Clinical relevance of vertebral fractures
- Vrije Universiteit Medical Centre; Slotervaart Hospital; Jan van Breemen Institute, Amsterdam, The Netherlands
- Correspondence to:
Dr W F Lems
Department of Rheumatology 4A42, Vrije Universiteit Medical Centre, Postbox 7057, 1007 MB Amsterdam, The Netherlands;
- Accepted 7 October 2006
Why are vertebral fractures so often overlooked?
Osteoporotic fractures occur quite frequently: the lifetime fracture risk for a 50-year-old woman is 40%.1 Bone mineral density (BMD) is an important predictor of future fractures: the risk is increased twofold for each standard deviation (SD) decrease in BMD, whereas the correlation between low BMD and fractures is strongest for measurements at the same site as that of the fracture.2 BMD is often measured for diagnosing osteoporosis (T score ⩽−2.5 SD, according to the World Health Organization criteria), although these criteria were developed for epidemiological studies. However, the two-dimensional dual-energy x ray absorptiometry images do not measure two other important properties of bone strength: the microarchitecture and its material composition.3
In a large meta-analysis, it has been shown that having a fracture is associated with an increased relative risk of subsequent fractures.4 In Maastricht, The Netherlands, a large study on 2419 patients aged ⩾50 years was performed: the absolute risk of developing a new clinical fracture within 2 years after a fracture was >10%.5 In Glasgow, UK, a low BMD was found in 50–70% of the patients aged ⩾50 years with a clinical (nearly all non-vertebral) fracture.6 As effective osteoporosis drugs, particularly bisphosphonates, are nowadays available,7 awareness is growing that patients should be diagnosed and treated for osteoporosis in the case of a low BMD, particularly in combination with a clinical (non-vertebral) fracture.
The first reason for failing to diagnose vertebral fractures is its clinical presentation: non-vertebral fractures, for example, from the wrist or hip, are easy to diagnose in patients with severe pain and a deformity, usually after a fall. By contrast, diagnosing vertebral fractures is more complicated. They usually occur during daily activities, such as climbing stairs or bending forward, without a fall. The …