Osteoporosis International

, Volume 3, Issue 3, pp 138–147 | Cite as

The assessment of vertebral deformity: A method for use in population studies and clinical trials

  • E. V. McCloskey
  • T. D. Spector
  • K. S. Eyres
  • E. D. Fern
  • N. O'Rourke
  • S. Vasikaran
  • J. A. Kanis
Original Article


The absence of specific criteria for the definition of vertebral fracture has major implications for assessing the apparent prevalence and incidence of vertebral deformity. Also, little is known of the effect of using different criteria for new vertebral fractures in clinical studies. We therefore developed radiological criteria for vertebral fracture in women for assessing both the prevalence and the incidence of vertebral osteoporosis in population and in prospective studies and compared these with several other published methods. Normal ranges for vertebral shape were obtained from radiographs in 100 women aged 45–50 years. These included ranges for the ratios of anterior/posterior, central/posterior and posterior/predicted posterior vertebral heights from T4 to L5. The predicted posterior height was calculated from adjacent vertebrae. In contrast to other methods, our definition of fracture required the fulfilment of two criteria at each vertebral site, and was associated with a lower apparent prevalence of fracture in the control women due to a lower false positive rate. The prevalence and incidence of vertebral deformity using different criteria were then compared in a series of women with skeletal metastases from breast cancer in whom radiographs were obtained 6 months apart. The prevalence of vertebral deformity and the specificity for deformity varied markedly with differing criteria. Using a cut-off of 3 standard deviations the prevalence of vertebral deformity in the women with breast cancer was 46%. Using other methods, the prevalences of deformity ranged from 33% to 74%. Over a 6-month interval 25% of patients with breast cancer sustained 61 deformities using our method, of which only 8% resulted from errors in reproducibility. The number of patients sustaining new deformities was increased twofold when assessed by other methods (45%–53%), but errors of reproducibility may have accounted for 21% of the new deformities. The magnitude and distribution of these errors have important implications for the apparent therapeutic efficacy of agents in clinical trials of osteoporosis. The rapid semi-automated technique for assessing vertebral deformities on lateral spine radiographs that we have developed has a high specificity, and reduces the impact of errors of reproducibility on estimates of prevalence and incidence. The method should prove a value in assessing vertebral deformity both in population studies and in prospective clinical trials.


Incidence Morphometry Prevalence Sensitivity Specificity Vertebral fracture 


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  1. 1.
    Riggs BL, Melton LJ. Involutional osteoporosis. N Engl J Med 1986;314:1676–86.Google Scholar
  2. 2.
    Spector TD, Cooper C, Fenton Lewis A. Trends in admissions for hip fracture in England and Wales, 1968–85. BMJ 1990;300:1173–4.Google Scholar
  3. 3.
    Kanis JA, Pitt FA. Epidemiology of osteoporosis. Bone 1992; 13Suppl 1:S7-S15.Google Scholar
  4. 4.
    Jensen KK, Tougaard L. A simple x-ray method for monitoring progress of osteoporosis. Lancet 1981;2:19–20.Google Scholar
  5. 5.
    Riggs BL, Seeman E, Hodgson SF, Taves DR, O'Fallon WM. Effect of the fluoride/calcium regimen on vertebral fracture occurrence in postmenopausal osteoporosis. N Engl J Med 1982;306:446–50.Google Scholar
  6. 6.
    Kleerekoper M, Parfitt AM, Ellis J. Measurement of vertebral fracture rates in osteoporosis. In: Christiansen C, Arnaud CD, Nordin BEC, Parfitt AM, Peck WA, Riggs BL, editors. Proceedings of the Copenhagen International Symposium on Osteoporosis. Copenhagen: Glostrup Hospital, 1984:103–9.Google Scholar
  7. 7.
    Gallagher JC, Hedlund LR, Stoner S, Meeger C. Vertebral morphometry: normative date. Bone Miner 1988; 4:189–96.Google Scholar
  8. 8.
    Hedlund LR, Gallagher JC. Vertebral morphometry in diagnosis of spinal fractures. Bone Miner 1988;5:59–67.Google Scholar
  9. 9.
    Minne HW, Leidig C, Wuster CHR. A newly developed spine deformity index (SDI) to quantitate vertebral crush fractures in patients with osteoporosis. Bone Miner 1988;3:335–49.Google Scholar
  10. 10.
    Melton LJ, Kan SH, Frye MA, Wahner HW, O'Fallon WM, Riggs BL. Epidemiology of vertebral fractures in women. Am J Epidemiol 1989;129:1000–11.Google Scholar
  11. 11.
    Davies KM, Recker RR, Heaney RP. Normal vertebral dimensions and normal variation in serial measurements of vertebrae. J Bone Miner Res 1989;4:341–9.Google Scholar
  12. 12.
    Raymakers, JA, Kapelle JW, van Beresteijn ECH, Duursma SA. Assessment of osteoporotic spine deformity: a new method. Skeletal Radiol 1990;19:91–7.Google Scholar
  13. 13.
    Nelson D, Peterson E, Tilley B, et al. Measurement of vertebral area on spine x-rays in osteoporosis: reliability of digitizing techniques. J Bone Miner Res 1990;5:707–16.Google Scholar
  14. 14.
    Eastell R, Cedel SL, Wahner HW, Riggs BL, Melton LJ. Classification of vertebral fractures. J Bone Miner Res 1991;6:207–15.Google Scholar
  15. 15.
    Smith-Bindman R, Cummings SR, Steiger P, Genant HK. A comparison of morphometric definitions of vertebral fracture. J Bone Miner Res 1991;6:25–34.Google Scholar
  16. 16.
    Black DM, Cummings SR, Stone K, Hudes E, Palermo L, Steiger P. A new approach to defining normal vertebral dimensions. J Bone Miner Res 1991;6:882–92.Google Scholar
  17. 17.
    Leidig G, Minne HW, Sauer P, et al. A study of complaints and their relation to vertebral destruction in patients with osteoporosis. Bone Miner 1990;8:217–29.Google Scholar
  18. 18.
    Benger U, Johnell O, Redlund-Johnell I. Changes in incidence and prevalence of vertebral fractures during 30 years. Calcif Tissue Int 1988;42:293–6.Google Scholar
  19. 19.
    Harma M, Heliovaara M, Aromaa A, Knekt P. Thoracic spine compression fractures in Finland. Clin Orthop 1986;205:188–94.Google Scholar
  20. 20.
    Pogrund H, Makin M, Robin G, Menczel J, Steinberg R. Osteoporosis in patients with fractured femoral neck in Jerusalem. Clin Orthop 1977;124:165–72.Google Scholar
  21. 21.
    Ross PD, Wasnich RD, Vogel JM. Detection of prefracture spinal osteoporosis using bone mineral absorptiometry. J Bone Miner Res 1988;3:1–11.Google Scholar
  22. 22.
    Jensen GF, Christiansen C, Boesen J, Hegedus V. Epidemiology of postmenopausal spinal and long bone fractures. Clin Orthop 1982;166:75–81.Google Scholar
  23. 23.
    Riggs BL, Hodgson SF, O'Fallon WM, et al. Effect of fluoride treatment on the fracture rate in postmenopausal women with osteoporosis. N Engl J Med 1990;322:802–9.Google Scholar
  24. 24.
    Storm T, Thamsborg G, Steiniche T, Genant HK, Sorensen OH. Effect of intermittent cyclical etidronate therapy on bone mass and fracture rate in women with postmenopausal osteoporosis. N Engl J Med 1990;322:1265–71.Google Scholar
  25. 25.
    Gallagher JC, Goldgar D. Treatment of postmenopausal osteoporosis with high doses of synthetic calcitriol. Ann Intern Med 1990;113:649–55.Google Scholar
  26. 26.
    Tilyard M, Spears GFS, Thomson J, Dovey S. Treatment of postmenopausal osteoporosis with calcitriol or calcium. N Engl J Med 1992;326:357–62.Google Scholar
  27. 27.
    Kleerekoper M, Peterson EL, Nelson D, et al. A randomised trial of sodium fluoride as a treatment for postmenopausal osteoporosis. Osteoporosis Int 1991;1:155–61.Google Scholar
  28. 28.
    Sauer P, Leidig G, Minne HW, et al. Spine deformity index (SDI) versus other objective procedures of vertebral fracture identification in patients with osteoporosis: a comparative study. J Bone Miner Res 1991;6:227–38.Google Scholar
  29. 29.
    Watts NB, Harris ST, Genant HK, et al. Intermittent cyclical etidronate treatment of postmenopausal osteoporosis. N Engl J Med 1990;323:73–9.Google Scholar
  30. 30.
    Kleerekoper M, Nelson DA. Vertebral fracture or vertebral deformity. Calcif Tissue Int 1992;50:5–6.Google Scholar
  31. 31.
    Kanis JA, Caulin F, Russell RGG. Problems in the design of clinical trials in osteoporosis. In: St J Dixon A, Russell RGG, Stamp TCB, editors. Osteoporosis: a multidisciplinary problem. New York: Grune and Stratton, 1983: 205–22.Google Scholar
  32. 32.
    Kanis JA, McCloskey EV. Epidemiology of vertebral osteoporosis. Bone 1992;13:S1-S10.Google Scholar
  33. 33.
    Kanis JA, McCloskey EV. Detection of vertebral osteoporosis. Rorer Foundation 1993 (in press).Google Scholar
  34. 34.
    Spector TD, McCloskey EV, Mastoswamy I, et al. Epidemiology of vertebral fractures in the general population: the Chingford Study. J Bone Miner Res 1991;6(Suppl 1):S277.Google Scholar
  35. 35.
    McCloskey EV, Spector TD, Eyres KS, et al. Relationship between criteria for vertebral deformity and bone mass in a population study. J Bone Miner Res 1992;7(Suppl 1):S137.Google Scholar
  36. 36.
    Ross PD, Davis JW, Epstein RS, Wasnich RD. Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med 1991;114:919–23.Google Scholar
  37. 37.
    Ettinger B, Black DM, Nevitt MC, et al. Contribution of vertebral deformities to chronic back pain and disability. J Bone Miner Res 1992;7:449–56.Google Scholar

Copyright information

© European Foundation for Osteoporosis 1993

Authors and Affiliations

  • E. V. McCloskey
    • 1
  • T. D. Spector
    • 2
  • K. S. Eyres
    • 1
  • E. D. Fern
    • 1
  • N. O'Rourke
    • 1
  • S. Vasikaran
    • 1
  • J. A. Kanis
    • 1
  1. 1.WHO Collaborating Centre for Metabolic Bone Disease, Department of Human Metabolism and Clinical BiochemistryUniversity of SheffieldSheffieldUK
  2. 2.Department of Environmental and Preventive MedicineSt Bartholomew's Hospital Medical CollegeLondonUK

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