severe low-trauma fracture was 2.00 [1.24-3.25], p = 0.005. CONCLUSIONS: This proof of concept study, based on a prototype version of the TBS-EOS, demonstrated the feasibility of the measurement of TBS® on low-dose EOS® imaging devices. Results show that the TBS-EOS was lower in patients with severe low-trauma fractures compared to nonfractured patients independently from bone mineral density. Some technical issues need to be solved before its eventual use in routine clinical settings. Additional prospective studies are still needed to define the actual contribution of this new technique.

Sagittal balance of the spine in patients with osteoporotic vertebral fractures.

UNLABELLED: This study aims to compare the sagittal global spinal balance of patients consulting for osteoporosis, aged above 50 years with and without osteoporotic vertebral fractures (VFs). Global spinal balance is abnormal even in subjects without VFs. VFs and age are determinants of sagittal global balance; however, pelvic parameters play a role in compensatory mechanisms. INTRODUCTION: This study aims to compare the spine curvatures, pelvic parameters, and the sagittal global spinal balance of patients aged above 50 years with and without osteoporotic vertebral fractures. METHODS: Two hundred patients (95 % women) aged 68.3 ± 9.5 years underwent full skeleton radiographs in the standing position, by EOS®, a low dose biplane X-ray imaging system. VFs were evaluated according to Genant's classification. Spinal (thoracic and lumbar Cobb's indices, thoracic and lumbar tilts) and pelvic (pelvic tilt, sacral slope, and pelvic incidence) parameters were measured. Sagittal spinal balance was measured using the C7 plumb line and the spinosacral angle (SSA). We compared these parameters in patients with and without vertebral fracture and assessed the determinants of abnormal sagittal spinal balance. RESULTS: Sixty-nine patients had at least one VF. The sagittal spinal balance was significantly altered in patients with at least one VF, and there was an effect of the number and severity of VFs on parameters. Discriminative value for identification of patients with at least one VF, assessed by Area Under the Curves (AUCs) was 0.652 and 0.706 for C7 plumbline and SSA, respectively. Using multivariate analysis, parameters significantly associated with abnormal spinal balance (SSA) were the presence of at least one VF (OR = 4.96, P < 0.0001), age (OR = 1.07, P = 0.0006), and high pelvic incidence as a protective factor (OR = 0.93, P < 0.0001). CONCLUSIONS: Global spinal balance is abnormal in subjects consulting for osteoporosis, even in subjects without VFs. VFs and age are determinants of abnormal sagittal global balance; however, pelvic parameters play a role in compensatory mechanisms.

Evaluation of collected outcome measures in axial spondyloarthritis in daily-care rheumatology settings: the experience of the RHEVER network.

OBJECTIVES: Nowadays, the recommended measures for optimal monitoring of axial Spondyloarthritis (ax-SpA) disease activity are either BASDAI and CRP, or ASDAS-CRP. However, there could be a gap between recommendations and daily practice. We aimed to determine the measures collected by rheumatologists in an ax-SpA follow-up visit, and to determine the impact of a meeting (where rheumatologists reached a consensus on the measures to be collected) on the collection of such measures. METHODS: A consensual meeting of a local network of 32 rheumatologists proposed, four months later, to report at least the BASDAI score in the medical file of every ax-SpA patient at every follow-up visit. An independent investigator reviewed the medical files of 10 consecutive patients per rheumatologist, seen twice during the year (e.g. before and after the meeting). The most frequently collected measures were assessed, and then, the frequency of collection before and after the meeting was compared. RESULTS: A total of 456 medical files from 228 patients were reviewed. Treatment (>60%), CRP (51.3%) and total BASDAI (28.5%) were the most reported measures in medical files. Before/After the meeting, the frequencies of collected measures in medical files were 28.5%/51.7%, 51.3%/52.2%, 16.7%/31.6% and 0.9%/6.1% for BASDAI, CRP, BASDAI + CRP and ASDAS, respectively reaching a statistically significance for BASDAI, ASDAS and BASDAI+CRP (p<0.05). CONCLUSIONS: This study revealed a low rate of systematic report of the recommended outcome measures in ax-SpA. However, it suggests that a consensual meeting involving practicing rheumatologists might be relevant to improve the implementation of such recommendations.

Diagnosis of vertebral fractures using a low-dose biplanar imaging system.

UNLABELLED: Vertebral fractures (VFs) are independent risk factors for new fractures. However, spine radiographs cannot be used as a screening method. EOS® has a good diagnostic value for the diagnosis of VF with a better legibility of upper thoracic spine and a higher concordance between readers compared to vertebral fracture assessment (VFA). INTRODUCTION: Vertebral fractures (VFs) are risk factors for new fractures. However, spine radiographs cannot be used as a screening method for both cost and radiation concerns. EOS® X-ray imaging system which allows the acquisition of biplane images in an upright weight-bearing position with low radiation dose was used. The objective of this study was to compare EOS® to VFA for the diagnosis of VF. METHODS: We conducted a cross-sectional study in subjects aged above 50 years with indication for spine imaging. EOS® and VFA of the spine were performed the same day. Sensitivity (Se), specificity (Sp), negative predictive value (NPV), and the interobserver precision of EOS® were compared to VFA for the diagnosis of VF. RESULTS: Two hundred patients (mean age 66.2 years) were included. At the vertebral level, 2.4 and 3.6 % of vertebrae were not legible using EOS® and VFA, respectively (p = 0.0007). The legibility of spine was significantly affected by scoliosis (odds ratio (OR) = 2.8, p < 0.0001, for EOS®, and OR = 1.8, p = 0.0041, for VFA). Sixty-six patients (33.0 %) and 69 (34.5 %) had at least one VF using VFA and EOS®, respectively. At patient level, Se, Sp, and NPV for the diagnosis of VF of EOS® were 79.7, 91.6, and 99 %, respectively. Concordance between both observers was very good for EOS® (kappa-score = 0.89), higher than for VFA (κ = 0.67). CONCLUSIONS: This study shows that EOS® has a good diagnostic value for the diagnosis of VF with a better legibility of upper thoracic spine and a higher concordance between readers compared to VFA.

TBS result is not affected by lumbar spine osteoarthritis.

UNLABELLED: The effect of lumbar osteoarthritis on bone density and trabecular bone score (TBS) was evaluated cross-sectionally and prospectively in postmenopausal women. Lumbar spine osteoarthritis was graded according to Kellgren and Lawrence grades. Lumbar osteoarthritis was found to increase lumbar spine bone density, but not TBS. INTRODUCTION: Lumbar osteoarthritis overestimates lumbar bone density (areal bone mineral density (aBMD)). A new texture parameter, the TBS, has been proposed. Calculation of aBMD uses grey level value, while TBS uses grey level variation. Therefore, our hypothesis was that TBS is not influenced by lumbar spine osteoarthritis. METHODS: Menopausal women participating in osteoporosis and ultrasound (OPUS) study were included. They had an aBMD measurement of the spine and hip at baseline and 6-year visit. TBS was calculated on lumbar spine dual-energy X-ray absorptiometry (DXA) scans in an automated manner. The presence of lumbar osteoarthritis was evaluated on baseline radiographs using Kellgren and Lawrence (K&L) classification. Grades range from 0 to 4. In our study, osteoarthritis was defined by at least K&L grade 2. RESULTS: This study included 1,254 menopausal women (66.7 ± 7.1 years). Among them, 727 attended the 6-year follow-up visit. Patients with lumbar osteoarthritis had an aBMD higher than those without lumbar osteoarthritis at the lumbar spine, but not at the hip. However, the aBMD significantly increased in all sites with the grade of K&L. In contrast, spine TBS was not different between patients with and without lumbar osteoarthritis (p = 0.70), and it was not correlated with K&L grade. Spine TBS and aBMD at all sites were negatively correlated with age (p < 0.0001). Body mass index was correlated positively with aBMD and negatively with spine TBS (p < 0.0001). The 6-year change of aBMD was significant in the hip and nonsignificant in the lumbar spine. That of TBS was significant, with a 3.3 % decrease (p < 0.0001), independent of K&L grade (p = 0.28). CONCLUSION: In postmenopausal women, lumbar osteoarthritis leads to an increase in lumbar spine aBMD. In contrast, spine TBS is not affected by lumbar osteoarthritis.

Added value of trabecular bone score over bone mineral density for identification of vertebral fractures in patients with areal bone mineral density in the non-osteoporotic range.

UNLABELLED: Detection of patients with vertebral fracture is similar for areal bone mineral density (aBMD) and trabecular bone score (TBS) in patients with non-vertebral fracture. In non-osteoporotic patients, TBS adds information to lumbar spine aBMD and is related to an index of spine deterioration. INTRODUCTION: Vertebral fractures (VFs) are more predictive of future fracture than aBMD. The number and severity of VFs are related to microarchitecture deterioration. TBS has been shown to be related to microarchitecture. The study aimed at evaluating TBS in the prediction of the presence and severity of VFs. METHODS: Patients were selected from a Fracture Liaison Service (FLS): aBMD and vertebral fracture assessment (VFA) were assessed after the fracture, using dual-energy X-ray-absorptiometry (DXA). VFs were classified using Genant's semiquantitative method and severity, using the spinal deformity index (SDI). TBS was obtained after analysis of DXA scans. Performance of TBS and aBMD was assessed using areas under the curves (AUCs). RESULTS: A total of 362 patients (77.3% women; mean age 74.3 ± 11.7 years) were analysed. Prevalence of VFs was 36.7%, and 189 patients (52.2%) were osteoporotic. Performance of TBS was similar to lumbar spine (LS) aBMD and hip aBMD for the identification of patients with VFs. In the population with aBMD in the non-osteoporotic range (n = 173), AUC of TBS for the discrimination of VFs was higher than the AUC of LS aBMD (0.670 vs 0.541, p = 0.035) but not of hip aBMD; there was a negative correlation between TBS and SDI (r = -0.31; p < 0.0001). CONCLUSION: Detection of patients with vertebral fracture is similar for aBMD and TBS in patients with non-vertebral fracture. In patients with aBMD in the non-osteoporotic range, TBS adds information to lumbar spine aBMD alone and is related to an index of spine deterioration.

Challenges of cardiovascular risk assessment in the routine rheumatology outpatient setting: an observational study of 110 rheumatoid arthritis patients.

OBJECTIVE: An annual assessment of cardiovascular (CV) risk factors in rheumatoid arthritis (RA) is recommended, but its practical modalities have not been determined. The objective was to assess the feasibility and usefulness of a standardized CV risk assessment in RA, performed by rheumatologists during outpatient clinics. METHODS: We used a cross-sectional design within a network of rheumatologists. Each rheumatologist included 5 consecutive unselected patients with definite RA. Data collection included standardized assessment of CV risk factors: blood pressure, interpretation of glycemia and of lipid levels, and calculation of the Framingham CV risk score. Outcome criteria included feasibility (missing data and time taken to assess the patients) and usefulness (the CV risk assessment was considered useful if at least 1 modifiable and previously unknown CV risk factor was evidenced). RESULTS: Twenty-two rheumatologists (77% in office-based practice) assessed 110 RA patients. The mean ± SD age was 57 ± 10 years, and the mean ± SD RA duration was 11 ± 9 years; 50 patients (45%) were treated with biologic agents, and 76% were women. Regarding feasibility, missing data were most frequent for glycemia (27% of patients) and cholesterolemia (14% of patients). The mean ± SD duration of the CV risk assessment was 15 ± 5 minutes. The CV risk assessment was considered useful in 33 patients (30%), evidencing dyslipidemia (15% of patients) or high blood pressure (9% of patients) as the most frequently previously unknown CV risk factor. CONCLUSION: The assessment of CV risk factors is feasible, but labor intensive, during an outpatient rheumatology clinic. This assessment identified modifiable CV risk factors in 30% of the patients. These results suggest that RA patients are not sufficiently assessed and treated for CV risk factors.

Prevalence of vertebral fractures in patients with rheumatoid arthritis: revisiting the role of glucocorticoids.

SUMMARY: Vertebral fracture assessment (VFA) is a convenient tool for the diagnosis of vertebral fracture in RA. Optimal control of inflammation may be an effective means to protect against vertebral fractures. INTRODUCTION: The aim of this case-control study was to assess the prevalence of vertebral fractures (VFs) in patients with RA using VFA technology. METHODS: Consecutive women (N = 101, 56.1 ± 14.2 years) with RA (mean disease duration, 14.9 ± 10 years) were recruited in the study. Clinical and biological statuses and treatments including glucocorticoids were assessed. Controls (N = 303), randomly selected from the general population, were individually matched to each case for age. RESULTS: The prevalences of osteoporosis were 55.4% and 10.5% in patients and controls, respectively. Among the subjects, 21.7% and 4.2% had a vertebral fracture in the RA and control groups, respectively. Compared with controls, patients with RA had an increased risk of VFs: odds ratio (OR) (CI 95%) adjusted on body mass index was 6.5 (3.1, 13.9). In a multiple logistic regression analysis, VFs were independently associated with presence of non-vertebral fractures (OR = 9.2 [2.5-33.5]), presence of a fall in the previous year (OR = 4.6 [1.2-18.3]), current use of disease-modifying anti-rheumatic drugs (DMARDs) (OR = 0.05 [0.004, 0.51]) and current use of steroids (OR = 0.17 [0.04, 0.67]). CONCLUSION: Rheumatoid arthritis is a risk factor of VF (OR = 6.5). VFA is a convenient tool for this diagnosis. Presence of VF is inversely related to the use of DMARD and glucocorticoids, enhancing the hypothesis that an appropriate control of the disease may be a protective factor against bone fragility.

Increase in vertebral body size in postmenopausal women with osteoporosis.

Bone geometry plays a prominent role in bone strength. Cross-sectional studies have shown that advancing age is associated with increasing diameter of long bones, related to both periostal apposition and endosteal resorption. However, there are few data provided by prospective studies, especially concerning the changes in vertebral body dimensions. The objective of this prospective study was to measure the changes occurring in the vertebral body size of women with postmenopausal osteoporosis. Three-year data from placebo groups of the SOTI and TROPOS trials, performed in women with postmenopausal osteoporosis, were used for this study. In these trials, patients underwent lateral radiographs of the thoracic and lumbar spine at baseline and annually over 3 years, according to standardized procedures. Six-point digitization method was used: the four corner points of the vertebral body from T4 to L4 are marked, as well as an additional point in the middle of the upper and lower endplates. From these 6 points, the vertebral body perimeter, area and depth were measured at baseline and at 3 years. The analysis excluded all vertebrae with prevalent or incident fracture. A total of 2017 postmenopausal women (mean age 73.4+/-6.1 years) with a mean lumbar spine T score of -3.1+/-1.5, and a mean femoral neck T score of -3.0+/-0.7 are included in the analysis. Vertebral body dimensions increased over 3 years, by 2.1+/-5.5% (mean depth+/-SD), by 1.7+/-8.3% (mean area+/-SD) and by 1.5+/-4.9% (mean perimeter+/-SD) at the thoracic level (T4 to T12). At the lumbar level (L1 to L4), these dimensions increased as well: 1.4+/-3.6% (mean depth+/-SD), 1.4+/-5.7% (mean area+/-SD), 0.7+/-2.9% (mean perimeter+/-SD). A significant increase in vertebral body size was observed for each vertebral level from T5 to L4 for each of these parameters (p<0.01). These prospective results demonstrate that vertebral body dimensions increase over 3 years in women with postmenopausal osteoporosis.

Spinal deformity index (SDI) is a good predictor of incident vertebral fractures.

UNLABELLED: The spinal deformity index is a convenient tool to quantify the number and the severity of prevalent vertebral fractures. It is a predictor of the risk of sustaining incident vertebral fracture. This quantification must be taken into account to improve management of patients. INTRODUCTION: Prevalent fractures are strong risk factors for subsequent fractures. METHODS: The study subjects were women from the placebo groups of two studies of strontium ranelate in postmenopausal osteoporosis (N = 723 and 637 patients, respectively). Three lateral radiographs of the spine were obtained at baseline and annually over 3 years, according to standardized procedures. The semiquantitative visual assessment of each vertebra from T4 to L4 was performed by the same reader throughout the study. A spinal deformity index (SDI) was calculated by summing for each patient the grade of each vertebra from T4 to L4. RESULTS: There was a linear relationship between baseline SDI and the 3-year incidence of vertebral fracture (adjusted R(2) = 0.76). The 3-year incidence of vertebral fractures was different among the tertiles of baseline SDI: 17.3 +/- 3.6%, 25.4 +/- 2.6%, and 47.6 +/- 3.1% from the lowest to the highest, respectively. There was no relationship between SDI and non-vertebral fractures incidence. CONCLUSION: SDI is a good predictor of incident vertebral fractures. Patients with highest SDI should receive highest priority to treatment.

Strontium ranelate reduces the risk of vertebral fracture in young postmenopausal women with severe osteoporosis.

OBJECTIVES: Early osteoporotic fractures have a great impact on disease progression, the first fracture being a major risk factor for further fractures. Strontium ranelate efficacy against vertebral fractures is presently assessed in a subset of women aged 50-65 years. METHODS: The Spinal Osteoporosis Therapeutic Intervention (SOTI) was an international, double blind, placebo controlled trial, supporting the efficacy of strontium ranelate 2 g/day in reducing the risk of vertebral fractures in postmenopausal women with osteoporosis and a prevalent vertebral fracture. 353 of these randomly assigned women were included in this analysis. RESULTS: Over 4 years, strontium ranelate significantly reduced the risk of vertebral fracture by 35% (relative risk 0.65; 95% CI 0.42 to 0.99, p<0.05). In the strontium ranelate group, the bone mineral density increased from baseline by 15.8% at lumbar spine and 7.1% at femoral neck. CONCLUSION: These data demonstrate a significant vertebral antifracture efficacy of strontium ranelate in young postmenopausal women aged 50-65 years with severe osteoporosis and confirm the efficacy of this antiosteoporotic treatment to prevent vertebral fractures, whatever the age of the patient.

Professional practice assessment in ambulatory private rheumatology: a pilot evaluation of the medical file content for rheumatoid arthritis.

OBJECTIVE: Professional Practice Assessment (PPA) has become an obligation for all physicians in France, however its modalities remain unclear. The objective of this work was to evaluate the feasibility and accuracy of a PPA for private practice rheumatologists performed in the context of a network. METHODS: A list of items considered mandatory to collect during an outpatient visit for rheumatoid arthritis, was prepared by the network. Non hospital-based rheumatologists, members of the network then evaluated some of their patient files selected by chronological order over a one-month period of time using this list. These files were then assessed by another private rheumatologist, member of the group, randomly allocated, using the same list of items. RESULTS: Eighty percent of the private-practice doctors accepted to participate. The mean time to evaluate 15 patient files was 2 hours. Agreement between auto-evaluation and external evaluation for each file was good (agreement statistic, 0.75-1.0). Items mandatory to collect were collected in a high proportion of cases (84.6%). CONCLUSION: PPA can be performed in the context of a network, auto-evaluation is a valid method and when the list of items is decided on by the network, the data are collected satisfactorily.

Inverse relationship between vertebral fractures and spine osteoarthritis in postmenopausal women with osteoporosis.

BACKGROUND: Although the coexistence of osteoarthritis and osteoporosis is considered as uncommon, it has been suggested that, in postmenopausal women, disc space narrowing increases the risk of vertebral fracture. The aim of this study was to check this hypothesis in postmenopausal women with osteoporosis. OBJECTIVE: We analysed the relationship between vertebral fractures and spine osteoarthritis in 410 postmenopausal women with osteoporosis: in this population both disc space narrowing and osteophytes are inversely related to vertebral fractures. PATIENTS AND METHODS: This study is based on baseline data collected in a multicentre, prospective and 6-month longitudinal observational study. 410 postmenopausal women (74+/-5 years) were enrolled who had consulted for back pain, and had osteoporosis (according to WHO definition). Spine x-rays were performed according to standardised procedures. Vertebral fractures were evaluated from T4 to L4 using the Genant's semiquantitative method; osteoarthritis was evaluated by scoring osteophytes and disc space narrowing at all levels of the thoracic and lumbar spine, and by a qualitative assessment of facet joint arthritis. RESULTS: The prevalence of vertebral fractures was 52.4%. At least one osteophyte, one disc space narrowing and one facet arthritis were present in 90.2, 64.6 and 77.8% of patients respectively. There was an inverse association between vertebral fractures and osteoarthritis: odds ratios adjusted for age and weight (95% CI) were 0.38 (0.17-0.86), p = 0.02 and 0.27 (0.16-0.46), p<10(-4) for the presence of at least one osteophyte, and of at least three disc space narrowings respectively. In a cluster analysis, it was possible to identify a subgroup of patients without any disc space narrowing, and another subgroup with all patients having at least one disc space narrowing; the proportion of patients having more than three vertebral fractures was 25.2 and 15.9% in these two clusters respectively. CONCLUSIONS: Disc space narrowing and osteophytes are associated with a decreased vertebral fracture prevalence in postmenopausal women with osteoporosis.

Effects of strontium ranelate on spinal osteoarthritis progression.

OBJECTIVE: The aim of this study was to determine whether a 3-year treatment with strontium ranelate could delay the progression of spinal osteoarthritis (OA). METHODS: This study was a post-hoc analysis of pooled data from the Spinal Osteoporosis Therapeutic Intervention (SOTI) and TReatment Of Peripheral OSteoporosis (TROPOS) trials performed on 1105 women with osteoporosis and concomitant radiological spinal OA at baseline, and for whom lumbar x-rays were available at baseline and over the 3-year treatment period. The presence and severity of osteophytes, disc space narrowing and sclerosis in the lumbar intervertebral spaces was graded according to a validated method, and an overall OA score was calculated for each intervertebral space. Back pain (measured on a five-point Likert scale only in SOTI) and health-related quality of life (SF-36 questionnaire) were assessed at baseline and after 3 years. Patients who suffered an incident or progressive vertebral fracture during the study were excluded from the analysis. RESULTS: The proportion of patients with worsening overall spinal OA score was reduced by 42% in the strontium ranelate group, compared with placebo (RR, 0.58; 95% CI, 0.42 to 0.79; p = 0.0005). Significantly more patients in the strontium ranelate group experienced an improvement in back pain after 3 years, compared with placebo (p = 0.03), while no significant difference was observed in terms of health-related quality of life between these patient groups. CONCLUSIONS: The results of this post-hoc analysis suggest that strontium ranelate could reduce the progression of the radiographic features of spinal OA and back pain in women with osteoporosis and prevalent spinal OA.

Mild prevalent and incident vertebral fractures are risk factors for new fractures.

UNLABELLED: This prospective four-year study indicates that post-menopausal osteoporotic women with mild prevalent and incident vertebral fractures have an increased risk of incident fractures. INTRODUCTION: Mild vertebral fractures are under diagnosed as there is disagreement about their clinical significance. Our aim was to assess the risk of subsequent fractures induced by both prevalent and incident mild vertebral fractures in osteoporotic post-menopausal women. PATIENTS AND METHODS: Three thousand three hundred and fifty-eight patients, aged 74 +/- 6 years, with post-menopausal osteoporosis included in the placebo groups of two clinical trials of strontium ranelate were followed for 4 years. A Cox regression model adjusted on age, body mass index and bone mineral density was used to calculate the relative risk (RR) of fracture in subjects with only mild fractures as compared to patients without fracture, and to patients with at least one grade >or= 2 fracture. These calculations were made for prevalent and then incident fractures. RESULTS: The RR of vertebral fracture in 4 years was 1.8 (1.3-2.4) p < 0.001, and 2.7 (2.3-3.3) p < 0.001 for patients having only mild vertebral fractures and at least one grade >or= 2 fracture at baseline respectively. The RR of vertebral fracture in the 3rd and 4th years of follow-up was 1.7 (1.1-2.6) p = 0.01, and 1.9 (1.3-2.6) p < 0.001 for patients having during the first 2 years incident mild fractures only, and for patients having at least one grade >or= 2 incident fracture respectively. The RR of non-vertebral fracture in 4 years was 1.3 (0.9-1.9) p = 0.15 and 1.7 (1.4-2.1) p < 0.001 for patients having only mild or at least one grade >or= 2 vertebral fracture at baseline respectively. For patients aged more than 70 years, these RR were 1.45 (0.99-2.11) (p = 0.06), and 1.72 (1.36-2.18) p < 0.001 respectively. The RR of non-vertebral fracture in the 3rd and 4th years was 1.68 (1.36-2.09) p < 0.001 for patients having at least one grade >or= 2 incident fracture during the 2 first years of follow-up. CONCLUSION: Mild vertebral fractures are a risk factor for subsequent vertebral and non-vertebral fracture in postmenopausal women with osteoporosis; 1 out of 4 patients with an incident mild vertebral fracture in 2 years will fracture again within the 2 next years.

A clinical tool to determine the necessity of spine radiography in postmenopausal women with osteoporosis presenting with back pain.

BACKGROUND: Vertebral fractures are underdiagnosed, although the resulting mortality and morbidity in postmenopausal women with osteoporosis is now recognised. In a population of postmenopausal women with osteoporosis and back pain, symptoms may be related to vertebral fractures or degenerative changes of the spine. AIM: To evaluate a population of postmenopausal women presenting with back pain and factors associated with vertebral fractures which were assessable in a clinical setting in order to determine the necessity for spine radiography. METHODS: Patient questioning and physical examination were carried out and spinal radiographic data collected from 410 postmenopausal women with osteoporosis, with an average age of 74 years, who consulted a rheumatologist for back pain. Of these, 215 (52.4%) patients were diagnosed with at least one vertebral fracture. Logistic regression was used to identify the most relevant clinical features associated with existing vertebral fractures, and to derive a quantitative index of risk. RESULTS: The model included six parameters: age, back pain intensity, height loss, history of low trauma non-vertebral fractures, thoracic localisation of back pain and sudden occurrence of back pain. The scoring system, or the quantitative index, had a maximal score of 16. For a score >or=7, the probability of existing vertebral fracture was >or=43%. The correlation between this quantitative index and the logistic model probability was 0.98, suggesting an excellent and highly significant approximation of the original prediction equation. CONCLUSIONS: From six clinical items, an index was built to identify women with osteoporosis and back pain who should have spine radiography. This simple tool may help clinicians to optimise vertebral fracture diagnosis and to make a proper therapeutic decision.

The severity of vertebral fractures and health-related quality of life in osteoporotic postmenopausal women.

Vertebral fractures are the hallmark of osteoporosis, responsible for increased back pain, impairment of mobility and functional limitations. These factors have an impact on patients' health-related quality of life (QOL). The aim of this study was to assess QOL, using QUALEFFO, in osteoporotic postmenopausal women, according to the number and the severity of the vertebral fractures. A group of 629 osteoporotic postmenopausal women (60-80 years) with symptoms that, according to a rheumatologist, could be related to a vertebral fracture, had spine X-rays with standardized procedures. All the X-rays were assessed in a central facility. The number of fractures was a determinant of a low QOL, as indicated by an increased score in physical function (P=0.001), social function (P=0.002) and total score (P=0.027). Patients with higher grades of vertebral deformities, i.e., more severe fractures, had low QOL in these three domains, too (P<0.0001, P<0.0001 and P=0.005, respectively). There was no difference in QOL according to the thoracic or lumbar location of the fractures. Both anterior and middle deformities of the vertebral bodies had a negative impact on QOL. In none of the analyses were the pain and mental function domains of QUALEFFO discriminant among the patients. QOL, assessed by an osteoporosis-specific instrument, is decreased in osteoporotic women as a function of both the number and the severity of the vertebral fractures. Treating women with prevalent fractures may avoid a further decrease in their quality of life.

Reporting of vertebral fractures on spine X-rays.

Vertebral fractures are the hallmark of osteoporosis, responsible for increased morbidity and mortality in post-menopausal women. However, two-thirds of vertebral fractures do not come to clinical attention. The aim of this study was to compare the identification of vertebral fractures on spine X-rays among rheumatologists. Study subjects were women aged 60-80 years having potential signs of vertebral fracture and visiting a rheumatologist. X-rays were performed according to standardized procedures. In 629 patients (among 824 included) at least one vertebral fracture was diagnosed, and the X-rays were then sent to a central facility where a semi-quantitative assessment of vertebral fracture was performed by a single rheumatologist trained for this evaluation. According to the vertebral level, kappa scores were between 0.20 to 0.77, i.e., below 0.6 from T4 to T7, and between 0.6 and 0.77 from T8 to L4. The false-negative fractures rate was 25.8% (and 15.7% of them were related to a numbering discrepancy). The rate of false positive fractures was 6.3%. At the patient level 6.8% had actually no fracture. This study shows that 25% of overall vertebral fractures are not diagnosed among patients considered as having at least one fracture. As a consequence, patients who require treatment to reduce fracture risk are not being properly identified.

Three-dimensional X-ray absorptiometry (3D-XA): a method for reconstruction of human bones using a dual X-ray absorptiometry device.

Three-dimensional accurate evaluation of the geometry of the proximal femur may be helpful for hip fracture risk evaluation. The purpose of this study was to apply and validate a stereo-radiographic 3D reconstruction method of the proximal femur, using contours identification from biplanar DXA images. Twenty-five excised human proximal femurs were investigated using a standard DXA unit. Three-dimensional personalized models were reconstructed using a dedicated non-stereo corresponding contours (NSCC) algorithm. Three-dimensional CT-scan reconstructions obtained on a clinical CT-scan unit were defined as geometric references for the comparison protocol, in order to assess accuracy and reproducibility of the 3D stereo-radiographic reconstructions. The precision of a set of 3D geometric parameters (femoral-neck axis length, mid-neck cross-section area, neck-shaft angle), obtained from stereo-radiographic models was also evaluated. This study shows that the NSCC method may be applied to obtain 3D reconstruction from biplanar DXA acquisitions. Applied to the proximal femur, this method showed good accuracy as compared with high-resolution personalized CT-scan models (mean error = 0.8 mm). Moreover, precision study for the set of 3D parameters yielded coefficients of variation lower than 5%. This is the first study providing 3D geometric parameters from standard 2D DXA images using the NSCC method. It has good accuracy and reproducibility in the present study on cadaveric femurs. In vivo prospective studies are needed to evaluate its discriminating potential on hip fracture risk prediction.