A critical appraisal of vertebral fracture assessment in paediatrics

Kyriakou, Andreas; Shepherd, Sheila; Mason, Avril; Ahmed, S Faisal

doi:10.1016/j.bone.2015.07.032

Cited by 31 publications

(34 citation statements)

References 44 publications

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“…However, some vertebrae were non-readable. About 93% of non-readable vertebrae occurred between T6 and T9 [44]. A large proportion of VF in chronic disease is in the mid-thoracic region, and for that reason screening with DXA-based VFA may still have its limitations in GC-treated conditions [5,6].…”

Section: Assessment Of Bone Healthmentioning

confidence: 99%

Skeletal Fragility in Children with Chronic Disease

2016

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Skeletal fragility associated with underlying childhood chronic disease is a systemic disorder of poor bone growth and reduction in bone turnover which can lead to abnormal bone mass, geometry and microarchitecture. Due to the growth potential unique to children, remarkable bone recovery following a transient threat to the bone can occur if there is concurrent growth. Addressing bone health in these children should focus on improvement in growth, puberty and removing the primary insult. In conditions where there is a little scope for bone recovery and limited residual growth, bone-targeted therapy may need to be considered, even though there is currently limited evidence. The importance of early detection of signs of bone fragility, by active screening for vertebral fracture using newer imaging techniques such as dual-energy X-ray absorptiometry lateral vertebral morphometry, may now be possible. There is currently, a paucity of evidence to support prophylactic use of anti-resorptive therapy. Where poor growth and low bone turnover are seen, the use of growth-promoting therapies and anabolic bone-protective agents may be more physiological and should be evaluated in well-designed trials. Collaborative studies on long-term fracture outcome and well-designed trials of bone-protective therapies are needed and to be encouraged.

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Section: Assessment Of Bone Healthmentioning

confidence: 99%

Skeletal Fragility in Children with Chronic Disease

2016

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“…These previous studies show that the 6point technique programs have very high sensitivity and specificity, reaching 98% and 99%, respectively, and excellent inter-observer agreement of 99%, with kappa ranging from 0.86 to 0.97. In fact, these adult studies show significantly higher diagnostic accuracy than those of all previous studies evaluating 6-point semi-automated programs in children [7,8,12,16].…”

Section: Discussionmentioning

confidence: 60%

“…For AVERT™, kappa scores for R1 and R2 using VFA were 0.79 (95%CI 0.69, 0.90) and 0.73 (95%CI 0.66, 0.82), respectively. Table 4 summarises the overall results of this current study and compares with those of all previous studies that have evaluated semi-automated software techniques in children [7,8,12,15].…”

Section: Resultsmentioning

confidence: 99%

“…Currently, the gold standard for identifying VFs in children is the lateral spine radiograph. Recent studies have shown that spine images acquired by dual-energy X-ray absorptiometry (DXA) are comparable to radiographs [6][7][8], allowing reduced exposure to radiation. The diagnosis of VFs from DXA is termed vertebral fracture assessment (VFA).…”

Section: Introductionmentioning

confidence: 99%

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Are semi-automated software program designed for adults accurate for the identification of vertebral fractures in children?

2019

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Objectives To assess whether diagnostic accuracy of morphometric vertebral fracture (VF) diagnosis in children can be improved using AVERT™ (a 33-point semi-automated program developed for VF diagnosis in adults) compared with SpineAnalyzer™ (a 6-point program), which has previously been shown to be of insufficient accuracy. Materials and methods Lateral spine radiographs (XR) and dual-energy X-ray absorptiometry (DXA) scans of 50 children and young people were analysed by two observers using two different programs (AVERT™ and SpineAnalyzer™). Diagnostic accuracy (sensitivity, specificity, false-negative (FN) and false-positive rates (FP)) was calculated by comparing with a previously established consensus arrived at by three experienced paediatric musculoskeletal radiologists, using a simplified algorithm-based qualitative scoring system. Observer agreement was calculated using Cohen's kappa. Results For XR, overall sensitivity, specificity, FP and FN rates using AVERT™ were 36%, 95%, 5% and 64% respectively and 26%, 98%, 2% and 75% respectively, using SpineAnalyzer™. For DXA, overall sensitivity, specificity, FP and FN rates using AVERT™ were 41%, 91%, 9% and 59% respectively and 31%, 96%, 4% and 69% respectively, using SpineAnalyzer. Reliability (kappa) ranged from 0.34 to 0.37 (95%CI, 0.26-0.46) for AVERT™ and from 0.26 to 0.31 (95%CI, 0.16-0.44) for SpineAnalyzer™. Inter-and intraobserver agreement ranged from 0.41 to 0.47 for AVERT™ and from 0.50 to 0.79 for SpineAnalyzer™. Conclusion AVERT™ has slightly higher accuracy but lower observer reliability for the representation of vertebral morphometry in children when compared with SpineAnalyzer™. However, neither software program is satisfactorily reliable for VF diagnosis in children. Key Points• SpineAnalyzer™ and AVERT™ have low diagnostic accuracy and observer agreement when compared to three paediatric radiologists' readings for the diagnosis of vertebral fractures (VF) in children. • Neither AVERT™ nor SpineAnalyzer™ is satisfactorily reliable for VF diagnosis in children.• Development of specific paediatric software and normative values (incorporating age-related physiological variation in children) is required.

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“…However, more recent studies in children showed reliable diagnostic performance of VFA as a screening tool for vertebral fracture. 1516 Additionally, studies in adults and children with osteogenesis imperfecta found that VFA had comparable diagnostic accuracy when compared with LS radiograph in detecting moderate to severe vertebral fracture but was suboptimal in mild vertebral deformity. 17–19 While VFA is promising as a low-radiation imaging modality to screen for vertebral fractures in children, it is not currently recommended by the ISCD’s Pediatric guidelines.…”

Section: Discussionmentioning

confidence: 99%

Lumbar Spine Bone Mineral Density Z-Score Discrepancies by Dual X-Ray Absorptiometry Do Not Predict Vertebral Fractures in Children

Harindhanavudhi

Petryk

Jones

et al. 2018

Journal of Investigative Medicine

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Dual X-ray absorptiometry (DXA) remains the most common mode of bone mineral density (BMD) evaluation. In adults, presence of a lumbar spine (LS) BMD T-score discrepancy (>1 SD difference between adjacent vertebrae) can indicate a vertebral fracture. In children, however, the clinical significance of such discrepancies is unknown. We conducted a retrospective study to evaluate the association between LS DXA and LS morphology to elucidate the clinical significance of an LS BMD Z-score discrepancy. We identified 360 DXA scans performed between September 2014 and May 2016 in patients 5–18 years of age. DXA scans were cross-referenced against available LS radiographs and vertebral fracture assessment (VFA) within the 6 months preceding or following a DXA scan. After excluding 44 DXA scans because of spinal hardware, incomplete DXA, or repeat scans, 316 DXA scans were included; 81 (25.6%) had either an LS radiograph or a VFA. Twenty-five of 81 patients (30.9%) had >1 SD difference between adjacent vertebrae in LS BMD Z-score. Two of these 25 patients (8%) had a lumbar vertebral fracture documented by a spine radiograph. Of the remaining 56 patients who did not have a discrepancy >1 SD, 6 patients (11%) had a lumbar vertebral fracture. Discrepancies in LS BMD Z-scores were not associated with lumbar vertebral fractures and, in the absence of fractures, likely represented vertebral developmental variants in children whose skeletons are still growing. Therefore, it does not appear justified to recommend further imaging based solely on the results of a DXA scan without clinically meaningful indications.

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A critical appraisal of vertebral fracture assessment in paediatrics

Cited by 31 publications

References 44 publications

Skeletal Fragility in Children with Chronic Disease

Skeletal Fragility in Children with Chronic Disease

Are semi-automated software program designed for adults accurate for the identification of vertebral fractures in children?

Lumbar Spine Bone Mineral Density Z-Score Discrepancies by Dual X-Ray Absorptiometry Do Not Predict Vertebral Fractures in Children

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