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The Accuracy of Incident Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches
Jinhui Ma1, Kerry Siminoski2, Peiyao Wang3
1Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
Insights
This study evaluated strategies for detecting new vertebral fractures in children on glucocorticoids. Combining low bone density with existing fractures or back pain improved detection accuracy and targeted radiography effectively.
Area of Science:
- Pediatric Endocrinology
- Pediatric Rheumatology
- Pediatric Oncology
- Pediatric Nephrology
Background:
- Vertebral fractures are significant complications in children with various chronic diseases.
- Glucocorticoid therapy increases the risk of vertebral fractures in pediatric patients.
- Accurate detection of incident vertebral fractures (IVF) is crucial for timely intervention.
Purpose of the Study:
- To assess the effectiveness of different case-finding strategies for detecting incident vertebral fractures (IVF) in glucocorticoid-treated children.
- To compare strategies in both prevalent vertebral fracture (PVF) known and unknown scenarios.
- To provide guidance for optimizing spine radiography in at-risk pediatric populations.
Main Methods:
- A 2-year prospective study of 343 children treated with glucocorticoids for leukemia, rheumatic disorders, or nephrotic syndrome.
- Measurement of lumbar spine bone mineral density (LS BMD) using dual-energy X-ray absorptiometry.
- Quantification of vertebral fractures on spine radiographs (modified Genant method) and assessment of back pain via patient report.
Main Results:
- 12.8% of patients experienced incident vertebral fractures (IVF).
- In the PVF scenario, low LS BMD and PVF were significant predictors of IVF.
- In the non-PVF scenario, low LS BMD plus back pain demonstrated high specificity (87%) and accuracy (82%), with a low radiography rate (17%).
Conclusions:
- Case-finding strategies incorporating low LS BMD and patient-reported symptoms can effectively target spine radiography in children at risk for vertebral fractures.
- The combination of low LS BMD and back pain is a highly specific and accurate approach for detecting IVF in children with unknown baseline fracture status.
- These findings support the development of evidence-based guidelines for vertebral fracture screening in pediatric populations undergoing long-term glucocorticoid therapy.
Abstract:
Vertebral fractures are clinically important sequelae of a wide array of pediatric diseases. In this study, we examined the accuracy of case-finding strategies for detecting incident vertebral fractures (IVF) over 2 years in glucocorticoid-treated children (n = 343) with leukemia, rheumatic disorders, or nephrotic syndrome. Two clinical situations were addressed: the prevalent vertebral fracture (PVF) scenario (when baseline PVF status was known), which assessed the utility of PVF and low lumbar spine bone mineral density (LS BMD; Z-score <-1.4), and the non-PVF scenario (when PVF status was unknown), which evaluated low LS BMD and back pain. LS BMD was measured by dual-energy X-ray absorptiometry, vertebral fractures were quantified on spine radiographs using the modified Genant semiquantitative method, and back pain was assessed by patient report. Forty-four patients (12.8%) had IVF. In the PVF scenario, both low LS BMD and PVF were significant predictors of IVF. Using PVF to determine which patients should have radiographs, 11% would undergo radiography (95% confidence interval [CI] 8-15) with 46% of IVF (95% CI 30-61) detected. Sensitivity would be higher with a strategy of PVF or low LS BMD at baseline (73%; 95% CI 57-85) but would require radiographs in 37% of children (95% CI 32-42). In the non-PVF scenario, the strategy of low LS BMD and back pain produced the highest specificity of any non-PVF model at 87% (95% CI 83-91), the greatest overall accuracy at 82% (95% CI 78-86), and the lowest radiography rate at 17% (95% CI 14-22). Low LS BMD or back pain in the non-PVF scenario produced the highest sensitivity at 82% (95% CI 67-92), but required radiographs in 65% (95% CI 60-70). These results provide guidance for targeting spine radiography in children at risk for IVF. © 2021 American Society for Bone and Mineral Research (ASBMR).
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