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The course of the acute vertebral body fragility fracture: its effect on pain, disability and quality of life during 12 months

The course of the acute vertebral body fragility fracture: its effect on pain, disability and... Eur Spine J (2008) 17:1380–1390 DOI 10.1007/s00586-008-0753-3 O R I G IN AL ARTI CL E The course of the acute vertebral body fragility fracture: its effect on pain, disability and quality of life during 12 months Nobuyuki Suzuki Æ Osamu Ogikubo Æ Tommy Hansson Received: 28 April 2008 / Revised: 24 June 2008 / Accepted: 3 August 2008 / Published online: 27 August 2008 The Author(s) 2008. This article is published with open access at Springerlink.com Abstract The vertebral body fracture is the most frequent mobilized and allowed to return home while the remaining bone fragility fracture. In spite of this there is considerable were hospitalized. The average pain intensity score after uncertainty about the frequency, extent and severity of the 3 weeks was 70.9 (SD 19.3), the disability score 68.9 (SD acute pain and even more about the duration of pain, the 23.6), the ADL score 37.7 (SD 22.1) and EQ-5D score of magnitude of disability and how much daily life is dis- 0.37 (SD 0.37). The largest improvements, 10–15%, turbed in the post-fracture period. The aim of the present occurred between the initial visit and the 3 months follow- study was to follow the course of pain, disability, ADL and up and were quite similar for all the measures. From QoL in patients during the year after an acute low energy 3 months, all the outcome measures leveled out or tended vertebral body fracture. The study design was a longi- to deteriorate resulting in a mean pain intensity score of tudinal cohort study with prospective data collection. All 60.5, disability score of 53.9, ADL score of 47.6, and EQ- the patients over 40 years admitted to the emergency unit 5D score 0.52 after 12 months. After a whole year the because of back pain with a radiologically acute vertebral fractured patients’ condition was similar to the preopera- body fracture were eligible. A total of 107 patients were tive condition of patients with a herniated lumbar disc, followed for a year. The pain, disability (von Korff pain central lumbar spinal stenosis or in patients 100% work and disability scores), ADL (Hannover ADL score), disabled due to back or neck problems. Instead of the and QoL (EQ-5D) were measured after 3 weeks, 3, 6 and generally believed good prognosis for the greater majority 12 months. Two-thirds of the patients were women, and of those fractured, the acute vertebral body fracture was the were similar in average age, as the men around 75 years. beginning of a long-lasting severe deterioration of their A total of 65.4% of the fractures were due to a level fall or health. a minor trauma, whereas 34.6% had no recollection of trauma or a specific event as the cause of the fracture. A Keywords Vertebral body fracture  Osteoporosis total of 76.6% of the fractured patients were immediately Pain  Quality of life  Disability  Compression fracture Introduction N. Suzuki  O. Ogikubo The vertebral body fracture is the most frequent type of Department of Orthopaedic Surgery, osteoporotic fracture [12]. Approximately 30–50% of Nagoya City University Graduate School of Medical Sciences, women and 20–30% of men develop vertebral fractures 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, and half of them develop multiple fractures during their Aichi 467-8601, Japan lifetime, compared with a 15.6% lifetime risk of a hip T. Hansson (&) fracture [50]. The annual incidence rate of a vertebral Department of Orthopaedics, Sahlgrenska Academy, body fracture in women over 50 years of age has been Gothenburg University, Bruna Straket 11, found to be 17.8 in 1,000 person-years [43]. In Sweden, a 413 45 Goteborg, Sweden remarkable increase in incidence and prevalence for this e-mail: tommy.hansson@orthop.gu.se 123 Eur Spine J (2008) 17:1380–1390 1381 type of fracture, especially among those of older age was Materials and methods noted between the 1950s and 1980s [6]. It is well known and frequently reported that the vertebral body fracture All patients over 40 years of age who were admitted to the causes pain, disability and has a negative effect on the emergency unit at Sahlgrenska University Hospital, Goth- patient’s health-related quality of life (QoL) [2, 8–10, 13, enburg, Sweden because of back pain and had a 15, 19, 20, 30, 34, 39, 41, 46, 49, 51, 53]. Both pro- and radiologically acute vertebral fracture which resulted from retrospective data suggest that the deterioration of health a low energy trauma were eligible for the study. Patients after a vertebral fracture can last for many years and with with an acute fracture in an earlier fractured spine were also included. The study was conducted from December sequel that usually are worse than for the other bone fragility fractures [29, 30, 34, 45]. It has also been noted 2003 to November 2006. that many patients, mainly women, with numerous frac- Excluded were those with any other type of acute tures have never come to clinical attention [14, 22]. So- fracture (forearm, hip etc.), fracture/fractures related to called subclinical vertebral fractures have been found to malignancy, infection or any other bone disease, except exert only a moderate effect on the patient’s QoL. Not osteoporosis, that could affect the mechanical integrity of surprisingly, it has likewise been noted that the time since the vertebrae in the lumbar or thoracic spines. The presence the fracture occurred is of importance for the reported or suspicion of more than one acute fracture excluded from QoL, irrespective of age [1, 4, 9]. The most negative the study. influence of subclinical fractures has been reported in the Within 10 days after the visit to the hospital’s emer- domains of pain, general health, and social and physical gency unit, all eligible patients received written functioning [3, 38]. The effect on QoL of the vertebral information about the study and an invitation to participate. fracture was prospectively studied in two Swedish studies. The patients who agreed to participate received a first These studies suggested that this fracture type had a more questionnaire at the latest 3 weeks after the fracture had negative and long-lasting impact on the patient’s QoL than been diagnosed and then after 3, 6 and 12 months. The any other type of osteoporotic fracture, including the hip questionnaires were self explanatory and intended to be fracture [8, 30]. used for postal surveys. The patients returned the filled-in Several different instruments for determining the effect questionnaires which seemed to make later comparisons on the QoL, such as SF-36, SF-12, or EQ-5D, have been unlikely. The questionnaires described below were used in used for patients with vertebral body fractures [2, 3, 8, 9, the study; all of the questionnaires were used at each of the 40, 44, 51, 57]. four follow-up times. In spite of the high incidence and prevalence of this Questionnaires fracture type, surprisingly little is known about its long- term course. Generally it has been believed that the prob- lems related to this type of fracture are self-limiting. The von Korff pain intensity and disability questionnaires pain after an acute vertebral compression fracture for example, has been reported as intense at the fracture site up This instrument is self-administered and was designed and to 4–6 weeks, and turning into chronic pain only in patients validated for use among patients with among others back with multiple compression fractures, height loss, and low pain outside the hospital setting [55, 56]. It includes three bone density [52]. It has also been reported that sponta- pain intensity and four disability items. The three pain neous pain, measured using a visual analog scale, did not items ask the patient to rate the back pain intensity right decrease significantly until day 15, but had decreased by now, the worst pain and the average pain since the start of approximately 40% when measured at day 30 [26]. Others the pain problem where 0 is ‘‘no pain’’ and 10 is ‘‘pain as have found that acute fracture pain decreased by 22% at bad could be’’. The Pain Intensity score is calculated as the day 7, and by 33% at day 14 [42]. average of the three 0–10 ratings multiplied by 10 to yield There is considerable uncertainty about the frequency, a 0–100 score. Three of the disability items also have a extent and severity of the acute pain and even more 10-graded response possibility. One item is about the about the duration of pain, the magnitude of disability interference of the back pain on the daily activities ranging and how much daily life is disturbed in the post-fracture between 0, ‘‘no interference’’ and 10, ‘‘unable to carry on period. any activities’’ and two are about how the back pain has Although several studies have evaluated large samples changed the ability to take part in family, social or recre- of patients with non acute vertebral fractures, the aim of the ational activities, or the ability to work (including household) both ranging between 0, ‘‘no change’’ and 10, present study was to prospectively evaluate the course over 12 months of non-surgically treated acute vertebral com- ‘‘extreme change’’. The fourth disability question asks pression fractures on pain, disability, ADL, and QoL. about the number of days the subject, due to the pain, has 123 1382 Eur Spine J (2008) 17:1380–1390 been kept from the usual activities during the last with the normal neighboring vertebrae, (2) pain at or near 6 months. This fourth question is not used in this study. the fracture deformation, (3) an evident sharp edge in the The Disability score is calculated as the average of three 0– deformed region [5] and (4) no callus formation at the 10 interference ratings in daily, social and work activities fractured vertebra [5]. The type of fracture was determined multiplied by 10 to yield a 0–100 score [55, 56]. The scores as wedge, concave, or crush [48] and the grade of fracture have been used in several international and Swedish studies was assessed according to the emiquantitative method by of long-term back pain [32] (see Appendix). Genant et al. [23–25]. In questionable cases, previous or subsequent imaging examinations e.g. MR were used to Hannover ADL score confirm or reject the presence of the acute fracture. In cases of divergent opinions, the cases were discussed and con- This questionnaire is also self-administered and consists of sensus reached. 12 items. It assesses functional limitations in activities of daily living (ADL) among patients with musculoskeletal Preventive treatment disorders. Item examples are; ‘‘Can you wash and dry yourself from head to toe?’’ and ‘‘Can you raise yourself A total of 14 of the 107 patients reported that they had from a lying position?’’ The response alternatives are three taken medication during the year prior to the actual fracture (circle one); 1. Either unable to do or able only with help to increase their bone mineral. (score = 0), 2. Yes, but with some difficulties (score = 1), or 3. Yes, without difficulties (score = 2). The 12 items are Statistical analysis scored, summed and transformed on to a scale from 0 (worst back function) to 100 (best back function [37]. The The SPSS statistical software program was used for ana- questionnaire has been used in several international and lyzing the data. Swedish studies of long-term back pain [32] (see Parametric tests, independent or paired t tests were used Appendix). for parametric scale variables. Differences between groups were analyzed with parametric methods. Nominal variables EQ-5D were tested using the Chi-square test. For comparison of repeated measurements, repeated ANOVA was used. If the This is a generic health-related quality of life measure. It repeated ANOVA was significant, the Bonferroni/Dunn provides a single index. The individuals classify their own procedure was used as a post hoc test. All tests were two- health status into five dimensions: mobility, self-care, sided. The results were considered to be significant at P \ 0.05. usual activity, pain/discomfort and anxiety/depression within three levels (i.e. no problems, moderate problems and severe problems). The instrument yields a total of 243 Ethical approval possible health states, and the Time Trade Off method is used to rate the different states of health. The value 0 The study was ethically approved by the Research Ethical indicates ‘‘dead’’ and 1 indicates ‘‘full health’’ [16, 17]. Committee of the Medical Faculty, Gothenburg University, Negative values are possible and represent conditions 17 June 2003 (S 270–03). worse than dead. In Sweden, the instrument has been validated on extensive cohorts of back pain patients and of ages similar to those expected in the present study Results [11]. Study population Spinal radiographs A total of 341 patients were invited to participate in the Lateral and frontal view radiographs of the spine were study. A total of 67 of those actively refused to participate taken at the first visit to the hospital’s emergency unit, due to old age and/or co-morbidities as the main reasons. A when there was a suspicion of an acute vertebral body total of 122 patients did not respond to the invitation, thus fracture as the cause of the back pain. The presence of an were excluded. Five patients had died within the weeks acute fracture was primarily decided by the attending after the fracture episode. A total of 147 patients accepted radiologist. For the purpose of the study, two experienced to participate. Among the 147 patients, 110 answered the spine surgeons separately re-evaluated the radiographs. questionnaires at all four of the follow-ups; 29 patients did The acute vertebral body fracture was determined based not answer the 1 year follow-up questionnaires in spite of on: (1) the existence of a fracture deformation compared three reminders, and 8 patients died during the 1 year 123 Eur Spine J (2008) 17:1380–1390 1383 follow-up. Three of 110 patients underwent vertebroplasty Fracture location during the follow-up period and were excluded. The final analysis included 107 patients followed for 1 year. The acute fractures diagnosed in this study were located Due to internal missing data in the response to von between Th6 and L4, and were most frequent at the tho- racolumbar junction (Fig. 1). Korff’s disability score, six patients had to be excluded from the analysis of this particular instrument. Pain, disability, ADL and Quality of life The average age for those refraining from participation, irrespective of reason, was 81.1 years (SD 13.2) which was The main outcome measures at 3 weeks, and 3, 6 and older (P \ 0.05) than for those included in the study. There was no difference between the proportion of women and 12 months after the osteoporotic vertebral fracture are men in the two groups (P [ 0.05). shown in Table 2 and Fig. 2. Patient characteristics von Korff pain intensity score The characteristics of the patients included in this study As can be seen in Fig. 2, the average pain intensity reduced during the first 3 months to just above 60 (P \ 0.001) and are presented in Table 1. There was no age difference between men and women (P [ 0.05). There was no dif- remained at this rather high level even at the 1-year follow- up (P [ 0.05). Through the follow-up, the women consis- ference at any time during the follow-up in any of the outcome measures between those with a known trauma tently reported more pain than the men, although the differences were statistically significant only at 3 months. causing the fracture (fall, lift, undefined trauma or traffic accident) and those without such a trauma or between the When the initial pain intensity for each individual was patients that after the fracture waited differently long grouped into quartiles, 50 patients (46.7%) belonged to the before they visited the emergency unit. Better ADL and fourth quartile with a pain intensity between 75 and 100, 54 higher QoL after one year was found among the patients patients (50.5%) belonged to the second and third quartiles immediately returning home than among those hospital- and only 3 patients (2.8%) to the lowest quartile with a pain ized (P \ 0.05). intensity less than 25 (Fig. 3). The biggest shift in pain Table 1 Baseline Patient characteristic characteristics of the patients included in this study Total population 107 Age, mean ± SD (range) 75.5 ± 11.9 (42–96) Gender Female (%), age mean ± SD (range) 72 (67.3), 75.3 ± 12.3 (42–96) Male (%), age mean ± SD (range) 35 (32.7), 76.1 ± 11.2 (43–92) Cause of trauma A level fall (%) 62 (57.9) Lift of a heavy object (%) 2 (1.9) Unidentified trauma (%) 2 (1.9) Traffic accident (%) 4 (3.7) No recollection of trauma (%) 37 (34.6) Time elapsed before visiting the emergency unit Within the first week (%) 72 (67.3) Within 1 month (%) 16 (14.9) Unidentified (%) 19 (17.8) Post fracture status Immediate return home (%) 82 (76.6) Hospitalized (%) 23 (21.5) Nursing home (%) 2 (1.9) Days in hospital, mean ± SD (range) 16.7 ± 8.1 (3–35) Brace prescription (%) 12 (11.2) 123 1384 Eur Spine J (2008) 17:1380–1390 Fig. 1 The location of the New fracture location distribution fracture in the 107 patients N=1 N=1007 7 30% 30% 28% 28% 32 32 32 30 30 30 11 11 11 9 9 9 5 5 5 5 5 5 4 4 4 3 3 3 3 3 3 3 3 3 2 2 2 Th6 Th7 Th8 Th9 Th10 Th11 Th12 L1 L2 L3 L4 Fracture location Table 2 The results of the four questionnaires at the follow-ups (3 weeks, 3, 6 and 12 months) 3 weeks 3 months 6 months 12 months Mean SD Mean SD (P) Mean SD (P) Mean SD (P) von Korff pain intensity score 70.9 19.3 61.5 21.4 (0.000) 60.7 21.6 (0.000) 60.5 23.0 (0.000) von Korff disability score 68.9 23.6 56.4 25.5 (0.000) 51.0 27.5 (0.000) 53.9 27.8 (0.000) Hannover ADL score 37.7 22.1 48.0 25.0 (0.000) 45.8 26.3 (0.000) 47.6 26.4 (0.000) EQ-5D 0.37 0.37 0.52 0.35 (0.000) 0.54 0.36 (0.000) 0.52 0.38 (0.000) P values are given for differences between 3, 6 and 12 months and baseline (3 weeks) intensity between the acute state and the 3-month follow- EQ-5D up was among those in the highest quartile (worst pain). After 12 months, less than 10% of the patients had a pain Initially, average quality of life, as measured using EQ- 5D, for all patients was 0.37 (SD 0.37). In comparison to intensity below 25, while 81 patients (75.7%) still experi- enced a pain intensity over 50. this initial value, improvement was shown at all three subsequent follow-ups (P \ 0.000). Even if improved the von Korff disability score EQ-5D remained low after 3 months with an average value of 0.52 (SD 0.38) at the 1-year follow-up. The Disability like pain intensity showed the largest improve- gender-differentiated quality of life paralleled each other ment between 3 weeks and 3 months but unlike pain to a great extent, but with a statistically significant higher intensity the disability score continued to improve until value for the men only after 3 months (P \ 0.041). Except 6 months (P \ 0.021) (Fig. 2). among those younger than 70 years of age, the EQ-5D values tended to deteriorate at the 6 and 12 months fol- Hannover ADL score low-ups. When EQ-5D was divided into five dimensions Hannover ADL score improved with more than ten units (mobility, self-care, usual activity, pain/discomfort, and anxiety/depression) and analyze the percentage of the between the first and second follow-ups (P \ 0.000). Except for the 6-month follow-up the men reported sta- patients who had moderate or severe problem, the pain/ discomfort was the most dominant deteriorated dimension tistically significant better ADL than the women (P \ 0.05). (Fig. 4). Number of patients M e a a n f f o r E Q - 5 5 D Eur Spine J (2008) 17:1380–1390 1385 The results of the four questionnaires Discussion The problems accompanying a vertebral body fracture are 7 70.9 0.9 generally regarded as self-limiting within weeks or a few 70 0.70 6 68.9 8.9 months and as having a good prognosis, at least for the majority of the fractured [47, 52]. The results of the present study revealed a contrasting view. By following individual 61 61.5 .5 60 60.7 .7 6 60.5 0.5 patients from the fracture occurrence and up to 1 year, it 60 0.60 was found that this fracture was the starting point of a long- 56 56.4 .4 lasting painful and disabling health condition that strongly 0.5 0.54. 4. 5 53.9 3.9 0. 0.52 52 reduced the patient’s health-related quality of life. Since 0 0.52 .52 51 51.0 .0 the large majority of the cohort members received nothing 50 0.50 48 48.0 .0 4 47.6 7.6 but symptomatic pain medication, general mobilization, 45 45.8 .8 and activity recommendations, it is reasonable to assume that the current findings closely represent the natural course 40 0.40 of an acute vertebral body fracture. 0 0..37 37 37 37.4 .4 Pain 3 weeks 3 months 6 months 12 months The initial pain intensity recorded 2–3 weeks after the Time occurrence of the fracture was lowered during the first von Korff pain intensity score Hannover ADL score 3 months, but remained on a high level for the rest of von Korff disability score EQ-5D the 1-year follow-up. The initial average pain intensity, as measured with von Korff’s pain intensity score was Fig. 2 The average pain intensity, disability, ADL, and QoL acutely high and reflected to some extent the initial fracture pain and after 3, 6 and 12 months for all participants (70.9, SD 19.3). The pain intensity after 6 months and 1 year remained at a high level. It was of the same von Korff pain intensity score distribution magnitude as the average pain intensity in a Swedish cohort of men and women who were fully work disabled for more than 3 months due to back [32]. Although not directly transferable, the pain intensity after a whole year in the fractured patients (average 60.5) was just as severe as the preoperative pain in the patients included in the Swedish National Spine Register subsequently undergo- ing surgery for lumbar disc herniation (VAS: back 45, leg 64) or central spinal stenosis (VAS: back 55, leg 61) [54]. It has been argued that 84% of clinically diagnosed 56 56 fractures are associated with pain and that around half of 51 51 50 50 48 48 49 49 those with a radiologically identified fracture have any symptoms [50, 52]. The present study showed that more 31 31 than 97% reported a pain intensity of a severity that 30 30 28 28 usually is regarded as clinically significant (Fig. 3). Since 19 19 pain most likely was the main reason for visiting the 15 15 15 15 11 11 emergency unit, it is likely that all the patients experi- 8 8 8 8 6 6 enced acute pain in direct relation to the fracture and 3 3 probably also more pain than what was reported in the 0-25 25-50 50-75 75-100 Quartiles of von Korff pain intensity score first questionnaire administered 2–3 weeks after the occurrence of the fracture. After 1 year, only around Time 10% reported no or very little pain while almost 76% 3 weeks 6 months still had pain intensity regarded as severe (Fig. 3). From 3 months 12 months a pain aspect, the current results revealed a situation much worse and more frequent than indicated before Fig. 3 The patient’s pain intensity distributed into quartiles at the four follow-ups [50]. N u m b e r o f p a t i i e n t s M e a n f o r r p a i n , , d i i s a b i i l l i t t y , , A D L 1386 Eur Spine J (2008) 17:1380–1390 Fig. 4 The frequency of those EQ-5D separated into five dimensions reporting moderate or severe Mobility problems in the five dimensions 97 97 Self-Care of EQ-5D at the four follow-ups Usual Activities 89 89 89 89 87 87 Pain / Discomfort 82 82 Anxiety / Depression 73 73 69 69 69 69 68 68 61 61 60 57 57 55 55 54 54 52 52 53 53 50 50 22 22 15 15 14 14 12 12 3 weeks 3 months 6 months 12 months Time In the US one-third of all the annually estimated that the odds of impaired ADL (defined as problems with 700,000 osteoporotic vertebral body compression fractures C3 physical or instrumental ADLs) were 2.3 times higher are believed to develop chronic pain [47]. The findings in among those with an earlier clinically diagnosed vertebral the present study suggest that more than  acquire severe fracture [18]. It has also been found that impairment of pain, lasting at least 1 year after this type of fracture. This ADL does not have to be related to the presence of pain, finding is corroborated by another Swedish study where it particularly not in patients with two or more prevalent was noted that in more than 70% of the women, the fractures [36]. occurrence of a vertebral body fracture was the beginning of a painful condition that could last at least up to 22 years EQ-5D [34]. The initial QoL, measured with EQ-5D, was quite low and Disability and ADL similar or worse than what has been noted for long-lasting disabling low back and neck pain and comparable to the The patient’s disability rating pattern was quite similar to preoperative levels for both a lumbar herniated disc and that for pain. In comparison to age-matched patients with central spinal stenosis [32, 35, 54]. In a wider context than non-osteoporotic chronic low back pain, it was found that problems of the spine, the 3, 6 and 12-month EQ-5D the disability was greater among those with a vertebral values among the fractured patients found in the present fracture [38]. In the present study, considerably lower study were similar or lower than the values found preop- values (worse) for disability and ADL were noted at all eratively in patients with hip and knee osteoarthritis, follow-ups in comparison to large cohorts of patients from undergoing subsequent total joint replacement [31]. In six different countries with disabling low back pain [32]. comparison to the average EQ-5D value of 0.52 reported When the impairment after a vertebral fracture was ana- 1 year after the fracture in the present cohort, the corre- lyzed in 1,010 women 6 years after the fracture, it was sponding values in hip fracture patients 1 year after total found that those with a previous fracture had up to seven hip replacement surgery was 0.73 and after internal fixa- times greater odds of reporting difficulties with a variety of tion surgery was 0.63 [7]. The EQ-5D values in the activities than those without [28]. Similarly, it was noted population of the city of Stockholm for the age groups T h e n u m b e r o f patients reporting m o d e r a t e o r s e v e r e p r o b l e m s ( % ) Eur Spine J (2008) 17:1380–1390 1387 represented in this study have been found to be just above Since an acute fracture in the present study was deter- 0.80 [11]. mined through clinical signs and plain X-rays, it is a risk The worsening trend between 6 and 12 months was that some fractures interpreted as acute might rather have noticeable not only in the quality of life recordings, but been relatively old. also for pain and disability as well, and seemed to Another explanation for the presence of relatively old emphasize the profound negative and lasting effect of this ‘‘new’’ fractures was the fact that almost 17.8% of the fracture [46]. In another Swedish cohort study, it was noted patients in the study had their fracture diagnosed 1 month that all of the SF-36 dimensions were significantly lowered, or more after the fracture occurred (Table 1). even 2 years after a vertebral body fracture, which was Since, in most cases, only one X-ray examination was worse than after a hip fracture [30]. evaluated it is possible that new fractures during the study year could have contributed to the problems during the Treatment post-fracture year. The findings in the present study revealed that the treat- Lack of controls and old age ment strategy which recommended as normal and early physical activity as possible seemed to have quite ques- Only the post-fracture situation is known. For this reason tionable positive effects. Presently we do not know whether it is possible that some of the patients due to strict or partial immobilization of the fractured spine is a co-morbidity, for example, had an already deteriorated more adequate treatment or not. In two Japanese studies, it health-related quality of life subsequently made worse has been suggested that in order to prevent collapse, by the new fracture. The study did not include any deformity and lasting pain, the acute fracture must be controls without a spinal fracture. That is to some diagnosed early and treated with a rigid external fixation, extent compensated by the fact that the scores used e.g. e.g. a hard brace or a body cast [21, 58]. At the same time, EQ-5D and Hannover ADL have age stratified popula- it is well understood that there is a need for early mobili- tion data. zation since bed rest and inactivity more or less The most important reason for the high number of non inescapably will lead to muscle waste and rapid bone responders was old age. Since this fracture type especially mineral loss from the already fragile vertebrae [27, 33]. involves older patients, this apparent weakness of the study The unsatisfactory long-term prognosis for the great is hard to overcome. majority of patients with a vertebral fracture suggest that the reportedly successful pain-relieving interventions like vertebro- and kyphoplasty can possibly be employed on a Conclusions much wider scale. Hitherto, the vertebral fragility fracture generally has been Limitations regarded as a condition with self-limiting problems and as having a relatively positive prognosis. This study revealed, Accuracy of X-ray assessment on the contrary that the vertebral fragility fracture has a severe impact on pain, disability, ADL, and QoL and that The assessment of prevalent or incident vertebral fractures the fracture is the beginning of a deterioration of the from spinal radiographs is sometimes quite difficult. In patients health lasting at least for a year. cases with minimal fracture deformation, there is frequent disagreement about whether a fracture is present or not. Acknowledgments The study was supported by grants from The Some of the difficulties are the result of the variations in Swedish Council for Working Life and Social Research, AFA Insurance, Sahlgrenska academy at Gothenburg University. The study shape from one vertebra to another and also between was made possible through the cooperation with the Department of individuals. To distinguish whether a fracture is incident or Orthopaedic Surgery, Nagoya City University, Nagoya Japan and its prevalent can be even more complicated, especially for chairman professor Takanobu Otsuka. patients with severe osteoporosis and multiple compression Open Access This article is distributed under the terms of the fractures. Some patients who present with back pain of Creative Commons Attribution Noncommercial License which sudden onset are erroneously diagnosed as having acute permits any noncommercial use, distribution, and reproduction in vertebral fractures when in fact the deformity has been any medium, provided the original author(s) and source are present on earlier films [50]. credited. 123 1388 Eur Spine J (2008) 17:1380–1390 Appendix 1: von Korff pain intensity and disability score von Korff pain intensity and disability score Pain intensity items (1) How would you rate your pain right now? [Current pain] No pain Pain as bad could be 012 34 567 89 10 (2) After the fracture-how intense was your worst pain? [Worst Pain] No pain Pain as bad could be 012 34 567 8 9 10 (3) After the fracture-how intense was your pain at an average? (That is, your usual pain at times you were experiencing pain.) [Average Pain] No pain Pain as bad could be 012 34 567 8 9 10 Disability items (4) After the fracture, how much has the pain interfered with your daily activities? [Daily Activities] No interference Unable to carry on any activities 012 34 567 89 10 (5) After the fracture, how much has the pain changed your ability to take part in recreational, social and family activities? [Social Activities] No change Extreme change 012 34 567 8 9 10 (6) After the fracture, how much has the pain changed your ability to work (including housework)? [Work Activities] No change Extreme change 012 34 567 8 9 10 von Korff pain intensity score = (((response question 1) + (response question 2) + (response question 3)) / 3) * 10 von Korff disability score = (((response question 4) + (response question 5) + (response question 6)) / 3) * 10 Appendix 2: Hannover ADL score 6. Can you sit for one hour on a hard chair? 7. Can you stand continuously for 30 min (for example in 1. Can you reach up and get, for example, a book from a a queue)? high shelf or cupboard? 8. Can you raise yourself in bed from a lying position? 2. Can you lift a full suitcase and carry it for 10 m? 9. Can you put on and take off socks or similar garments? 3. Can you wash and dry yourself from head to toe? 10. Can you bend sideways from a seated position to pick 4. Can you bend forward to pick up a small lightweight up a small object on the floor just beside your chair? object from the floor? 5. Can you wash your hair over a washbasin? 11. Can you lift a box (about 8 kg) onto a table? 123 Eur Spine J (2008) 17:1380–1390 1389 13. Cockerill W, Lunt M, Silman AJ, Cooper C, Lips P, Bhalla AK 12. Can you run 100 m fast without stopping in order to et al (2004) Health-related quality of life and radiographic ver- catch a bus? tebral fracture. Osteoporos Int 15:113–119. doi:10.1007/ s00198-003-1547-4 Those questions were answered by following score. 14. Cooper C, Atkinson EJ, O’Fallon WM, Melton LJ 3rd (1992) Incidence of clinically diagnosed vertebral fractures: a popula- 0. Either unable to do or able only with help. tion-based study in Rochester, Minnesota, 1985–1989. J Bone 1. Yes, but with some difficulties. Miner Res 7:221–227 2. Yes, without difficulties. 15. Crans GG, Silverman SL, Genant HK, Glass EV, Krege JH (2004) Association of severe vertebral fractures with reduced Hannover ADL score = (total score)/(2 9 (number of quality of life: reduction in the incidence of severe vertebral valid answers)) 9 100. fractures by teriparatide. Arthritis Rheum 50:4028–4034. doi: 10.1002/art.20671 16. Dolan P, Gudex C, Kind P, Williams A (1996) The time trade-off References method: results from a general population study. Health Econ 5:141–154. doi:10.1002/(SICI)1099-1050(199603)5:2\141:: 1. Adachi JD, Ioannidis G, Olszynski WP, Brown JP, Hanley DA, AID-HEC189[3.0.CO;2-N[pii] Sebaldt RJ et al (2002) The impact of incident vertebral and non- 17. Dolan P, Gudex C, Kind P, Williams A (1996) Valuing health vertebral fractures on health related quality of life in postmeno- states: a comparison of methods. J Health Econ 15:209–231. doi: pausal women. BMC Musculoskelet Disord 3:11. doi:10.1186/ 0167-6296(95)00038-0[pii] 1471-2474-3-11 18. Ensrud KE, Nevitt MC, Yunis C, Cauley JA, Seeley DG, Fox KM 2. Adachi JD, Ioannidis G, Pickard L, Berger C, Prior JC, Joseph et al (1994) Correlates of impaired function in older women. L et al (2003) The association between osteoporotic fractures J Am Geriatr Soc 42:481–489 and health-related quality of life as measured by the Health 19. Ettinger B, Black DM, Nevitt MC, Rundle AC, Cauley JA, Utilities Index in the Canadian Multicentre Osteoporosis Study Cummings SR et al (1992) Contribution of vertebral deformities (CaMos). Osteoporos Int 14:895–904. doi:10.1007/s00198-003- to chronic back pain and disability. The Study of Osteoporotic 1483-3 Fractures Research Group. J Bone Miner Res 7:449–456 3. Alekna V, Tamulaitiene M, Butenaite V (2006) The impact of 20. Fechtenbaum J, Cropet C, Kolta S, Horlait S, Orcel P, Roux C subclinical vertebral fractures on health-related quality of life in (2005) The severity of vertebral fractures and health-related women with osteoporosis. Medicina (Kaunas) 42:744–750 quality of life in osteoporotic postmenopausal women. Osteopo- 4. Begerow B, Pfeifer M, Pospeschill M, Scholz M, Schlotthauer T, ros Int 16:2175–2179. doi:10.1007/s00198-005-2023-0 Lazarescu A et al (1999) Time since vertebral fracture: an 21. Fukuda F (2006) Importance of early diagnosis and early treat- important variable concerning quality of life in patients with ment for the conservative treatment of vertebral compression postmenopausal osteoporosis. Osteoporos Int 10:26–33. doi: fracture in elderly people (Japanese). Mon Book Orthop 19:153– 10.1007/s001980050190 159 5. Bengner U, Johnell O, Redlund-Johnell I (1988) Changes in 22. Gallacher SJ, Gallagher AP, McQuillian C, Mitchell PJ, Dixon T incidence and prevalence of vertebral fractures during 30 years. (2007) The prevalence of vertebral fracture amongst patients Calcif Tissue Int 42:293–296. doi:10.1007/BF02556362 presenting with non-vertebral fractures. Osteoporos Int 18:185– 6. Bengner U, Johnell O, Redlund-Johnell I (1988) Changes in the 192. doi:10.1007/s00198-006-0211-1 incidence of fracture of the upper end of the humerus during a 30- 23. Genant HK, Jergas M (2003) Assessment of prevalent and inci- year period. A study of 2125 fractures. Clin Orthop Relat Res dent vertebral fractures in osteoporosis research. Osteoporos Int 231:179–182 14(Suppl 3):S43–S55. doi:10.1007/s00198-002-1348-1,10.1007/ 7. Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J s00198-003-1472-6 (2005) Comparison of internal fixation with total hip replacement 24. Genant HK, Jergas M, Palermo L, Nevitt M, Valentin RS, Black for displaced femoral neck fractures. Randomized, controlled D et al (1996) Comparison of semiquantitative visual and quan- trial performed at four years. J Bone Joint Surg Am 87:1680– titative morphometric assessment of prevalent and incident 1688. doi:87/8/1680[pii]10.2106/JBJS.D.02655 vertebral fractures in osteoporosis. The Study of Osteoporotic 8. Borgstrom F, Zethraeus N, Johnell O, Lidgren L, Ponzer S, Fractures Research Group. J Bone Miner Res 11:984–996 Svensson O et al (2006) Costs and quality of life associated with 25. Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral osteoporosis-related fractures in Sweden. Osteoporos Int 17:637– fracture assessment using a semiquantitative technique. J Bone 650. doi:10.1007/s00198-005-0015-8 Miner Res 8:1137–1148 9. Brenneman SK, Barrett-Connor E, Sajjan S, Markson LE, Siris 26. Gennari C, Agnusdei D, Camporeale A (1991) Use of calcitonin ES (2006) Impact of recent fracture on health-related quality of in the treatment of bone pain associated with osteoporosis. Calcif life in postmenopausal women. J Bone Miner Res 21:809–816. Tissue Int 49(Suppl 2):S9–S13. doi:10.1007/BF02561370 doi:10.1359/jbmr.060301 27. Gold DT (1996) The clinical impact of vertebral fractures: quality 10. Burger H, Van Daele PL, Grashuis K, Hofman A, Grobbee DE, of life in women with osteoporosis. Bone 18:185S–189S. doi: Schutte HE et al (1997) Vertebral deformities and functional 10.1016/8756-3282(95)00500-5 impairment in men and women. J Bone Miner Res 12:152–157. 28. Greendale GA, Barrett-Connor E, Ingles S, Haile R (1995) Late doi:10.1359/jbmr.1997.12.1.152 physical and functional effects of osteoporotic fracture in women: 11. Burstrom K, Johannesson M, Rehnberg C (2007) Deteriorating the Rancho Bernardo Study. J Am Geriatr Soc 43:955–961 health status in Stockholm 1998–2002: results from repeated 29. Hall SE, Criddle RA, Comito TL, Prince RL (1999) A case- population surveys using the EQ-5D. Qual Life Res 16:1547– control study of quality of life and functional impairment 1553. doi:10.1007/s11136-007-9243-z in women with long-standing vertebral osteoporotic fracture. 12. Cauley JA, Hochberg MC, Lui LY, Palermo L, Ensrud KE, Osteoporos Int 9:508–515. doi:10.1007/s001980050178 Hillier TA et al (2007) Long-term risk of incident vertebral 30. Hallberg I, Rosenqvist AM, Kartous L, Lofman O, Wahlstrom O, fractures. JAMA 298:2761–2767. doi:10.1001/jama.298.23.2761 Toss G (2004) Health-related quality of life after osteoporotic 123 1390 Eur Spine J (2008) 17:1380–1390 fractures. Osteoporos Int 15:834–841. doi:10.1007/s00198-004- are predictors of quality of life in patients with postmenopausal 1622-5 osteoporosis. Osteoporos Int 18:1397–1403. doi:10.1007/s00198- 31. Hansson T, Hansson E, Malchau H (2008) The utility of spine 007-0383-3 surgery. A comparison of common elective orthopaedic surgical 45. O’Neill TW, Cockerill W, Matthis C, Raspe HH, Lunt M, Cooper procedures. Accepted in Spine C et al (2004) Back pain, disability, and radiographic vertebral 32. Hansson TH, Hansson EK (2000) The effects of common medical fracture in European women: a prospective study. Osteoporos Int interventions on pain, back function, and work resumption in 15:760–765. doi:10.1007/s00198-004-1615-4 patients with chronic low back pain: a prospective 2-year cohort 46. Oleksik AM, Ewing S, Shen W, van Schoor NM, Lips P (2005) study in six countries. Spine 25:3055–3064. doi:10.1097/ Impact of incident vertebral fractures on health related quality of 00007632-200012010-00013 life (HRQOL) in postmenopausal women with prevalent vertebral 33. Hansson TH, Roos BO, Nachemson A (1975) Development of fractures. Osteoporos Int 16:861–870. doi:10.1007/s00198-004- osteopenia in the fourth lumbar vertebra during prolonged bed 1774-3 rest after operation for scoliosis. Acta Orthop Scand 46:621–630 47. Phillips FM (2003) Minimally invasive treatments of osteoporotic 34. Hasserius R, Karlsson MK, Jonsson B, Redlund-Johnell I, Johnell vertebral compression fractures. Spine 28:S45–S53. doi: O (2005) Long-term morbidity and mortality after a clinically 10.1097/00007632-200308011-00009 diagnosed vertebral fracture in the elderly—a 12- and 22-year 48. Rao RD, Singrakhia MD (2003) Painful osteoporotic vertebral follow-up of 257 patients. Calcif Tissue Int 76:235–242. doi: fracture. Pathogenesis, evaluation, and roles of vertebroplasty and 10.1007/s00223-004-2222-2 kyphoplasty in its management. J Bone Joint Surg Am 85- 35. Jansson KA, Nemeth G, Granath F, Jonsson B, Blomqvist P A:2010–2022 (2005) Health-related quality of life in patients before and after 49. Romagnoli E, Carnevale V, Nofroni I, D’Erasmo E, Paglia F, De surgery for a herniated lumbar disc. J Bone Joint Surg Br 87:959– Geronimo S et al (2004) Quality of life in ambulatory postmen- 964. doi:10.1302/0301-620X.87B7.16240 opausal women: the impact of reduced bone mineral density and 36. Jinbayashi H, Aoyagi K, Ross PD, Ito M, Shindo H, Takemoto T subclinical vertebral fractures. Osteoporos Int 15:975–980. doi: (2002) Prevalence of vertebral deformity and its associations with 10.1007/s00198-004-1633-2 physical impairment among Japanese women: The Hizen-Oshima 50. Ross PD (1997) Clinical consequences of vertebral fractures. Am Study. Osteoporos Int 13:723–730. doi:10.1007/s001980200099 J Med 103:30S–42S. doi:10.1016/S0002-9343(97)90025-5 Dis- 37. Kohlmann T, Raspe H (1996) Hannover Functional Question- cussion 42S–43S naire in ambulatory diagnosis of functional disability caused by 51. Salaffi F, Cimmino MA, Malavolta N, Carotti M, Di Matteo L, backache. Rehabilitation (Stuttg) 35: I–VIII Scendoni P et al (2007) The burden of prevalent fractures on 38. Leidig-Bruckner G, Minne HW, Schlaich C, Wagner G, Scheidt- health-related quality of life in postmenopausal women with Nave C, Bruckner T et al (1997) Clinical grading of spinal osteoporosis: the IMOF study. J Rheumatol 34:1551–1560 osteoporosis: quality of life components and spinal deformity in 52. Silverman SL (1992) The clinical consequences of vertebral women with chronic low back pain and women with vertebral compression fracture. Bone 13(Suppl 2):S27–S31. doi:10.1016/ osteoporosis. J Bone Miner Res 12:663–675. doi:10.1359/jbmr. 8756-3282(92)90193-Z 1997.12.4.663 53. Silverman SL, Minshall ME, Shen W, Harper KD, Xie S (2001) 39. Leidig G, Minne HW, Sauer P, Wuster C, Wuster J, Lojen M et al The relationship of health-related quality of life to prevalent and (1990) A study of complaints and their relation to vertebral incident vertebral fractures in postmenopausal women with destruction in patients with osteoporosis. Bone Miner 8:217–229. osteoporosis: results from the multiple outcomes of Raloxifene doi:10.1016/0169-6009(90)90107-Q Evaluation Study. Arthritis Rheum 44:2611–2619. doi:10.1002/ 40. Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O et al 1529-0131(200111)44:11\2611::AID-ART441[3.0.CO;2-N (1999) Quality of life in patients with vertebral fractures: vali- 54. Stromqvist B, Fritzell P, Hagg O, Jonsson B (2005) One-year dation of the Quality of Life Questionnaire of the European report from the Swedish National Spine Register. Swedish Foundation for Osteoporosis (QUALEFFO). Working Party for Society of Spinal Surgeons. Acta Orthop Suppl 76:1–24. doi: Quality of Life of the European Foundation for Osteoporosis. Q62033144112T105[pii]10.1080/17453690510041950 Osteoporos Int 10:150–160. doi:10.1007/s001980050210 55. Von Korff M, Deyo RA, Cherkin D, Barlow W (1993) Back pain 41. Lyles KW, Gold DT, Shipp KM, Pieper CF, Martinez S, in primary care. Outcomes at 1 year. Spine 18:855–862. Mulhausen PL (1993) Association of osteoporotic vertebral doi:10.1097/00007632-199306000-00008 compression fractures with impaired functional status. Am J Med 56. Von Korff M, Ormel J, Keefe FJ, Dworkin SF (1992) Grading the 94:595–601. doi:10.1016/0002-9343(93)90210-G severity of chronic pain. Pain 50:133–149. doi:10.1016/0304- 42. Lyritis GP, Mayasis B, Tsakalakos N, Lambropoulos A, Gazi S, 3959(92)90154-4 Karachalios T et al (1989) The natural history of the osteoporotic 57. Vujasinovic-Stupar N, Radunovic G, Smailji M (2005) Quality of vertebral fracture. Clin Rheumatol 8(Suppl 2):66–69. doi: life assessment in osteoporotic patients with and without vertebral 10.1007/BF02207237 fractures. Med Pregl 58:453–458. doi:10.2298/MPNS0510453V 43. Melton LJ 3rd, Lane AW, Cooper C, Eastell R, O’Fallon WM, 58. Yoshida T (2002) Cases of osteoporotic spinal fracture devel- Riggs BL (1993) Prevalence and incidence of vertebral defor- oping marked vertebral body pressure deformity. Cent Jpn J mities. Osteoporos Int 3:113–119. doi:10.1007/BF01623271 Orthop Surg Traumatol 45:473–474 44. Miyakoshi N, Hongo M, Maekawa S, Ishikawa Y, Shimada Y, Itoi E (2007) Back extensor strength and lumbar spinal mobility http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Spine Journal Pubmed Central

The course of the acute vertebral body fragility fracture: its effect on pain, disability and quality of life during 12 months

European Spine Journal , Volume 17 (10) – Aug 27, 2008

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Abstract

Eur Spine J (2008) 17:1380–1390 DOI 10.1007/s00586-008-0753-3 O R I G IN AL ARTI CL E The course of the acute vertebral body fragility fracture: its effect on pain, disability and quality of life during 12 months Nobuyuki Suzuki Æ Osamu Ogikubo Æ Tommy Hansson Received: 28 April 2008 / Revised: 24 June 2008 / Accepted: 3 August 2008 / Published online: 27 August 2008 The Author(s) 2008. This article is published with open access at Springerlink.com Abstract The vertebral body fracture is the most frequent mobilized and allowed to return home while the remaining bone fragility fracture. In spite of this there is considerable were hospitalized. The average pain intensity score after uncertainty about the frequency, extent and severity of the 3 weeks was 70.9 (SD 19.3), the disability score 68.9 (SD acute pain and even more about the duration of pain, the 23.6), the ADL score 37.7 (SD 22.1) and EQ-5D score of magnitude of disability and how much daily life is dis- 0.37 (SD 0.37). The largest improvements, 10–15%, turbed in the post-fracture period. The aim of the present occurred between the initial visit and the 3 months follow- study was to follow the course of pain, disability, ADL and up and were quite similar for all the measures. From QoL in patients during the year after an acute low energy 3 months, all the outcome measures leveled out or tended vertebral body fracture. The study design was a longi- to deteriorate resulting in a mean pain intensity score of tudinal cohort study with prospective data collection. All 60.5, disability score of 53.9, ADL score of 47.6, and EQ- the patients over 40 years admitted to the emergency unit 5D score 0.52 after 12 months. After a whole year the because of back pain with a radiologically acute vertebral fractured patients’ condition was similar to the preopera- body fracture were eligible. A total of 107 patients were tive condition of patients with a herniated lumbar disc, followed for a year. The pain, disability (von Korff pain central lumbar spinal stenosis or in patients 100% work and disability scores), ADL (Hannover ADL score), disabled due to back or neck problems. Instead of the and QoL (EQ-5D) were measured after 3 weeks, 3, 6 and generally believed good prognosis for the greater majority 12 months. Two-thirds of the patients were women, and of those fractured, the acute vertebral body fracture was the were similar in average age, as the men around 75 years. beginning of a long-lasting severe deterioration of their A total of 65.4% of the fractures were due to a level fall or health. a minor trauma, whereas 34.6% had no recollection of trauma or a specific event as the cause of the fracture. A Keywords Vertebral body fracture  Osteoporosis total of 76.6% of the fractured patients were immediately Pain  Quality of life  Disability  Compression fracture Introduction N. Suzuki  O. Ogikubo The vertebral body fracture is the most frequent type of Department of Orthopaedic Surgery, osteoporotic fracture [12]. Approximately 30–50% of Nagoya City University Graduate School of Medical Sciences, women and 20–30% of men develop vertebral fractures 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, and half of them develop multiple fractures during their Aichi 467-8601, Japan lifetime, compared with a 15.6% lifetime risk of a hip T. Hansson (&) fracture [50]. The annual incidence rate of a vertebral Department of Orthopaedics, Sahlgrenska Academy, body fracture in women over 50 years of age has been Gothenburg University, Bruna Straket 11, found to be 17.8 in 1,000 person-years [43]. In Sweden, a 413 45 Goteborg, Sweden remarkable increase in incidence and prevalence for this e-mail: tommy.hansson@orthop.gu.se 123 Eur Spine J (2008) 17:1380–1390 1381 type of fracture, especially among those of older age was Materials and methods noted between the 1950s and 1980s [6]. It is well known and frequently reported that the vertebral body fracture All patients over 40 years of age who were admitted to the causes pain, disability and has a negative effect on the emergency unit at Sahlgrenska University Hospital, Goth- patient’s health-related quality of life (QoL) [2, 8–10, 13, enburg, Sweden because of back pain and had a 15, 19, 20, 30, 34, 39, 41, 46, 49, 51, 53]. Both pro- and radiologically acute vertebral fracture which resulted from retrospective data suggest that the deterioration of health a low energy trauma were eligible for the study. Patients after a vertebral fracture can last for many years and with with an acute fracture in an earlier fractured spine were also included. The study was conducted from December sequel that usually are worse than for the other bone fragility fractures [29, 30, 34, 45]. It has also been noted 2003 to November 2006. that many patients, mainly women, with numerous frac- Excluded were those with any other type of acute tures have never come to clinical attention [14, 22]. So- fracture (forearm, hip etc.), fracture/fractures related to called subclinical vertebral fractures have been found to malignancy, infection or any other bone disease, except exert only a moderate effect on the patient’s QoL. Not osteoporosis, that could affect the mechanical integrity of surprisingly, it has likewise been noted that the time since the vertebrae in the lumbar or thoracic spines. The presence the fracture occurred is of importance for the reported or suspicion of more than one acute fracture excluded from QoL, irrespective of age [1, 4, 9]. The most negative the study. influence of subclinical fractures has been reported in the Within 10 days after the visit to the hospital’s emer- domains of pain, general health, and social and physical gency unit, all eligible patients received written functioning [3, 38]. The effect on QoL of the vertebral information about the study and an invitation to participate. fracture was prospectively studied in two Swedish studies. The patients who agreed to participate received a first These studies suggested that this fracture type had a more questionnaire at the latest 3 weeks after the fracture had negative and long-lasting impact on the patient’s QoL than been diagnosed and then after 3, 6 and 12 months. The any other type of osteoporotic fracture, including the hip questionnaires were self explanatory and intended to be fracture [8, 30]. used for postal surveys. The patients returned the filled-in Several different instruments for determining the effect questionnaires which seemed to make later comparisons on the QoL, such as SF-36, SF-12, or EQ-5D, have been unlikely. The questionnaires described below were used in used for patients with vertebral body fractures [2, 3, 8, 9, the study; all of the questionnaires were used at each of the 40, 44, 51, 57]. four follow-up times. In spite of the high incidence and prevalence of this Questionnaires fracture type, surprisingly little is known about its long- term course. Generally it has been believed that the prob- lems related to this type of fracture are self-limiting. The von Korff pain intensity and disability questionnaires pain after an acute vertebral compression fracture for example, has been reported as intense at the fracture site up This instrument is self-administered and was designed and to 4–6 weeks, and turning into chronic pain only in patients validated for use among patients with among others back with multiple compression fractures, height loss, and low pain outside the hospital setting [55, 56]. It includes three bone density [52]. It has also been reported that sponta- pain intensity and four disability items. The three pain neous pain, measured using a visual analog scale, did not items ask the patient to rate the back pain intensity right decrease significantly until day 15, but had decreased by now, the worst pain and the average pain since the start of approximately 40% when measured at day 30 [26]. Others the pain problem where 0 is ‘‘no pain’’ and 10 is ‘‘pain as have found that acute fracture pain decreased by 22% at bad could be’’. The Pain Intensity score is calculated as the day 7, and by 33% at day 14 [42]. average of the three 0–10 ratings multiplied by 10 to yield There is considerable uncertainty about the frequency, a 0–100 score. Three of the disability items also have a extent and severity of the acute pain and even more 10-graded response possibility. One item is about the about the duration of pain, the magnitude of disability interference of the back pain on the daily activities ranging and how much daily life is disturbed in the post-fracture between 0, ‘‘no interference’’ and 10, ‘‘unable to carry on period. any activities’’ and two are about how the back pain has Although several studies have evaluated large samples changed the ability to take part in family, social or recre- of patients with non acute vertebral fractures, the aim of the ational activities, or the ability to work (including household) both ranging between 0, ‘‘no change’’ and 10, present study was to prospectively evaluate the course over 12 months of non-surgically treated acute vertebral com- ‘‘extreme change’’. The fourth disability question asks pression fractures on pain, disability, ADL, and QoL. about the number of days the subject, due to the pain, has 123 1382 Eur Spine J (2008) 17:1380–1390 been kept from the usual activities during the last with the normal neighboring vertebrae, (2) pain at or near 6 months. This fourth question is not used in this study. the fracture deformation, (3) an evident sharp edge in the The Disability score is calculated as the average of three 0– deformed region [5] and (4) no callus formation at the 10 interference ratings in daily, social and work activities fractured vertebra [5]. The type of fracture was determined multiplied by 10 to yield a 0–100 score [55, 56]. The scores as wedge, concave, or crush [48] and the grade of fracture have been used in several international and Swedish studies was assessed according to the emiquantitative method by of long-term back pain [32] (see Appendix). Genant et al. [23–25]. In questionable cases, previous or subsequent imaging examinations e.g. MR were used to Hannover ADL score confirm or reject the presence of the acute fracture. In cases of divergent opinions, the cases were discussed and con- This questionnaire is also self-administered and consists of sensus reached. 12 items. It assesses functional limitations in activities of daily living (ADL) among patients with musculoskeletal Preventive treatment disorders. Item examples are; ‘‘Can you wash and dry yourself from head to toe?’’ and ‘‘Can you raise yourself A total of 14 of the 107 patients reported that they had from a lying position?’’ The response alternatives are three taken medication during the year prior to the actual fracture (circle one); 1. Either unable to do or able only with help to increase their bone mineral. (score = 0), 2. Yes, but with some difficulties (score = 1), or 3. Yes, without difficulties (score = 2). The 12 items are Statistical analysis scored, summed and transformed on to a scale from 0 (worst back function) to 100 (best back function [37]. The The SPSS statistical software program was used for ana- questionnaire has been used in several international and lyzing the data. Swedish studies of long-term back pain [32] (see Parametric tests, independent or paired t tests were used Appendix). for parametric scale variables. Differences between groups were analyzed with parametric methods. Nominal variables EQ-5D were tested using the Chi-square test. For comparison of repeated measurements, repeated ANOVA was used. If the This is a generic health-related quality of life measure. It repeated ANOVA was significant, the Bonferroni/Dunn provides a single index. The individuals classify their own procedure was used as a post hoc test. All tests were two- health status into five dimensions: mobility, self-care, sided. The results were considered to be significant at P \ 0.05. usual activity, pain/discomfort and anxiety/depression within three levels (i.e. no problems, moderate problems and severe problems). The instrument yields a total of 243 Ethical approval possible health states, and the Time Trade Off method is used to rate the different states of health. The value 0 The study was ethically approved by the Research Ethical indicates ‘‘dead’’ and 1 indicates ‘‘full health’’ [16, 17]. Committee of the Medical Faculty, Gothenburg University, Negative values are possible and represent conditions 17 June 2003 (S 270–03). worse than dead. In Sweden, the instrument has been validated on extensive cohorts of back pain patients and of ages similar to those expected in the present study Results [11]. Study population Spinal radiographs A total of 341 patients were invited to participate in the Lateral and frontal view radiographs of the spine were study. A total of 67 of those actively refused to participate taken at the first visit to the hospital’s emergency unit, due to old age and/or co-morbidities as the main reasons. A when there was a suspicion of an acute vertebral body total of 122 patients did not respond to the invitation, thus fracture as the cause of the back pain. The presence of an were excluded. Five patients had died within the weeks acute fracture was primarily decided by the attending after the fracture episode. A total of 147 patients accepted radiologist. For the purpose of the study, two experienced to participate. Among the 147 patients, 110 answered the spine surgeons separately re-evaluated the radiographs. questionnaires at all four of the follow-ups; 29 patients did The acute vertebral body fracture was determined based not answer the 1 year follow-up questionnaires in spite of on: (1) the existence of a fracture deformation compared three reminders, and 8 patients died during the 1 year 123 Eur Spine J (2008) 17:1380–1390 1383 follow-up. Three of 110 patients underwent vertebroplasty Fracture location during the follow-up period and were excluded. The final analysis included 107 patients followed for 1 year. The acute fractures diagnosed in this study were located Due to internal missing data in the response to von between Th6 and L4, and were most frequent at the tho- racolumbar junction (Fig. 1). Korff’s disability score, six patients had to be excluded from the analysis of this particular instrument. Pain, disability, ADL and Quality of life The average age for those refraining from participation, irrespective of reason, was 81.1 years (SD 13.2) which was The main outcome measures at 3 weeks, and 3, 6 and older (P \ 0.05) than for those included in the study. There was no difference between the proportion of women and 12 months after the osteoporotic vertebral fracture are men in the two groups (P [ 0.05). shown in Table 2 and Fig. 2. Patient characteristics von Korff pain intensity score The characteristics of the patients included in this study As can be seen in Fig. 2, the average pain intensity reduced during the first 3 months to just above 60 (P \ 0.001) and are presented in Table 1. There was no age difference between men and women (P [ 0.05). There was no dif- remained at this rather high level even at the 1-year follow- up (P [ 0.05). Through the follow-up, the women consis- ference at any time during the follow-up in any of the outcome measures between those with a known trauma tently reported more pain than the men, although the differences were statistically significant only at 3 months. causing the fracture (fall, lift, undefined trauma or traffic accident) and those without such a trauma or between the When the initial pain intensity for each individual was patients that after the fracture waited differently long grouped into quartiles, 50 patients (46.7%) belonged to the before they visited the emergency unit. Better ADL and fourth quartile with a pain intensity between 75 and 100, 54 higher QoL after one year was found among the patients patients (50.5%) belonged to the second and third quartiles immediately returning home than among those hospital- and only 3 patients (2.8%) to the lowest quartile with a pain ized (P \ 0.05). intensity less than 25 (Fig. 3). The biggest shift in pain Table 1 Baseline Patient characteristic characteristics of the patients included in this study Total population 107 Age, mean ± SD (range) 75.5 ± 11.9 (42–96) Gender Female (%), age mean ± SD (range) 72 (67.3), 75.3 ± 12.3 (42–96) Male (%), age mean ± SD (range) 35 (32.7), 76.1 ± 11.2 (43–92) Cause of trauma A level fall (%) 62 (57.9) Lift of a heavy object (%) 2 (1.9) Unidentified trauma (%) 2 (1.9) Traffic accident (%) 4 (3.7) No recollection of trauma (%) 37 (34.6) Time elapsed before visiting the emergency unit Within the first week (%) 72 (67.3) Within 1 month (%) 16 (14.9) Unidentified (%) 19 (17.8) Post fracture status Immediate return home (%) 82 (76.6) Hospitalized (%) 23 (21.5) Nursing home (%) 2 (1.9) Days in hospital, mean ± SD (range) 16.7 ± 8.1 (3–35) Brace prescription (%) 12 (11.2) 123 1384 Eur Spine J (2008) 17:1380–1390 Fig. 1 The location of the New fracture location distribution fracture in the 107 patients N=1 N=1007 7 30% 30% 28% 28% 32 32 32 30 30 30 11 11 11 9 9 9 5 5 5 5 5 5 4 4 4 3 3 3 3 3 3 3 3 3 2 2 2 Th6 Th7 Th8 Th9 Th10 Th11 Th12 L1 L2 L3 L4 Fracture location Table 2 The results of the four questionnaires at the follow-ups (3 weeks, 3, 6 and 12 months) 3 weeks 3 months 6 months 12 months Mean SD Mean SD (P) Mean SD (P) Mean SD (P) von Korff pain intensity score 70.9 19.3 61.5 21.4 (0.000) 60.7 21.6 (0.000) 60.5 23.0 (0.000) von Korff disability score 68.9 23.6 56.4 25.5 (0.000) 51.0 27.5 (0.000) 53.9 27.8 (0.000) Hannover ADL score 37.7 22.1 48.0 25.0 (0.000) 45.8 26.3 (0.000) 47.6 26.4 (0.000) EQ-5D 0.37 0.37 0.52 0.35 (0.000) 0.54 0.36 (0.000) 0.52 0.38 (0.000) P values are given for differences between 3, 6 and 12 months and baseline (3 weeks) intensity between the acute state and the 3-month follow- EQ-5D up was among those in the highest quartile (worst pain). After 12 months, less than 10% of the patients had a pain Initially, average quality of life, as measured using EQ- 5D, for all patients was 0.37 (SD 0.37). In comparison to intensity below 25, while 81 patients (75.7%) still experi- enced a pain intensity over 50. this initial value, improvement was shown at all three subsequent follow-ups (P \ 0.000). Even if improved the von Korff disability score EQ-5D remained low after 3 months with an average value of 0.52 (SD 0.38) at the 1-year follow-up. The Disability like pain intensity showed the largest improve- gender-differentiated quality of life paralleled each other ment between 3 weeks and 3 months but unlike pain to a great extent, but with a statistically significant higher intensity the disability score continued to improve until value for the men only after 3 months (P \ 0.041). Except 6 months (P \ 0.021) (Fig. 2). among those younger than 70 years of age, the EQ-5D values tended to deteriorate at the 6 and 12 months fol- Hannover ADL score low-ups. When EQ-5D was divided into five dimensions Hannover ADL score improved with more than ten units (mobility, self-care, usual activity, pain/discomfort, and anxiety/depression) and analyze the percentage of the between the first and second follow-ups (P \ 0.000). Except for the 6-month follow-up the men reported sta- patients who had moderate or severe problem, the pain/ discomfort was the most dominant deteriorated dimension tistically significant better ADL than the women (P \ 0.05). (Fig. 4). Number of patients M e a a n f f o r E Q - 5 5 D Eur Spine J (2008) 17:1380–1390 1385 The results of the four questionnaires Discussion The problems accompanying a vertebral body fracture are 7 70.9 0.9 generally regarded as self-limiting within weeks or a few 70 0.70 6 68.9 8.9 months and as having a good prognosis, at least for the majority of the fractured [47, 52]. The results of the present study revealed a contrasting view. By following individual 61 61.5 .5 60 60.7 .7 6 60.5 0.5 patients from the fracture occurrence and up to 1 year, it 60 0.60 was found that this fracture was the starting point of a long- 56 56.4 .4 lasting painful and disabling health condition that strongly 0.5 0.54. 4. 5 53.9 3.9 0. 0.52 52 reduced the patient’s health-related quality of life. Since 0 0.52 .52 51 51.0 .0 the large majority of the cohort members received nothing 50 0.50 48 48.0 .0 4 47.6 7.6 but symptomatic pain medication, general mobilization, 45 45.8 .8 and activity recommendations, it is reasonable to assume that the current findings closely represent the natural course 40 0.40 of an acute vertebral body fracture. 0 0..37 37 37 37.4 .4 Pain 3 weeks 3 months 6 months 12 months The initial pain intensity recorded 2–3 weeks after the Time occurrence of the fracture was lowered during the first von Korff pain intensity score Hannover ADL score 3 months, but remained on a high level for the rest of von Korff disability score EQ-5D the 1-year follow-up. The initial average pain intensity, as measured with von Korff’s pain intensity score was Fig. 2 The average pain intensity, disability, ADL, and QoL acutely high and reflected to some extent the initial fracture pain and after 3, 6 and 12 months for all participants (70.9, SD 19.3). The pain intensity after 6 months and 1 year remained at a high level. It was of the same von Korff pain intensity score distribution magnitude as the average pain intensity in a Swedish cohort of men and women who were fully work disabled for more than 3 months due to back [32]. Although not directly transferable, the pain intensity after a whole year in the fractured patients (average 60.5) was just as severe as the preoperative pain in the patients included in the Swedish National Spine Register subsequently undergo- ing surgery for lumbar disc herniation (VAS: back 45, leg 64) or central spinal stenosis (VAS: back 55, leg 61) [54]. It has been argued that 84% of clinically diagnosed 56 56 fractures are associated with pain and that around half of 51 51 50 50 48 48 49 49 those with a radiologically identified fracture have any symptoms [50, 52]. The present study showed that more 31 31 than 97% reported a pain intensity of a severity that 30 30 28 28 usually is regarded as clinically significant (Fig. 3). Since 19 19 pain most likely was the main reason for visiting the 15 15 15 15 11 11 emergency unit, it is likely that all the patients experi- 8 8 8 8 6 6 enced acute pain in direct relation to the fracture and 3 3 probably also more pain than what was reported in the 0-25 25-50 50-75 75-100 Quartiles of von Korff pain intensity score first questionnaire administered 2–3 weeks after the occurrence of the fracture. After 1 year, only around Time 10% reported no or very little pain while almost 76% 3 weeks 6 months still had pain intensity regarded as severe (Fig. 3). From 3 months 12 months a pain aspect, the current results revealed a situation much worse and more frequent than indicated before Fig. 3 The patient’s pain intensity distributed into quartiles at the four follow-ups [50]. N u m b e r o f p a t i i e n t s M e a n f o r r p a i n , , d i i s a b i i l l i t t y , , A D L 1386 Eur Spine J (2008) 17:1380–1390 Fig. 4 The frequency of those EQ-5D separated into five dimensions reporting moderate or severe Mobility problems in the five dimensions 97 97 Self-Care of EQ-5D at the four follow-ups Usual Activities 89 89 89 89 87 87 Pain / Discomfort 82 82 Anxiety / Depression 73 73 69 69 69 69 68 68 61 61 60 57 57 55 55 54 54 52 52 53 53 50 50 22 22 15 15 14 14 12 12 3 weeks 3 months 6 months 12 months Time In the US one-third of all the annually estimated that the odds of impaired ADL (defined as problems with 700,000 osteoporotic vertebral body compression fractures C3 physical or instrumental ADLs) were 2.3 times higher are believed to develop chronic pain [47]. The findings in among those with an earlier clinically diagnosed vertebral the present study suggest that more than  acquire severe fracture [18]. It has also been found that impairment of pain, lasting at least 1 year after this type of fracture. This ADL does not have to be related to the presence of pain, finding is corroborated by another Swedish study where it particularly not in patients with two or more prevalent was noted that in more than 70% of the women, the fractures [36]. occurrence of a vertebral body fracture was the beginning of a painful condition that could last at least up to 22 years EQ-5D [34]. The initial QoL, measured with EQ-5D, was quite low and Disability and ADL similar or worse than what has been noted for long-lasting disabling low back and neck pain and comparable to the The patient’s disability rating pattern was quite similar to preoperative levels for both a lumbar herniated disc and that for pain. In comparison to age-matched patients with central spinal stenosis [32, 35, 54]. In a wider context than non-osteoporotic chronic low back pain, it was found that problems of the spine, the 3, 6 and 12-month EQ-5D the disability was greater among those with a vertebral values among the fractured patients found in the present fracture [38]. In the present study, considerably lower study were similar or lower than the values found preop- values (worse) for disability and ADL were noted at all eratively in patients with hip and knee osteoarthritis, follow-ups in comparison to large cohorts of patients from undergoing subsequent total joint replacement [31]. In six different countries with disabling low back pain [32]. comparison to the average EQ-5D value of 0.52 reported When the impairment after a vertebral fracture was ana- 1 year after the fracture in the present cohort, the corre- lyzed in 1,010 women 6 years after the fracture, it was sponding values in hip fracture patients 1 year after total found that those with a previous fracture had up to seven hip replacement surgery was 0.73 and after internal fixa- times greater odds of reporting difficulties with a variety of tion surgery was 0.63 [7]. The EQ-5D values in the activities than those without [28]. Similarly, it was noted population of the city of Stockholm for the age groups T h e n u m b e r o f patients reporting m o d e r a t e o r s e v e r e p r o b l e m s ( % ) Eur Spine J (2008) 17:1380–1390 1387 represented in this study have been found to be just above Since an acute fracture in the present study was deter- 0.80 [11]. mined through clinical signs and plain X-rays, it is a risk The worsening trend between 6 and 12 months was that some fractures interpreted as acute might rather have noticeable not only in the quality of life recordings, but been relatively old. also for pain and disability as well, and seemed to Another explanation for the presence of relatively old emphasize the profound negative and lasting effect of this ‘‘new’’ fractures was the fact that almost 17.8% of the fracture [46]. In another Swedish cohort study, it was noted patients in the study had their fracture diagnosed 1 month that all of the SF-36 dimensions were significantly lowered, or more after the fracture occurred (Table 1). even 2 years after a vertebral body fracture, which was Since, in most cases, only one X-ray examination was worse than after a hip fracture [30]. evaluated it is possible that new fractures during the study year could have contributed to the problems during the Treatment post-fracture year. The findings in the present study revealed that the treat- Lack of controls and old age ment strategy which recommended as normal and early physical activity as possible seemed to have quite ques- Only the post-fracture situation is known. For this reason tionable positive effects. Presently we do not know whether it is possible that some of the patients due to strict or partial immobilization of the fractured spine is a co-morbidity, for example, had an already deteriorated more adequate treatment or not. In two Japanese studies, it health-related quality of life subsequently made worse has been suggested that in order to prevent collapse, by the new fracture. The study did not include any deformity and lasting pain, the acute fracture must be controls without a spinal fracture. That is to some diagnosed early and treated with a rigid external fixation, extent compensated by the fact that the scores used e.g. e.g. a hard brace or a body cast [21, 58]. At the same time, EQ-5D and Hannover ADL have age stratified popula- it is well understood that there is a need for early mobili- tion data. zation since bed rest and inactivity more or less The most important reason for the high number of non inescapably will lead to muscle waste and rapid bone responders was old age. Since this fracture type especially mineral loss from the already fragile vertebrae [27, 33]. involves older patients, this apparent weakness of the study The unsatisfactory long-term prognosis for the great is hard to overcome. majority of patients with a vertebral fracture suggest that the reportedly successful pain-relieving interventions like vertebro- and kyphoplasty can possibly be employed on a Conclusions much wider scale. Hitherto, the vertebral fragility fracture generally has been Limitations regarded as a condition with self-limiting problems and as having a relatively positive prognosis. This study revealed, Accuracy of X-ray assessment on the contrary that the vertebral fragility fracture has a severe impact on pain, disability, ADL, and QoL and that The assessment of prevalent or incident vertebral fractures the fracture is the beginning of a deterioration of the from spinal radiographs is sometimes quite difficult. In patients health lasting at least for a year. cases with minimal fracture deformation, there is frequent disagreement about whether a fracture is present or not. Acknowledgments The study was supported by grants from The Some of the difficulties are the result of the variations in Swedish Council for Working Life and Social Research, AFA Insurance, Sahlgrenska academy at Gothenburg University. The study shape from one vertebra to another and also between was made possible through the cooperation with the Department of individuals. To distinguish whether a fracture is incident or Orthopaedic Surgery, Nagoya City University, Nagoya Japan and its prevalent can be even more complicated, especially for chairman professor Takanobu Otsuka. patients with severe osteoporosis and multiple compression Open Access This article is distributed under the terms of the fractures. Some patients who present with back pain of Creative Commons Attribution Noncommercial License which sudden onset are erroneously diagnosed as having acute permits any noncommercial use, distribution, and reproduction in vertebral fractures when in fact the deformity has been any medium, provided the original author(s) and source are present on earlier films [50]. credited. 123 1388 Eur Spine J (2008) 17:1380–1390 Appendix 1: von Korff pain intensity and disability score von Korff pain intensity and disability score Pain intensity items (1) How would you rate your pain right now? [Current pain] No pain Pain as bad could be 012 34 567 89 10 (2) After the fracture-how intense was your worst pain? [Worst Pain] No pain Pain as bad could be 012 34 567 8 9 10 (3) After the fracture-how intense was your pain at an average? (That is, your usual pain at times you were experiencing pain.) [Average Pain] No pain Pain as bad could be 012 34 567 8 9 10 Disability items (4) After the fracture, how much has the pain interfered with your daily activities? [Daily Activities] No interference Unable to carry on any activities 012 34 567 89 10 (5) After the fracture, how much has the pain changed your ability to take part in recreational, social and family activities? [Social Activities] No change Extreme change 012 34 567 8 9 10 (6) After the fracture, how much has the pain changed your ability to work (including housework)? [Work Activities] No change Extreme change 012 34 567 8 9 10 von Korff pain intensity score = (((response question 1) + (response question 2) + (response question 3)) / 3) * 10 von Korff disability score = (((response question 4) + (response question 5) + (response question 6)) / 3) * 10 Appendix 2: Hannover ADL score 6. Can you sit for one hour on a hard chair? 7. Can you stand continuously for 30 min (for example in 1. Can you reach up and get, for example, a book from a a queue)? high shelf or cupboard? 8. Can you raise yourself in bed from a lying position? 2. Can you lift a full suitcase and carry it for 10 m? 9. Can you put on and take off socks or similar garments? 3. Can you wash and dry yourself from head to toe? 10. Can you bend sideways from a seated position to pick 4. Can you bend forward to pick up a small lightweight up a small object on the floor just beside your chair? object from the floor? 5. Can you wash your hair over a washbasin? 11. Can you lift a box (about 8 kg) onto a table? 123 Eur Spine J (2008) 17:1380–1390 1389 13. Cockerill W, Lunt M, Silman AJ, Cooper C, Lips P, Bhalla AK 12. Can you run 100 m fast without stopping in order to et al (2004) Health-related quality of life and radiographic ver- catch a bus? tebral fracture. Osteoporos Int 15:113–119. doi:10.1007/ s00198-003-1547-4 Those questions were answered by following score. 14. Cooper C, Atkinson EJ, O’Fallon WM, Melton LJ 3rd (1992) Incidence of clinically diagnosed vertebral fractures: a popula- 0. Either unable to do or able only with help. tion-based study in Rochester, Minnesota, 1985–1989. J Bone 1. Yes, but with some difficulties. Miner Res 7:221–227 2. Yes, without difficulties. 15. Crans GG, Silverman SL, Genant HK, Glass EV, Krege JH (2004) Association of severe vertebral fractures with reduced Hannover ADL score = (total score)/(2 9 (number of quality of life: reduction in the incidence of severe vertebral valid answers)) 9 100. fractures by teriparatide. Arthritis Rheum 50:4028–4034. doi: 10.1002/art.20671 16. Dolan P, Gudex C, Kind P, Williams A (1996) The time trade-off References method: results from a general population study. Health Econ 5:141–154. doi:10.1002/(SICI)1099-1050(199603)5:2\141:: 1. Adachi JD, Ioannidis G, Olszynski WP, Brown JP, Hanley DA, AID-HEC189[3.0.CO;2-N[pii] Sebaldt RJ et al (2002) The impact of incident vertebral and non- 17. Dolan P, Gudex C, Kind P, Williams A (1996) Valuing health vertebral fractures on health related quality of life in postmeno- states: a comparison of methods. J Health Econ 15:209–231. doi: pausal women. BMC Musculoskelet Disord 3:11. doi:10.1186/ 0167-6296(95)00038-0[pii] 1471-2474-3-11 18. Ensrud KE, Nevitt MC, Yunis C, Cauley JA, Seeley DG, Fox KM 2. Adachi JD, Ioannidis G, Pickard L, Berger C, Prior JC, Joseph et al (1994) Correlates of impaired function in older women. L et al (2003) The association between osteoporotic fractures J Am Geriatr Soc 42:481–489 and health-related quality of life as measured by the Health 19. Ettinger B, Black DM, Nevitt MC, Rundle AC, Cauley JA, Utilities Index in the Canadian Multicentre Osteoporosis Study Cummings SR et al (1992) Contribution of vertebral deformities (CaMos). Osteoporos Int 14:895–904. doi:10.1007/s00198-003- to chronic back pain and disability. The Study of Osteoporotic 1483-3 Fractures Research Group. J Bone Miner Res 7:449–456 3. Alekna V, Tamulaitiene M, Butenaite V (2006) The impact of 20. Fechtenbaum J, Cropet C, Kolta S, Horlait S, Orcel P, Roux C subclinical vertebral fractures on health-related quality of life in (2005) The severity of vertebral fractures and health-related women with osteoporosis. Medicina (Kaunas) 42:744–750 quality of life in osteoporotic postmenopausal women. Osteopo- 4. Begerow B, Pfeifer M, Pospeschill M, Scholz M, Schlotthauer T, ros Int 16:2175–2179. doi:10.1007/s00198-005-2023-0 Lazarescu A et al (1999) Time since vertebral fracture: an 21. Fukuda F (2006) Importance of early diagnosis and early treat- important variable concerning quality of life in patients with ment for the conservative treatment of vertebral compression postmenopausal osteoporosis. Osteoporos Int 10:26–33. doi: fracture in elderly people (Japanese). Mon Book Orthop 19:153– 10.1007/s001980050190 159 5. Bengner U, Johnell O, Redlund-Johnell I (1988) Changes in 22. Gallacher SJ, Gallagher AP, McQuillian C, Mitchell PJ, Dixon T incidence and prevalence of vertebral fractures during 30 years. (2007) The prevalence of vertebral fracture amongst patients Calcif Tissue Int 42:293–296. doi:10.1007/BF02556362 presenting with non-vertebral fractures. Osteoporos Int 18:185– 6. Bengner U, Johnell O, Redlund-Johnell I (1988) Changes in the 192. doi:10.1007/s00198-006-0211-1 incidence of fracture of the upper end of the humerus during a 30- 23. Genant HK, Jergas M (2003) Assessment of prevalent and inci- year period. A study of 2125 fractures. Clin Orthop Relat Res dent vertebral fractures in osteoporosis research. Osteoporos Int 231:179–182 14(Suppl 3):S43–S55. doi:10.1007/s00198-002-1348-1,10.1007/ 7. Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J s00198-003-1472-6 (2005) Comparison of internal fixation with total hip replacement 24. Genant HK, Jergas M, Palermo L, Nevitt M, Valentin RS, Black for displaced femoral neck fractures. Randomized, controlled D et al (1996) Comparison of semiquantitative visual and quan- trial performed at four years. J Bone Joint Surg Am 87:1680– titative morphometric assessment of prevalent and incident 1688. doi:87/8/1680[pii]10.2106/JBJS.D.02655 vertebral fractures in osteoporosis. The Study of Osteoporotic 8. Borgstrom F, Zethraeus N, Johnell O, Lidgren L, Ponzer S, Fractures Research Group. J Bone Miner Res 11:984–996 Svensson O et al (2006) Costs and quality of life associated with 25. Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral osteoporosis-related fractures in Sweden. Osteoporos Int 17:637– fracture assessment using a semiquantitative technique. J Bone 650. doi:10.1007/s00198-005-0015-8 Miner Res 8:1137–1148 9. Brenneman SK, Barrett-Connor E, Sajjan S, Markson LE, Siris 26. Gennari C, Agnusdei D, Camporeale A (1991) Use of calcitonin ES (2006) Impact of recent fracture on health-related quality of in the treatment of bone pain associated with osteoporosis. Calcif life in postmenopausal women. J Bone Miner Res 21:809–816. Tissue Int 49(Suppl 2):S9–S13. doi:10.1007/BF02561370 doi:10.1359/jbmr.060301 27. Gold DT (1996) The clinical impact of vertebral fractures: quality 10. Burger H, Van Daele PL, Grashuis K, Hofman A, Grobbee DE, of life in women with osteoporosis. Bone 18:185S–189S. doi: Schutte HE et al (1997) Vertebral deformities and functional 10.1016/8756-3282(95)00500-5 impairment in men and women. J Bone Miner Res 12:152–157. 28. Greendale GA, Barrett-Connor E, Ingles S, Haile R (1995) Late doi:10.1359/jbmr.1997.12.1.152 physical and functional effects of osteoporotic fracture in women: 11. Burstrom K, Johannesson M, Rehnberg C (2007) Deteriorating the Rancho Bernardo Study. J Am Geriatr Soc 43:955–961 health status in Stockholm 1998–2002: results from repeated 29. Hall SE, Criddle RA, Comito TL, Prince RL (1999) A case- population surveys using the EQ-5D. Qual Life Res 16:1547– control study of quality of life and functional impairment 1553. doi:10.1007/s11136-007-9243-z in women with long-standing vertebral osteoporotic fracture. 12. Cauley JA, Hochberg MC, Lui LY, Palermo L, Ensrud KE, Osteoporos Int 9:508–515. doi:10.1007/s001980050178 Hillier TA et al (2007) Long-term risk of incident vertebral 30. Hallberg I, Rosenqvist AM, Kartous L, Lofman O, Wahlstrom O, fractures. JAMA 298:2761–2767. doi:10.1001/jama.298.23.2761 Toss G (2004) Health-related quality of life after osteoporotic 123 1390 Eur Spine J (2008) 17:1380–1390 fractures. Osteoporos Int 15:834–841. doi:10.1007/s00198-004- are predictors of quality of life in patients with postmenopausal 1622-5 osteoporosis. Osteoporos Int 18:1397–1403. doi:10.1007/s00198- 31. Hansson T, Hansson E, Malchau H (2008) The utility of spine 007-0383-3 surgery. A comparison of common elective orthopaedic surgical 45. O’Neill TW, Cockerill W, Matthis C, Raspe HH, Lunt M, Cooper procedures. Accepted in Spine C et al (2004) Back pain, disability, and radiographic vertebral 32. Hansson TH, Hansson EK (2000) The effects of common medical fracture in European women: a prospective study. Osteoporos Int interventions on pain, back function, and work resumption in 15:760–765. doi:10.1007/s00198-004-1615-4 patients with chronic low back pain: a prospective 2-year cohort 46. Oleksik AM, Ewing S, Shen W, van Schoor NM, Lips P (2005) study in six countries. Spine 25:3055–3064. doi:10.1097/ Impact of incident vertebral fractures on health related quality of 00007632-200012010-00013 life (HRQOL) in postmenopausal women with prevalent vertebral 33. Hansson TH, Roos BO, Nachemson A (1975) Development of fractures. Osteoporos Int 16:861–870. doi:10.1007/s00198-004- osteopenia in the fourth lumbar vertebra during prolonged bed 1774-3 rest after operation for scoliosis. Acta Orthop Scand 46:621–630 47. Phillips FM (2003) Minimally invasive treatments of osteoporotic 34. Hasserius R, Karlsson MK, Jonsson B, Redlund-Johnell I, Johnell vertebral compression fractures. Spine 28:S45–S53. doi: O (2005) Long-term morbidity and mortality after a clinically 10.1097/00007632-200308011-00009 diagnosed vertebral fracture in the elderly—a 12- and 22-year 48. Rao RD, Singrakhia MD (2003) Painful osteoporotic vertebral follow-up of 257 patients. Calcif Tissue Int 76:235–242. doi: fracture. Pathogenesis, evaluation, and roles of vertebroplasty and 10.1007/s00223-004-2222-2 kyphoplasty in its management. J Bone Joint Surg Am 85- 35. Jansson KA, Nemeth G, Granath F, Jonsson B, Blomqvist P A:2010–2022 (2005) Health-related quality of life in patients before and after 49. Romagnoli E, Carnevale V, Nofroni I, D’Erasmo E, Paglia F, De surgery for a herniated lumbar disc. J Bone Joint Surg Br 87:959– Geronimo S et al (2004) Quality of life in ambulatory postmen- 964. doi:10.1302/0301-620X.87B7.16240 opausal women: the impact of reduced bone mineral density and 36. Jinbayashi H, Aoyagi K, Ross PD, Ito M, Shindo H, Takemoto T subclinical vertebral fractures. Osteoporos Int 15:975–980. doi: (2002) Prevalence of vertebral deformity and its associations with 10.1007/s00198-004-1633-2 physical impairment among Japanese women: The Hizen-Oshima 50. Ross PD (1997) Clinical consequences of vertebral fractures. Am Study. Osteoporos Int 13:723–730. doi:10.1007/s001980200099 J Med 103:30S–42S. doi:10.1016/S0002-9343(97)90025-5 Dis- 37. Kohlmann T, Raspe H (1996) Hannover Functional Question- cussion 42S–43S naire in ambulatory diagnosis of functional disability caused by 51. Salaffi F, Cimmino MA, Malavolta N, Carotti M, Di Matteo L, backache. Rehabilitation (Stuttg) 35: I–VIII Scendoni P et al (2007) The burden of prevalent fractures on 38. Leidig-Bruckner G, Minne HW, Schlaich C, Wagner G, Scheidt- health-related quality of life in postmenopausal women with Nave C, Bruckner T et al (1997) Clinical grading of spinal osteoporosis: the IMOF study. J Rheumatol 34:1551–1560 osteoporosis: quality of life components and spinal deformity in 52. Silverman SL (1992) The clinical consequences of vertebral women with chronic low back pain and women with vertebral compression fracture. Bone 13(Suppl 2):S27–S31. doi:10.1016/ osteoporosis. J Bone Miner Res 12:663–675. doi:10.1359/jbmr. 8756-3282(92)90193-Z 1997.12.4.663 53. Silverman SL, Minshall ME, Shen W, Harper KD, Xie S (2001) 39. Leidig G, Minne HW, Sauer P, Wuster C, Wuster J, Lojen M et al The relationship of health-related quality of life to prevalent and (1990) A study of complaints and their relation to vertebral incident vertebral fractures in postmenopausal women with destruction in patients with osteoporosis. Bone Miner 8:217–229. osteoporosis: results from the multiple outcomes of Raloxifene doi:10.1016/0169-6009(90)90107-Q Evaluation Study. Arthritis Rheum 44:2611–2619. doi:10.1002/ 40. Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O et al 1529-0131(200111)44:11\2611::AID-ART441[3.0.CO;2-N (1999) Quality of life in patients with vertebral fractures: vali- 54. Stromqvist B, Fritzell P, Hagg O, Jonsson B (2005) One-year dation of the Quality of Life Questionnaire of the European report from the Swedish National Spine Register. Swedish Foundation for Osteoporosis (QUALEFFO). Working Party for Society of Spinal Surgeons. Acta Orthop Suppl 76:1–24. doi: Quality of Life of the European Foundation for Osteoporosis. Q62033144112T105[pii]10.1080/17453690510041950 Osteoporos Int 10:150–160. doi:10.1007/s001980050210 55. Von Korff M, Deyo RA, Cherkin D, Barlow W (1993) Back pain 41. Lyles KW, Gold DT, Shipp KM, Pieper CF, Martinez S, in primary care. Outcomes at 1 year. Spine 18:855–862. Mulhausen PL (1993) Association of osteoporotic vertebral doi:10.1097/00007632-199306000-00008 compression fractures with impaired functional status. Am J Med 56. Von Korff M, Ormel J, Keefe FJ, Dworkin SF (1992) Grading the 94:595–601. doi:10.1016/0002-9343(93)90210-G severity of chronic pain. Pain 50:133–149. doi:10.1016/0304- 42. Lyritis GP, Mayasis B, Tsakalakos N, Lambropoulos A, Gazi S, 3959(92)90154-4 Karachalios T et al (1989) The natural history of the osteoporotic 57. Vujasinovic-Stupar N, Radunovic G, Smailji M (2005) Quality of vertebral fracture. Clin Rheumatol 8(Suppl 2):66–69. doi: life assessment in osteoporotic patients with and without vertebral 10.1007/BF02207237 fractures. Med Pregl 58:453–458. doi:10.2298/MPNS0510453V 43. Melton LJ 3rd, Lane AW, Cooper C, Eastell R, O’Fallon WM, 58. Yoshida T (2002) Cases of osteoporotic spinal fracture devel- Riggs BL (1993) Prevalence and incidence of vertebral defor- oping marked vertebral body pressure deformity. Cent Jpn J mities. Osteoporos Int 3:113–119. doi:10.1007/BF01623271 Orthop Surg Traumatol 45:473–474 44. Miyakoshi N, Hongo M, Maekawa S, Ishikawa Y, Shimada Y, Itoi E (2007) Back extensor strength and lumbar spinal mobility

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European Spine JournalPubmed Central

Published: Aug 27, 2008

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