2013 Position Development Conference on Bone DensitometryThe Official Positions of the International Society for Clinical Densitometry: Vertebral Fracture Assessment
Introduction
Vertebral compression fractures (VCF) occur commonly among postmenopausal women and older men, such that the prevalence is estimated to be 10%–26% among women and men older than 50 yr, the prevalence of moderate to severe VCF being 5%–15%. Prior VCF are a powerful predictor of subsequent fractures, particularly of incident VCF. Unlike fractures at other skeletal sites, however, only 25% of VCF are clinically apparent at the time of their occurrence, and spine imaging is required to document their presence. Densitometric lateral spine imaging, called vertebral fracture assessment (VFA), can efficiently and quickly be done at the time of a bone density test and can accurately detect moderate-to-severe vertebral fractures. Hence, imaging the lateral spine at the time of a bone density test can substantially improve fracture prediction and identification of those for whom fracture prevention therapies are appropriate.
The 2007 Position Development Conference (PDC) produced extensive Position Statements that constitute guidelines and standards regarding the indications for, acquisition of, and interpretation and reporting of VFA tests (1). The 2007 PDC recommended VFA for those who had one of the following:
- 1.
Age ≥70 yr for women and ≥80 yr for men
- 2.
Historic height loss (HHL) of >4 cm for women or >6 cm for men
- 3.
Prospective height loss of >2 cm for women or >3 cm for men
- 4.
Glucocorticoid use
- 5.
Self-reported but unconfirmed VCF
In addition, combinations of ≥2 lesser risk factors likewise gave patients high enough a risk of prevalent VCF to warrant VFA. These included the following:
- 6.
Age 60–70 yr for women or 70–80 yr for men
- 7.
HHL of 2–4 cm for women or 3–6 cm for men
- 8.
Self-reported nonvertebral fractures
- 9.
Chronic systemic diseases such as chronic obstructive pulmonary disease, rheumatoid arthritis, or Crohn's disease
- 10.
Orchiectomy or androgen deprivation therapy (men)
Although these statements are highly evidence based, they appear to be too complex for practitioners to remember and apply. For 3 of the 5 single criteria (age, HHL, and prospective height loss), the criterion cutpoint is different for men compared with women. The combinations of lesser risk factors that give yet different cutoffs for the previous criteria adds additional complexity. Lastly, the chronic disease criterion is confusing, in that it included certain risk factors that are included in FRAX such as rheumatoid arthritis but included other risk factors that are not included in FRAX such as chronic obstructive pulmonary disease. Additionally, FRAX included certain chronic diseases that were not included in the VFA criteria, such as type I diabetes mellitus. Informal polling of colleagues with a serious commitment to the field of bone densitometry revealed that few were able to recall these complex criteria, which does not auger well for generalists to be able to remember and apply these guidelines.
The 2013 VFA Task Force's charge was to revisit the indications for VFA, review the literature published since the 2007 PDC, and to use heretofore unpublished cohort data to develop evidence-based indications for VFA. Moreover, in light of the fact that many health-care organizations do not have bone densitometers with lateral spine imaging capability, the Task Force guideline indications for VFA were shaped with the intention that they apply for use of lateral spine radiography to detect clinically unapparent vertebral fracture.
This article will describe the methodology of the Task Force and questions posed to the Task Force, the Statement addressing those questions that were voted as appropriate without disagreement by the 2013 International Society for Clinical Densitometry (ISCD) PDC Expert Panel and approved by ISCD Board of Directors, and explain the rationale behind the statement. Separate articles will describe the development of and comparison between prediction models for prevalent VCF for women and men using, respectively, data from the Study of Osteoporotic Fractures (SOF) and Osteoporotic Fractures in Men (MrOS) cohort studies.
Section snippets
Methodology
The methods used to develop and grade the Official Position Statement for VFA presented in this document are presented in the Executive Summary of the 2013 PDC regarding bone densitometry that is also in this issue. In brief, the Position Statement presented here was rated as appropriate without disagreement by the Expert Panel of the 2013 ISCD PDC. This position was also rated by the Expert Panel on quality of evidence, strength of recommendation, and applicability. Quality of evidence is
2013 ISCD Official Position
Lateral spine imaging with standard radiography or densitometric VFA is indicated when T-score is less than −1.0 and of one or more of the following is present:
- a.
Women age ≥70 yr or men age ≥80 yr
- b.
Historical height loss >4 cm (>1.5 inches)
- c.
Self-reported but undocumented prior vertebral fracture
- d.
Glucocorticoid therapy equivalent to ≥5 mg of prednisone or equivalent per day for ≥3 mo
Grade: Fair-B-W
Rationale
The Task Force thought that the 2007 PDC recommendations for VFA were, and continue to be, valid. The
Questions for Future Research
All the prediction models and decision rules the Task Force considered are modest in their power to discriminate those with from those without prevalent vertebral fracture. Future research is needed to determine if other predictors can be identified that may improve the efficiency of lateral spine imaging to identify those with clinically unrecognized vertebral fractures. Moreover, studies will be needed on new care processes within health-care delivery organizations to identify those who
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