Osteoporosis 2016 | Fracture Risk Assessment: Vertebral fractures: Dr Emma Clark #osteo2016

$Page 1: Osteoporosis 2016 | Fracture Risk Assessment: Vertebral fractures: Dr Emma Clark #osteo2016$
Fracture Risk Assessment: Vertebral Fractures

Dr Emma ClarkConsultant Senior Lecturer in Rheumatology

7th November, 2016

Disclosures

Unrestricted educational grants• Lilly• Servier• Amgen

Unrestricted research grant• P&G (now WC)

Consultancy work• Servier

• Why are vertebral fractures important?

• Clinical assessment: Might this person have a vertebral fracture?

• Maximising case finding – a systematic approach

• Summary




• Summary

Fracture risk assessment: importance of vertebral fractures

• Clinical tools such as FRAX under-estimate future fracture risk in someone with a vertebral fracture1

• In FRAX, fracture is a dichotomous variable, but….

[1] Blank RD et al (2011) J Clin Densitom 14(3):205-2011[2] Klotzbuecher CM et al (2000) J Bone Miner Res 15(4):721-739[3] Siris ES et al (2007) Osteop Int 18(6):761-770



• Clinical tools such as FRAX under-estimate future fracture risk in someone with a vertebral fracture1

• In FRAX, fracture is a dichotomous variable, but….

• Prior vertebral fracture increases future fracture risk 4-fold, whereas prior non-vertebral fracture doubles subsequent fracture risk2

• And – there is an association between severity of prior vertebral fractures and subsequent fracture risk3, independent of BMD

[1] Blank RD et al (2011) J Clin Densitom 14(3):205-2011[2] Klotzbuecher CM et al (2000) J Bone Miner Res 15(4):721-739[3] Siris ES et al (2007) Osteop Int 18(6):761-770


• Presence of vertebral fracture improves estimation of future fracture risk

• Understanding of severity of vertebral fracture improves fracture risk assessment

• Presence of vertebral fracture may change management




• Summary

Should I X-ray this person?

Clinical features that might indicate someone has a vertebral fracture

• History

• Examination


• History

• Examination


• History

– Pain– Reported height loss– Traditional risk factors for osteoporosis


• History


Pain

• VFs may be clinically "silent“

[1] O'Neill et al, Osteop Int 2004; 15: 760-765

[2] Ismail et al, Osteop Int 1999; 9: 206-213

Pain

• New vertebral fractures occurring during a 4-year follow-up that did not come to clinical attention, were nonetheless associated with a two- to three-fold increase in back pain and limitation

• Attitudes toward back pain in older women, and access to health care

[1] Nevitt MC et al, Ann Int Med 1998; 128: 793-800

7223 white women older than 65 from SOF

Pain

• VFs may be clinically "silent"

• No more back pain than women without VFs1

• More VFs means more pain2

• Quality of back pain?

[1] O'Neill et al, Osteop Int 2004; 15: 760-765

[2] Ismail et al, Osteop Int 1999; 9: 206-213

•Site•Intensity•Specific quality e.g. stabbing, burning

Lateral back pain identifies prevalent vertebral fractures in postmenopausal women: cross-sectional analysis of a

primary-care based cohortEM Clark, AP Hutchinson, EV McCloskey, MD Stone,

JC Martin, AK Bhalla, JH Tobias (2009) Rheumatology 49:505-512

Thoracic area

Waist area

Lower back/buttock area

• Lateral waist pain is associated with a 4.5 fold increased risk of VFs (OR 4.48, 95%CI 2.02 to 9.94, P<0.001)




Using self-reports of pain and other variables to distinguish between older women with back pain due to vertebral fractures

and those with back pain due to degenerative changesEM Clark, R Gooberman-Hill, TJ Peters (2016) Osteop Int 27:1459-1467

• Women aged >65 who had a thoracic spinal radiograph in the previous 3 months were recruited

• Used the McGill Pain Questionnaire along with other questions about back pain





With vertebral fracture Without vertebral fracture▪ Pain for a few days/weeks ▪ Pain for months to years▪ Brief or momentary pain ▪ Other severe pain experiences▪ Improvement of pain on lying ▪ Negative effect of weather▪ Pain described as crushing ▪ Pain radiating down legs

No difference in pain severity, or bothersomeness of back pain



Independent predictors:•Age•History of previous fracture•Pain described as crushing•Pain improving on lying down•Pain not spreading down legs

AUC 0.85 (95 % CI 0.79 to 0.92)


• History


History of height loss

• Reported height loss= reported height at aged 25 minus measured height now– is associated with presence of vertebral fractures1,2

• Trousers or skirts now too long• Can’t reach up to cupboards that could reach before

[1] Nicholson PHF et al, Osteop Int 1993; 3: 300-307

[2] Tobias JH et al, Osteop Int 2007; 18: 35-43


• History


Risk factors for osteoporosis

• In addition to age and gender• Late menarche associated with increased risk1,2

• Current smoking is associated with increased risk2,3

• Steroid usage particularly important in children4 and men5, but probably not in inflammatory disease6

[1] Roy DK et al, Osteop Int 2003; 14: 19-26

[2] van der Klift M et al, JBMR 2004; 19: 1172-1180

[3] Jaramillo JD et al, Annals Am Thor Soc 2015; 12(5): 648-656

[4] LeBlanc CM et al, JBMR 2015; 30(9): 1667-1675

[5] Sugiyama T et al, Int Med 2011; 50(8): 817-824

[6] Ghazi M et al, Osteop Int 2012; 23(2): 581-587


• History

• Examination


• History

• Examination– Increased thoracic kyphosis– Rib to pelvis distance


• History


Increased thoracic kyphosis

• Kyphosis measured by video rasterstereograph1 or radiographic angle measurement2 can predict women with vertebral fractures

• The majority of men and women with the most exaggerated kyphoses have no evidence of vertebral fracture or osteoporosis3

– Degenerative disc disease was the most common finding

[1] Tan B-K et al, J Rheum 2008; 35(2):327-334

[2] Ensrud KE et al, J Am Ger Soc 1997; 45(6):682-687

[3] Schneider DL et al, J Rheum 2004; 31(4):747-752

1407 people aged 50-96 from the Rancho Bernado study in the US


• History


Rib to pelvis distance

[1] Siminoski K et al, Am J Med 2003; 115:233-236


[1] Tobias et al, Osteop Int 2007; 18:35-43


[1] Tobias et al, Osteop Int 2007; 18:35-43

3.2%

12.2%

Examination for recent onset vertebral fractures

• New osteoporotic vertebral fractures are tender to gentle percussion whereas degenerative spinal disease is not1

[1] Langdon J et al (2010) Annals Royal Col Surg Eng 92(2):163-166

Summary of potentially useful features in history and examination

• Traditional risk factors for osteoporosis– Females – Older age– Previous fracture– Smoking– Steroids in men and children

• Back pain– Lateral waist pain– Back pain improving on lying down

• Reported height loss of >4cm• Rib-to-pelvis distance of 1 finger




• Summary

Maximising case finding: A systematic approach for vertebral fractures

• Spinal radiographs

• VFAs

• Raising awareness in radiology


• Spinal radiographs– In unselected older women from primary care– In older women with back pain from primary care



COSHIBA = RCT1 of a clinical tool for identifying which older women should have spinal radiographs

[1] Clark EM et al (2012) JBMR 27(3):664-671






Yes NoYes 13 45

No 16 248

VF on X-ray

Presence of lateral waist

pain

Sensitivity: 44.8%Specificity: 84.6%




COSHIBA

• Simple screening tool (based on a pilot study1)– History of previous fracture at any age– Reported height loss– Margolis back pain score– Rib-pelvis distance

• Use of score with predetermined threshold– Predicts all those with 2 or more VFs, and half of those with 1VF– AUC 0.88 (0.80 to 0.97)

• Women were randomised to screening or standard approach

[1] Tobias et al, 2007 Osteop Int 18: 35-43.

COSHIBACohort for Skeletal

Health in Bristol and Avon

Results

primary and secondary outcomes:

Control arm Screening arm

n (%) n (%) OR (95%CI), P value

NEW OSTEOPOROSIS MEDICATION PRESCRIPTION

Within 6 months of joining the study n=2921 yes no

17 (0.9)1925 (99.1)

19 (1.9)960 (98.1)

2.24 (1.16, 4.33), P=0.016

Between 6 and 12 months of joining the study n=2710 yes no

18 (1.0)1788 (99.0)

9 (1.0)895 (99.0)

0.99 (0.45, 2.23), P=0.998

NEW FRACTURES


34 (1.8)1908 (98.2)

15 (1.5)964 (98.5)

0.87 (0.47, 1.61), P=0.664


41 (2.3)1752 (97.7)

6 (0.7)904 (99.3)

0.28 (0.12, 0.67), P=0.004

[1] Clark et al, 2012 J Bone Miner Res 27:664-671



Results

primary and secondary outcomes:

Control arm Screening arm

n (%) n (%) OR (95%CI), P value

NEW OSTEOPOROSIS MEDICATION PRESCRIPTION


17 (0.9)1925 (99.1)

19 (1.9)960 (98.1)

2.24 (1.16, 4.33), P=0.016


18 (1.0)1788 (99.0)

9 (1.0)895 (99.0)

0.99 (0.45, 2.23), P=0.998

NEW FRACTURES


34 (1.8)1908 (98.2)

15 (1.5)964 (98.5)

0.87 (0.47, 1.61), P=0.664


41 (2.3)1752 (97.7)

6 (0.7)904 (99.3)

0.28 (0.12, 0.67), P=0.004




COSHIBA Discussion

• COSHIBA is unlikely to be cost effective from an NHS perspective

• Rough estimate of cost per QALY of £30,000

• Need to target any systematic screening to a higher risk subgroup








Independent predictors:•Age•History of previous fracture•Pain described as crushing•Pain improving on lying down•Pain not spreading down legs

•A cut-off of 0.39 gives a sensitivity of 0.77 and a specificity of 0.78•Applying this cut-off to a group of older women with back pain would identify 77% of those with a vertebral fracture whilst reducing the number of radiographs performed by 60 %



• VFAs


VFAs as a routine part of traditional DXA scans

• Vertebral Fracture Assessment

VFA: vertebral fracture assessment




• Take extra time – To carry out the scan - particularly on older machines– To report

• Unselected VFAs vs a targeted approach



• Take extra time – To carry out the scan - particularly on older machines– To report

• Unselected VFAs vs a targeted approach

• Need to have an impact on patient care i.e. change management in enough to justify the extra resources

Our experience in Bristol1

Eligibility criteria for VFA•Women aged >65 and men aged >70

– Osteopaenia with intermediate FRAX scores– Very low T scores <-3.5

We report VFAs as•No vertebral fracture seen (give level which can be interpreted)•Definite vertebral fracture•Suspicious for vertebral fracture and recommend a spinal radiograph

[1] P33 Impact of VFA on management within the real-life setting of a busy NHS DXA service


Our experience in Bristol1

Practicalities•Patient completes pre-DXA questionnaire•DXA performed and answers to questions put into FRAX•Whilst patient is still on the table, technician decides whether a VFA should be performed

Impact over an 8-month period•170 VFAs performed•Management was changed in 18 (10.6%)

WARNING: do not rely on the manufacturers software without human interpretation

[1] P33 Impact of VFA on management within the real-life setting of a busy NHS DXA service




• VFAs


Systematic approaches for radiology departments

• Use the ‘F’ word – Vertebral Fracture Initiative by IOFwww.iofbonehealth.org/



Systematic approaches for radiology departments

• Use the ‘F’ word – Vertebral Fracture Initiative by IOFwww.iofbonehealth.org/– In all images that show a vertebral fracture e.g. CXR, spinal

radiographs, pelvis radiographs

• Sagittal realignment of all CT chest abdo pelvis scans

http://www.iofbonehealth.org/




• Summary

Fracture Risk Assessment: Vertebral Fractures

• Presence of vertebral fracture improves fracture risk assessment, and may change management

• For individual patients, when assessing future fracture risk, consider spinal radiographs if they have features in the history and examination – more research needed

• For a systematic approach, routine VFAs on a selected subgroup, and full engagement with radiology departments seem promising

Thank you

Healthcare

Osteoporosis 2016 | Fracture Risk Assessment: Vertebral fractures: Dr Emma Clark #osteo2016