Skip to main content

Advertisement

SpringerLink
Log in

Spinal radiographs in those with back pain—when are they appropriate to diagnose vertebral fractures?

  • Review
  • Published:
Osteoporosis International Aims and scope Submit manuscript

Abstract

The presence of an osteoporotic vertebral fracture improves fracture risk assessment and may change management, so it is vital for healthcare professionals to assess patients for the presence or absence of these fractures. This may be particularly important in the presence of back pain. However, the correlation between low back symptoms and spinal imaging results is poor and the pathophysiology of most low back pain is not known, leading to a common conclusion that spinal radiographs are not appropriate for the assessment of back pain. For individual patients with back pain, spinal radiographs should be considered if they have certain features in the history and examination. As well as the traditional risk factors for osteoporosis, self-reported descriptives of back pain and novel physical examination findings have been shown to make the presence of vertebral fractures more likely. Systematic approaches have the potential to improve bone health across the population but need to be targeted to be cost-effective. Spinal radiographs should be considered for individual older patients with back pain if they have certain additional features in the history and examination.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Maniadakis N, Gray A (2000) The economic burden of back pain in the UK. Pain 84(1):95–103

    Article  CAS  PubMed  Google Scholar 

  2. Deyo RA, Weinstein JN (2001) Low back pain. N Engl J Med 344(5):363–370

    Article  CAS  PubMed  Google Scholar 

  3. National Institute for Health and Care Excellence (NICE) guideline 59. Published 30 Nov 2016. Low back pain and sciatica in over 16s: assessment and management. ISBN: 978-1-4731-2186-7

  4. Chou R et al (2007) Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 147:478–491

    Article  PubMed  Google Scholar 

  5. Klotzbuecher CM et al (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15(4):721–739

    Article  CAS  PubMed  Google Scholar 

  6. Cooper C et al (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota. J Bone Miner Res 7:221–227

    Article  CAS  PubMed  Google Scholar 

  7. Tobias JH et al (2007) Use of clinical risk factors to identify postmenopausal women with vertebral fractures. Osteoporos Int 18:35–43

    Article  CAS  PubMed  Google Scholar 

  8. Lentle BC et al (2007) Recognizing and reporting vertebral fractures: reducing the risk of future osteoporotic fractures. Can Assoc Radiol J 58(1):27–36

    PubMed  Google Scholar 

  9. Fechtenbaum J et al (2005) Reporting of vertebral fractures on spine X-rays. Osteoporos Int 16(12):1823–1826

    Article  CAS  PubMed  Google Scholar 

  10. Clark EM et al (2010) Lateral back pain identifies prevalent vertebral fractures in post-menopausal women: cross-sectional analysis of a primary care-based cohort. Rheumatology 49:505–512

    Article  PubMed  Google Scholar 

  11. Clark EM, Gooberman-Hill R, Peters TJ (2016) Using self-reports of pain and other variables to distinguish between older women with back pain due to vertebral fractures and those with pain due to degenerative change. Osteoporos Int 27:1459–1467

    Article  CAS  PubMed  Google Scholar 

  12. Clark EM et al (2012) Randomized controlled trial of a primary care-based screening programme to identify older women with prevalent osteoporotic vertebral fractures. J Bone Miner Res 27(3):664–671

    Article  PubMed  Google Scholar 

  13. Nevitt MC et al (1998) The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med 128(10):793–800

    Article  CAS  PubMed  Google Scholar 

  14. Fink H et al (2014) Association of incident radiographic vertebral fracture with back pain symptoms in older men: the Osteoporotic Fractures in Men (MrOS) Study. J Bone Miner Res 29(Supplement 1):S99 [Abstract FR0316]

    Google Scholar 

  15. Downie A et al (2013) Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 347:f7095

    Article  PubMed  PubMed Central  Google Scholar 

  16. Underwood M and Buchbinder R 2013 Red flags for back pain. BMJ. 347:f7432. doi:10.1136/bmj.f7432

  17. Ling XU et al (2000) Vertebral fractures in Beijing, China: the Beijing osteoporosis project. J Bone Miner Res 15(10):2019–2025

    Article  CAS  PubMed  Google Scholar 

  18. Schousboe JT et al (2014) Prediction models of prevalent radiographic vertebral fractures among older women. J Clin Densitom 17(3):378–385

    Article  PubMed  PubMed Central  Google Scholar 

  19. Schousboe JT et al (2014) Prediction models of prevalent radiographic vertebral fractures among older men. J Clin Densitom 17:449–457

    Article  PubMed  Google Scholar 

  20. Kaptoge S et al (2004) When should the doctor order a spine X-ray? Identifying vertebral fractures for osteoporosis care: results from the European Prospective Osteoporosis Study (EPOS). J Bone Miner Res 19(12):1982–1993

    Article  PubMed  Google Scholar 

  21. El Maghraoui A et al (2013) Systematic VFA in asymptomatic postmenopausal women. Bone 52(1):176–180

    Article  CAS  PubMed  Google Scholar 

  22. Black DM, Steinbuch M, Palermo L (2001) An assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int 12:519–528

    Article  CAS  PubMed  Google Scholar 

  23. Papaioannou A et al (2005) Risk factors associated with incident clinical vertebral and nonvertebral fractures in postmenopausal women: the Canadian Multicentre Osteoporosis Study (CaMos). Osteoporos Int 16:568–178

    Article  PubMed  Google Scholar 

  24. Vokes TJ, Gillen DL (2010) Using clinical risk factors and BMD to determine who among patients undergoing bone densitometry should have VFA. Osteoporos Int 21:2083–2091

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Van der Jagt-Willems HC et al (2012) Why do geriatric outpatients have so many moderate and severe vertebral fractures? Exploring prevalence and risk factors. Age Ageing 41(2):200–206

    Article  PubMed  Google Scholar 

  26. Middleton ET, Gardiner ED, Steel SA (2009) Which women should be selected for VFA? Comparing different methods of targetting VFA. Calcif Tissue Int 85:203–210

    Article  CAS  PubMed  Google Scholar 

  27. Roy DK et al (2003) Determinants of incident vertebral fracture in men and women: results from the European Prospective Osteoporosis Study (EPOS). Osteoporos Int 14(1):19–26

    Article  CAS  PubMed  Google Scholar 

  28. Walsh LJ et al (2002) The impact of oral corticosteroid use on bone mineral density and vertebral fracture. American Journal of Respiratory & Critical Care Medicine 166(5):691–695

    Article  Google Scholar 

  29. Kamimura M et al (2016) Associations of self-reported height loss and kyphosis with vertebral fractures in Japanese women 60 years and older: a cross-sectional survey. Scientific Reports 6:29199

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. van der Klift M et al (2004) Risk factors for incident vertebral fractures in men and women: the Rotterdam Study. J Bone Miner Res 19(7):1172–1180

    Article  PubMed  Google Scholar 

  31. Jaramillo JD et al (2015) Reduced bone density and vertebral fractures in smokers: men and COPD patients at increased risk. Ann Am Thorac Soc 12(5):648–656

    Article  PubMed  PubMed Central  Google Scholar 

  32. Siminoski K et al (2003) Accuracy of physical examination using the rib-pelvis distance for detection of lumbar vertebral fractures. Am J Med 115(3):233–236

    Article  PubMed  Google Scholar 

  33. Green AD et al (2004) The rational clinical examination: does this woman have osteoporosis? JAMA 292(23):2890–2900

    Article  CAS  PubMed  Google Scholar 

  34. Abe K et al (2008) Use of anthropometric indicators in screening for undiagnosed vertebral fractures: a cross-sectional analysis of the Fukui Osteoporosis Cohort (FOC) study. BMC Musculoskelet Disord 9:157

    Article  PubMed  PubMed Central  Google Scholar 

  35. Langdon J et al (2010) Vertebral compression fractures—new clinical signs to aid diagnosis. Annals of the Royal College of Surgeons, England 92(2):163–166

    Article  Google Scholar 

  36. Siminoski K et al (2011) The accuracy of clinical kyphosis examination for detection of thoracic vertebral fractures: comparison of direct and indirect kyphosis measures. J Musculoskelet Nueronal Interact 11(3):249–256

    CAS  Google Scholar 

  37. van der Jagt-Willems HC et al (2015) Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in adults: a prospective cohort study. BMC Geriatr 15:34

    Article  PubMed  PubMed Central  Google Scholar 

  38. Schneider DL et al (2004) Kyphosis does not equal vertebral fractures: the Rancho Bernardo study. J Rheumatol 31(4):747–752

    PubMed  Google Scholar 

  39. O’Neill TW et al (1996) The prevalence of vertebral deformity in european men and women: the European Vertebral Osteoporosis Study. J Bone Miner Res 11(7):1010–1018

    Article  PubMed  Google Scholar 

  40. Cosman F et al (2017) Spine fracture prevalence in a nationally representative sample of US women and men aged >40: results from the National Health and Nutrition Examination Survey (NHANES) 2013-2014. Osteoporos Int. doi:10.1007/s00198-017-3948-9

    Google Scholar 

  41. Clark EM et al (2014) Vertebral fracture assessment (VFA) by lateral DXA scanning may be cost-effective when used as part of fracture liaison services or primary care screening. Osteoporos Int 25:953–964

    Article  CAS  PubMed  Google Scholar 

  42. Schousboe JT et al (2014) Use of a performance algorithm improves utilization of VFA in clinical practice. Osteoporos Int 25:965–972

    Article  CAS  PubMed  Google Scholar 

  43. Schousboe JT et al (2013) Executive summary of the 2013 ISCD Position Development Conference on bone densitometry. J Clin Densitom 16(4):455–467

    Article  PubMed  Google Scholar 

  44. Clark EM et al (2016) Impact of VFA on management within the real-life setting of a busy NHS DXA service: service evaluation audit. Osteoporos Int 27(Suppl 2):S640–Abstract P33

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK

    E.M. Clark

  2. California Pacific Medical Centre Research Institute, San Francisco, USA

    S.R. Cummings

  3. Park Nicollet Osteoporosis Center and HealthPartners Institute, Minneapolis, MN, USA

    J.T. Schousboe

Authors
  1. E.M. Clark
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S.R. Cummings
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. J.T. Schousboe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to E.M. Clark.

Ethics declarations

Conflict of interest

Emma Clark, Steve Cummings and John Schousboe have no disclosures.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Clark, E., Cummings, S. & Schousboe, J. Spinal radiographs in those with back pain—when are they appropriate to diagnose vertebral fractures?. Osteoporos Int 28, 2293–2297 (2017). https://doi.org/10.1007/s00198-017-4052-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00198-017-4052-x

Keywords

Search

Navigation