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id="par0005" class="elsevierStylePara elsevierViewall">Vertebral fractures (VF) are the most frequent fragility fractures, causing a significant loss in quality of life and an increase in morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Their early identification allows patients to be reclassified according to the risk of fractures, especially if these are recent, severe or multiple, and to start treatment in accordance with current clinical practice guidelines.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The prevalence of VFs varies according to age, gender, and the diagnostic criteria used in the fracture definition. In the Spanish population of over 50<span class="elsevierStyleHsp" style=""></span>s, following the imaging criteria of Genant et al.,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> a prevalence of 21–27% in women and 21% in men has been described.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> These are data very similar to those published by the <span class="elsevierStyleItalic">Canadian Multicentre Osteoporosis Study</span> cohort (CaMos cohort).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> And in the very elderly Spanish population (>75 years), this prevalence increases to 55% in women and 31% in men.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In contrast, the prevalence is lower when other VF detection techniques are used, such as vertebral morphometry (<span class="elsevierStyleItalic">Vertebral Fracture Assessment</span> [VFA]) by dual energy x-ray absorptiometry (DXA), when it was found to be only 4.3% in postmenopausal women between 59 and 70 years of age.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> With regard to incidence, a mean daily incidence of VF of 19.3 has recently been reported,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> although it is most likely to have been underdiagnosed, since up to 60% of VFs are asymptomatic,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> and can go unnoticed by healthcare personnel and even by the patients themselves. The lack of coding of VFs and the variability in their imaging description<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> may also justify the lower incidence recorded in clinical practices. In contrast, the mean daily incidence of hip fractures is 25.2,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> since practically all hip fractures require medical evaluation and hospitalisation (and probably increased coding).</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is well known that the presence of a VF increases the risk of developing new VFs and, in turn, this risk increases depending on the number, severity and type of vertebral deformity,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> both in symptomatic and asymptomatic VF (or morphometric or radiological findings).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Thus, it has been described that up to 19.2% of patients with a recent clinical VF present a new incidental VF at one year.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the case of morphometric VFs (of indeterminate onset), the incidence of a new VF at one year is 4.6%, while in patients without VF, it drops to 1.9%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It should also be noted that patients with multiple VFs (2 or more) present a greater increased risk of a new fracture at one year with a relative risk (RR) of 11.6 (CI95%: 1.5–90.1; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.02).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In fact, along these same lines, the term ‘imminent risk’ of a fracture has been coined in recent years to identify those patients who present a high risk of fragility fractures in the short term, within just 2 years.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> So the presence of a recent fragility fracture is the main factor associated with the development of a new fracture (also known as a second fracture or subsequent fracture), with an RR of 1.86 (CI95%: 1.75–1.98)<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>; especially if they are multiple (<span class="elsevierStyleItalic">hazard rate</span> [HR]: 1.8; CI95%: 1.2–2.7)<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> or vertebral (HR: 2.72 with respect to hip fracture, CI95%: 2.58–2.88).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Also, age, female gender, glucocorticoid therapy, repeated falls or a very low bone mass in the hip (less than −3.5 standard deviations [SD]) are accompanied by a greater risk of fracture in the short term.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–14</span></a> The development of clinical care units in accordance with the <span class="elsevierStyleItalic">Capture The Fracture</span> programme developed by the <span class="elsevierStyleItalic">International Osteoporosis Foundation</span> (IOF), baptized with the name of <span class="elsevierStyleItalic">Fracture Liaison Service</span> [FLS], enables those patients with a recent fragility fracture (<3 months) to be identified and assessed for anti-osteoporosis treatment. These functional units have proven to be cost-effective (increase of 0.082 quality-adjusted life years [QALY] in 10 years, at a cost of 563.69<span class="elsevierStyleHsp" style=""></span>Є per patient)<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and significantly reduce the risk of refracture (−5%; CI95%: −0.08−0.03).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It is important to note that clinical VF is also associated with a significant loss of quality of life (0.92; CI95%: 0.89−0.95), even higher than that associated with hip fracture (0.63; CI95%: 0.61−0.65), which is more noticeable in women and in older patients.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In addition, the presence of a VF is also associated with higher mortality at 5 years, compared to patients of a similar age and sex with other fractures,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and contrary to the previous scenario, this is more noticeable the younger the patients are. Thus, in patients >60 years of age, an increase in mortality has been described with an HR of 2.36 (CI95%: 1.39–4.00) at 5 years after VF, while in patients older than 70 years it is 1.85 (CI95%: 1.37–2.49).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Apart from the previously described morbidity and mortality, these fractures are also associated with impaired spinal stability (especially in patients with spinal fractures), chronic axial pain (can reach up to 25% of clinical VFs), decreased height, decreased forced vital capacity, with worse spirometry parameters, and significant disability.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,18</span></a> Therefore, in the case of acute axial pain (with no known cause), loss of height (2<span class="elsevierStyleHsp" style=""></span>cm with respect to a previous measurement or 4<span class="elsevierStyleHsp" style=""></span>cm with respect to the historical height reported by the patient), or a tendency to kyphosis, it is recommended to screen for incidental VFs with simple X-rays of the thoracic and lumbar spine in lateral projection.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> Additionally, the authors point out the importance of ensuring a correct imaging description is obtained in accordance with the imaging criteria of Genant et al. (reporting "vertebral fractures" in a clear and concise way).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, the presence of a VF is one of the criteria for classifying patients as "very high risk of fracture" according to clinical practice guidelines, especially if they are recent, severe, or multiple; and furthermore, it affects the decision as to which anti-osteoporosis treatment should be started.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Thus, the latest guidelines from the Spanish Society for Bone and Mineral Metabolism Research (SEIOMM) classify the following clinical situations as <span class="elsevierStyleItalic">“very high risk of fracture”</span>: (a) patients with ≥2<span class="elsevierStyleHsp" style=""></span>VFs or equivalent situation (e.g., a VF together with a hip fracture); (b) patients with a VF together with osteoporosis with a <span class="elsevierStyleItalic">T-score</span> <−3.0<span class="elsevierStyleHsp" style=""></span>SD; (c) patients with very low bone mass (<span class="elsevierStyleItalic">T-score</span> <−3.5<span class="elsevierStyleHsp" style=""></span>SD).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These patients would be candidates for bone formation treatment (with teriparatide or romosozumab, the latter with a dual effect on the bone) as the first option, unless there are contraindications.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The same guidelines classify patients with a previous fragility fracture and the presence of densitometric osteoporosis with a <span class="elsevierStyleItalic">T-score</span> <−2.5<span class="elsevierStyleHsp" style=""></span>SD as <span class="elsevierStyleItalic">"high risk of fracture” and</span> recommend initiating antiresorptive therapy (oral or parenteral with bisphosphonates or denosumab).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In addition, it should be noted that the guidelines agree that, whatever the indicated anti-osteoporosis treatment, it must be started early given the risk of new fragility fractures. Therefore, the identification of VFs has diagnostic and therapeutic implications since it determines which antiosteoporosis treatment should be started.</p><p id="par0035" class="elsevierStylePara elsevierViewall">All in all, the presence of a VF has diagnostic implications (it allows the classification of the patient based on fracture risk), prognostic implications (it is accompanied by significant morbidity and mortality and a high risk of a subsequent fracture in the short term) and therapeutic implications (it affects the decision regarding which anti-osteoporosis treatment to start). For this reason, it is important to actively search for a VF (symptomatic or morphometric), ensure a correct imaging description is made (report as "vertebral fractures"), assess the patient's risk of fracture, and start anti-osteoporosis treatment in accordance with clinical practice guidelines.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0040" class="elsevierStylePara elsevierViewall">For the realization of this editorial the approval of the Centre's Clinical Research Ethics Committee (CREC) has not been required.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">No funding was necessary for this editorial.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">Dr. Laia Gifre declares that she has received fees for conferences and/or grants for attending congresses from Amgen, UCB, Eli Lilly, Stada, Astellas, Gebro and Kyowa Kyrin.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Dr. Agueda Prior declares having received fees for lectures and/or travel grants from Eli Lilly, Amgen, UCB, Theramex and GP-Pharma.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interests" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk of new vertebral fracture in the year following a fracture" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. 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Journal Information
Vol. 161. Issue 5.
Pages 205-206 (September 2023)
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Vol. 161. Issue 5.
Pages 205-206 (September 2023)
Editorial
Vertebral fragility fractures: The importance of its identification
Fracturas vertebrales por fragilidad: la importancia de su identificación
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