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Vertebral Fractures: Clinical Importance and Management

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Vertebral fractures are the most common type of osteoporotic fracture and are associated with substantial morbidity and decreased survival. In the United States, annual direct management costs for vertebral fractures are more than $1 billion (United States dollars in 2011).

Vertebral fracture, once suspected, can be confirmed by X-rays, computerized tomography, magnetic resonance imaging, or vertebral fracture assessment. Vertebral fracture assessment can be completed at the time of bone mineral density assessment with dual-energy X-ray absorptiometry. Information on radiation dose, image resolution, and relative cost for these imaging modalities can be found in. Nonfracture causes of vertebral height loss and deformity need to be ruled out before confirming vertebral fracture.

Asymptomatic (morphometric) and symptomatic vertebral fracture can be diagnosed using the Genant semiquantitative method, which requires a ≥20% decrease in vertebral height (anterior, mid, or posterior dimensions), estimated visually, to diagnose a vertebral fracture. In intervention and epidemiologic studies, aprevalent vertebral fracture is a fracture identified at the baseline of the study; incident vertebral fractures are those occurring after the baseline.

Vertebral fractures can also be diagnosed by standard quantitative morphometry or by comparing a vertebral body with adjacent vertebrae. By vertebral comparison, a vertebral fracture can be diagnosed if there is a greater than 3 standard deviation difference in vertebral heights between adjacent vertebral levels. Endplate depression, discontinuity of the endplate, or anterior cortex disruption is expected when fracture is the cause of the vertebral deformity. The Algorithm-Based Qualitative methodology relies on recognition of vertebral endplate deformity to identify vertebral fracture. When comparing clinical trials or epidemiology studies, it is important to understand how vertebral fractures were defined, because this can have important implications on interpretation of the findings. Tables 2 and 3 illustrate the diversity in study criteria for vertebral fracture.

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-D.L. Kendler, MD, D.C. Bauer, MD, K.S. Davison, PhD, L. Dian, MBBS, D.A. Hanley, MD, S.T. Harris, MD, M.R. McClung, MD, P.D. Miller, MD, J.T. Schousboe, MD, C.K. Yuen, MD, MBA, E.M. Lewiecki, MD

This article originally appeared in the February 2016 issue of The American Journal of Medicine.

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