Abstract
Background
Osteoporosis, a multifactorial systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to increased bone fragility, is a worldwide public health problem. Vertebral fractures affect approximately 20% of postmenopausal women and are a hallmark of osteoporosis, but they may pass unnoticed, although they may lead to long-term immobility and disability.
Questions/purposes
The aims of the present study were (1) to determine the prevalence and the severity of vertebral fractures in a large cohort of Italian women aged 60 years or older with reduced values of quantitative ultrasound parameters; and (2) to assess whether vertebral fractures and other variables may be associated with health-related quality of life.
Methods
A total of 2450 women without back pain aged 60 years or older, after the completion of the Quality of Life Questionnaire of the European Foundation for Osteoporosis QUALEFFO, underwent quantitative ultrasound evaluation of the calcaneus; in those with a stiffness t-score of ≤ −2 (n = 1194), radiographic evaluation of the thoracic and lumbar spine was carried out and then quantitative morphometry was performed by dedicated software (MorphoXpress). The radiographic analysis was carried out on 885 women who presented films of adequate quality. Multivariate regression was used to adjust for confounding variables.
Results
Of those who underwent radiographic analysis, 681 had no vertebral fractures, and 204 women (23.1%) had one or more previously undiagnosed vertebral fractures. The prevalence of previously undiagnosed vertebral fractures increased with advancing age with more than 30% of women older than 75 years having at least one fracture. Older age, body mass index, and severe vertebral fractures were independently associated with a worse total QUALEFFO score.
Conclusions
We found that approximately one in four women showed evidence of undiagnosed vertebral fractures, and there was a strong age effect trend. Moreover, the severity grade of vertebral fractures, more than the number of fractures, was associated with a worsening of health-related quality of life as assessed by QUALEFFO. These findings confirm the clinical relevance of an early diagnosis of vertebral fractures and seem to support the usefulness of quantitative ultrasound measurements in the stratification of postmenopausal women at increased fracture risk.
Level of Evidence
Level III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
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References
Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res. 2007;22:465–475.
Cauley JA, Thompson DE, Ensrud KC, Scott JC, Black D. Risk of mortality following clinical fractures. Osteoporos Int. 2000;11:556–561.
Chrischilles E, Shireman T, Wallace R. Cost and health effects of osteoporotic fractures. Bone. 1994;15:377–386.
Clark P, Cons-Molina F, Deleze M, Ragi S, Haddock L, Zanchetta JR, Jaller JJ, Palermo L, Talavera JO, Messina DO, Morales-Torres J, Salmeron J, Navarrete A, Suarez E, Pérez CM, Cummings SR. The prevalence of radiographic vertebral fractures in Latin American countries: the Latin American Vertebral Osteoporosis Study (LAVOS). Osteoporos Int. 2009;20:275–282.
Cockerill W, Lunt M, Silman AJ, Cooper C, Lips P. Health-related quality of life and radiographic vertebral fracture. Osteoporos Int. 2004;15:113–119.
Crans GG, Genant HK, Krege JH. Prognostic utility of a semiquantitative spinal deformity index. Bone. 2005;37:175–179.
Delmas PD, Genant HK, Crans GG, Stock JL, Wong M, Siris E, Adachi JD. Severity of prevalent vertebral fractures and the risk of subsequent vertebral and nonvertebral fractures: results from the MORE trial. Bone. 2003;33:522–532.
Fechtenbaum J, Cropet C, Kolta S, Horlait S, Orcel P, Roux C. The severity of vertebral fractures and health-related quality of life in osteoporotic postmenopausal women. Osteoporos Int. 2005;16:2175–2179.
Genant HK, Jergas M, Palermo L, Nevitt M, Valentin RS, Black D, Cummings SR. Comparison of semiquantitative visual and quantitative morphometric assessment of prevalent and incident vertebral fractures in osteoporosis. The Study of Osteoporotic Fractures Research Group. J Bone Miner Res. 1996;11:984–996.
Grados F, Marcelli C, Dargent-Molina P, Roux C, Vergol JF, Meunier PJ, Fardellone P. Prevalence of vertebral fractures in French women older than 75 years from the EPIDOS study. Bone. 2004;34:362–367.
Guglielmi G, Stoppino LP, Placentino MG, D’Errico F, Palmieri F. Reproducibility of a semi-automatic method for 6-point vertebral morphometry in a multi-center trial. Eur J Radiol. 2009;69:173–178.
Hans D, Hartl F, Krieg MA. Device-specific weighted T-score for two quantitative ultrasounds: operational propositions for the management of osteoporosis for 65 years and older women in Switzerland. Osteoporos Int. 2003;14:251–258.
Hasserius R, Redlund-Johnell I, Mellström D, Johansson C, Nilsson BE, Johnell O. Vertebral deformation in urban Swedish men and women: prevalence based on 797 subjects. Acta Orthop Scand. 2001;72:273–278.
Johnell O, Kanis JA, Odén A, Sernbo I, Redlund-Johnell I, Petterson C, De Laet C, Jönsson B. Mortality after osteoporotic fractures. Osteoporos Int. 2004;15:38–42.
Kaptoge S, Armbrecht G, Felsenberg D, Lunt M, Weber K, Boonen S, Jajic I, Stepan JJ, Banzer D, Reisinger W, Janott J, Kragl G, Scheidt-Nave C, Felsch B, Matthis C, Raspe HH, Lyritis G, Póor G, Nuti R, Miazgowski T, Hoszowski K, Armas JB, Vaz AL, Benevolenskaya LI, Masaryk P, Cannata JB, Johnell O, Reid DM, Bhalla A, Woolf AD, Todd CJ, Cooper C, Eastell R, Kanis JA, O’Neill TW, Silman AJ, Reeve J. Whom to treat? The contribution of vertebral X-rays to risk-based algorithms for fracture prediction. Results from the European Prospective Osteoporosis Study. Osteoporos Int. 2006;17:1369–1381.
Kauppi M, Impivaara O, Mäki J, Heliövaara M, Jula A. Quantitative ultrasound measurements and vitamin D status in the assessment of hip fracture risk in a nationally representative population sample. Osteoporos Int. 2013;24:2611–2618.
Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2000;15:721–739.
Kovacs FM, Abraira V, Zamora J, Teresa Gil del Real M, Llobera J, Fernández C, Bauza JR, Bauza K, Coll J, Cuadri M, Duro E, Gili J, Gestoso M, Gómez M, González J, Ibañez P, Jover A, Lázaro P, Llinás M, Mateu C, Mufraggi N, Muriel A, Nicolau C, Olivera MA, Pascual P, Perelló L, Pozo F, Revuelta T, Reyes V, Ribot S, Ripoll J, Ripoll J, Rodríguez E; Kovacs-Atención Primaria Group. Correlation between pain, disability, and quality of life in patients with common low back pain. Spine. 2004;29:206–210.
Krieg MA, Barkmann R, Gonnelli S, Stewart A, Bauer DC, Del Rio Barquero L, Kaufman JJ, Lorenc R, Miller PD, Olszynski WP, Poiana C, Schott AM, Lewiecki EM, Hans D. Quantitative ultrasound in the management of osteoporosis: the 2007 ISCD Official Positions. J Clin Densitom. 2008;11:163–187.
Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens P, Flowers K, Stracke H, Seeman E. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001;285:320–323.
Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O, Kanis JA, Kellingray S, Leplege A, Liberman UA, McCloskey E, Minne H, Reeve J, Reginster J-Y, Scholz M, Todd C, de Vernejoul MC, Wiklund I. Quality of life in patients with vertebral fractures: validation of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). Osteoporos Int. 1999;10:150–160.
Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O, Kanis JA, Liberman U, Minne H, Reeve J, Reginster JY, de Vernejoul MC, Wiklund I. Quality of life as outcome in the treatment of osteoporosis: the development of a questionnaire for quality of life by the European Foundation for Osteoporosis. Osteoporos Int. 1997;7:36–38.
Moayyeri A, Adams JE, Adler RA, Krieg MA, Hans D, Compston J, Lewiecki EM. Quantitative ultrasound of the heel and fracture risk assessment: an updated meta-analysis. Osteoporos Int. 2012;23:143–153.
Netelenbos JC, Lems WF, Geusens PP, Verhaar HJ, Boermans AJ, Boomsma MM, Mulder PG, Papapoulos SE. Spine radiographs to improve the identification of women at high risk for fractures. Osteoporos Int. 2009;20:1347–1352.
NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285:785–795.
Oleksik AM, Ewing S, Shen W, van Schoor NM, Lips P. Impact of incident vertebral fractures on health related quality of life (HRQOL) in postmenopausal women with prevalent vertebral fractures. Osteoporos Int. 2005;16:861–870.
O’Neill TW, Felsenberg D, Varlow J, Cooper C, Kanis JA, Silman AJ. The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study. J Bone Miner Res. 1996;11:1010–1018.
Pluijm SM, Tromp AM, Smit JH, Deeg DJ, Lips P. Consequences of vertebral deformities in older men and women. J Bone Miner Res. 2000;15:1564–1572.
Romagnoli E, Carnevale V, Nofroni I, D’Erasmo E, Paglia F, De Geronimo S, Pepe J, Raejntroph N, Maranghi M, Minisola S. Quality of life in ambulatory postmenopausal women: the impact of reduced bone mineral density and subclinical vertebral fractures. Osteoporos Int. 2004;15:975–980.
Ross PD, Davis JW, Epstein RS, Wasnich RD. Pain and disability associated with new vertebral fractures and other spinal conditions. J Clin Epidemiol. 1994;47:231–239.
Rostom S, Allali F, Bennani L, Abouqal R, Hajjaj-Hassouni N. The prevalence of vertebral fractures and health-related quality of life in postmenopausal women. Rheumatol Int. 2012;32:971–980.
Silverman SL, Minshall ME, Shen W, Harper KD, Xie S. Health-Related Quality of Life Subgroup of the Multiple Outcomes of Raloxifene Evaluation Study. The relationship of health-related quality of life to prevalent and incident vertebral fractures in postmenopausal women with osteoporosis: results from the Multiple Outcomes of Raloxifene Evaluation Study. Arthritis Rheum. 2001;44:2611–2619.
van Schoor NM, Smit JH, Twisk JW, Lips P. Impact of vertebral deformities, osteoarthritis, and other chronic diseases on quality of life: a population-based study. Osteoporos Int. 2005;16:749–756.
Wilson S, Sharp CA, Davie MW. Health-related quality of life in patients with osteoporosis in the absence of vertebral fracture: a systematic review. Osteoporos Int. 2012;23:2749–2768.
Wu CY, Li J, Jergas M, Genant HK. Comparison of semiquantitative and quantitative techniques for the assessment of prevalent and incident vertebral fractures. Osteoporos Int. 1995;5:354–370.
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This work was performed at the Department of Internal Medicine and Neurosciences, University of Siena, Siena, Italy.
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Nuti, R., Caffarelli, C., Guglielmi, G. et al. Undiagnosed Vertebral Fractures Influence Quality of Life in Postmenopausal Women With Reduced Ultrasound Parameters. Clin Orthop Relat Res 472, 2254–2261 (2014). https://doi.org/10.1007/s11999-014-3588-8
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DOI: https://doi.org/10.1007/s11999-014-3588-8