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Observational Study
. 2017:2017:9265259.
doi: 10.1155/2017/9265259. Epub 2017 May 25.

A Clinical Prospective Observational Cohort Study on the Prevalence and Primary Diagnostic Accuracy of Occult Vertebral Fractures in Aged Women with Acute Lower Back Pain Using Magnetic Resonance Imaging

Atsushi Terakado  1 , Sumihisa Orita  1   2 , Kazuhide Inage  1   2 , Go Kubota  2 , Tomohiro Kanzaki  1 , Hiroshi Mori  1 , Yuji Shinohara  1 , Junichi Nakamura  2 , Yusuke Matsuura  2 , Yasuchika Aoki  2 , Takeo Furuya  2 , Masao Koda  2 , Seiji Ohtori  2
Affiliations
Observational Study

A Clinical Prospective Observational Cohort Study on the Prevalence and Primary Diagnostic Accuracy of Occult Vertebral Fractures in Aged Women with Acute Lower Back Pain Using Magnetic Resonance Imaging

Atsushi Terakado et al. Pain Res Manag. 2017.

Abstract

Background: Elderly female patients complaints of acute low back pain (LBP) may involve vertebral fracture (VF), among which occult VF (OVF: early-stage VF without any morphological change) is often missed to be detected by primary X-ray examination. The current study aimed to investigate the prevalence of VF and OVF and the diagnostic accuracy of the initial X-ray in detecting OVF.

Method: Subjects were elderly women (>70 years old) complaining of acute LBP with an accurate onset date. Subjects underwent lumbar X-ray, magnetic resonance imaging (MRI), and bone mineral density (BMD) measurement at their first visit. The distribution of radiological findings from X-ray and magnetic resonance imaging (MRI) as well as the calculation of the prevalence of VF and OVF are investigated.

Results: The prevalence of VF among elderly women with LBP was 76.5% and L1 was the most commonly injured level. Among VF cases, the prevalence of OVF was 33.3%. Furthermore, osteoporotic patients tend to show increased prevalence of VF (87.5%). The predictive values in detecting VF on the initial plain X-ray were as follows: sensitivity, 51.3%; specificity, 75.0%; and accuracy rate, 56.7%.

Conclusions: Acute LBP patients may suffer vertebral injury with almost no morphologic change in X-ray, which can be detected using MRI.

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Figures

Figure 1
Figure 1
Patient selection flowchart. Among the total of 5,988 new outpatients, 551 (9.2%) were female (>70 years old). Acute LBP patients with exact origins amounted to 60 cases (1.0%). Among these, 9 cases were unavailable for MRI due to medical contraindication. The final 51 cases were included in the current study.
Figure 2
Figure 2
Onset of LBP. Apparent injury cases amounted to 47.1% (a + b), while no cause and light loading cases amounted to 52.9% (c + d + e).
Figure 3
Figure 3
Fracture levels detected using MRI. The most common level was the L1 vertebra, followed by T12, L2, and L3.
Figure 4
Figure 4
Coincidence between the X-ray findings and MRI findings. Among the cases with fractures confirmed using MRI, 28.2% ((a) 11/39) showed a positive fracture finding both on X-ray and on MRI, while 38.5% ((b) 15/39) showed divergence between these two radiological modalities. The remaining 13 cases ((c) 33.3%) showed a positive MRI finding with a negative X-ray finding, suggesting a true occult fracture (no deformity or fracture in the plain X-ray with positive MRI findings).
Figure 5
Figure 5
A 71-year-old woman with osteoporosis (T-score <−2.5 SD) and a history of no falls/injuries. (a) Plain lumbar radiography showed a possible L1 fracture (solid arrow). (b) T1-weighted MRI showed a compression fracture at the caudal adjacent L2 vertebral body (arrowheads) with a high intensity change in the T2-STIR image (c) not at the presumed level (dotted arrow) (c).
Figure 6
Figure 6
A 79-year-old woman with preosteoporosis (T-score = −2.0 SD) and a history of strain. Plain lumbar X-ray showed spondylosis with no apparent fracture (a). MRI showed a low intensity lesion in the T1-weighted image (b) with a high intensity change in the T2-STIR image (c) indicating an occult fracture at the L4 vertebral body (arrowheads).
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