Value and potential limitations of vertebral fracture assessment (VFA) compared to conventional spine radiography: experience from a fracture liaison service (FLS) and a meta-analysis

Abstract

SummaryWe evaluated the value of VFA in the identification of vertebral fractures using a retrospective study and a meta-analysis. Performance of VFA was adequate in the meta-analysis although this was not demonstrated in our centre. We recommend checking the performance of VFA tools before exclusively relying on this tool.IntroductionVertebral fractures are traditionally diagnosed using conventional radiographs of the spine. Vertebral fracture assessment (VFA) has been advocated as an alternative tool in the diagnosis of these fractures.MethodsWe conducted a retrospective study as well as a systematic review and a meta-analysis to evaluate the performance of VFA compared to conventional spinal radiography in patients who had sustained a fracture and thus at risk for osteoporosis. A risk of bias analysis was also performed.ResultsThe diagnostic study included 542 patients (25% male) with fractures. The sensitivity of low-radiation VFA to detect a patient with a vertebral fracture ≥ Genant grade 2 was 0.77 and its specificity 0.80. Two hundred ninety-seven (55%) patients had ≥1 and 135(25%) ≥3 unevaluable vertebrae. The systematic review identified 16 studies including a total of 3238 subjects (19% male) with a mean age range of 45 to 74 years. Seven studies had a low risk of bias and 9 had an intermediate risk, mainly due to not consecutively including patients. The pooled sensitivity of VFA to detect a patient with a vertebral fracture ≥Genant grade 2 was 0.84 (95% CI, 0.72–0.92) and specificity 0.90 (95% CI, 0.84–0.94).ConclusionsOur findings from the meta-analysis suggest an adequate performance of VFA for the detection of vertebral fractures. However, we could not demonstrate these findings in our center, especially the specificity. Our data advocate caution with exclusively relying on VFA in the assessment of vertebral fractures without identifying performance and potential limitations of the technique.Electronic supplementary materialThe online version of this article (doi:10.1007/s00198-017-4137-6) contains supplementary material, which is available to authorized users.

Vertebral Fracture Assessment Increases Use of Pharmacologic Therapy for Fracture Prevention in Clinical Practice

“…In Canada, Manitoba is the only province that currently systematically employs VFA as part of their provincial bone densitometry and fracture assessment protocols. VFA at the time of bone densitometry is inexpensive, convenient, point‐of‐care testing with minimal patient radiation exposure and minimal added bone technologist time commitment to perform . Our study and others have shown that bone density technologists can successfully implement a decision rule to identify those referred for bone densitometry as also appropriate candidates for VFA.…”

“…VFA at the time of bone densitometry is inexpensive, convenient, point-of-care testing with minimal patient radiation exposure and minimal added bone technologist time commitment to perform. (13,(41)(42)(43)(44) Our study and others (19,42) have shown that bone density technologists can successfully implement a decision rule to identify those referred for bone densitometry as also appropriate candidates for VFA. Prior studies that have shown that clinicians can be easily trained to identify vertebral fractures on lateral spine images.…”

“…Densitometric thoracolumbar lateral spine images for vertebral fracture assessment (VFA) can be obtained at the time of bone densitometry with dual-energy X-ray absorptiometry (DXA) at very low cost and much less radiation exposure than standard radiography, and moderate to severe radiographic vertebral fractures can be identified on these images with high accuracy. (13,14) Prevalent vertebral fracture identified specifically on bone density VFA images predict, after adjustment for both age and BMD, incident clinical fractures (regardless of skeletal site); (15,16) osteoporotic fractures; (15,16) hip fractures; (16,17) vertebvertebral fractures; (16,17) and fracture hospitalizations. (17) Importantly, these associations are equally strong in the subsets without osteoporosis by BMD criteria or low-to-moderate estimated fracture risk (before prevalent vertebral fracture status is known), who otherwise might not be considered candidates for pharmacologic fracture prevention therapies.…”

Bone Mineral Density and Risk of Osteoporotic Fractures in Women with Parkinson’s Disease

“…Vertebral fracture assessment is one of the substantial additional methods of bone tissue appraisal in patients with osteoporosis [1,[16][17][18]. According to Genant's classification [19] which is based on the vertebral shape with respect to vertebral height loss and included in DXA software, the loss of >25% of vertebral height (anterior, posterior, and/or middle) is confirmed as moderate and severe VDs (grades 2 and 3).…”

“…e investigator confirmed the fracture history according to medical source. Vertebral fractures were affirmed by vertebral fracture assessment (VFA) which was performed additionally to BMD measurements by DXA on the lateral VFA images of the spine [16][17][18]. During this procedure, the patient was in supine position and a cushion supported the knees.…”