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Osteoporotic vertebral fractures: A diagnostic challenge in the 21st century
Fracturas vertebrales osteoporóticas: un reto diagnóstico en el siglo XXI
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Capdevila-Reniu, M. Navarro-López, A. López-Soto" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Capdevila-Reniu" "email" => array:1 [ 0 => "aicapdev@clinic.ub.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Navarro-López" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." 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According to the World Health Organization, osteoporosis affects 3.5 million people in Spain. The estimated incidence of osteoporosis in Catalonia is 10.91 per 1000 individuals older than 50 years per year, and a significant increase is predicted due to the aging of the population.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The osteoporotic vertebral fracture (OVF) is the most common vertebral fracture, which, according to the European Prospective Osteoporosis Study, has an estimated incidence rate of 1,400,000 fractures per year, equivalent to 20–25% of postmenopausal women older than 50 years.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> A national study showed a OVF rate of 62.6% in postmenopausal patients admitted for concomitant osteoporotic hip fractures.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> OVFs are more common in elderly patients, with a prevalence >40% for patients older than 80 years.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> The epidemiological studies FRAVO in women and Camargo in men, both conducted in Spain, reported a OVF incidence rate of 21.3% in women and in men older than 50 years and a higher rate (46%) in women ≥75 years compared with men of the same age (32.6%).<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite the high percentage of especially elderly patients with OVF, this number is underestimated because most OVFs are undiagnosed and go unnoticed by the patient and attending doctor, to the point where it has been considered the “silent epidemic of the 21st century”.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The 2014 clinical guidelines of the National Osteoporosis Foundation consider the presence of a vertebral fracture compatible with the diagnosis of osteoporosis, as is the case for any nonvertebral fracture of osteoporotic characteristics, even in the absence of densitometric osteoporosis, and is therefore an indication for drug treatment to improve the secondary prevention of new osteoporotic fractures.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Imminent risk of fractures</span><p id="par0020" class="elsevierStylePara elsevierViewall">OVFs are caused by a fall from the patient’s height or lower or through low-impact effort such as crouching, climbing stairs and sneezing.</p><p id="par0025" class="elsevierStylePara elsevierViewall">OVFs are not harmless for the patient and promote future fractures,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13</span></a> both vertebral and nonvertebral, and are associated with greater mortality and poorer quality of life.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> Studies have estimated that an OVF quadruples the risk of a new OVF and doubles the risk of an osteoporotic fracture of the femoral neck.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The risk of new fractures is 7–10% during the first year after the onset of the fracture and rises to 18% at 2 years of the fracture. In individuals older than 75 years, the risk increases to 25% at 2 years of the fracture<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12,17,18</span></a> and is higher for women.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> An early and accurate diagnosis is therefore essential for starting treatment as soon as possible. The dorsal-lumbar hinge is the most affected area.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Morbidity and mortality</span><p id="par0030" class="elsevierStylePara elsevierViewall">A US population study conducted with patients older than 65 years with OVF showed an increase in mortality in this group twice that of the control group, with survival rates of 50% at 3 years, 30% at 5 years and only 10% at 7 years. The patients’ mean age was 80 years, and the increase in mortality was higher in men.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Similar results were obtained from an Australian cohort that also showed that mortality was not higher after OVF in older patients with fractures compared with the younger patients.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Pain is the first manifestation but is only present in a third of fractures, and only 10% of patients with pain consult for it in medical centers.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6,7</span></a> Pain is secondary to the same fracture; apart from the pain in the paravertebral area, patients with multiple fractures can present pain due to the impact of the ribs on the pelvic bones. Another common manifestation is the patients’ loss of stature, many times attributed to other causes, such as age-associated degenerative processes. A documented loss >2 cm in the past year or a loss of 4–6 cm from the height recorded in their youth should alert clinicians to the presence of an OVF.</p><p id="par0040" class="elsevierStylePara elsevierViewall">One of the characteristics of OVFs is the rare involvement of the medullary canal (<1%), possibly due to the fact that the posterior wall of the vertebral body and the posterior arch are unaffected. Spinal injuries, if they occur, are secondary to the posterior displacement of a fragment of the vertebral body. Neurological symptoms concomitant with pain should raise suspicion about other etiologies. Impairment above T5 is also rare. Fractures in the first dorsal or cervical vertebra are therefore rarely secondary to osteoporosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The presence of multiple fractures can also result in restrictive lung disease due to a reduction in the thoracic cavity, gastroesophageal transit disorders due to diaphragmatic compensation with abdominal cavity reduction, and physical activity limitations due to pain, with the consequent acceleration of bone waste, increased sarcopenia and physical dependency and can also increase the number of falls due to loss of equilibrium. Likewise, medical complications secondary to immobility can appear, such as pressure ulcers and venous embolism.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Screening for osteoporotic vertebral fractures</span><p id="par0050" class="elsevierStylePara elsevierViewall">The International Osteoporosis Foundation considers the early detection of OVFs an essential element in preventing new fractures, both OVFs and osteoporotic nonvertebral fractures.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Various research studies have recently been published<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,23</span></a> on algorithms for the early detection of asymptomatic OVFs. The main predictors are advanced age, poorer bone mineral density, the use of corticosteroids and the loss of stature. In terms of the bone densitometry values in the lumbar spine as predictors of fractures, there is disagreement among the studies, although a higher prevalence of osteopenia instead of osteoporosis has been observed in the lumbar spine of patients with OVFs.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Given that vertebral fractures are the most common osteoporotic fracture, early and accurate detection should be conducted to decrease the risk of new fractures and to properly establish secondary prevention.</p><p id="par0065" class="elsevierStylePara elsevierViewall">National and international societies on osteoporosis and frailty fractures do not recommend universal screening for vertebral fractures using spine radiography. Screening is recommended only for patients with symptoms suggestive of OVF or for elderly patients with other previous osteoporotic fractures or densitometric osteoporosis.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,25</span></a> The recent guidelines of the National Osteoporosis Foundation and International Society for Clinical Densitometry include the recommendations shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> for the search for vertebral fractures.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,25</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Once a first screening for OVFs has been conducted and potential fractures have been identified, repeating the imaging test is advised only if there is a documented loss of height or new onset dorsal-lumbar pain (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Classification of vertebral fractures</span><p id="par0075" class="elsevierStylePara elsevierViewall">OVFs are classified into 3 groups according to their morphology: anterior wedging (reduced anterior diameter of the vertebral body), biconcave (reduced middle diameter) or compressed (reduced anterior, middle and posterior diameters). On very rare occasions, the posterior arch of the vertebra is affected and usually does not affect the medullary canal.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The first vertebral fracture assessment methods in spinal radiographs were quantitative and based on the vertebral form. One of the best known of these methods is by Eastell and Melton,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> which is based on vertebral body size abnormalities compared with populational standards, although the method offers low sensitivity and specificity. In 1993, Genant developed a semiquantitative system for classifying OVFs,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> defining 3 groups according to the percentage reduction in vertebral body diameters compared with the adjoining vertebras that showed no structural abnormalities. This method classified fractures with a 20–25% reduction of one of these diameters as grade 1 or mild fracture, fractures with a 25–40% reduction as grade 2 or moderate and fractures with a >40% reduction as grade 3 or severe. This method does not use populational reference values.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Jiang et al. subsequently described an algorithm-based qualitative (ABQ) identification system for fractures, which is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28,29</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Various studies have compared the identification of OVFs using the 3 methods, showing a low correlation between results. However, the Genant semiquantitative system identified the most fractures (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Recently published studies have recommended starting the detection of OVFs with the Genant semiquantitative method. For grade 1 OVFs, the studies recommend applying the ABQ method.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30–32</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Diagnostic methods for vertebral fractures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Spine radiography</span><p id="par0100" class="elsevierStylePara elsevierViewall">Spine radiography is the gold standard technique and the easiest for detecting OVFs. However, it has certain limitations, the first of which is its operator-dependency, wherein the obliquity at which the radiography is performed can create false images. The second limitation is the difficulty in interpreting the images, if there are deformities such as inadequate curvature, osteoarthritis, developmental disorders (Scheuermann’s disease), disc degeneration and Schmorl nodes.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Lastly, although this technique helps diagnose moderate and severe vertebral fractures, mild fractures can go unnoticed, especially in the dorsal-cervical area.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Two projections need to be performed: a dorsal centered on D7 and a lumbar centered on L2, although a radiography in anteroposterior projection can be useful in some cases.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Lateral chest radiography is a widely used technique and is useful for detecting OVFs in asymptomatic patients, visualizing the dorsal spine and the dorsal-lumbar hinge area, which is the area most affected by vertebral fractures.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Retrospective studies conducted in internal medicine and emergency departments that have assessed the detection of OVFs in lateral chest radiographs have achieved a detection rate of 50%.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,35,36</span></a> The technique has low sensitivity and specificity, especially during the acute phase of the fracture.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Vertebral morphometry</span><p id="par0115" class="elsevierStylePara elsevierViewall">Vertebral morphometry (or vertebral fracture assessment) came into use in the 1990s and is a program incorporated into bone densitometry that enables the concomitant assessment of the spine. Thus, the same examination can obtain more information and avoid radiography, thereby sparing the patient from unnecessary radiation. The technique is estimated to use <1% of the radiation of conventional radiography (3 µSv) and has been shown to be a cost-effective technique. In each vertebral body, the program automatically creates 6 points that can be manually adjusted by a technician if they do not fit the diameters of the vertebral bodies. Their interpretation uses Genant’s semiquantitative method<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> and assesses the standard deviations of the diameters compared with adjacent healthy vertebras.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The technique has a sensitivity of 70–93% and a specificity of 95% in detecting moderate to severe fractures<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37,38</span></a> (especially of T4 to L4) but has poorer detection of mild fractures. The resolution of the cervical spine is poor compared with other techniques.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39,40</span></a> Vertebral morphometry helps diagnose 94% of grade 2 and 3 fractures.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">A study sponsored by the National Health and Nutrition Examination Survey reported a prevalence of 5.4% for OVFs in patients older than 40 years detected through vertebral morphometry, 59% of which were moderate and severe.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Other techniques: computed tomography of the spine, magnetic resonance imaging of the spine, bone scintigraphy, positron emission tomography</span><p id="par0130" class="elsevierStylePara elsevierViewall">Computed tomography with axial or sagittal slices has low sensitivity for detecting fractures, is operator-dependent and is not cost-effective for diagnosing fractures.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> Clinical studies of chest and abdomen computed tomography have observed that a considerable number of mild OVFs were not diagnosed by radiologists.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging and bone scintigraphy are useful examinations soon after a fracture, given that OVFs might not be visible in spine radiography. These examinations can help reveal abnormalities that indicate that the fracture is acute, they can help assess the elapsed time, especially when there is no associated trauma, and assess the need for surgery for the fracture.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging is the technique that shows abnormalities the earliest. A reduced signal in the T1 and T2 sequences is observed when there is bone marrow edema and can help assess impairment of the medullary canal. In bone scintigraphy, an image suggestive of a fracture will be observed 7 days after the trauma, with a linear image located in the affected vertebra. The technique can also help perform a complete assessment of the entire skeleton. Scintigraphy is a highly sensitive but poorly specific technique for osteoporotic fractures, given that uptake is observed in all fractures regardless of their etiology.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45–47</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Fluorodeoxyglucose positron emission tomography can help differentiate between OVFs and pathological fractures due to high fluorodeoxyglucose uptake in the latter.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Pain treatment</span><p id="par0150" class="elsevierStylePara elsevierViewall">Acute mechanical pain, if it occurs, usually lasts 6–12 weeks and is treated with conventional analgesics (according to the World Health Organization scale), muscle relaxants and rest. If the pain does not decrease, the patient can be started on more potent morphine derivatives, especially during the first 2 weeks of treatment. Opioids and rest are not exempt from complications, especially in the elderly population. Follow-up should therefore be conducted. It has been reported that parathyroid hormone analogues can have an analgesic effect in OVFs, although compared with oral bisphosphonates, this improvement is not significant.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48,49</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The lumbar corset is a temporary treatment to help patients during the acute phase of a vertebral fracture. The prolonged use of a lumbar corset is counterproductive, because it limits the recovery of paravertebral extensor muscles and can worsen common comorbidities in these patients. There are rigid and semirigid lumbar corsets. The rigid corsets offer good support but are poorly tolerated by elderly individuals. In these cases, a good alternative is a CAMP semirigid corset with shoulder straps.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical techniques</span><p id="par0160" class="elsevierStylePara elsevierViewall">There are 2 techniques: percutaneous vertebroplasty and kyphoplasty. Percutaneous vertebroplasty was the first established minimally invasive technique (1987) consisting of an injection of radiopaque cement into the vertebral body. Kyphoplasty was validated in 1998 and consists of inserting a balloon into the interior of the fractured vertebral body and filling it with cement.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Both techniques are limited to patients with poorly controlled pain despite analgesic treatment and are always performed within the first 4 months of the fracture. Kyphoplasty is limited to the first weeks of the fracture and especially in compression fractures. When the fractures are subacute or chronic, the use of both techniques is more controversial.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a> A multidisciplinary assessment of each case is necessary, particularly when deciding on the best treatment with all the available clinical information.</p><p id="par0170" class="elsevierStylePara elsevierViewall">This is a surgical procedure that is not exempt from complications (2–4%), which include infections, cement embolism, hypotension and spinal cord impairment due to protrusion.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> There is controversy as to whether the technique predisposes to new OVFs, but recent published meta-analyses have shown no such relationship.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53,54</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Treatment for osteoporosis</span><p id="par0175" class="elsevierStylePara elsevierViewall">Drug treatment for osteoporosis helps reduce vertebral fractures in patients with risk factors and acts as secondary prevention of new fractures. The treatment is effective, and in some cases can decrease the risk of OVF by up to 70%. There are antiresorptive drugs (oral and intravenous bisphosphonates and subcutaneous denosumab), anabolic agents (subcutaneous teriparatide) and selective estrogen receptor modulators (raloxifene and bazedoxifene).<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,24</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The treatment of choice for patients with more than 2 OVFs and for patients who present an OVF along with nonvertebral fractures is subcutaneous teriparatide.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">OVFs are highly prevalent in the elderly population and have major clinical and functional consequences. Historically, the problem has received little interest. Understanding the importance of the disease and its consequences can help improve our patients’ quality of life. There are simple and accessible tools currently available for all clinicians for the early detection of these fractures. Cost-effective prevention strategies for decreasing the high rates of osteoporotic fractures need to be established.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0190" class="elsevierStylePara elsevierViewall">Aina Capdevila Reniu received funding from “Ajut a la Recerca Josep Font” Clinic Hospital of Barcelona, Spain.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1454560" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1326358" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1454561" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1326357" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Imminent risk of fractures" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Morbidity and mortality" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Screening for osteoporotic vertebral fractures" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Classification of vertebral fractures" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Diagnostic methods for vertebral fractures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Spine radiography" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Vertebral morphometry" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Other techniques: computed tomography of the spine, magnetic resonance imaging of the spine, bone scintigraphy, positron emission tomography" ] ] ] 10 => array:3 [ "identificador" => "sec0050" "titulo" => "Treatment" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Pain treatment" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Surgical techniques" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Treatment for osteoporosis" ] ] ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0075" "titulo" => "Funding" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-28" "fechaAceptado" => "2019-09-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1326358" "palabras" => array:4 [ 0 => "Vertebral fracture" 1 => "Osteoporosis" 2 => "Radiography" 3 => "Vertebral morphometry" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1326357" "palabras" => array:4 [ 0 => "Fractura vertebral" 1 => "Osteoporosis" 2 => "Radiografía" 3 => "Morfometría vertebral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Vertebral fractures are the most prevalent osteoporotic fractures and are paradoxically the most underdiagnosed. While only one-third of patients have acute pain, they can present other associated chronic complications. Vertrebal fractures are associated with the onset of new fractures, both vertebral and nonvertebral. Radiography of the dorsal-lumbar spine is a useful tool for detecting them but depends on the subjective interpretation of the physician conducting the assessment. New techniques, such as vertebral morphometry, have recently demonstrated greater efficacy in detecting v vertebral fractures and are performed concomitantly with bone densitometry. Knowing how to identify vertebral fractures is essential for the secondary prevention of new fractures and improving our patients’ quality of life.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las fracturas vertebrales son las fracturas osteoporóticas más prevalentes y paradójicamente siguen siendo también las más infradiagnosticadas. Solo un tercio de los pacientes presentan dolor agudo, pero también pueden presentar otras complicaciones crónicas asociadas. Las fracturas vertebrales se asocian a la aparición de nuevas fracturas tanto vertebrales como no vertebrales. La radiografía de columna dorso-lumbar es una buena herramienta para su detección, pero es una técnica que depende de la interpretación subjetiva del médico que la valora. Recientemente nuevas técnicas, como la morfometría vertebral, que se realiza de forma concomitante a la densitometría ósea, han demostrado una mayor eficacia en la detección de fracturas vertebrales. Identificar las fracturas vertebrales es primordial para la prevención secundaria de nuevas fracturas y para mejorar la calidad de vida de nuestros pacientes.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Capdevila-Reniu A, Navarro-López M, López-Soto A. Fracturas vertebrales osteoporóticas: un reto diagnóstico en el siglo XXI. Rev Clin Esp. 2021;221:118–124.</p>" ] ] "multimedia" => array:4 [ 0 => array:9 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Adapted from Genant et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1350 "Ancho" => 2167 "Tamanyo" => 186753 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Semiquantitative Genant classification of vertebral fractures.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1763 "Ancho" => 2167 "Tamanyo" => 242458 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Vertebral morphometry showing wedge fracture of T11 and L4 according to the Genant semiquantitative assessment.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">NOF \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ISCD \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T-score < −1 SD and ≥70 years (women) or ≥80 years (men), \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T-score < −1 SD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T-score < −1.5 SD and age 65–69 years (women) or 70–79 years (men). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age ≥70 years (women) or ≥80 years (men) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age ≥50 years and one of the following: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Loss of more than 4 cm of height compared with baseline \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fracture due to a low-impact fall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Loss of more than 4 cm of height compared with baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous medical history of vertebral fracture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Loss of more than 2 cm in the past few months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment with corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Long-term glucocorticoid therapy \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2501373.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Recommendations of the National Osteoporosis Foundation (NOF) and International Society for Clinical Densitometry (ISCD) for finding osteoporotic vertebral fractures.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lateral dorsal-lumbar radiography \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vertebral morphometry \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Easy availability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Available along with bone densitometry \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Short time for performing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Requires more time to perform \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Operator-dependent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Standardized technique \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Difficulty interpreting the results \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Greater ease interpreting the results \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Operator-dependent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Operator-dependent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Standard radiation for radiographs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low radiation \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2501372.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Comparison of radiological techniques for detecting vertebral fractures.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:54 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Burden of osteoporotic fractures in primary health care in Catalonia (Spain): a population-based study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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