Rev. Bras. Reumatol. vol.55 número5

r e v b r a s r e u m a t o l . 2015;55(5):464–467

w w w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Brief

communication

Diagnosing

vertebral

fractures:

missed

opportunities

João

Lindolfo

Cunha

Borges

,

Julianne

Lira

Maia

,

Renata

Faria

Silva

,

Edward

Michael

Lewiecki

a_{CentrodePesquisaClínicadoBrasil,Brasília,DF,Brazil}

b_{UniversidadeCatólicadeBrasília,Brasília,DF,Brazil}

c_{NewMexicoClinicalResearch&OsteoporosisCenter,Albuquerque,UnitedStates}

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Articlehistory:

Received29May2014 Accepted7December2014 Availableonline16March2015

Keywords:

Vertebralfractures Osteoporoticfractures Osteoporosis

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Vertebral fractures are the single most common type of osteoporotic fracture. Post-menopausalwomenareatincreasedriskforosteoporoticvertebralfracturescomparedwith womenofchildbearingage.Vertebralfracturesareassociatedwithanincreaseinmorbidity, mortality,andhighriskofasubsequentvertebralfracture,regardlessofbonemineral den-sity.Despitethecommonoccurrenceandseriousconsequencesofvertebralfractures,they areoftenunrecognizedormisdiagnosedbyradiologists.Moreover,vertebralfracturesmay bedescribedbyvariableterminologythatcanconfuseratherthanenlightenreferring physi-cians.WeconductedasurveyofspineX_{-rayreportsfromagroupofpostmenopausalwomen}

screenedforparticipationinastudyofosteoporosisatCentrodePesquisaClínicadoBrasil. Adescriptiveanalysisevaluatedthevariabilityofreportsin7patients.Fourindependent generalradiologistsissuedreportsassessingvertebralfracturesthroughablindedanalysis. Theobjectiveofthisstudywastoevaluateforconsistencyinthesereports.Theanalysis foundmarkedvariabilityinthediagnosisofvertebralfracturesandtheterminologyusedto describethem.Incommunitymedicalpractices,suchvariabilitycouldleadtodifferences inthemanagementofpatientswithosteoporosis,withthepotentialforundertreatmentor overtreatmentdependingonclinicalcircumstances.Accurateandunambiguousreporting ofvertebralfracturesislikelytobeassociatedwithimprovedclinicaloutcomes.

©2015ElsevierEditoraLtda.Allrightsreserved.

∗ _{Correspondingauthor.}

E-mail:jlborges@metabolismo.com.br(J.L.C.Borges).

http://dx.doi.org/10.1016/j.rbre.2014.12.008

rev bras reumatol.2015;55(5):464–467

465

Diagnóstico

de

fraturas

vertebrais:

oportunidades

perdidas

Palavras-chave:

Fraturasvertebrais Fraturasosteoporóticas Osteoporose

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Asfraturasvertebraissãootipomaiscomumdefraturaosteoporótica.Asmulheresna pós-menopausatêmumriscoaumentadodefraturasvertebraisosteoporóticasemcomparac¸ão comasmulheresemidadefértil.Asfraturasvertebraisestãoassociadasaumaumento namorbidadeemortalidadeeàelevac¸ãodoriscodefraturavertebralsubsequente, inde-pendentementedadensidademineralóssea.Apesardaocorrênciacomumedasgraves consequências dasfraturasvertebrais,elasmuitas vezespassam despercebidasousão erroneamentediagnosticadaspelosradiologistas.Alémdisso,asfraturasvertebraispodem serdescritascomumaterminologiavariável,quepodeconfundiremvezdeesclarecero médicosolicitante.Foifeitoumlevantamentodoslaudosdasradiografiasdecoluna verte-braldeumgrupodemulheresnapós-menopausaselecionadasparaparticipardeumestudo deosteoporosenoCentrodePesquisaClínicadoBrasil.Aanálisedescritivaavalioua vari-abilidadedoslaudosemsetepacientes.Quatroradiologistasgeraisindependentesemitiram laudosdeavaliac¸ãodasfraturasvertebraispormeiodeumaanálisecega.Oobjetivodeste estudofoiavaliaraconsistênciadesseslaudos.Aanálisedescobriuumaacentuada variabil-idadenodiagnósticodasfraturasvertebraisenaterminologiausadaparadescrevê-las.Na práticaclínicadacomunidade,essavariabilidadepoderialevaradiferenc¸asnotratamento depacientescomosteoporose,comopotencialdesubtratamentooutratamentoexagerado, adependerdascircunstânciasclínicas.Laudosprecisoseinequívocosdefraturasvertebrais sãosusceptíveisdeestarassociadosamelhoresdesfechosclínicos.

©2015ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

AccordingtotheNationalOsteoporosisFoundation,44million peopleintheUnitedStateshaveosteoporosisorosteopenia.1

It isestimated that osteoporosis affects about 200 million womenworldwide,withoccurrenceofanosteoporotic frac-ture every 3s and a vertebral fracture every 22s.1,2 _The

annual incidence of osteoporotic fractures in the United States is higher than the combined incidence of heart attack, stroke and breast cancer. The prevalence of verte-bral fractures in Caucasians over 50 years old is 20–25%, and in Latin American is 12%.1,3 _{Still, people at 50 years,}

present a major risk of osteoporotic fracture: 46–53% in womenand 21–22%in men;vertebral fracture in radiogra-phy: 27% in women and men 11%; and clinical vertebral fracture.4 _{Peri- and postmenopausal women witha}

preva-lent vertebral fracture have a two to five-fold increased riskofasubsequentvertebralfracturecomparedtowomen without a prevalent vertebral fracture, regardless of bone mineraldensity.5_{Inaddition,thepresenceofavertebral}

frac-ture increases the mortality rate and the chances of new fractures.6,7 _{However,failure to identify vertebral fractures}

on radiographic studies is a common problem worldwide, withsomereportsofanoverallrateof34%formissed diag-noses,leadingtounder-treatmentandpoorclinicaloutcomes, includingbackpain,lossofindependence,andreduced qual-ity of life.6,8 _{We therefore undertook an investigation to}

evaluateconsistencyanddivergenceofreportsofspine radio-graphsinagroupofpostmenopausalwomendiagnosedwith osteoporosis.

Materials

and

methods

Spineradiographswereperformedin7womenparticipating inastudy ofosteoporosisatCentrode PesquisaClínicado Brasil.ThepurposeoftheseX-rayswastoevaluatefor preva-lentspinefracture.Digitizedspineimages(posterior-anterior andlateralviews)weresentto4generalradiologists,eachof whom wasaware ofthe purposeofthe X-rays,forblinded independentinterpretations.Thereportswerethencompared forconsistencyofterminologyanddiagnosisofvertebral frac-tures.

Results

The interpretation of each radiologist for diagnosis and descriptionofvertebralfracturesisprovidedintheTable1.

Discussion

Osteoporosisisanosteometabolicdiseasethatleadstolow bonemineraldensity,bonemicroarchitecturaldeterioration ofbone,andskeletal fragility,predisposinganindividualto fractures withminimaltrauma.9,10 _{Postmenopausalwomen}

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Table1–RadiologyreportsofspineX-raysby4radiologistsin7womenwithosteoporosis.Thisshowsmarked variabilityintheidentificationanddescriptionofvertebralfractures.

Report1 Report2 Report3 Report4

Patient1 Slightreductionofthe heightsofvertebralbodies.

AnteriorwedgingofT5. MildfracturesatL2andL3. Moreover,moderate reductionoftheheightof thethoracicvertebral bodies,morepronouncedat T5.

Fracture/Crushfracturein T5vertebralbody,andless evidentinL3.

Patient2 Absenceoffractures. Discreetanteriorwedging ofT11depressionofthe upperplateau.

Biconcaveinsufficiency vertebralbodyfracturesin severalthoracicvertebras. Anteriormildwedgingin T11.

Fracture/wedgingof vertebralbodiesofT10,T11, T13andT14.

Patient3 Absenceoffractures. Absenceoffractures. Biconcaveaspectof vertebralbodiesofthoracic andupperlumbarvertebra, mainlyinT11andT12.No significantvertebral collapse.

Absenceoffractures.

Patient4 Absenceoffractures. Absenceoffractures. Absenceoffractures. Absenceoffractures. Patient5 Absenceoffractures. Absenceoffractures. Absenceoffractures. Absenceoffractures. Patient6 Absenceoffractures. DiscretewedgingofL2

vertebralbody

Absenceoffractures. Diminishedheightofthe vertebralbodyofL2. Patient7 WedgingoftheL4vertebral

bodyaround15%.

AnteriorwedgingofT11 andT12.Superiorplateau fractureofL4

Discreetanteriorwedging L4.

Discretefracture/wedging intheupperplateauofL4.

ofvertebralfractureisthroughspineX-rays,ideallyfollowed byevaluationandappropriatetherapytoreducetheriskof futurefractures.Effectivetherapiesarewidelyavailableand canreducetheoccurrenceoffuturevertebralfracturesby30% to70%.However,inspiteofvertebral fractures beingquite commonand associatedwithdecreased qualityoflifeand increasedmortality, they are often unreportedor misdiag-nosedbyradiologists.1,12

Inarecentretrospectivestudyof934womenage60years and older,therewas radiographicevidence ofmoderateor severevertebral fracturesin132(14%), butonly50%ofthe radiological reportsmentioned thesefractures.6 _Inanother

study of 2000 postmenopausal women with osteoporosis, theaccuracyofspineX-rayinterpretationswasassessedby comparing the results oflocal radiographic reports with a radiographic central laboratory.8 _{This study showed}

false-negative rates between 27 and 45 percent for diagnosing vertebralfractures.8_{Inaddition,whenavertebraldeformity}

wasidentified,ambiguousterminologywasoftenusedinthe reports,leadingtopotentialconfusionindiagnosingvertebral fractures.6,8_{Despitethesmallnumberofpatients,ourresults}

aresimilartotheinternationalliterature.13 _{Thisisthefirst}

studyaddressingmissedopportunitiesfordiagnosing verte-bralfracturesinBrazil.

Conclusion

Thisstudy showsgreatvariability intheidentification and descriptionofvertebralfracturesinpostmenopausalwomen withosteoporosis.Clinicianswhorelyonaccuratereporting byradiologistsmayinturnmanagetheirpatientsdifferently dependingonwhichreportisreceived.Whenavertebral frac-tureisnotrecognizedorwhen adescriptionofavertebral

deformityisnotclear,thendecisionsforevaluatingand treat-ingpatientsmaybeincorrect.Improvementintheaccuracy and consistency ofreportingvertebral fractures islikelyto improvepatientcare.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgment

Wewouldliketothanktheradiologistswhowerewillingto assess theradiographsperformed,Bruno L.B.Cherulli,Elisa CristinaDias,PriscillaPiuzanaNogueira,SérgioVianaandthe doctorLudmillaPavlikHaddadforcollaboration.

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