The Spine Journal 14 (2014) 971–972
Commentary
Vertebral compression fracture rules Michael P. Stauff, MDa,*, Eugene J. Carragee, MDb a
Department of Orthopedics and Physical Rehabilitation, University of Massachusetts School of Medicine, Spine Center, Memorial Campus, 119 Belmont St, Worcester, MA 01605, USA b Department of Orthopedic Surgery, Stanford University School of Medicine, 450 Broadway Street, Pavilion C, MC 6342, Redwood City, CA 94063 USA Received 26 February 2014; accepted 1 March 2014
COMMENTARY ON: Postacchini R, Paolino M, Faraglia S, et al. Assessment of patient’s painrelated behavior at physical examination may allow diagnosis of recent osteoporotic vertebral fracture. Spine J. 2013;13:1126–33.
Vertebral compression fractures are common and their incidence is rising in conjunction with the aging population. Unfortunately, diagnosing vertebral compression fractures is challenging because the symptoms are generally parallel to those of patients with acute low back pain. Some evidence suggests that only one of four vertebral compression fractures are clinically recognized [1]. This is important because the treatment algorithm for a vertebral compression fracture is quite different from that of acute low back pain. Given that vertebral compression fractures are an opportunity to initiate specific treatment for osteoporosis, a ‘‘missed’’ diagnostic opportunity may unnecessarily predispose a patient to more fragility fractures [2]. In the primary care setting, acute low back pain is a relatively common chief complaint. In this setting, one of the challenges is to rule out specific diagnoses before attributing acute low back pain to benign degeneration or muscle ache. More serious spinal pathology is present in approximately 1% to 5% of patients presenting with acute low back pain in the primary care setting [3]. The most common, more serious pathologies include vertebral fracture,
FDA device/drug status: Not applicable. Author disclosures: MPS: Nothing to disclose. EJC: Stock Ownership: Simpirica (0 Shares: Less than 1%), Intrinsic Orthopedics (0 Shares, less than 1%). Other office: (F, Editor in Chief of The Spine Journal). Research Support - Investigator Salary: Kaiser - NIH grant (C, Role: Co-PI, Paid directly to institution/employer). Fellowship Support: Orthopaedic Education Research Foundation (OREF) (E, Fellowship training grant to Stanford University, Paid directly to institution/employer), AO Foundation (E, Fellowship training grant to Stanford University, Paid directly to institution/employer). * Corresponding author. Department of Orthopedic Surgery and Physical Rehabilitation, University of Massachusetts Memorial Medical Center, Spine Center, Memorial Campus, 119 Belmont St, Worcester, MA 01605, USA. Tel.: (508) 334-9764; fax: (508) 334-6052. E-mail address: [email protected] (M.P. Stauff) 1529-9430/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2014.03.005
malignancy, infection, and inflammatory disease [3]. Vertebral fracture is the most common diagnosis among these more serious pathologies. The use of ‘‘red flags’’ in the history has generally been advocated to assist with the diagnosis of vertebral compression fractures. These may include a history of recent trauma, corticosteroid use, age greater than 50 years, and the presence of a structural deformity. Unfortunately, using the red flags can sometimes ‘‘cast a net’’ that is too wide. In a recent Cochrane database review, Williams et al. [3] concluded that the regular use of red flags for the identification of vertebral compression fractures in patients presenting with acute low back pain led to many false positives. This could lead to unnecessary testing in many patients. So how can we more efficiently identify patients with vertebral compression fractures in the milieu of patients who present with axial pain? In the September 2013 issue of The Spine Journal, Postacchini et al. [4] reported the results of a study that analyzed the utility of assessing pain-related behavior to diagnose vertebral compression fractures in patients presenting to a spine clinic. Elderly patients presenting with back pain were put through a series of movements and their pain-related behavior was scored and used to diagnose patients with or without a vertebral compression fracture (fracture group or control group). One senior spine surgeon and three orthopedic surgeons who were not specialized in spine performed the scoring while blinded to the results of radiographs and magnetic resonance imaging. By using the scoring system, the four orthopedic surgeons identified those patients with a vertebral compression fracture with an accuracy of 79% to 89%. After performing an receiver operating characteristic analysis, the sensitivity and specificity of the pain-related behavior scoring system as a diagnostic tool was 91% to 95% and 95% to 97%, respectively, for each provider.
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M.P. Stauff and E.J. Carragee / The Spine Journal 14 (2014) 971–972
The investigators also reported excellent intra- (0.94) and interobserver agreement (0.88). In this investigation, Postacchini et al. [4] have developed a seemingly simple algorithm for objectifying a subjective variable, which is the patient’s observed pain-related behavior. Using ‘‘pain-related behavior’’ as a clinical variable is not new. In fact, most providers who care for patients with painful conditions use it frequently. We document it regularly with phrases like, ‘‘the patient is in no acute distress.’’ This phrase and others like it give a general sense of the patient’s appearance that is invariably linked to the provider’s judgment. The provider’s judgment is also important when using the scoring system presented by Postacchini et al.; however, it is more powerful because it is directly linked with a diagnosis of vertebral compression fracture. In this way, the scoring system can act as an important part of the physical examination for an elderly patient who presents with back pain. In our spine clinics, most patients have already had magnetic resonance imaging, radiographs, or both and carry a diagnosis of vertebral compression fracture. In some respects, the scoring system may be best used in the primary care setting. Years ago, a Canadian group presented a set of rules that can be used to determine the need for radiographs in a patient with an acute ankle injury [5]. The purpose of the scoring system was to minimize unnecessary ankle radiographs in the acute setting for those who are unlikely to have an ankle fracture. Since that time, the Ottawa ankle rules have been applied globally and validated in multiple studies. The rules are: age greater than 55 years, inability to bear weight immediately after the injury and for four steps in the emergency department, or bone tenderness at the posterior edge or tip of either malleolus. If any of these items are present, the patient should have ankle radiographs. In this system, there is a demographic variable (age), a physical examination finding (tenderness), and a pain-related behavior (difficulty with ambulation). We could use a similar model and apply it to vertebral compression fractures for patients presenting in the primary care setting. The ‘‘red flags’’ commonly purported as a sign of
possible vertebral compression fracture (a history of recent trauma, corticosteroid use, and age greater than 50 years) can be combined with the scoring system of Postacchini et al. [4]. By applying these variables in the primary care setting, we may identify these patients more accurately and apply specific treatment for the compression fracture and the osteoporosis to mitigate the risk of further fragility fractures. One weakness of the study, as noted by the authors, is the inclusion of compression fractures from T8–L4. Although T8–L4 are the most common levels for compression fractures, mid- and upper thoracic compression fractures do occur. How useful would the scoring system be for these fractures? We cannot say based on the results of this study. Also, as mentioned previously, the utility of the scoring system for diagnosing vertebral compression fracture in a spine specialty clinic is probably limited. This scoring system proposed by Postacchini et al. would be most useful in the primary care setting. The authors should be congratulated for a timely study that improves our ability to accurately diagnose vertebral compression fractures. Hopefully, a similar study can be performed in the primary care setting to validate the usefulness of the scoring system. References [1] Grigoryan M, Guermazi A, Roemer FW, et al. Recognizing and reporting osteoporotic vertebral fractures. Eur Spine J 2003;12(2 Suppl):S104–12. [2] Freedman BA, Potter BK, Nesti LJ, et al. Osteoporosis and vertebral compression fractures-continued missed opportunities. Spine J 2008;8:756–62. [3] Williams CM, Henschke N, Maher CG, et al. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst Rev 2013;1:CD008643. [4] Postacchini R, Paolino M, Faraglia S, et al. Assessment of patient’s pain-related behavior at physical examination may allow diagnosis of recent osteoporotic vertebral fracture. Spine J 2013;13:1126–33. [5] Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. JAMA 1993;269: 1127–32.
Commentary
Vertebral compression fracture rules Michael P. Stauff, MDa,*, Eugene J. Carragee, MDb a
Department of Orthopedics and Physical Rehabilitation, University of Massachusetts School of Medicine, Spine Center, Memorial Campus, 119 Belmont St, Worcester, MA 01605, USA b Department of Orthopedic Surgery, Stanford University School of Medicine, 450 Broadway Street, Pavilion C, MC 6342, Redwood City, CA 94063 USA Received 26 February 2014; accepted 1 March 2014
COMMENTARY ON: Postacchini R, Paolino M, Faraglia S, et al. Assessment of patient’s painrelated behavior at physical examination may allow diagnosis of recent osteoporotic vertebral fracture. Spine J. 2013;13:1126–33.
Vertebral compression fractures are common and their incidence is rising in conjunction with the aging population. Unfortunately, diagnosing vertebral compression fractures is challenging because the symptoms are generally parallel to those of patients with acute low back pain. Some evidence suggests that only one of four vertebral compression fractures are clinically recognized [1]. This is important because the treatment algorithm for a vertebral compression fracture is quite different from that of acute low back pain. Given that vertebral compression fractures are an opportunity to initiate specific treatment for osteoporosis, a ‘‘missed’’ diagnostic opportunity may unnecessarily predispose a patient to more fragility fractures [2]. In the primary care setting, acute low back pain is a relatively common chief complaint. In this setting, one of the challenges is to rule out specific diagnoses before attributing acute low back pain to benign degeneration or muscle ache. More serious spinal pathology is present in approximately 1% to 5% of patients presenting with acute low back pain in the primary care setting [3]. The most common, more serious pathologies include vertebral fracture,
FDA device/drug status: Not applicable. Author disclosures: MPS: Nothing to disclose. EJC: Stock Ownership: Simpirica (0 Shares: Less than 1%), Intrinsic Orthopedics (0 Shares, less than 1%). Other office: (F, Editor in Chief of The Spine Journal). Research Support - Investigator Salary: Kaiser - NIH grant (C, Role: Co-PI, Paid directly to institution/employer). Fellowship Support: Orthopaedic Education Research Foundation (OREF) (E, Fellowship training grant to Stanford University, Paid directly to institution/employer), AO Foundation (E, Fellowship training grant to Stanford University, Paid directly to institution/employer). * Corresponding author. Department of Orthopedic Surgery and Physical Rehabilitation, University of Massachusetts Memorial Medical Center, Spine Center, Memorial Campus, 119 Belmont St, Worcester, MA 01605, USA. Tel.: (508) 334-9764; fax: (508) 334-6052. E-mail address: [email protected] (M.P. Stauff) 1529-9430/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2014.03.005
malignancy, infection, and inflammatory disease [3]. Vertebral fracture is the most common diagnosis among these more serious pathologies. The use of ‘‘red flags’’ in the history has generally been advocated to assist with the diagnosis of vertebral compression fractures. These may include a history of recent trauma, corticosteroid use, age greater than 50 years, and the presence of a structural deformity. Unfortunately, using the red flags can sometimes ‘‘cast a net’’ that is too wide. In a recent Cochrane database review, Williams et al. [3] concluded that the regular use of red flags for the identification of vertebral compression fractures in patients presenting with acute low back pain led to many false positives. This could lead to unnecessary testing in many patients. So how can we more efficiently identify patients with vertebral compression fractures in the milieu of patients who present with axial pain? In the September 2013 issue of The Spine Journal, Postacchini et al. [4] reported the results of a study that analyzed the utility of assessing pain-related behavior to diagnose vertebral compression fractures in patients presenting to a spine clinic. Elderly patients presenting with back pain were put through a series of movements and their pain-related behavior was scored and used to diagnose patients with or without a vertebral compression fracture (fracture group or control group). One senior spine surgeon and three orthopedic surgeons who were not specialized in spine performed the scoring while blinded to the results of radiographs and magnetic resonance imaging. By using the scoring system, the four orthopedic surgeons identified those patients with a vertebral compression fracture with an accuracy of 79% to 89%. After performing an receiver operating characteristic analysis, the sensitivity and specificity of the pain-related behavior scoring system as a diagnostic tool was 91% to 95% and 95% to 97%, respectively, for each provider.
972
M.P. Stauff and E.J. Carragee / The Spine Journal 14 (2014) 971–972
The investigators also reported excellent intra- (0.94) and interobserver agreement (0.88). In this investigation, Postacchini et al. [4] have developed a seemingly simple algorithm for objectifying a subjective variable, which is the patient’s observed pain-related behavior. Using ‘‘pain-related behavior’’ as a clinical variable is not new. In fact, most providers who care for patients with painful conditions use it frequently. We document it regularly with phrases like, ‘‘the patient is in no acute distress.’’ This phrase and others like it give a general sense of the patient’s appearance that is invariably linked to the provider’s judgment. The provider’s judgment is also important when using the scoring system presented by Postacchini et al.; however, it is more powerful because it is directly linked with a diagnosis of vertebral compression fracture. In this way, the scoring system can act as an important part of the physical examination for an elderly patient who presents with back pain. In our spine clinics, most patients have already had magnetic resonance imaging, radiographs, or both and carry a diagnosis of vertebral compression fracture. In some respects, the scoring system may be best used in the primary care setting. Years ago, a Canadian group presented a set of rules that can be used to determine the need for radiographs in a patient with an acute ankle injury [5]. The purpose of the scoring system was to minimize unnecessary ankle radiographs in the acute setting for those who are unlikely to have an ankle fracture. Since that time, the Ottawa ankle rules have been applied globally and validated in multiple studies. The rules are: age greater than 55 years, inability to bear weight immediately after the injury and for four steps in the emergency department, or bone tenderness at the posterior edge or tip of either malleolus. If any of these items are present, the patient should have ankle radiographs. In this system, there is a demographic variable (age), a physical examination finding (tenderness), and a pain-related behavior (difficulty with ambulation). We could use a similar model and apply it to vertebral compression fractures for patients presenting in the primary care setting. The ‘‘red flags’’ commonly purported as a sign of
possible vertebral compression fracture (a history of recent trauma, corticosteroid use, and age greater than 50 years) can be combined with the scoring system of Postacchini et al. [4]. By applying these variables in the primary care setting, we may identify these patients more accurately and apply specific treatment for the compression fracture and the osteoporosis to mitigate the risk of further fragility fractures. One weakness of the study, as noted by the authors, is the inclusion of compression fractures from T8–L4. Although T8–L4 are the most common levels for compression fractures, mid- and upper thoracic compression fractures do occur. How useful would the scoring system be for these fractures? We cannot say based on the results of this study. Also, as mentioned previously, the utility of the scoring system for diagnosing vertebral compression fracture in a spine specialty clinic is probably limited. This scoring system proposed by Postacchini et al. would be most useful in the primary care setting. The authors should be congratulated for a timely study that improves our ability to accurately diagnose vertebral compression fractures. Hopefully, a similar study can be performed in the primary care setting to validate the usefulness of the scoring system. References [1] Grigoryan M, Guermazi A, Roemer FW, et al. Recognizing and reporting osteoporotic vertebral fractures. Eur Spine J 2003;12(2 Suppl):S104–12. [2] Freedman BA, Potter BK, Nesti LJ, et al. Osteoporosis and vertebral compression fractures-continued missed opportunities. Spine J 2008;8:756–62. [3] Williams CM, Henschke N, Maher CG, et al. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst Rev 2013;1:CD008643. [4] Postacchini R, Paolino M, Faraglia S, et al. Assessment of patient’s pain-related behavior at physical examination may allow diagnosis of recent osteoporotic vertebral fracture. Spine J 2013;13:1126–33. [5] Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. JAMA 1993;269: 1127–32.
