Asymptomatic vertebral deformity as a major risk factor for subsequent fractures and mortality: a long-term prospective study.

In elderly men and women, asymptomatic vertebral deformity was found to be associated with subsequent risk of symptomatic fractures, particularly vertebral fracture, and increased risk of mortality after a fracture. INTRODUCTION: Vertebral deformity is associated with an increased risk of fracture and mortality. However, it is unclear whether the three events of vertebral deformity, fracture, and mortality are linked with each other and what role BMD plays in these linkages. MATERIALS AND METHODS: Vertebral deformity was determined from quantitative analysis of thoracolumbar spine X-rays in 300 randomly individuals (114 men and 186 women) 60 years of age (as of mid-1989), who were randomly selected from the prospective Dubbo Osteoporosis Epidemiology Study. Incidence of atraumatic fractures and subsequent mortality were ascertained from 1989 to 2003. Cox's proportional hazards model was used to determine the association between asymptomatic vertebral deformities, osteoporotic fractures, and risk of mortality. RESULTS: The prevalence of asymptomatic vertebral deformity was 31% in men and 17% in women. During the follow-up period, subjects with vertebral deformity had a significantly higher risk of any fracture than those without vertebral deformity (44% versus 29%; hazards ratio [HR], 2.2; 95% CI, 1.4-3.7), particularly symptomatic vertebral fracture (relative risk [RR], 7.4; 95% CI, 3.2-17.0). Mortality rate was highest after a symptomatic fracture among those with vertebral deformity (HR, 9.0; 95% CI, 3.1-26.0). These associations were independent of age, sex, and BMD. CONCLUSION: Vertebral deformity was a strong predictor of subsequent risk of fractures, particularly symptomatic vertebral fracture, and may modify fracture-associated mortality in both elderly men and women.     

Prevalent vertebral deformities: Relationship to bone mineral density and spinal osteophytosis in elderly men and women

The aims of this study were to ascertain vertebral deformity prevalence in elderly men and women and to describe the association between bone mineral density (BMD) at the lumbar spine and femoral neck, severity of spinal degenerative disease and vertebral deformity prevalence. We performed standardized spinal radiographs in a random sample of 300 elderly men and women participating in the Dubbo Osteoporosis Epidemiology Study, a population-based study of fracture risk factors. Radiographs were read independently by masked observers for the prevalence of vertebral deformity and severity of osteophytosis. BMD was measured by dual-energy X-ray absorptiometry. The prevalence of vertebral deformities was critically dependent on the criterion used. The less strict criteria seemed to overestimate deformities at either end of the spine region analysed. However, irrespective of the criterion used, prevalence of deformity was higher in men than in women (25% vs 20% for the 3 SD criterion, 17% vs 12% for the 4 SD criterion and 27% vs 25% for the 25% criterion). Femoral neck BMD was more strongly associated with vertebral deformities than spinal BMD for the 25% criterion (OR/SD change in BMD 1.39 (p=0.02) vs 1.20 (p=0.19)), 3 SD criterion (OR/SD change in BMD 1.45 (p=0.01) vs 1.10 (p=0.34)) and 4 SD criterion (OR/SD change in BMD 1.98 (p=0.0002) vs 1.68 (p=0.008)). BMD was also more strongly associated with biconcave deformities than either wedge or crush deformities and more so in men than in women. Severity of spinal osteophytosis was not associated with vertebral deformity. In conclusion, femoral neck BMD is at least equivalent to the lumbar spine BMD in strength of association with prevalent vertebral fractures. Spinal osteophytosis falsely elevates BMD without a concomitant decrease in fracture risk, indicating that any interpretation of spinal BMD needs to be adjusted for osteophytosis. These findings support the use of femoral neck bone densitometry in older men and women. Moreover, these data indicate that current criteria for radiological assessment of vertebral deformity are sufficiently loose to include a substantial proportion of non-fractures in the elderly, with important implications for the design of clinical trials. However, irrespective of the criterion used, vertebral deformities in men are at least as common, if not more so, than in women, suggesting that vertebral osteoporotic fractures are overlooked in men.     

Enhanced prediction of fracture risk combining vertebral fracture status and BMD

Summary Prevalent vertebral fractures are associated with increased fracture risk, but the magnitude of this effect across a range of BMD T-scores has not been quantified. In this analysis, for any given BMD T-score, incident fracture risk varied up to twelve fold when information regarding prevalent radiographic vertebral fracture status was considered. Background Clinical fracture risk evaluation of older women usually includes assessment of bone mineral density (BMD) but often not vertebral fracture status. In this analysis, we quantified the impact of vertebral fracture burden on two year fracture risk across a range of BMD T-scores. Methods Data were from 2,651 postmenopausal women who were assigned to the placebo groups of the Fracture Prevention Trial (median observation 21 months) and the Multiple Outcomes of Raloxifene Evaluation Trial (MORE; observation 2 years). Using the Genant visual semiquantitative criteria, we defined prevalent vertebral fracture status as: a) presence or absence of fracture; b) fracture number; c) maximum semi-quantitative (SQ) score (normal=0, mild fracture=1, moderate fracture=2, severe fracture=3); and d) spinal deformity index (SDI) score (sum of SQ scores of T4 to L4 vertebrae). Incident fractures over two years were identified via lateral spine radiographs and outside the spine by questioning of patients and review of radiographs or radiographic reports. Results Femoral neck BMD T-score provided significant information regarding fracture risk. Across the range of T-scores, vertebral fracture status provided additional prognostic information. The risk increased with increasing number and severity of prevalent vertebral fractures and SDI, a summary measure of spine fracture burden. Across a range of BMD values, prevalent spine fracture burden as assessed by SDI increased the risk of incident vertebral fractures by up to 12-fold, nonvertebral fractures by about twofold, and any fractures by up to sevenfold. Conclusions These findings indicate that at any given BMD T-score, the risk of incident vertebral, non-vertebral, and any fracture depended heavily on prevalent radiographic vertebral fracture status. Assessment of vertebral fracture status, in addition to BMD, provides practical and relevant clinical information to aid in predicting fracture risk in postmenopausal women. This study was supported by Eli Lilly and Company.     

Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group.

Although vertebral deformities are known to predict future vertebral deformities, little is known about their ability to predict other osteoporotic fractures. We examined the association between prevalent vertebral deformities and incident osteoporotic fractures in the Study of Osteoporotic Fractures, a prospective study of 9704 women aged 65 years and older. Prevalent vertebral deformities were determined morphometrically from spinal radiographs at baseline and incident deformities from repeat spinal radiographs after a mean of 3.7 years. Appendicular fractures were collected by postcard every 4 months for a mean of 8.3 years. During follow-up, 389 women with new vertebral deformities, 464 with hip fractures, and 574 with wrist fractures were identified. Prevalent vertebral deformities were associated with a 5-fold increased risk (relative risk 5.4, 95% confidence interval [CI] 4.4, 6.6) of sustaining a further vertebral deformity; the risk increased dramatically with both the number and severity of the prevalent deformities. Similarly, the risks of hip and any nonvertebral fractures were increased with baseline prevalent deformity, with relative risks of 2.8 (95% CI 2.3, 3.4) and 1.9 (95% CI 1.7, 2.1), respectively. Risk increased with number and severity of deformities. These associations remained significant after adjustment for age and calcaneal bone mineral density (BMD). Although there was a small increased risk of wrist fracture, this was not significant after adjusting for age and BMD. In conclusion, the presence of prevalent morphometrically defined vertebral deformities predicts future vertebral and nonvertebral fractures, including hip but not wrist fractures. Spinal radiographs identifying prevalent vertebral deformities may be a useful additional measurement to classify further a woman's risk of future fracture.     

Seizure-induced thoracic spine compression fracture: case report

BACKGROUND: Vertebral fracture caused solely by a convulsive seizure has rarely been reported in the neurosurgical literature. CASE DESCRIPTION: We describe a 34-year-old male with severe back pain from a thoracic fracture occurring in association with a seizure during hospitalization for treatment of temporal lobe epilepsy. Bone mineral densities in the lumbar spine and the femoral neck were decreased, possibly by long-term anti-epileptic medication. Muscle contractions during a seizure can result in vertebral fractures, especially at the thoracic levels. CONCLUSION: A complaint of back pain after a convulsive seizure should prompt radiologic investigation for vertebral fracture, even in the absence of external trauma.     

Vertebral fractures and osteopenia in chronic alcoholic patients

To assess whether vertebral fractures are associated with osteopenia in chronic alcoholic patients, a transversal study was carried out in 76 chronic alcoholic males and 62 age-matched healthy males. Lumbar bone mineral density (BMD) by dual photon absorptiometry and spinal chest X-ray films were done in all patients. Twenty-seven patients (36%) had vertebral fractures, but only 5 of them had a BMD below the fracture threshold. Twenty-two patients (29%) had osteoporosis by densitometric criteria. There were no significant differences in lumbar BMD between alcoholic patients with and without vertebral fractures (1.11±0.2 versus 1.13±0.2, P=ns). Previous trauma was recorded in 24 of the 27 patients with vertebral fractures and in 28 of the 49 patients without vertebral fractures (P<0.001). Moreover, patients with vertebral fractures had more peripheral fractures than patients without vertebral fractures (81% versus 49%, P=0.01). Only one patient was aware of a previous episode of traumatic vertebral fracture. In conclusion, chronic alcoholics frequently have traumas and vertebral fractures, the latter despite having a lumbar BMD above the fracture threshold, suggesting a frequent but unrecognized association between both processes. These results suggest that both spine films and BMD measurements should be obtained for diagnosis of osteoporosis in alcoholic patients.     

Multiple seizure-induced thoracic vertebral compression fractures: a case report

Background:Musculoskeletal injuries stemming from forceful muscular contractions during seizures have been documented in the literature. Reports of multiple seizure-induced spinal fractures, in the absence of external trauma and without risk factors for fracture, are rare.Discussion:This report highlights the importance of a complete history and examination of patients with a history of tonic-clonic seizures and back pain, especially when considering spinal adjustments.Summary:This case report presents an argument that a tonic-clonic seizure, in the absence of external trauma or significant risk factors for fracture, resulted in multiple vertebral compression fractures.     

Association between self-reported prior wrist fractures and risk of subsequent hip and radiographic vertebral fractures in older women: a prospective study.

In this large prospective cohort study of elderly women, the relationships between prior wrist fracture and incident hip and radiographic vertebral fractures were significantly attenuated when adjusted for BMD. This study suggests that BMD thresholds for drug therapy to prevent osteoporotic fracture should be only modestly adjusted in those with prior wrist fracture compared with those without prior wrist fracture. Validation of such an approach would require intervention trials in patients with prior wrist fracture. INTRODUCTION: Prior wrist fracture has been identified as a risk factor for incident hip and vertebral fractures and proposed as a criterion for determining who should be offered drug therapy to prevent osteoporotic fracture, even if their hip BMD T score is > -2.5. Previously published studies of the relationships between prior wrist fracture and incident hip and vertebral fractures did not adjust for BMD. MATERIALS AND METHODS: We ascertained prior history of wrist fracture since age 50, measured calcaneal and hip BMD, and performed lateral spine films in a cohort of 9704 elderly community-dwelling women, and then followed them prospectively for incident vertebral and hip fractures. Incident vertebral fractures were defined by morphometry using lateral spine radiography at the first examination and an average of 3.7 years later. Incident hip fractures were confirmed with radiographic reports over a mean follow-up period of 10.1 years. RESULTS: Prior wrist fracture was associated with an age-adjusted 72% increased odds of incident radiographic vertebral fracture (odds ratio [OR], 1.72; 95% CI, 1.31-2.25). After adjustment for calcaneal BMD, the association of prior wrist fracture with incident radiographic vertebral fracture was attenuated (OR, 1.39; 95% CI, 1.05-1.83). Prior wrist fracture was also associated with an age-adjusted 43% excess rate of incident hip fracture (hazards ratio [HR], 1.43; 95% CI, 1.17-1.74). After adjustment for hip BMD, the association of prior wrist fracture with rate of incident hip fracture was no longer statistically significant (HR, 1.12; 95% CI, 0.92-1.38). CONCLUSION: In elderly women, prior wrist fracture is a risk factor for radiographic vertebral fracture independent of BMD. The association between prior wrist fracture and incident hip fracture is largely explained by hip BMD. Modest adjustment of BMD drug treatment thresholds for prevention of osteoporotic fractures in those with prior wrist fracture compared with those without prior wrist fracture may be reasonable, but validation of such an approach would require intervention trials in patients with prior wrist fracture.     

The prevalence and risk factors of vertebral fractures in Korea

We investigated the prevalence and risk factors of vertebral fractures in Korea. In a community-based prospective epidemiology study, 1,155 men and 1,529 women (mean age 59?years, range 43-74) were recruited from Ansung, a rural Korean community. Prevalent vertebral fractures were identified on the lateral spinal radiographs at T11 to L4 using vertebral morphometry. Bone mineral density (BMD) was measured at the lumbar spine, femur neck and total hip. Of the 2,684 subjects, 137 (11.9%) men and 227 (14.8%) women had vertebral fractures and the standardized prevalence for vertebral fractures using the age distribution of Korean population was 8.8% in men and 12.6% in women. In univariate analysis, older age, low hip circumference, low BMD, low income and education levels in both sexes, previous history of fracture in men, high waist-to-hip circumference ratio, postmenopausal status, longer duration since menopause, and higher number of pregnancies and deliveries in women were associated with an increased risk of vertebral fractures. However, after adjusting for age, only low BMD in both sexes and a previous history of fracture in men were significantly associated with an increased risk of vertebral fractures. Vertebral fractures are prevalent in Korea as in other countries. Older age, low BMD and a previous history of fracture are significant risk factors for vertebral fractures.     

Split coronal fractures of the lumbar spine

The clinical and radiological results of 12 patients with a split coronal vertebral fracture were analysed with minimum follow-up of 24 months. All patients were treated operatively with an AO internal spinal fixator and transpedicular bone grafting. The operation was supplemented with posterior bone grafts in 4 patients. All fractures healed without marked deformity. There were no vertebral body pseudarthroses. There were no neurological or vascular injuries due to the placement of pedicle screws or to transpedicular bone grafting. 10 patients, had excellent or good results.     

Association between prior non-spine non-hip fractures or prevalent radiographic vertebral deformities known to be at least 10 years old and incident hip fracture.

In this large cohort of elderly women, prior non-spine non-hip fractures and radiographic vertebral deformities >10 years old were modestly associated with incident hip fracture, but the excess risks of hip fracture attributable to those prior fractures and deformities seem to wane over time. INTRODUCTION: Whereas prior clinical fractures and prevalent radiographic vertebral deformities are well-documented predictors of incident hip fracture, the excess risks of incident fractures attributable to those prior fractures and deformities may decrease over time. Current guidelines regarding the assessment of fracture risk do not consider elapsed time since prior fracture or ascertainment of radiographic vertebral deformity. MATERIALS AND METHODS: We ascertained self-reported history of prior clinical fractures and calcaneal and total hip bone BMD and performed lateral spine radiographs in a cohort of 9516 community-dwelling elderly women who had not had a prior hip fracture. We prospectively followed them to assess incident hip fracture. Prevalent radiographic vertebral deformities were identified at baseline using morphometry, and incident hip fractures were confirmed by review of radiographic reports during three follow-up periods (0-5, >5-10, and >10 years after baseline exam). RESULTS: Among women who survived for 10 or more years after the baseline exam without having had a hip fracture, a history of non-spine non-hip fracture since age 50 reported at the baseline study examination was associated with a 21% age- and calcaneal BMD-adjusted excess risk (hazard ratio [HR], 1.21; 95% CI, 1.01-1.45) for subsequent incident hip fracture. Baseline radiographic vertebral deformity was associated with a 41% age- and BMD-adjusted excess risk (HR, 1.41; 95% CI, 1.15-1.73) of hip fracture after 10 years of follow-up. In comparison, the age- and BMD-adjusted HRs of incident hip fracture during the first 5 years of follow-up associated with prior non-spine non-hip fractures reported at the baseline study exam and prevalent radiographic vertebral deformities were 1.70 (95% CI, 1.30-2.22) and 2.10 (95% CI, 1.58-2.78), respectively. CONCLUSIONS: Self-reported prior non-spine non-hip fractures and prevalent radiographic vertebral deformities known to be at least 10 years old are modestly associated with incident hip fracture. The association between these predictor fractures and subsequent hip fractures seems to wane with increased time after ascertainment of the predictor fracture. Hip fracture risk assessment strategies incorporating prior fracture history should also consider elapsed time since those prior fractures.     

Repeat Low‐Trauma Fractures Occur Frequently Among Men and Women Who Have Osteopenic BMD

Fracture risk assessment based solely on BMD has limitations. Additional risk factors include the presence of a previous low‐trauma fracture. We sought to quantify the fracture burden attributable to first versus repeat fracture. We studied 2179 men and 5269 women, 50–90 yr of age, participating in the Canadian Multicentre Osteoporosis Study (CaMos). We included all low‐trauma fractures that occurred over 8 yr of follow‐up and classified these as either first or repeat clinical low‐trauma fracture based on lifetime fracture history. Analyses were further stratified by sex, age, BMD risk categories (normal, osteopenia, osteoporosis), and vertebral deformity status. There were 128 fractures in men and 577 fractures in women. About 25% of fractures in men and 40% in women were repeat fractures. Just over one half of first fractures occurred in those with osteopenic BMD (58% in men, 54% in women). Just under one half of repeat fractures also occurred in those with osteopenic BMD (42% in men, 47% in women). The incidence of repeat fracture was, in most cases, nearly double, but sometimes nearly quadruple, the incidence of first fracture within a given BMD risk category in both men and women. Repeat fractures contribute substantially to overall fracture burden, and the contribution is independent of BMD. Furthermore, those with a combination of prior low‐trauma fracture and another risk factor were at especially high risk of future fracture.     

Insufficiency fracture of the spine: a prospective analysis based on radiographic and scintigraphic diagnosis

To investigate the clinical characteristics of insufficiency fracture of the spine, patients aged 65 years or older, who had been hospitalized for acute low back pain without either an acute traumatic event or a previous history of malignant disease, were examined by plain radiographs and technetium-99m methylene disphosphonate bone scanning. Fifteen patients were diagnosed as having a vertebral insufficiency fracture on the basis of: (a) radiographic oseteopenia of the vertebra; (b) positive bone scan images; and (c) no episode of newly identified malignant disease in a subsequent 1 year follow up. These patients were analysed with respect to age, gender, bone mineral density, the number and distribution of the affected vertebrae, the extent of vertebral deformity, and consistency between radiographic and bone scan findings. Vertebral insufficiency fractures exhibited: (a) strict female predominance; (b) concave deformity of the affected vertebra; (c) a wide range of the vertebral height ratios and fracture distribution; and (d) low consistency between the vertebral deformity assessed by the lateral radiograph and positive activity on bone scanning. These findings represent a unique clinical feature of vertebral insufficiency fracture, and also emphasize the difficulty of radiographic diagnosis, as well as the importance of a comprehensive diagnostic approach.     

Risk factors for incident vertebral fractures in men and women: the Rotterdam Study.

Low BMD and prevalent vertebral fractures are known risk factors for incident vertebral fractures. In 3001 men and women from the Rotterdam Study, prevalent nonvertebral fractures, early menopause, current smoking, and walking aid use were also strong risk factors for incident vertebral fractures. INTRODUCTION: Thus far, age, low BMD, and prevalent vertebral fractures are the only well-known risk factors for incident vertebral fractures. Therefore, our aim was to investigate other potential risk factors for incident vertebral fractures in the elderly. MATERIALS AND METHODS: This study was based on the Rotterdam Study, a large prospective population-based cohort study among men and women > or =55 years of age. For 3001 subjects, spinal radiographs were obtained at baseline and again approximately 6.3 years later. These follow-up radiographs were scored for vertebral fractures using the McCloskey-Kanis method. Whenever a vertebral fracture was detected, the radiograph was compared with the baseline radiograph. If this fracture was not already present at baseline, it was considered incident. At baseline, information on potential risk factors was obtained. RESULTS: Low BMD and prevalent vertebral fractures were strong risk factors for incident vertebral fractures in both men and women (RR 2.3 [1.6-3.3] and 2.2 [0.9-5.0] for men and RR 2.1 [1.6-2.6] and 4.1 [2.5-6.7] for women, respectively). For women, age, early menopause (< or =45 years of age; RR 1.0 [1.1-3.5]), current smoking (2.1 [1.2-3.5]), and walking aid use (2.5 [1.1-5.5]) were additional independent risk factors. For men, only a history of nonvertebral fractures was a significant independent risk factor (OR 2.4 [1.2-4.8]). CONCLUSION: Apart from low BMD and prevalent vertebral fractures, prevalent nonvertebral fractures are associated with an increased incident vertebral fracture risk in men. In women, early menopause, current smoking, and walking aid use are additional independent risk factors for incident vertebral fractures.     

Impaired bone health and asymptomatic vertebral compressions in fracture-prone children: a case-control study

Frequent fractures in children may be a sign of impaired bone health, but it remains unestablished when and how fracture‐prone children should be assessed. This prospective study elucidated skeletal characteristics and predisposing factors in children with recurrent fractures. Findings were used to establish guidelines for screening. During a 12‐month period we recorded fracture history for all children (n = 1412) treated for an acute fracture at a large university hospital. All apparently healthy children over 4 years of age, who had sustained: (1) at least one vertebral fracture; (2) two long‐bone fractures before age 10 years; or (3) three long‐bone fractures before age 16 years, were recruited. They underwent dual‐energy X‐ray absorptiometry (DXA), laboratory tests, and spinal radiography. Information regarding family history and lifestyle factors were collected. Findings were compared with healthy controls. Sixty‐six fracture‐prone children (44 males, mean age 10.7 years; 5% of all children with fractures) were identified. Altogether, they had sustained 183 long‐bone fractures (median 3, range 0–7); 11 children had sustained vertebral fracture(s). Patients had significantly lower bone mineral density (BMD) at lumbar spine (p < 0.001), hip (p = 0.007), and whole body (p < 0.001) than the controls; only 5 children (8%) had a BMD Z‐score < ?2.0. Asymptomatic vertebral compressions were prevalent, especially in those under 10 years of age. Hypercalciuria (11%) and hyperphosphaturia (22%) were significantly more prevalent than in controls. Serum concentration of 25‐hydroxyvitamin D (S‐25OHD) was below 50 nmol/L in 55%; low levels were associated with low BMD and vertebral compressions. The fracture‐prone children had lower calcium intake, less physical activity, and more often had siblings with fractures than the controls. The findings suggest that a thorough pediatric evaluation, including DXA and spinal radiography, is often indicated already after a second significant low‐energy fracture in children, in order to detect potentially preventable adverse lifestyle factors and nutritional deficits and to identify those with compromised overall bone health. © 2012 American Society for Bone and Mineral Research.     

Comparison of methods for the visual identification of prevalent vertebral fracture in osteoporosis

The identification of vertebral fracture in osteoporosis is based mainly on the identification of abnormal variation in vertebral shape, but this can be misleading in the presence of a non-fracture deformity or normal variant of vertebral shape. Qualitative identification of vertebral fracture (Qual) is influenced by the subjectivity of the approach, and although more objective, the semiquantitative method (SQ) can be difficult to apply. In addition, there has been little independent evaluation of SQ in relation to other approaches. We aimed to evaluate a new algorithm-based approach for the qualitative identification of vertebral fracture (ABQ) and to compare it with SQ and Qual. Two radiologists reported spinal radiographs for 372 postmenopausal women using Qual (reader 1), and SQ and ABQ (reader 2). Non-fracture deformities and normal variants were also reported using Qual and ABQ. The prevalence of vertebral fracture by subjects was higher for SQ (24%) than for Qual (11%) and ABQ (7%). Agreement was poor between SQ and the other methods, and moderate between Qual and ABQ. Twenty-two women with vertebral fracture were agreed by all three methods, similar to the total identified by ABQ (25 women). Seventeen women diagnosed with fracture by Qual, had non-fracture deformity or normal variant (but no fracture) according to ABQ. Of the women with SQ fractures, 53% and 70% were identified negative for fracture but positive for non-fracture deformity or normal variant by ABQ and Qual. The main sources of discrepancy between SQ and the other methods were Scheuermanns disease, normal variation, and degenerative change accompanied by short anterior vertebral height. For all methods, bone mineral density (BMD) and BMD Z-scores were lower in women with vertebral fractures than in those with no fractures. Bone mineral density and BMD Z-scores were also lower at the lumbar spine and total body in women with vertebral fractures according to Qual and ABQ than they were for SQ, and were lower in women with SQ fractures agreed by Qual and ABQ, compared with those diagnosed negative for fracture by Qual and ABQ (p<0.01). We conclude that poor agreement between methods arises mainly from difficulties in differentiating true fracture from non-fracture deformity. Our new approach attempts to address this problem but requires further testing in a larger study population.     

Bilateral central dislocation of the hip. A case report

Bilateral posterior shoulder dislocations and vertebral fractures are well described complications of convulsive activity. A 72-year-old woman with osteoarthritis of both hips and knees centrally dislocated both hips during a tonic-clonic seizure. Bilateral central fracture dislocation of the hip, although rare, must be suspected in the postictal patient who complains of hip and knee pain.     

Risk factors for prevalent vertebral fractures in black and white female densitometry patients.

This cross-sectional study compared risk factors for prevalent vertebral fractures (diagnosed using densitometric spine image Vertebral Fracture Assessment [VFA]) in 176 black and 345 white women recruited during their clinical bone mineral density (BMD) testing at the University of Chicago Hospitals. We used logistic regression to assess the association of prevalent vertebral fractures and risk factors (age, height loss, history of nonvertebral fractures, BMD, and use of corticosteroids). The prevalence of vertebral fractures was 21% for both races. All risk factors of interest were significantly associated with vertebral fractures in white women. Among black women, only age and corticosteroid use were found to be significant predictors of presence of vertebral fracture(s). In women without history of corticosteroid use, the probability of having vertebral fracture(s) given age was lower (p=0.02) in black subjects. In 77 patients with a history of corticosteroid use, the probability of having vertebral fracture(s) was higher in black than in white women after adjustment for age (p=0.045), BMD (p=0.045), or cumulative corticosteroid dose (p=0.08). Fewer black women were prescribed pharmacologic therapy for osteoporosis, regardless of their BMD level and corticosteroid use. We conclude that use of corticosteroids may be associated with relatively greater vertebral fracture risk in blacks than in whites.     

Osteoporosis of the spine: correlation between vertebral deformity and bone mineral density in postmenopausal women

The purpose of this study is to evaluate the relation of bone mineral density (BMD) or the age-matched z score and osteoporotic vertebral fractures. The radiographs and spinal bone mineral density of 131 consecutive postmenopausal patients were retrospectively reviewed. The vertebral fractures between T4 and L4 were graded. Sixty-two patients had no fractures, and 69 had 1 or more fractures. In the nonfracture group, the mean age was 62.6 years, BMD was 0.88 g/cm2, and the z score was -1.00. In the fracture group, the mean age was 69.6 years, BMD was 0.788 g/cm2, and the z score was -1.26. Patients with 2 and 3 or more fractures had a lower mean BMD than that of the nonfracture group (P < .01). The z score (adjusted for age) was significantly lower only in patients with 3+ fractures (P < .05). Patients with grade 2 and grade 3 of any fracture type had significantly lower BMD (P < .01). The z score was lower only in those with grade 3 fracture (P < .05). Our study indicates that the clinical use of BMD z score adjusted for age is a better predictor of severity of vertebral fractures than is BMD alone.     

Association of prevalent vertebral fractures, bone density, and alendronate treatment with incident vertebral fractures: effect of number and spinal location of fractures. The Fracture Intervention Trial Research Group

Vertebral fractures are the most common osteoporotic fracture and are associated with significant pain and disability. Prior vertebral fracture and low bone mineral density (BMD) are strong predictors of new vertebral fracture. Using data from 6082 women, ages 55-80 years, in the Fracture Intervention Trial (a randomized, placebo-controlled trial of the antiresorptive agent, alendronate), we explored the association of the number of prior vertebral fractures with the risk of new fractures and whether this association is influenced by the spinal location of fractures. The risk of future vertebral fractures increased with the number of prevalent fractures, independently of age and BMD; in the placebo group, more than half of the women with five or more fractures at baseline developed new vertebral fractures, compared to only 3.8% of women without prior vertebral fractures. The magnitude of association with an increased risk of future vertebral fractures was equal for prevalent fractures located in either the "lower" (T12-L4) (relative risk [RR] = 2.9; 95% CI = 1.9, 3.6) or "upper" (T4-10) spine (RR = 2.6; 95% CI = 1.9, 3.6). We found no evidence that the effectiveness of alendronate in reducing the risk of future vertebral fracture was attenuated in women with up to five or more prevalent fractures, or that it varied by the location of prevalent fractures. However, prevalent vertebral fractures in any location were more strongly associated with risk of new fractures in the upper (RR = 5.2; 95% CI = 3.2, 8.3) than in the lower spine (2.3; 1.6, 3.3). In addition, each 1 SD decrease in spinal BMD was associated with a 2.1 (1.7, 2.6) times greater odds of new fracture in the upper spine, compared with 1.5 (1.3, 1.8) for the lower spine. These findings suggest that, in older women, osteoporosis may be a stronger risk factor for new fractures in the upper (vs. lower) thoracolumbar spine, although we found no evidence that the location of prior fractures should influence treatment decisions. Physicians should recognize that prior vertebral fractures are a strong risk factor for future fractures, and consider treating such patients to reduce their risk of subsequent fractures.