Franck Grados

Radiographic methods for evaluating osteoporotic vertebral fractures

UNLABELLED Reproducible methods for the radiological assessment of osteoporotic vertebral fractures, defined based on accurate criteria, are needed in everyday practice and in therapeutic trials and epidemiological studies. OBJECTIVES To describe and to evaluate methods for osteoporotic vertebral fracture assessment based on standard radiographs or dual-energy X-ray absorptiometry (DXA) and to determine the role for each method in clinical practice, therapeutic trials, and epidemiological studies. METHODS A review written by a rheumatologist based on his clinical experience and on a literature review was submitted to four experts. Studies in English or French published between 1975 and February 2008 were retrieved from Medline using the keywords vertebral fracture, osteoporosis, vertebral deformity, and vertebral fracture assessment. RESULTS One hundred forty-nine articles were selected and read in their full-text version. There was no consensus regarding the definition of osteoporotic vertebral fractures. The following methods were evaluated: visual assessment, Genants semi-quantitative assessment, Jiangs algorithm-based qualitative method, morphometric radiography, and DXA of the spine. In everyday practice, Genants semi-quantitative assessment on standard radiographs may provide useful information on the severity and prognosis of osteoporosis. DXA done for bone mineral density measurement may detect vertebral fractures in asymptomatic patients. Assessment of standard radiographs remains the reference standard for diagnosing vertebral fractures in patients with suggestive symptoms (e.g., pain in the thoracic or lumbar spine, height loss, or thoracic kyphosis). For therapeutic trials and epidemiological studies, Genants semi-quantitative assessment used by a trained and experienced observer is the preferred method, based on its good reproducibility and ability to differentiate fractures from other deformities. However, thousands of radiographs may be needed, making routine interpretation by an expert impractical. A visual semi-quantitative method may be used to separate normal radiographs from radiographs showing possible or obvious fractures, which can then be read by an expert. Alternatively, radiomorphometric indices can be determined on digitized radiographs in combination with a semi-quantitative assessment, with discordant cases being reviewed by an expert. We do not recommend Jiangs method at present, as it is still undergoing validation.

Effects on bone mineral density of calcium and vitamin D supplementation in elderly women with vitamin D deficiency.

OBJECTIVE Calcium and vitamin D deficiency is common in older individuals, particularly those who live in nursing homes, and increases the risk of osteoporosis and fractures. METHODS We conducted a randomized double-blind placebo-controlled study of combined supplementation with 500 mg of elemental calcium, as carbonate, and 400 IU of vitamin D bid for 12 months in women older than 65 years of age with vitamin D deficiency, defined as serum 25(OH)D concentrations </=12 ng/ml. RESULTS Mean patient age was 75 +/- 7 years, and median daily dietary intakes of calcium and vitamin D were 697 mg and 66.8 IU in the supplemented group (n = 95) and 671 mg and 61.8 IU in the placebo group (n = 97). The median serum 25(OH)D level was 7.0 ng/ml in both groups, and the medial intact parathyroid hormone (PTHi) levels were 49 and 48 pg/ml in the supplemented and placebo groups, respectively. The median increase in serum 25(OH)D was 22.0 ng/ml in the supplemented group and 4 ng/ml in the placebo group (P < 0.0001), and the median PTHi decrease was 17 and 5 pg/ml, respectively (P < 0.0001). The median bone mineral density increase was significantly greater in the supplemented group than in the placebo group: +2.98% vs. -0.21% at L2-L4 (P = 0.0009), +1.19% and -0.83% at the femoral neck (P = 0.015), +0.86% and -0.56% at the trochanter (P = 0.015), and +0.99% and +0.11% for the whole body (P = 0.01). Similarly, the median decrease in the main bone markers was significantly greater in the treated group than in the placebo group: -1.35 microg/l vs. +0.50 microg/l for bone alkaline phosphatase (P = 0.008), -16.6 nmol/mmol creatinine vs. -2.3 nmol/mmol creatinine for urinary type I amino-terminal telopeptide (P = 0.001), and -896 pmol/l vs. -201 pmol/l for serum type I carboxy-terminal telopeptide (P = 0.003). We found no significant differences between the two groups for serum calcium, although urinary calcium excretion changed more in the supplemented group than in the placebo group. In conclusion, bone mass in older women with vitamin D deficiency increases significantly at the lumbar spine, femur, trochanter, and whole body after calcium and vitamin D supplementation for 1 year, and concomitantly bone markers improved as vitamin D levels returned to normal.

Should percutaneous vertebroplasty be used to treat osteoporotic fractures? An update.

Acrylic cement vertebroplasty is being increasingly used to treat osteoporotic vertebral compression fractures (VCFs), although no controlled studies supporting this trend have been published. Vertebroplasty remains controversial as a treatment for osteoporotic fractures because it is a local response to a systemic disease and because the pain caused by osteoporotic fractures usually subsides within a few days or weeks. Current data suggest that pain severity may decrease by half, on average, in 90-100% of patients. Although vertebroplasty is usually well tolerated, serious neurological complications have been reported in a few patients. The most common adverse event is nerve root pain, usually caused by leakage of the cement into the intervertebral foramen. Whether vertebroplasty is followed by an increased risk of osteoporotic fractures in the adjacent vertebras remains unclear. Resorbable cements are being developed and may provide better results than the acrylic cements used today. At present, acrylic cement vertebroplasty to treat osteoporotic VCFs is appropriate in only a minority of patients selected carefully by a multidisciplinary team including a rheumatologist.

Musculoskeletal Ultrasonography in Healthy Subjects and Ultrasound Criteria for Early Arthritis (The ESPOIR Cohort)

Objective. To confirm the occurrence of bone erosions and synovitis in healthy subjects detectable by ultrasound (US) and to establish US criteria for early arthritis. Methods. Our study involved 127 healthy subjects matched with a cohort of patients with early arthritis (the ESPOIR cohort). The second and fifth metacarpophalangeal (MCP) joints and the fifth metatarsophalangeal (MTP) joint of both hands and feet were assessed with US to detect bone erosion; and the second, third, fourth, and fifth MCP and the fifth MTP were evaluated for synovial thickening in B-mode US and synovial vascularity in power Doppler. Bone erosion and synovitis were defined according to the Outcome Measures in Rheumatology Clinical Trials consensus. Results. Bone erosion and grade 2–3 synovial thickening in B-mode were detected in 11% and 9% of healthy subjects. To consider the diagnosis of early arthritis, a cutoff at 1 case of synovial thickening in B-mode enabled discrimination between patients with early arthritis and healthy subjects, with a good sensitivity of 74.8% (95% CI 67.2%–82.3%) and a high specificity of 90.5% (95% CI 85.4%–95.6%). If higher specificity is required to confirm the diagnosis of early arthritis, cutoff at 2 cases of synovial thickening in B-mode or at 2 cases of bone erosion gave optimal results, with specificity of 98.4% (95% CI 96.2%–100%) and 100%, respectively, and lower sensitivity of 59.8% (95% CI 51.2%–68.3%) and 17% (95% CI 10.5%–23.5%) (area under the curve = 0.85 for synovitis and 0.63 for bone erosion). Neither the combination of power Doppler signal plus bone erosion, nor bone erosions plus synovial thickening on the same joint, were seen in healthy subjects. Conclusion. A single case of bone erosion or synovial thickening in B-mode is common in healthy subjects. However, more than 1 case of synovial thickening in B-mode or bone erosion is a strong argument for the diagnosis of early inflammatory arthritis.

Influence of Age and Sex on Vertebral Shape Indices Assessed by Radiographic Morphometry

Abstract: Vertebral shape indices (VSI) assessed by radiographic morphometry are currently used to define vertebral fractures in clinical trials and epidemiologic studies on osteoporosis. However, there is little information concerning the influence of sex or age on VSI. Furthermore, previous reports on the variation of VSI with age showed conflicting results. The aim of this study was to assess the influence of sex and age on VSI in order to better define reference values for the clinical and epidemiologic evaluation of vertebral osteoporotic fractures. Measurements were performed on thoracic and lumbar spine radiographs from 50 men and 50 women (age range 25–75 years) without evidence of osteoporotic, degenerative or other disease-related vertebral deformity. The anterior (AH), middle (MH) and posterior (PH) heights of each vertebral body from T4 to L5 were measured and VSI were calculated as follows: wedging = (AH minus PH) divided by PH; concavity = (MH minus PH) divided by PH. Wedging and concavity, especially at the mid and lower thoracic spine, increased significantly with age in both sexes. We also demonstrated that VSI at the lumbar spine were significantly dependent on gender, with greater values of wedging and concavity in men than in women. Consequently, reference values used for the definition of vertebral osteoporotic fractures assessed by radiographic morphometry should take into account both sex and age effects.

First case of human spondylodiscitis due to Shewanella algae

We present the first case of human spondylodiscitis due to Shewanella algae. Our patient did not have any predisposing factors. The portal of entry was probably a cutaneous lesion on the leg, exposed to seawater. Bacteria were isolated in pure culture from a needle biopsy specimen of the vertebral disk. Automated identification systems identified the organism as Shewanella putrefaciens. However, molecular biology identified it as S. algae. Treatment with ceftriaxone and amikacin, then ciprofloxacin successfully addressed the infection. We also review four published cases of human osteoarticular infections caused by Shewanella spp: two cases of arthritis and two cases of osteomyelitis. Two patients had predisposing factors, and contact with water was found in two cases. The clinical, radiological and biological characteristics of S. algae spondylodiscitis are indistinguishable from those of spondylodiscitis of other causes. A cutaneous lesion with exposure to water is a potential portal of entry. Molecular typing is necessary to obtain a precise bacteriological identification.

Longitudinal femoral shaft fracture due to bone insufficiency. A review of three cases

Abstract We report three new cases of longitudinal femoral shaft fracture due to bone insufficiency and review the eight cases reported in the literature. The typical patient is a woman older than 65 years of age who present with mechanical pain in the thigh and/or groin. Palpation of the thigh may reproduce the pain. The diagnosis is often made late because the radiographs are normal initially. However, an early and consistent finding is increased radionuclide uptake along the femoral shaft. The fracture line is readily evidenced by computed tomography but may be difficult to see on magnetic resonance imaging. Use of crutches for 6 weeks to protect the bone from weight bearing ensures healing of the fracture.

Hematogenous Staphylococcus aureus discitis in adults can start outside the vertebral body

BACKGROUND Textbooks describe hematogenous discitis in adults as starting in the anterior vertebral body near the endplates. CASE REPORT Hematogenous Staphylococcus aureus discitis developed at L1-L2 in an 81-year-old woman. On the first magnetic resonance imaging (MRI) scan performed 4 days after symptom onset, the only abnormalities were high signal from the disk on T2-weighted images, gadolinium enhancement of the soft tissues anterior to L1-L2, and epidural involvement. The endplates and vertebral bodies were normal. A subsequent MRI scan showed features typical of infectious discitis. DISCUSSION We found a single similar case report in the medical literature, indicating that discitis starting outside the anterior vertebral body is rare. Nevertheless, an increasing number of similar cases may be diagnosed in the future, as MRI is being performed increasingly early in patients with a clinical suspicion of infectious discitis. CONCLUSION Hematogenous infectious discitis in adults may start in some patients within the disk, soft tissues anterior to the disk, or epidural space. To avoid diagnostic and therapeutic delays, physicians should be aware of this unusual presentation of infectious discitis on very early MRI scans. When the clinical picture suggests discitis and findings from the early MRI scan are atypical, a repeat MRI scan should be obtained 1 week later to confirm the diagnosis.

Difficulties in the diagnosis of vertebral fracture in men: Agreement between doctors

UNLABELLED The agreement for vertebral fracture (VF) diagnosis in men, between doctors is poor. OBJECTIVES To assess the agreement for VF diagnosis, in men, on standard radiographs, between experts, before and after consensual workshop and establishing an algorithm. METHODS The agreement between thirteen experimented rheumatologists has been calculated in thirty osteoporotic men. Then, the group discussed in a workshop and 28 other radiograph sets of osteoporotic men with follow-up radiographs and incident confirmed VF, have been reviewed. The experts identified and hierarchised 18 pathological features of vertebral deformation and established an algorithm of VF diagnosis. Eleven experts have realized a second reading of the first set of radiographs. We compared the agreement between the 2 readings without and with the algorithm. RESULTS After consensus and the use of the algorithm the results are: number of fractured patients (with at least 1 VF) according to the experts varies from 13 to 26 patients out of 30 (13 to 28 during the first reading). The agreement between the experts at the patient level is 75% (70% at the first reading). Among the 390 vertebrae analyzed by the experts, the number of VF detected varies from 18 to 59 (18 to 98 at the first reading). The agreement between the experts at the vertebral level is 92% (89% at the first reading). The algorithm allows a good improvement of the agreement, especially for 8 of the 11 experts. Discrepancies for the VF diagnosis between experts exist. The algorithm improves the agreement.

Biological Effects of Supplementation with Vitamin D and Calcium in Postmenopausal Women with Low Bone Mass Receiving Alendronate

ObjectiveTo investigate the biological effects of supplementation with vitamin D and calcium versus supplementation with calcium alone during the first 3 months of treatment with alendronate in postmenopausal women with a risk of fracture and with vitamin D and calcium insufficiency.DesignRandomised, double-blind trial.SubjectsThe study randomised 48 osteopenic and osteoporotic women, mean age 70 ± 6 years and at least 5 years after menopause, who were living at home. Inclusion criteria were low bone mineral density (more than 1 SD below reference value), serum 25-hydroxy-vitamin D3 (25-OHD, calcifediol) <12 μg/L and dietary calcium intake <1 g/day.MethodsThe women were divided into two groups. The first group (n = 23) received alendronate 10mg once daily supplemented with calcium and vitamin D (elemental calcium 500mg, colecalciferol [vitamin D3] 400IU) twice daily for 3 months. The second group (n = 25) received the same dosage of alendronate and a placebo with calcium alone (500 mg/day). Blood, serum and urine samples were obtained for measurement of calcaemia, intact parathyroid hormone (i-PTH) and markers of bone remodelling such as the N- and C-terminal telopeptides of type I collagen (NTX and CTX).ResultsSupplementation with calcium and vitamin D caused a rapid increase of 25-OHD levels without changes in calcaemia or i-PTH levels. In the two groups, serum and urinary CTX and urinary NTX were dramatically and significantly decreased after as little as 15 days of treatment and remained decreased throughout the course of treatment. No significant difference between the two treatments was observed, but the combined treatment resulted in a more pronounced effect as assessed by the Hodge-Lehman test, particularly after 1 month for the bone resorption markers serum CTX (p = 0.064) and urinary NTX (p = 0.076).ConclusionSupplementation with calcium and vitamin D could be appropriate in elderly women with calcium and vitamin D insufficiencies being treated with alendronate in order to achieve rapid reduction of bone remodelling.