Incidence of new fractures in women with osteoporosis-induced vertebral fractures detected on routine lateral chest radiographs

Purpose

Vertebral fractures represent one of the major complications of osteopororis. Diagnosis is followed by a pharmacological, interventional or surgical treatment. Up to day there are non practice guidelines for a screening evaluation of bone fractures in elderly and most of the fractures remain undiagnosed. We prospectively evaluated the prevalence of vertebral fractures on chest X-rays to determine the diagnostic and prognostic roles of chest X-ray in predicting new bone fractures 2 years after the initial radiogram.

Materials and methods

Between March 2004 and October 2005, 4,045 women underwent chest X-ray in our radiology department for any indication. We identified 166 women with the presence of at least one vertebral fracture. A questionnaire was administered to these women to collect information about diagnosis of osteoporosis, history of malignancy, systemic diseases, osteoporosis-inducing drugs and pharmacological, radiological or surgical treatment received.

Results

Out of the 166 women (age 73±10.5 years) with vertebral fractures, we interviewed 101 women; 13 had died and 52 were not found. Most of the patients were on menopause (97.1%, 98/101) with an average age of menopause of 48,2 years (±6 years). Among the patients on menopause, 15,8% (16/101) had undergone hysterectomy. All patients received a diagnosis of osteoporosis, which was reached with a chest X-ray report in 23.7% (24/101) of cases. A new skeletal fracture occurred in 20.5% (5/27) of patients receiving treatment against a frequency of 20.8% (16/74) in patients without treatment. No statistical difference was found between the groups (p = 0.374).

Conclusions

Inadequate treatment may explain the lack of a substantial difference in new fracture risk between treated and untreated patients. For these reason we discuss about the evaluation of an adeguate therapeutic approaches in prevention of osteoporosis-induced fractures.     

Underreporting of vertebral fractures on routine chest radiography

OBJECTIVE: Osteoporosis is underdiagnosed and therefore undertreated. We determined the potential usefulness of chest radiography for detecting clinically important vertebral fractures by performing semiquantitative reviews and quantitative digital morphometry on 100 routine chest radiographs taken in the emergency department and comparing the yield of these independent reviews with official radiology reports. MATERIALS AND METHODS: One hundred randomly selected chest radiographs of patients 60 years or older who presented to the emergency department of a tertiary care hospital were evaluated. Radiographs were selected without knowledge of the presenting complaint and were independently reviewed by two board-certified radiologists and a radiology resident. A validated semiquantitative method was used to assess lateral chest radiographs for vertebral fracture. In addition, quantitative digital morphometry was undertaken. A clinically important vertebral fracture was defined as one that was at least moderate to severe (loss of height >or=> 25%). RESULTS: Mean age of the population was 75 years, 47% were women, and 46% were admitted to the hospital. According to the reference radiologist, prevalence of moderate to severe vertebral fractures was 22%. Simple agreement was 87-88% among reviewers; kappa values were moderate (0.56-0.58). The greatest agreement was between the reference standard radiologist and quantitative digital morphometry (89% agreement; kappa = 0.67). Only 55% (12/22) of vertebral fractures we identified were mentioned in the official radiology reports. CONCLUSION: Chest radiography has potential as a screening tool for revealing previously undiagnosed vertebral fractures, although in this study only half of moderate to severe fractures that we identified were mentioned in official reports.     

Pneumothorax: appearance on lateral chest radiographs

The appearance of pneumothorax on lateral radiographs obtained with the patient erect were reviewed in 100 patients (122 total examinations). A pneumothorax could be seen on the lateral projection in 89% of the examinations (109 of 122). The displaced pleural line was most frequently identified anteriorly or posteriorly and was less commonly identified at the lung apex or in a subpulmonic location. In 11 cases, an air-fluid level was the only recognizable finding of a pneumothorax on the lateral projection. Although in 27% of examinations (32 of 122) the pneumothorax was either not seen (11%) (n = 13) or was a subtle finding (16%) (n = 19), in 14% of examinations (17 of 122) the lateral projection provided helpful information to supplement the posteroanterior projection.     

Diagnosis of vertebral fractures on lateral chest X-ray: Intraobserver agreement of semi-quantitative vertebral fracture assessment

BackgroundIn clinical practice lateral images of the chest are performed for various reasons. As these lateral chest X rays show the vertebrae of the thoracic and thoraco-lumbar region, we wondered if these X-rays can be used for evaluation of vertebral fractures instead of separate thoracic spine X-rays.MethodsTo evaluate the agreement and intraobserver reliability of the semi-quantitative method for vertebral fractures on the lateral chest X-ray (X-chest) in comparison to the lateral thoracic spine X-ray (X-Tspine), two observers scored vertebral fractures on X-Tspine and twice on X-chest, separately, blinded and in different time periods. Agreement and Cohens’ kappa were calculated for a diagnosis of any fracture on patient level and on vertebral body level. The study was done in patients visiting an outpatient geriatric day clinic, with a high prevalence of vertebral fractures.Results109 patients were included. The intraobserver agreement for X-chest versus X-Tspine was 95–98% for the two levels of fracturing, with a Cohen's kappa of 0.88–0.91. The intraobserver agreement and reliability of the re-test on the X-chest showed an agreement between 91 and 98% with a Cohen's kappa of 0.81–0.93. More vertebrae were visible on the X-chest, mean 10.2, SD 0.66 versus mean 9.8, SD 0.73 on the X-Tspine (p < 0.001).ConclusionThe results show good agreement and intraobserver reliability on the X-chest compared to the X-Tspine for visualizing vertebral fractures. The results of this study emphasizes that the routinely performed X-chest is reliable in order to diagnose vertebral fractures.     

Detection of pleural effusions on supine chest radiographs

A prospective analysis of anteroposterior supine radiographs in 34 patients was undertaken to determine the detectability of pleural effusions on supine radiographs. The presence of pleural effusions and quantity of fluid (small, moderate, or large) were evaluated by using the following radiographic signs: increased homogeneous density superimposed over the lung, loss of the hemidiaphragm silhouette, blunted costophrenic angle, apical capping, elevation of the hemidiaphragm, decreased visibility of lower-lobe vasculature, and accentuation of the minor fissure. Decubitus radiographs were performed to identify and to estimate the quantity of pleural fluid. Sixty-two hemithoraces were evaluated by three observers. From a total of 36 pleural effusions shown on decubitus views, 24 were correctly identified on supine radiographs (sensitivity of 67%, specificity of 70%, and accuracy of 67%). The most frequent but least specific criterion for detecting pleural effusions on supine radiographs is blunting of the costophrenic angle. Other helpful signs include loss of the hemidiaphragm and increased density of the hemithorax. A normal supine radiograph does not exclude a pleural effusion. Our results show that supine radiographs are only moderately sensitive and specific for the evaluation of pleural effusions.     

乳腺成像时偶然发现椎体骨折:MR定位像的潜在价值

目的偶然发现椎体骨折是评价骨骼健康情况的关键因素。该研究目的是回顾性评价乳腺MRI的定位像作为显示骨质疏松性椎体骨折的潜在价值。方法 3位肌骨放射学专家采用半定量方法回顾性分析了856例乳腺MRI的矢状定位像以发现椎体骨折。同时研究病人的病史和基本信息。回顾正式的乳腺MRI与既往的影像学检查,以确定病人病史中是否有椎体骨折或其他相关骨病的情况。结果 856例病人[21～89岁,平均(54.7±12.2)岁]中,780例(91.1%)由于肿瘤原因而进行MRI检查,76例(8.9%)由于非肿瘤因素而参与本研究;57例的MRI定位像不能达到诊断要求而被排除。剩余799例中,71例(8.9%)MRI定位像中发现椎体骨折。其中63例(88.7%)的椎体骨折在影像学报告和既往病史中均未提到(P<0.001)。任何乳腺报告中都没有提到椎体骨折。4例病人的MRI定位像中发现了椎体转移瘤。结论系统评价MRI定位像能够获得额外的临床信息,以防止漏诊椎体骨折。在其他影像学检查时,MRI定位像可用于椎体骨折的筛查。     

Detection of incidental vertebral fractures in breast imaging: the potential role of MR localisers

Objectives

Incidental diagnosis of vertebral fractures (VFs) may represent a key point in the assessment of bone health status. Our purpose was to retrospectively evaluate localisation sequences (MR-loc) of breast MRI as a potential tool to detect osteoporotic VFs.

Methods

MR-loc sagittal images of 856 breast MRIs were reviewed by three expert musculoskeletal radiologists with a semiquantitative approach to detecting VFs. Anamnesis and data of patients were investigated. Official breast MRI and previous imaging reports were checked to understand if VFs or other relevant bone findings were known in patients’ clinical history.

Results

A total of 780/856 female patients (91.1?%) undergoing MRI for oncological reasons and 76/856 (8.9?%) with non-oncological aims were recruited into the study (54.7?±?12.2?years old, 21–89?years); 57/856 MR-loc images (6.7?%) were considered inadequate for diagnostic purposes and were excluded from the analysis. MR-loc detected VFs in 71/799 patients (8.9?%). VFs were neither reported nor previously known in the clinical history of 63/71 patients (88.7?%; P?<?0.001). No mention of VFs was found in any breast MR reports. In four patients MR-loc identified vertebral metastases.

Conclusions

A systematic evaluation of MR-loc may offer additional clinical information to prevent unrecognised VFs. MR-loc may screen for VFs in other imaging settings.

Key Points

? Vertebral fractures are usually a hallmark of osteoporosis. ? Localisation sequences before breast MR examinations can identify vertebral fractures. ? MR localisers should be inspected for vertebral fractures in other clinical settings.     

Pneumatosis intestinalis in bone-marrow transplantation patients: diagnosis on routine chest radiographs

We report seven cases of pneumatosis intestinalis that was initially detected on routine chest radiographs made in adult bone-marrow transplantation patients. The cases were collected over a 13-month period. The chest radiographs generally underestimated the extent of the pneumatosis, as subsequently seen on plain abdominal films. However, the portions of bowel most extensively involved were those seen on the chest radiographs (transverse colon, hepatic and splenic flexures, stomach). One patient had pneumoperitoneum also. Pneumatosis developed within 6-293 days after transplantation. The cause of pneumatosis intestinalis was multifactorial. Three patients were asymptomatic. Clinical management of all seven patients was altered because of the detection of pneumatosis. The dose of steroids was increased in three patients to treat graft-vs-host disease, antibiotic drugs were given to three patients for enteric pathogens, and bowel rest was prescribed for one patient with mucosal injury from intense chemotherapy and radiation therapy. These cases show that the chest radiograph makes early diagnosis of pneumatosis intestinalis possible in posttransplantation patients.     

Superior mediastinal widening from spine fractures mimicking aortic rupture on chest radiographs

Mediastinal widening on chest radiographs associated with lower cervical and upper thoracic spine fractures can mimic the radiographic findings of aortic rupture. Frontal chest radiographs from 54 patients with traumatic fractures of at least one vertebral body from C6 to T8 were examined for signs suggestive of aortic rupture. These signs included (1) mediastinal width equal to or greater than 8 cm; (2) presence of a left apical cap; (3) a right paratracheal stripe of 5 mm or more; and (4) deviation of the nasogastric tube, when present, to the right of the T4 spinous process. Thirty-seven patients (69%) had radiographic signs suggestive of aortic rupture on the initial anteroposterior chest film. The single patient in this group who actually had an aortic rupture died in the emergency department shortly after admission. The spine fracture could be identified on the initial chest radiograph in 19 (51%) of the 37 patients. These results show that a widened mediastinum on chest radiographs after trauma is not a specific finding of aortic rupture. In these cases, the upper thoracic spine should be examined closely on the initial frontal chest radiograph for evidence of fracture. If a fracture of the upper thoracic spine is identified, an aortic rupture is unlikely in the absence of clinical signs and symptoms supporting this diagnosis.     

Missed incidental vertebral compression fractures on computed tomography imaging: More optimism justified

Missed incidental vertebral compression fractures on computed tomography (CT) imaging are a common problem. Although numerous publications are available on this topic, recent publications still show a high percentage of such missed fractures. The rate of such missed fractures in the authors department is much lower than that in the reported literature when routine multiplanar reconstructions are used for reporting CT scans. Therefore, a more optimistic view on this topic seems to be justified.     

胸侧位像椎体压缩骨折诊断忽视原因浅析

目的 试分析常规X线胸像椎体压缩骨折诊断忽视的原因.方法 回顾分析1638例住院治疗患者的X线胸正侧位影像.年龄范围从50～91岁,平均(64±9)岁,其中男871例,女767例.所有患者的主诉或申请X线胸像检查的原因均与骨质疏松症和骨折无关.椎体压缩及分度的判定及分度方法选用Genant半定量(semiquantitative)目测法,椎体压缩骨折Ⅰ、Ⅱ、Ⅲ度的标准分别为椎体高度约减低20%～25%(Ⅰ度)、26%～40%(Ⅱ度)及41%以上(Ⅲ度),将椎体压缩骨折的影像评阅的结果与其既往X线报告结果和相应出院后病历记录进行比较分析.结果 1638例胸侧位影像评阅结果显示,椎体压缩骨折患者84例,压缩骨折的椎体总数为100个,其中X线影像报告已诊断为压缩骨折者共30例,X线影像报告未诊断的患者有54例.30例已诊断为椎体压缩骨折的X线影像报告中均未进行椎体压缩骨折的分度诊断.54例患者X线报告未诊断椎体压缩骨折63个,其中单发椎体压缩骨折47个,占X线报告未诊断椎体压缩骨折的75%;X线报告未诊断的Ⅰ度椎体压缩骨折34个(54%),Ⅱ度骨折21个(33%),而Ⅲ度骨折仅8个(13%).84例椎体压缩骨折患者中,行双能X线骨密度测量者仅有5例(6%),出院诊断椎体压缩骨折者仅有5例(6%),而出院带治疗骨质疏松症药物者也仅有15例(18%).15例带药患者所带与骨质疏松症治疗有关的药物均为钙类制剂.结论 无论影像科还是其他科室的医师均应增强对骨质疏松症的全面认识,对患者X线胸像侧位片所示的椎体骨质疏松性压缩骨折应做出及时、完整的影像诊断,并予规范化的防治和干预.     

Normal radiographic anatomy of thoracic structures: analysis of 316 lateral chest radiographs

PURPOSE: To study the frequency of visualization and characteristics of normal thoracic structures on lateral chest radiographs in the Japanese population. MATERIALS AND METHODS: We reviewed 316 lateral chest radiographs of men and women ranging in age from 20 to 90 years. The frequency of visualization and configuration of structures including major, minor, superior and inferior accessory fissures, and orifices of the right and left upper lobe bronchi were reviewed. RESULTS: On lateral chest radiographs, major fissure and minor fissure were visualized in 99.4% and 87.3%, respectively. Superior accessory fissure and inferior accessory fissure were visualized in 1.9% and 9.5%, respectively. Orifices of the right and left upper bronchi were seen in 92.4% and 98.4%, respectively. CONCLUSION: Frequency of visualization and characteristics of various normal anatomic structures on lateral chest radiographs in the Japanese population differ from those reported previously from the West. Familiarity with these normal thoracic structures and variations is important for daily image interpretation.     

Automated registration of frontal and lateral radionuclide lung scans with digital chest radiographs

RATIONALE AND OBJECTIVES: The purpose of this study was to develop and evaluate a fully automated method that spatially registers anterior, posterior, and lateral ventilation/perfusion (V/Q) images with posteroanterior and lateral digital chest radiographs to retrospectively combine the physiologic information contained in the V/Q scans with the anatomic detail in the chest radiographs. MATERIALS AND METHODS: Gray-level thresholding techniques were used to segment the aerated lung regions in the radiographic images. A variable-thresholding technique combined with an analysis of image noise was used to segment the adequately perfused or ventilated lung regions in the scintigraphic images. The physical dimensions of the segmented lung regions in images from both modalities were used to properly scale the radiographic images relative to the radionuclide images. Computer-determined locations of anatomic landmarks were then used to rotate and translate the images to achieve registration. Pairs of corresponding radionuclide and radiographic images were enhanced with color and then merged to create superimposed images. RESULTS: Five observers used a five-point rating scale to subjectively evaluate four image combinations for each of 50 cases. Of these ratings, 95.5% reflected very good, good, or fair registration. CONCLUSION: The automated method for the registration of radionuclide lung scans with digital chest radiographs to produce images that combine functional and structural information should benefit nuclear medicine physicians and radiologists, who must visually correlate images that differ greatly in physical size, resolution properties, and information content.     

Tilted air-fluid interfaces on chest radiographs

Three patients had hydropneumothoraces in which the air-fluid interfaces were tilted from the horizontal. One was examined fluoroscopically, and the interface "seesawed" synchronously with the heartbeat. Displacement of the fluid by cardiac pulsation is the most likely usual cause of tilted air-fluid interfaces in the chest.     

Automatic detection of osteoporotic vertebral fractures in routine thoracic and abdominal MDCT

Objectives

To develop a prototype algorithm for automatic spine segmentation in MDCT images and use it to automatically detect osteoporotic vertebral fractures.

Methods

Cross-sectional routine thoracic and abdominal MDCT images of 71 patients including 8 males and 9 females with 25 osteoporotic vertebral fractures and longitudinal MDCT images of 9 patients with 18 incidental fractures in the follow-up MDCT were retrospectively selected. The spine segmentation algorithm localised and identified the vertebrae T5-L5. Each vertebra was automatically segmented by using corresponding vertebra surface shape models that were adapted to the original images. Anterior, middle, and posterior height of each vertebra was automatically determined; the anterior-posterior ratio (APR) and middle-posterior ratio (MPR) were computed. As the gold standard, radiologists graded vertebral fractures from T5 to L5 according to the Genant classification in consensus.

Results

Using ROC analysis to differentiate vertebrae without versus with prevalent fracture, AUC values of 0.84 and 0.83 were obtained for APR and MPR, respectively (p?<?0.001). Longitudinal changes in APR and MPR were significantly different between vertebrae without versus with incidental fracture (ΔAPR: -8.5 %?±?8.6 % versus -1.6 %?±?4.2 %, p?=?0.002; ΔMPR: -11.4 %?±?7.7 % versus -1.2 %?±?1.6 %, p?<?0.001).

Conclusions

This prototype algorithm may support radiologists in reporting currently underdiagnosed osteoporotic vertebral fractures so that appropriate therapy can be initiated.

Key points

? This spine segmentation algorithm automatically localised, identified, and segmented the vertebrae in MDCT images. ? Osteoporotic vertebral fractures could be automatically detected using this prototype algorithm. ? The prototype algorithm helps radiologists to report underdiagnosed osteoporotic vertebral fractures.