Elsevier

Journal of Clinical Densitometry

Volume 16, Issue 4, October–December 2013, Pages 482-488
Journal of Clinical Densitometry

2013 Position Development Conference on Bone Densitometry
The Official Positions of the International Society for Clinical Densitometry: Vertebral Fracture Assessment

https://doi.org/10.1016/j.jocd.2013.08.003Get rights and content

Abstract

Vertebral fracture assessment (VFA) is a low-cost method of accurately identifying individuals who have clinically unrecognized or undocumented vertebral fractures at the time of bone density test. Because prevalent vertebral fractures predict subsequent fractures independent of bone mineral density and other clinical risk factors, their recognition is an important part of strategies to identify those who are at high risk of fracture, so that prevention therapies for those individuals can be implemented. The 2007 Position Development Conference developed detailed guidelines regarding the indications for acquisition of, and interpretation and reporting of densitometric VFA tests. The purpose of the 2013 VFA Task Force was to simplify the indications for VFA yet keep them evidence based. The Task Force reviewed the literature published since the 2007 Position Development Conference and developed prediction models based on 2 large cohort studies (the Study of Osteoporotic Fractures and the Osteoporotic Fractures in Men Study) and the densitometry database of the University of Chicago. Based on these prediction models, indications for VFA were reduced to a simplified set of criteria based on age, historical height loss, use of systemic glucocorticoid therapy, and self-reported but undocumented prior vertebral fracture.

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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