Elsevier

Academic Radiology

Volume 13, Issue 5, May 2006, Pages 538-545
Academic Radiology

Radiology alliance for health services research
RAHSR symposium: Evidence-based radiology: Lessons learned from vertebroplasty research
Epidemiology of Vertebral Fractures: Implications for Vertebral Augmentation1

https://doi.org/10.1016/j.acra.2006.01.005Get rights and content

To put vertebral augmentation (eg, vertebroplasty) into perspective, the etiology and outcomes of vertebral fractures are reviewed. There is considerable debate about which criteria should be used to define a vertebral fracture because there is no consistent relation between symptoms and the degree of vertebral deformity. However, it is the more significant vertebral body deformities that are most closely associated with frequent or severe back pain, and the referrals for vertebral augmentation come mainly from this subset of patients. In addition to their vertebral fractures, these patients typically have osteoporosis or elevated bone turnover, and they are at greatly increased risk of subsequent fractures as a result of falling or, more often, excessive spinal loads from activities of everyday living. Additional risk factors for new vertebral fractures include the number and severity of vertebral deformities at baseline. Moreover, new fractures are most likely in nearby vertebrae, and they occur more frequently in the mid-thoracic or thoracolumbar regions of the spine. Interestingly, these are also the characteristics of the subsequent fractures of contiguous vertebrae considered by some to represent a complication of vertebral augmentation, yet they characterize vertebral fracture risk even in untreated patients. Vertebral fractures are very common among older men and postmenopausal women; they are associated with substantial morbidity and mortality; and they may have a devastating impact on the patient’s quality of life. Vertebral augmentation may be able to help many of these patients, although opportunities exist to optimize management strategies with respect to the other factors that influence long-term outcomes in this patient population.

Section snippets

Frequency of vertebral fractures

The first issue that must be addressed is: What constitutes a vertebral fracture? This is problematic because vertebral “deformities” are equated with vertebral “fractures,” yet there is no consistent relation between back pain and changes in vertebral shape on radiographs (1). Thus it has not been possible to unequivocally distinguish fractures from other vertebral body abnormalities. This is a particularly difficult problem in epidemiologic studies, in which subjects are assessed in the

Risk factors for vertebral fractures

Some vertebral fractures that present for vertebral augmentation result from severe trauma or lytic bone lesions. However, specific pathologies and severe trauma account for just 3% and 14%, respectively, of all clinically evident vertebral fractures in the community (13). The vast majority of vertebral fractures, including those treated with vertebral augmentation, in North America are related instead to osteoporosis. Thus the effects of age, sex, and race on vertebral fracture risk are

Natural history of vertebral fractures

The most potent risk factor for fracture is a history of a previous fracture. One meta-analysis concluded that the occurrence of a vertebral fracture increases the risk of another one at least fourfold among postmenopausal white women, with an even greater excess among other patient populations (38). This estimate is supported by placebo results from the FIT and Multiple Outcomes of Raloxifene (MORE) trials where the risk of a new vertebral fracture was about four times higher in the women who

Outcomes of vertebral fractures

Optimal management of vertebral fractures is essential because they are so common and so often linked with adverse outcomes. Thus the lifetime risk of a clinically evident vertebral fracture among postmenopausal white women from age 50 years onward has been estimated at about 16%; the lifetime risk in white men is only about 5% because their vertebral fracture incidence rates are somewhat lower and their life expectancy is considerably less than that in women (49). Although complete (ie,

Conclusion

Although there are opportunities for primary prevention of vertebral fractures (eg, by diagnosing and treating osteoporosis), much of the disease burden noted above results from recurrent vertebral fractures. However, these are also preventable to a significant degree by medical therapies (eg, bisphosphonates, selective estrogen receptor modulators) as demonstrated by a number of large, randomized, controlled clinical trials (27). Any contribution of vertebral augmentation to fracture

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    Supported in part by research grants AG04875, AR27065, and AR30582 from the National Institutes of Health, U.S. Public Health Service.

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