1 Recognition and Reporting of Vertebral Fractures VERTEBRAL FRACTURE INITIATIVE Slide Kit Part 2: International Osteoporosis Foundation & European Society of Musculoskeletal Radiology

2 What is the vertebral fracture initiative? An educational initiative to improve recognition and reporting of vertebral fractures. Pilot phase in five European countries. An educational initiative to improve recognition and reporting of vertebral fractures. Pilot phase in five European countries. Initiative leaders: Pierre D Delmas & Harry K Genant Initiative leaders: Pierre D Delmas & Harry K Genant France: Jean-Denis Larédo & Pierre D Delmas France: Jean-Denis Larédo & Pierre D Delmas Germany: Helmut Minne & Michael Jergas / Dieter Felsenberg Germany: Helmut Minne & Michael Jergas / Dieter Felsenberg Italy: Silvano Adami & Giuseppe Guglielmi Italy: Silvano Adami & Giuseppe Guglielmi Spain: Jorge Cannata & Francisco Aparisi Spain: Jorge Cannata & Francisco Aparisi UK: David Reid & Judith Adams UK: David Reid & Judith Adams A clinician and radiologist team taking the lead in each country

3 What does the Vertebral Fracture Initiative include? 1. Presentations at Radiology Conferences 2. Articles in radiology and related publications 3. A resource document and a slide kit including: Part 1. Osteoporosis and Related Fractures: Clinical Perspectives Part 2. Recognition and Reporting of Vertebral Fractures 4. Summary handout 5. Interactive teaching program on CD-Rom Teaching tools available from: Teaching tools available from:

4 Osteoporosis Educational Program for Radiologists Improve the understanding of the importance and nature of osteoporosis Improve the understanding of the importance and nature of osteoporosis Improve the recognition and reporting of vertebral fractures Improve the recognition and reporting of vertebral fractures Improve the economic pathways to wider access for radiologic services in osteoporosis Improve the economic pathways to wider access for radiologic services in osteoporosis

5 Background Worldwide, a substantial percentage of vertebral fractures are not diagnosed by radiologists or clinicians It is likely that this contributes to unnecessary pain and suffering and to the under treatment of osteoporosis Identification of patients with a vertebral fracture is important because the presence of prevalent fracture greatly increases the risk of future fracture Recent widespread approval of effective treatments for patients with osteoporotic vertebral fractures

Age (yrs) Prevalence of Deformities* (%) Melton, % of women over age 50 have Vertebral Deformities High Prevalence of Vertebral Deformities

7 Number of Spine Fractures at Start of Year High Rate of Repeat Fractures Lindsay, Multiple % of Patients Fracturing Again within 1 Year 20% of women with new vert fx will re-fracture within one year

Black '99Ettinger '99Ross '93Harris '99, Reginster '00 Relative Risk 3.7 years3 years RR = Incident fractures in patients with / without prevalent fxs Prevalent Vertebral Fractures Predict Incident Fracture

9 SQ0SQ1SQ2SQ3 % of Women With >1 New Fracture MORE Trial – Placebo Group at 3 years * 4.3 * 7.2 * Baseline Fracture Severity (SQ Grade) Predicts Risk of New Vertebral Fractures Baseline SQ Grade Genant et al., Endocrine Soc 2002 *p<0.05 compared to SQ

SQ0SQ1SQ2SQ3 % of Women With >1 New Fracture MORE Trial – Placebo Group at 3 years * 5.5 * 7.2 * Baseline Fracture Severity (SQ Grade) Predicts Risk of New Non-Vert Fractures Baseline SQ Grade Genant et al., Endocrine Soc 2002 *p<0.05 compared to SQ3 Includes clavicle, humerus and wrist, pelvis, hip, and leg

11 Unrecognized Vertebral Fractures On X-Ray Gehlbach SH et al, Osteoporos Int 2000;11: women age 60 and older, hospitalized for various reasons Chest x-rays reviewed for fracture Fracture Present Mentioned in Report 52% Summary 23% in Med Record Osteoporosis 17% Treatment for Osteoporosis 7% Number of Subjects

12 Prevalent Vertebral Fracture Severity Predicts Subsequent Vertebral and Nonvertebral Fracture Risk in Postmenopausal Women with Osteoporosis - Indication of Bone Fragility - - Indication for Treatment -

13 B/L 10YR20YR Prevent Vertebral Fracture Cascade

14 Problem: Vertebral Fracture Assessment by Radiologists Not being identified Not being identified Not being reported Not being reported Not being acted upon Not being acted upon Vertebral Fractures are:

15 Vertebral Fracture in Osteoporosis, eds, Genant et. al (1995) Vertebral Fracture Assessment Shape Recognition …The Challenge

16 Vertebral Fracture: Semiquantitative Assessment (Visual) Meunier ‘76 Meunier ‘76 Jensen ’84 Jensen ’84 Epstein ’86 Epstein ’86 Genant ’90 Genant ’90 Nielsen ’91 Nielsen ’91 Jergas ’94 Jergas ’94 Felsenberg ’94 Felsenberg ’94 Wu ‘95 Wu ‘95

17 SQ Semiquantitative: Visually normal spine T spine L spine

18 ObliqueOrthograde

19 Under-Penetrated Over-Penetrated

20 Under-Penetrated Over-Penetrated

21 Radiographic Osteopenia

22 Radiographic Osteopenia

23 Osteoporosis – Radiographic Differential Diagnosis Post Menopausal Osteomalacia Hyperparathyroidism Hypercortisolism Hyperthyroidism Renal insufficiency Chronic immobilization

24 Osteogenesis imperfecta Hepatic insufficiency Diabetes mellitus Multiple myeloma Metastatic disease Drug induced Osteoporosis – Radiographic Differential Diagnosis

25 Post-Menop Osteoporotic Fx

26 Post-Menop Osteoporotic Fx: Variations

27 Osteomalacia

28 Cushings Steroids

29 Multiple Myeloma

30 Congenital Anomalies

31 Congenital Anomalies - Fusion

32 Acquired Deformities – Scheurmann’s

33 Acquired Deformities - Hyperostosis

34 Remote Trauma Hemangioma

35 Semiquantitative visual grading of vertebral fractures Genant & Wu Normal (Grade 0) Wedge fractureBiconcave fractureCrush fracture Mild fracture (Grade 1, ~20-25%) Moderate fracture (Grade 2, ~25-40%) Severe fracture (Grade 3, ~40%)

36 Mild Fxs: loss of adjacent continuity

37 SQ Mild Fx SQ Severe FX

38 SQ Incident Mild Fx 0 1

39 SQ Incident Moderate Fx 02

40 SQ Incident Severe & Moderate Fxs

41 Vertebral Fracture Developments in Morphometry Barnett, Nordin ’60Raymakers, Duursma ’90 Hurxthal ’68Genant ’90 Kleerekoper, Parfitt ’84Smith-Bindman, Genant ’91 Minne, Leidig’88Black, Cummings, Nevitt ’91 Hedlung, Gallagher ’88Eastell, Melton ’91 Davies, Recker, Heaney ’89Ross, Wasnich ’93 Melton, Riggs ’89McCloskey, Kanis ’93

42 Morphometry: Placement of six digitizing points for different projections of the vertebrae

43 Electronic Cursor for Morphometry

44 QM with Six-Point Placements QM with Six-Point Placements

45 OARG/UCSF Six-PointVideo-Assisted Verterbal Morphometry

46 Vertebral Fracture Assessment (VFA) Vertebral Fracture Assessment (VFA) Point of Care BMD VFA

47 Lateral Vertebral Assessment: Lateral Vertebral Assessment: Lateral Decubitus and Point-of-Care tools. Qualitative and quantitative!

48 VFA Quality image choices… Dual or single energy. It’s the operators choice! Dual Single

49 VFA showed good sensitivity (>80%) in identifying moderate/severe XSQ deformities and excellent negative predictive value (>90%) in distinguishing subjects without from those with vertebral deformities on a per subject basis.VFA showed good sensitivity (>80%) in identifying moderate/severe XSQ deformities and excellent negative predictive value (>90%) in distinguishing subjects without from those with vertebral deformities on a per subject basis. J. Rea et al Osteoporos Int 2000 Poor sensitivity to detect mild vertebral fractures, especially at the upper thoracic spine.Poor sensitivity to detect mild vertebral fractures, especially at the upper thoracic spine. Visual Assessment of Vertebral Fracture Using Lateral DXA Scan

50 Multi-Slice Computed Tomography in Diagnosis and Characterization of Vertebral Fracture

51 MS-CT MS-CT Fractures in sagittal in sagittalReformations T. Link

52 MRI Assessment of Vertebral Fractures Differentiation of Malignant vs Benign Vertebral Fracture

53 Benign Vertebral Collapse Abnormal signal parallels fractures Abnormal signal parallels fractures Flat posterior borders of fractured vertebrae Flat posterior borders of fractured vertebrae Other vertebral deformities with normal signal Other vertebral deformities with normal signal Rare paravertebral ST mass Rare paravertebral ST mass Normal signal in non-fractured vertebrae Normal signal in non-fractured vertebrae Abnormal signal of fractures stabilizes in months Abnormal signal of fractures stabilizes in months Low signal on diffusion-weighted images Low signal on diffusion-weighted images

54 Malignant Vertebral Collapse Abnormal signal in non-fractured vertebrae Abnormal signal in non-fractured vertebrae Abnormal signal of entire fractured vertebrae Abnormal signal of entire fractured vertebrae Convex posterior borders of fractured vertebrae Convex posterior borders of fractured vertebrae No vertebral deformities with normal signal No vertebral deformities with normal signal Occasional paravertebral ST mass Occasional paravertebral ST mass Abnormal signal progresses to destruction Abnormal signal progresses to destruction High signal on diffusion weighted images High signal on diffusion weighted images

55 Benign Fracture T1 T1 Andrea Baur T2 DWI

56 Malignant Fracture Malignant Fracture Andrea Baur T1 T1 T2 DWI

57 Conclusions: Relevance of Vertebral Fracture Vertebral Fracture is a common and important risk factor in osteoporosis Vertebral Fracture is a common and important risk factor in osteoporosis Assessment of Vert Fxs is important in clinical research and patient management Assessment of Vert Fxs is important in clinical research and patient management Vert Fx assessment can be done with conventional and newer imaging techniques Vert Fx assessment can be done with conventional and newer imaging techniques Available therapies reduce Fx risk by 30 to 65% specifically in patients with Vert Fxs Available therapies reduce Fx risk by 30 to 65% specifically in patients with Vert Fxs Current international initiatives support a global outreach for improved detection of Vert Fxs Current international initiatives support a global outreach for improved detection of Vert Fxs