Recognizing osteoporotic vertebral deformity on frontal view radiograph: a cohort analysis and a pictorial review



Opportunities exist to detect osteoporotic vertebral deformities (VDs) on frontal radiograph (FR) indicated for lung or abdominal diseases, while literature have been mostly based on lateral radiograph (LR). This study analyzed the detectability of moderate and severe grades VD on FR.


There were 105 female cases (mean 72 years, range 55~93 year), who were referred for digital spine FR and LR with back and/or leg pain. The LR and FR were read, osteoporotic VDs with < 20%, 20–25%, 25–40%, and > 40% vertebral body height loss were recorded as minimal, mild, moderate, and severe grades, respectively. After a 10-month interval, only FRs were read again, and each vertebra was classified as (1) no notable VD, (2) with notable VD, and (3) ambiguous. The first reading was the reference, while the second reading was allowed to miss minimal/mild VCD and endplate/cortex fracture.


Counting by subjects, for 98 cases, the two reading sessions had agreement, including 43 “true negative” cases and 55 true positive cases. There were two false positive cases, and five ambiguous cases. In total, 1286 vertebra were assessed, FR reading had 1126 vertebrae “true negative,” 130 vertebrae true positive, one vertebra false negative, 3 vertebrae false positive, and 26 ambiguous vertebrae (65.4% being true negative and 34.6% being true positive). Most of the disagreements were associated with kyphosis or poor X-ray projection. Nineteen illustrative cases are presented graphically.


Moderate and severe grades of VD are identifiable on FR as long as the involved vertebrae are clearly filmed.

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  1. 1.

    Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC et al (1996) Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 348:1535–1541

    CAS  Article  Google Scholar 

  2. 2.

    Nuti R, Brandi ML, Isaia G, Tarantino U, Silvestri S, Adami S (2009) New perspectives on the definition and the management of severe osteoporosis: the patient with two or more fragility fractures. J Endocrinol Investig 32:783–788

    CAS  Article  Google Scholar 

  3. 3.

    Jager PL, Jonkman S, Koolhaas W, Stiekema A, Wolffenbuttel BH, Slart RH (2011) Combined vertebral fracture assessment and bone mineral density measurement: a new standard in the diagnosis of osteoporosis in academic populations. Osteoporos Int 22:1059–1068

    CAS  Article  Google Scholar 

  4. 4.

    Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739

    CAS  Article  Google Scholar 

  5. 5.

    Kendler DL, Bauer DC, Davison KS, Dian L, Hanley DA, Harris ST et al (2016) Vertebral fractures: clinical importance and management. Am J Med (129):221.e1–221.10

    Article  Google Scholar 

  6. 6.

    Kanis JA, Oden A, Johnell O, De Laet C, Jonsson B (2004) Excess mortality after hospitalisation for vertebral fracture. Osteoporos Int (15):108–112

  7. 7.

    Wang YX (2018) Senile osteoporosis is associated with disc degeneration. Quant Imaging Med Surg 8:551–556

    Article  Google Scholar 

  8. 8.

    Wang XR, Kwok TCY, Griffith JF, Man Yu BW, Leung JCS, Wang Y (2019) Prevalence of cervical spine degenerative changes in elderly population and its weak association with aging, neck pain, and osteoporosis. Ann Transl Med 7(18):486

    Article  Google Scholar 

  9. 9.

    Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V et al (2008) Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women, Cochrane Database Syst Rev:CD003376

  10. 10.

    Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V et al (2008) Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women, Cochrane Database Syst Rev:CD001155

  11. 11.

    Delmas PD, van de Langerijt L, Watts NB, Eastell R, Genant H, Grauer A, Cahall DL, IMPACT Study Group (2005) IMPACT study group. Underdiagnosis of vertebral fractures is a worldwide problem: the IMPACT study. J Bone Miner Res 20:557–563

    Article  Google Scholar 

  12. 12.

    Kim N, Rowe BH, Raymond G, Jen H, Colman I, Jackson SA, Siminoski KG, Chahal AM, Folk D, Majumdar SR (2004) Underreporting of vertebral fractures on routine chest radiography. Am J Roentgenol 182:297–300

    CAS  Article  Google Scholar 

  13. 13.

    Majumdar SR, Kim N, Colman I, Chahal AM, Raymond G, Jen H, Siminoski KG, Hanley DA, Rowe BH (2005) Incidental vertebral fractures discovered with chest radiography in the emergency department. Arch Intern Med 165:905–909

    Article  Google Scholar 

  14. 14.

    Lansdown D, Bennet B, Thiel S, Ahmed O, Dixon L, Vokes TJ (2011) Prevalence of vertebral fractures on chest radiographs of elderly African American and Caucasian women. Osteoporos Int 22:2365–2371

    CAS  Article  Google Scholar 

  15. 15.

    Gehlbach SH, Bigelow C, Heimisdottir M, May S, Walker M, Kirkwood JR (2000) Recognition of vertebral fracture in a clinical setting. Osteoporos Int 11:577–582

    CAS  Article  Google Scholar 

  16. 16.

    Yu W, Yao JP, Lin Q, Mou WB (2010) Cause analysis of missing diagnosis for vertebral fracture on lateral chest radiography (in Chinese). Chin J Radiol 44:504–507

  17. 17.

    Li Y, Yan L, Cai S, Wang P, Zhuang H, Yu H (2018) The prevalence and under-diagnosis of vertebral fractures on chest radiograph. BMC Musculoskelet Disord 19:235

  18. 18.

    Bartalena T, Rinaldi MF, Modolon C, Braccaioli L, Sverzellati N, Rossi G et al (2010) Incidental vertebral compression fractures in imaging studies: lessons not learned by radiologists. World J Radiol 2:399–404

  19. 19.

    Du MM, Che-Nordin N, Ye PP, Qiu SW, Yan ZH, Wang YX (2019) Underreporting characteristics of osteoporotic vertebral compressive fracture in back pain clinic patients of a tertiary hospital in China. J Orthop Translat.

  20. 20.

    Oschatz E, Prosch H, Kohansal R, Valipour A, Mostbeck G (2009) COPD and osteoporosis: detection and grading of vertebral fractures on lateral chest radiography. J Thorac Imaging 24:212–215

    Article  Google Scholar 

  21. 21.

    Kim YJ, Chae SU, Kim GD, Park KH, Lee YS, Lee HY (2013) Radiographic detection of osteoporotic vertebral fracture without collapse. J Bone Metab 20:89–94

    Article  Google Scholar 

  22. 22.

    Wang YX, Che-Nordin N (2019) Some radiographically ‘occult’ osteoporotic vertebral fractures can be evidential if we look carefully. Quant Imaging Med Surg 9:1992–1995

  23. 23.

    Genant HK, Wu CY, van Kuijk C, Nevitt M (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148

    CAS  Article  Google Scholar 

  24. 24.

    Genant HK, Jergas M (2003) Assessment of prevalent and incident vertebral fractures in osteoporosis research. Osteoporos Int 14(Suppl 3):S43–S55

    Article  Google Scholar 

  25. 25.

    Wang YX (2019) A modified semi-quantitative (mSQ) grading scheme for osteoporotic vertebral fracture in elderly women. Quant Imaging Med Surg 9:146–150

    Article  Google Scholar 

  26. 26.

    Jiang G, Eastell R, Barrington NA, Ferrar L (2004) Comparison of methods for the visual identification of prevalent vertebral fracture in osteoporosis. Osteoporos Int 15:887–896

    CAS  Article  Google Scholar 

  27. 27.

    Wang YX, Santiago RF, Deng M, Nogueira-Barbosa MH (2017) Identifying osteoporotic vertebral endplate and cortex fractures. Quant Imaging Med Surg 7:555–591

    Article  Google Scholar 

  28. 28.

    Wang YX, Deng M, He LC, Che-Nordin MN, Santiago RF (2018) Osteoporotic vertebral endplate and cortex fractures: a pictorial review. J Orthop Translat 25:35–49

  29. 29.

    Harvey NCW, McCloskey EV, Mitchell PJ, Dawson-Hughes B, Pierroz DD, Reginster JY, Rizzoli R, Cooper C, Kanis JA (2017) Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int 28:1507–1529

    CAS  Article  Google Scholar 

  30. 30.

    Lentle BC, Brown JP, Khan A, Leslie WD, Levesque J, Lyons DJ, Siminoski K, Tarulli G, Josse RG, Hodsman A, Scientific Advisory Council of Osteoporosis Canada, Canadian Association of Radiologists (2007) Scientific Advisory Council of Osteoporosis Canada; Canadian Association of Radiologists recognizing and reporting vertebral fractures: reducing the risk of future osteoporotic fractures. Can Assoc Radiol J 58:27–36

    PubMed  Google Scholar 

  31. 31.

    Delmas PD, Genant HK, Crans GG, Stock JL, Wong M et al (2003) Severity of prevalent vertebral fractures and the risk of subsequent vertebral and nonvertebral fractures: results from the MORE trial. Bone 33:522–532

    CAS  Article  Google Scholar 

  32. 32.

    Wang YX, Che-Nordin N, Deng M, Leung JC, Kwok AWL, He LC et al (2019) Osteoporotic vertebral deformity with endplate/cortex fracture is associated with higher further vertebral fracture risk: the Ms. OS (Hong Kong) study results. Osteoporos Int 30:897–905

    CAS  Article  Google Scholar 

  33. 33.

    Diacinti D, Guglielmi G (2019) How to define an osteoporotic vertebral fracture? Quant Imaging Med Surg 9:1485–1494

    Article  Google Scholar 

  34. 34.

    Fink HA, Milavetz DL, Palermo L, Nevitt MC, Cauley JA, Genant HK, Fracture Intervention Trial Research Group et al (2005) What proportion of incident radiographic vertebral deformities is clinically diagnosed and vice versa? J Bone Miner Res 20:1216–1222

    Article  Google Scholar 

  35. 35.

    Cooper C, O’Neill T, Silman A (1993) The epidemiology of vertebral fractures. European Vertebral Osteoporosis Study Group. Bone 14(Suppl 1):S89–S97

    Article  Google Scholar 

  36. 36.

    Freitas SS, Barrett-Connor E, Ensrud KE, Fink HA, Bauer DC, Cawthon PM, Osteoporotic Fractures in Men (MrOS) Research Group et al (2008) Rate and circumstances of clinical vertebral fractures in older men. Osteoporos Int 19:615–623

    CAS  Article  Google Scholar 

  37. 37.

    Wang YX, Wang XR, Che-Nordin N, Xu FR, Huang QL (2019) On the possibility of over-diagnosis of osteoporotic vertebral fracture at mid-thoracic level. J Thorac Dis.

  38. 38.

    Deng M, Zeng XJ, He LC, Leung JCS, Kwok AWL, Griffith JF, Kwok T, Leung PC, Wáng YX (2019) Osteoporotic vertebral fracture prevalence in elderly Chinese men and women: a comparison of endplate/cortex fracture-based and morphometrical deformity-based methods. J Clin Densitom (22):409–419

  39. 39.

    Lentle BC, Berger C, Probyn L, Brown JP, Langsetmo L, Fine B et al (2018) For the CaMos Research Group. Comparative analysis of the radiology of osteoporotic vertebral fractures in women and men: cross-sectional and longitudinal observations from the Canadian Multicentre Osteoporosis Study (CaMos). J Bone Miner Res 33:569–579

    CAS  Article  Google Scholar 

  40. 40.

    Wang YX, Che-Nordin N, Deng M, Griffith JF, Leung JCS, Kwok AWL, et al (2019) Elderly males with or without existing osteoporotic vertebral fracture have much lower future vertebral fracture risk than elderly females: the MrOS (Hong Kong) year-4 follow-up spine radiograph study. Osteoporos Int 30:2505–2514

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This study is partially supported by ITF project of Hong Kong SAR (code: ITS/334/18).

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Correspondence to Yì Xiáng J. Wáng or Zhi-Han Yan.

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Wáng, Y.X.J., Du, MM., Che-Nordin, N. et al. Recognizing osteoporotic vertebral deformity on frontal view radiograph: a cohort analysis and a pictorial review. Arch Osteoporos 15, 41 (2020).

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  • Osteoporosis
  • Radiograph
  • Spine
  • Vertebral fracture
  • Frontal view