Non-osteoporotic causes of compression fractures

[oneforfighting]

80+yo patient PMH leukemia. Initially found to have acute L5 VCF seen on hip MRI managed conservatively (no back pain). DEXA normal -> T score 0.64 L-spine and 0.69 femur. Sent him back to oncologist for w/u but was told that none needed as blood work has been normal and leukemia does not routinely metastasize to the spine. Now comes in 4 months later with acute back pain found to have subacute compression fracture at L2 and acute at L4.

2 questions:
1) What further workup would you do for this patient who appears at high risk for future fractures? Would you refer to endo/rheum?
2) Very minimal endplate edema on recent MRI at L2 and L5 with BME throughout on L4. Would you treat 3 levels...or just L4 and observe results?

---

Members don't see this ad.

 

[lobelsteve]

L2 looks like a Schmersal snowed. L5 is now a healed fracture and L4 appears acute. If you consider the diagnosis of osteoporosis can be made on a nontraumatic spine fracture then you have your answer. Why don’t you fix L4 and leave the others alone get a biopsy while you’re there and you’ll have all the answers you need.

 

[oneforfighting]

L2 looks like a Schmersal snowed. L5 is now a healed fracture and L4 appears acute. If you consider the diagnosis of osteoporosis can be made on a nontraumatic spine fracture then you have your answer. Why don’t you fix L4 and leave the others alone get a biopsy while you’re there and you’ll have all the answers you need.

Yeah I'm hoping biopsy answers the question. It appears specificity of DEXA is not great.

 

[lobelsteve]

Yeah I'm hoping biopsy answers the question. It appears specificity of DEXA is not great.

Validity of the DEXA diagnosis of involutional osteoporosis in patients with femoral neck fractures

There exists no study comparing dual energy X-ray absorptimetry (DEXA) with histomorphometry to evaluate its accuracy and validity as an assessment tool. A prospective study was done comparing the measurements of osteoporosis in patients with femoral ...

www.ncbi.nlm.nih.gov

Using the WHO cutoff value for the definition of osteoporosis based on the t-score of ≤ –2.5 the specificity is increased from 25% to 62.5%. This increase in the specificity is still inadequate to establish the diagnosis of osteoporosis with a reasonably high confidence since the PPV is only 83.3%. The sensitivity is lower (88.2%), i.e., DEXA at this cutoff value can detect up to 88.2% of possible cases with osteoporosis.

“The sensitivity of 94.1% for the DEXA t-score at the low cutoff value of ≤ –1 and the specificity (62.5%) or PPV (83.3%) at the high cutoff value of ≤ –2.5 would be useful indicators for the physician in deciding treatment for osteoporosis in addition to other parameters derived from patient history and clinical examination.”

Fx is an easier definition to establish.

 

[oneforfighting]

Validity of the DEXA diagnosis of involutional osteoporosis in patients with femoral neck fractures

There exists no study comparing dual energy X-ray absorptimetry (DEXA) with histomorphometry to evaluate its accuracy and validity as an assessment tool. A prospective study was done comparing the measurements of osteoporosis in patients with femoral ...

www.ncbi.nlm.nih.gov

Using the WHO cutoff value for the definition of osteoporosis based on the t-score of ≤ –2.5 the specificity is increased from 25% to 62.5%. This increase in the specificity is still inadequate to establish the diagnosis of osteoporosis with a reasonably high confidence since the PPV is only 83.3%. The sensitivity is lower (88.2%), i.e., DEXA at this cutoff value can detect up to 88.2% of possible cases with osteoporosis.

“The sensitivity of 94.1% for the DEXA t-score at the low cutoff value of ≤ –1 and the specificity (62.5%) or PPV (83.3%) at the high cutoff value of ≤ –2.5 would be useful indicators for the physician in deciding treatment for osteoporosis in addition to other parameters derived from patient history and clinical examination.”

Fx is an easier definition to establish.

Yep, same article I googled