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Contents lists available at ScienceDirect

Maturitas

jo u r n al hom ep age: www.elsev ier .com/ locate /matur i tas

revalence of osteoporotic vertebral fracture in Spanish womenver age 45

ntonio Herreraa,d,∗, Jesús Mateoa,b,d, Jorge Gil-Albarovaa,b,d, Antonio Lobo-Escolara,c,d,osé M. Artigase, Fernando López-Prats f,g, Manuel Mesah, Elena Ibarz i, Luis Gracia i

Department of Surgery, University of Zaragoza, Domingo Miral s/n, 50009 Zaragoza, SpainDepartment of Orthopaedic Surgery and Traumatology, Miguel Servet University Hospital, Avda Isabel la Católica 3, 50009 Zaragoza, SpainDepartment of Orthopaedic Surgery and Traumatology, San Jorge Hospital, Avda Martínez de Velasco 36, 22004 Huesca, SpainAragón Health Sciences Institute, Zaragoza, SpainDepartment of Radiology, Miguel Servet University Hospital, Avda Isabel la Católica, 3, 50009 Zaragoza, SpainDepartment of Orthopaedic Surgery and Traumatology, General University Hospital, Cí. Almassera 11, 03203 Elche, Alicante, SpainDepartment of Surgery, Miguel Hernandez University, Avda. de la Universidad s/n, 03202 Elche, Alicante, SpainUnit of Orthopaedic Surgery and Traumatology, Valle de los Pedroches Hospital, Juan del Rey Calero s/n. 14.400 Pozoblanco, Córdoba, SpainDepartment of Mechanical Engineering, University of Zaragoza, María de Luna, 3, 50018 Zaragoza, Spain

r t i c l e i n f o

rticle history:eceived 27 October 2014ccepted 7 December 2014vailable online xxx

eywords:steoporosisertebral fracturepanish womenisk factorsogt’s questionary

a b s t r a c t

The aim of this work is to study the prevalence of osteoporotic vertebral fractures in Spanish womenover 45 years of age, based on the selection of a nationwide sample. An observational, cross-sectional,multicenter study was conducted during 2006, in all of Spain’s regions. The sample analyzed was of 5000individuals, proportional to the female population over age 45 in Spain.

A questionnaire was used to determine which factors are most often associated with vertebral fractures.Finally, we wonder whether the Prevalent Vertebral Fracture Index, proposed by Vogt, is useful to pre-sume a possible osteoporotic vertebral fracture. Five hundred orthopedic surgeons, from various Spanishregions, were trained in different aspects of the study: inclusion and exclusion criteria, management ofrisk factors questionnaire, and implementation of the Vogt questionnaire.

The number of fracture cases was 1549 (31.79%). 528 Women (34.08%) had a single vertebral fracture,and 1021 (65.92%) had multiple vertebral fractures. The following factors were statistically significantwith vertebral fracture: age, late menarche, early menopause, diabetes mellitus, hyperparathyroidism,rheumatoid arthritis, height loss, daily physical activity, corticosteroid therapy, personal history of osteo-

porotic fracture and previous diagnosis of osteoporosis. The differences in Vogt score according to ageand fracture were statistically significant.

The conclusion of the study is that vertebral osteoporotic fracture in the female Spanish populationis frequent. The high prevalence in the Spanish population older than 60 years is probably related tomalnutrition in the period from 1936 to 1952.

Please cite this article in press as: Herrera A, et al. Prevalence of osteopo(2015), http://dx.doi.org/10.1016/j.maturitas.2014.12.004

Abbreviations: PVFI, prevalent vertebral fracture index; CI, confidence inter-al; SD, standard deviation; DXA, dual-energy X-rays absorptiometry; BMD, boneineral density.∗ Corresponding author at: Department of Surgery, Medicine School, Universityf Zaragoza, Domingo Miral s/n, 50009 Zaragoza. Spain. Tel.: +34 976 76 17 34.

E-mail addresses: antonio.herrera@unizar.es (A. Herrera), jmateoa@ono.comJ. Mateo), jgilalba@unizar.es (J. Gil-Albarova), aloboescolar@yahoo.esA. Lobo-Escolar), jmartigas@salud.aragon.es (J.M. Artigas), fernando.lopez@umh.esF. López-Prats), mmesar@hotmail.com (M. Mesa), eibarz@unizar.es (E. Ibarz),ugravi@unizar.es (L. Gracia).

ttp://dx.doi.org/10.1016/j.maturitas.2014.12.004378-5122/© 2014 Elsevier Ireland Ltd. All rights reserved.

© 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

Vertebral fracture is the most common osteoporotic fracture,being more prevalent in women than men [1]. Osteoporotic ver-tebral fractures lead to back pain, kyphosis, and severe functionaland vital impact in 30–50% of patients [2]. The first vertebral frac-ture causes few symptoms and no radiographic examinations areperformed, so lack of diagnosis is usual [3]. Furthermore, fracturesremain undiagnosed in up to 40% of cases, even if obvious clini-

rotic vertebral fracture in Spanish women over age 45. Maturitas

cal symptoms are present [2]. Some authors have estimated thatonly one-third of vertebral fractures are diagnosed [3]. Of greaterconcern is that, even if a vertebral fracture has been shown up onX-ray tests, neither this diagnosis is stated in the hospital discharge

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Table 1Points assigned in accordance with Vogt’s scale.

Risk factor Vogt’s points

Previous vertebral fracture 6

Loss of height 2–4 cm 1>4 cm 2

Diagnosis of osteoporosis 1

Age (years) <60 060–69 170–79 2

versus 1.6 ± 2.3 cm, ratio of mean values of 3.8:1).The results of Vogt questionnaire scores are shown in Table 2 and

Fig. 2. The differences in Vogt score according to age are statisticallysignificant (p < 0.001). Differences in Vogt score between fracture

Table 2Results of Vogt questionnaire scores.

Age group Vogt scores

0–2 3–4 5 Or more

<55 558 (91.33%) 34 (5.56%) 19 (3.11%)55–59 673 (85.95%) 47 (6.00%) 63 (8.05%)60–64 297 (48.85%) 277 (45.56%) 34 (5.59%)

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eport, nor osteoporosis treatment is advised [4]. The first vertebralracture is associated with a high risk of new fractures, which mayffect vertebrae or other skeletal sites [5], leading to the so-calledracture cascade.

The prevalence of osteoporotic vertebral fractures varies widelyn international studies, and ranging from 7.8% to 39.0% in theeviewed references [3,6–16]. In Spain, this is an under diagnosednd undertreated condition, on the lines of our European neigh-ors. Epidemiological studies published in 1998 [17] estimated thennual incidence of vertebral fractures at 70,000 cases. In 2000,

survey revealed a prevalence rate of 24% [18]. More recently,nother local study has shown a 21.4% prevalence of vertebral frac-ures in women over the age of 50 [19]. Finally, a multicenter study,n a sample of 289 osteopenic women, indicated a prevalence ratef 50% [20].

The purpose of this study is to assess the prevalence of osteo-orotic vertebral fractures in women over 45 years of age, based onhe selection of a nationwide sample.

. Methods

An observational, cross-sectional, study was conducted duringhe months of February–April 2006, in all of Spain’s provinces.ample selection was proportional to the female population overge 45 in Spain (8597,580 from the National Institute for Statis-ics, 2006). For such population, considering a confidence intervalCI) of 95%, and estimating a 20% average prevalence rate ofertebral fractures, the minimum sample required is of 4491 indi-iduals.

They were randomly selected by age with data from the Nationalealth Service covering 100% of the population. The criteria for

nclusion in the study were women over 45 years old, and thexclusion criteria were: previous surgery of spine, neoplasic andraumatic disorders. The first selection of population was 6000omen with their origin being both urban and rural areas in a

imilar proportion maintaining with them a phone conversationo explain the purpose of the study and discard those did presentome of the exclusion criteria. After that, 388 (6.47%) were rejectednd 276 (4.60%) did not accept participate.

The rest (5336, 88.93%) were cited by mail and a written con-ent was obtained in each case. The study was approved by thethics Committee of The Institute of Health Sciences of Aragón. Thetudy was conducted in orthopedic surgeon’s offices, after a randomelection of these doctors according to the number of practicingpecialists in each area. Five hundred orthopedic surgeons, from allpanish regions, were trained in different aspects of the study andmplementation of the Vogt questionnaire [7]. Fifty-nine radiolo-ists with training in musculoskeletal radiology participate in thetudy. They were instructed in the application of the method ofenant [21], insisting that should be diagnosed as suspected of frac-

ure any morphological alteration of the vertebral bodies, becausehe X-rays would be reevaluated.

In all cases, age, weight and height data were collected, and bodyass index was calculated. Medical history was also included, and

questionnaire survey about the risk factors was made (Table 1).hose risk factors were chosen according with Spanish and Inter-ational Guidelines of Osteoporosis [22]. Daily sun exposure waslso collected for its role in the metabolism of vitamin D. Votg’sVFI scale [7] was calculated (Table 2).

All patients underwent X-ray examination consisting of a lateraliew of the thoracic spine centered at T7, and a lateral view of the

Please cite this article in press as: Herrera A, et al. Prevalence of osteop(2015), http://dx.doi.org/10.1016/j.maturitas.2014.12.004

umbar spine centered at L2 (focal length 110 cm). X-ray imagesere examined by each center’s radiologist to look for vertebral

ractures between T4 and L4, using the semi-quantitative techniquef Genant [21]. X-ray images deemed to be showing a fracture were

≥80 3

History of non-vertebral fracture 1

archived for a later review by two skilled radiologists, who analyzedthe cases separately. In cases of disagreement, the images wereexamined by both radiologists concurrently and a final diagnosiswas made. Patients with a prior diagnosis of osteoporosis wereasked about previous therapies.

Statistical analysis of data was performed using �2 analysisfor categorical data and percentages comparison. The significantlevel was set at p < 0.001. Moreover a multivariable correlation wasestablished among grade of fracture, single or multiple fracturesand Vogt’s score for every age group.

3. Results

Of the total sample of five thousand three hundred thirty-sixwomen, 336 (6.30%) were excluded due to present exclusion crite-ria and 128 cases (2.40%) were excluded due to missing data.Therefore, 4872 cases (91.30%) could be included in the study. Theremaining individuals were arranged by age into seven age groups(<55, 55–59, 60–64, 65–69, 70–74, 75–79, ≥80). The age distribu-tion is shown in Fig. 1. Cases with vertebral fracture had a mean age(±SD) of 69.0 ± 10.1, while non-fracture patients had a mean age(±SD) of 59.9 ± 10.2. Mean age difference between groups is statis-tically significant (p < 0.001). By age group, less than 55 years old thefracture rate was 27.75% while in the group with of 80 years or olderthe fracture rate was 72.25% (260.36% more). Body mass index waspractically similar in both groups: a mean (±SD) of 26.3 ± 4.6 forthe fracture group, and 27.1 ± 4.6 for the non-fracture group. Wefound no significant association between vertebral fractures andtoxic habits (22.36% without fracture and 22.12% with fracture),maternal history of osteoporotic fracture, location and number offractures and hyperthyroidism. The results of the risk factors ques-tionnaire are shown in Table 3, and their statistical significance isdetailed in Table 4.

Height loss, indicative of vertebral fracture, was higher in caseswith fracture versus those without vertebral fracture (6.1 ± 5.3

orotic vertebral fracture in Spanish women over age 45. Maturitas

65–69 269 (37.26%) 398 (55.12%) 55 (7.62%)70–74 61 (8.33%) 188 (25.68%) 483 (65.98%)75–79 12 (1.55%) 117 (15.14%) 644 (83.31%)≥80 – – 643 (100.00%)

Please cite this article in press as: Herrera A, et al. Prevalence of osteoporotic vertebral fracture in Spanish women over age 45. Maturitas(2015), http://dx.doi.org/10.1016/j.maturitas.2014.12.004

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Fig. 1. Study flow diagram. A randomized sample of 6000 subjects from all Spanish regions was recruited. Of the total sample, 388 cases (6.47%) were rejected due to exclusioncriteria and 276 (4.60%) did not accept participate in the first interview. After final data examination, 336 (6.30%) were excluded due exclusion criteria and 128 cases (2.40%)were excluded due to missing data. The 4872 (91.30%) cases remaining could be included in the study.

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Table 3Risk factors: incidence in fracture and non-fracture groups.

Factor Without fracture With fracture

Age 59.9 ± 10.2 69.0 ± 10.1Late menarche (>15 years old) 9.7% 15.4%Early menopause 7.1% 14.4%Diabetes mellitus 12.9% 29.8%Hyperparathyroidism 0.4% 1.8%Hyperthyroidism 2.9% 4.7%Rheumatoid arthritis 4.8% 8.7%Tobacco use (cigarettes/day)

(mean ± SD)5.5 ± 8.3 3.7 ± 7.4

Percentage of smokers 22.36% 22.12%Heavy alcohol use 1% 2%Weight loss over the last two years

(kg) (mean ± SD)2.2 ± 3.6 2.8 ± 3.9

Height loss (cm) (mean ± SD) 1.6 ± 2.3 6.1 ± 5.3Physical inactivity 29.0% 42.4%Oral or parenteral corticosteroid

therapy4.2% 14.6%

Mother’s history of osteoporoticfracture

24.4% 25.8%

Personal history of osteoporoticfracture

11.6% 42.1%

Prior diagnosis of osteoporosis 20.5% 56.4%Vogt Index 2.32 ± 1.83 7.13 ± 2.48Calcium intake (mg/day)

(mean ± SD)984.6 ± 453.5 879.2 ± 443.0

Sun exposure (hours/day) 2.1 ± 1.6 2.0 ± 1.6

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Table 4Risk factors: statistical analysis.

Comparative items Significant? p-Value

VOGT score—fracture Yes <0.001VOGT score (>5)—fracture Yes <0.001VOGT score (>8)—fracture Yes <0.001VOGT score—age Yes <0.001VOGT score (>5)—age Yes <0.001Location—number of fractures No 0.999Fracture grade—age Yes <0.001Multiple fractures—age Yes <0.001Fracture—age Yes <0.001Fracture—late menarche Yes <0.001Fracture—early menopause Yes <0.001Fracture—diabetes Yes <0.001Fracture—alcohol use No 0.004Fracture—corticosteroid therapy Yes <0.001Fracture—physical inactivity Yes <0.001Fracture—mother’s history No 0.086Fracture—previous fracture Yes <0.001Fracture—prior diagnosis of osteoporosis Yes <0.001Fracture—hyperparathyroidism Yes <0.001Fracture—hyperthyroidism No 0.001

(mean ± SD)

nd non-fracture groups are shown in Fig. 3 and are also statisticallyignificant (p < 0.001).

.1. Analysis of vertebral fractures

Vertebrae included in the segment T4–L4 were analyzed in two

Please cite this article in press as: Herrera A, et al. Prevalence of osteop(2015), http://dx.doi.org/10.1016/j.maturitas.2014.12.004

ateral radiographs of the spine, using the technique describedn the protocol. The first film evaluation identified 1921 cases

ith suspicion of vertebral fractures, which means a prevalence of9.43%. Subsequent review by two skilled radiologists specialized

Fig. 2. Vogt score versus age groups. The differences in Vogt sco

Fracture—rheumatoid arthritis Yes <0.001

in radiology of spine and they excluded 372 cases, so that the finalnumber of fracture cases was 1549 (31.79%). Applying Kappa-scoreintra-reader agreement was excellent for both readers: 0.81(95% CI) for reader A and 0.92 (95% CI) for reader B. Agreementbetween readers was also excellent: 0.84 (95% CI). For qualitycontrol we reviewed 1250 negative radiographs, randomly chosenproportional to its area of origin and we did not detect any fracture.

Considering single or multiple fractures, 528 women (34.09%)had a single vertebral fracture, and 1021 (65.91%) had multiplevertebral fractures. In the later, the average was 2.76 fracturesper patient. After the first X-ray evaluation, false positive casesamounted to 19.40% of the cases labeled as suspicion of vertebral

orotic vertebral fracture in Spanish women over age 45. Maturitas

fracture. Among the cases that showed multiple vertebral fractures(1021 women) 835 (81.78%) had 8 o more points according to Vogtscore and having a prior diagnosis of vertebral fracture.

re according to age are statistically significant (p < 0.001).

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F tween increases in fracture groups with respect to non-fracture groups, being statisticallys

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Table 5Correlations coefficients (R2 of Pearson) corresponding to multivariable analysis offracture grade, single or multiple fractures and Vogt score. More significant corre-lations among different variables are highlighted in bold.

Grade I Grade II Grade III

Fracture grade—type of fractureSingle fracture 0.995 −0.498 −0.414Multiple fractures −0.535 0.988 0.985

Fracture grade—Vogt’s score0–2 0.663 −0.487 −0.3822–4 −0.321 −0.313 −0.345>5 −0.494 0.553 0.466

Vogt’s score—type of fracture

Fa

ig. 3. Vogt score for groups with and without fracture. Differences in Vogt score beignificant (p < 0.001).

The vertebrae levels most often affected were L1 (13.07%) and12 (12.12%), followed by L2 (8.90%) and T7 (8.52%). Fig. 4 showshe rates of single and multiple fractures at each vertebral level.

edge type was the most common fracture (53.20%), followed byiconcave vertebra (33.51%) and crush fracture (13.30%). Grade Iractures were present in 649 cases (41.90%), grade II in 594 cases38.35%) and grade III en 306 cases (19.75%). The degree of frac-ure is clearly related to age: 276 women with 75 years old or olderad fractures degree III (89.61% of total) and multiple fractures arelso age-related; 780 women with 75 years old or older had multi-le fractures (76.40% of total). In multiple fractures cases, the mosterious injury was considered for grade assessment. Distribution,y age group, of single and multiple fractures rate is shown in Fig. 5nd, similarly, grade fracture rates are given in Fig. 6. Both the num-er of fractures and their severity were found to be significantlyp < 0.001) related to age.

Please cite this article in press as: Herrera A, et al. Prevalence of osteopo(2015), http://dx.doi.org/10.1016/j.maturitas.2014.12.004

Results of multivariable analysis show an excellent correlationetween grade I of fracture and single fracture. In the same way aood correlation between grade II and III with multiple fracturesas obtained. Concerning grade of fracture and Vogt’s score, an

ig. 4. Fracture locations for groups with single and multiple fractures. The vertebrae levnd T7 (8.52%).

Single fracture 0.637 −0.353 −0.440Multiple fractures −0.494 −0.289 0.555

rotic vertebral fracture in Spanish women over age 45. Maturitas

acceptable correlation was found between grade I and 0–2 points,and between grades II and III with >5 points. Finally, Vogt’s scoreranging 0–2 has an acceptable correlation with single fracture, andVogt’s score >5 with multiple fractures (Table 5).

els most often affected were L1 (13.07%) and T12 (12.12%), followed by L2 (8.90%)

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Fig. 5. Single and multiple fractures versus age groups. The number of fractures was found to be statistically significant (p < 0.001) related to age. In the group of age over 80,all the women had multiple fractures.

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ig. 6. Fracture grade versus age groups. In multiple fractures cases, the most seritatistically significant (p < 0.001) related to age.

An amount of 1872 patients (38.42%) had a prior diagnosisf osteoporosis, of which 873 (46.63%) had a vertebral fracturend 999 (53.37%) had no fracture. Conversely, a prior diagnosisf osteoporosis was found in 56.36% of vertebral fracture cases.nly 54.49 per cent of women diagnosed with osteoporosis were

eceiving treatment, while 852 (45.51%) were not. When analyz-ng those cases receiving treatment, therapy was only right in 536ases (52.55%), according to the main clinical guides; therapy wasncorrect or insufficient in 484 cases (47.45%). Out of the 873

Please cite this article in press as: Herrera A, et al. Prevalence of osteop(2015), http://dx.doi.org/10.1016/j.maturitas.2014.12.004

omen diagnosed with osteoporosis and having a vertebral frac-ure, 507 (58.08%) were not on treatment, therapy was incorrect ornsufficient in 248 cases (28.40%), and only 118 women (13.52%)

ere on the right treatment

jury was considered for grade assessment. The grade of fractures was found to be

4. Discussion

This is the first study on spinal fracture carried out in Spain witha wide sample, representative of the female population older than45 years in each region. It should be said that the previous standard-ization of the orthopedic surgeons and radiologists involved in thestudy has led to high rates of inclusion of valid cases (91.30%).

One of the main concerns in the design of prevalence studiesof spinal fractures is the definition of what we consider a “case”

orotic vertebral fracture in Spanish women over age 45. Maturitas

of fracture as oppose to other spinal disorders. Prevalence ratesmay change depending on the selected criteria, those proposedby Eastell [23] and McCloskey [24] being the most used. Wechose the semi quantitative Genant’s method for its reliability and

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eproducibility, this method has shown high reliability for theiagnosis (97.60%) when compared to morphometric studies [25],nd it has been considered the most useful for studies like theresent one [26]. Dual-energy X-ray absorptiometry (DXA) wasuled out for difficulties in the access to a DXA study in certain areasf our country; on the other hand, the images of the upper thoracicertebrae were obtained with this method are hardly measurable.

The objective was not only the description of the prevalence ofertebral fracture, but also the study of associated risk factors inhe female population. The Vogt questionnaire [7] was also used inrder to determine its reliability for spinal fracture detection.

There are different options for the assessment. However, therevalent vertebral fracture index proposed by Vogt [7] seems to beore specific and easier to use. In our work a difference of 5 or more

n those scores was significantly associated with the presence ofertebral fracture, as had been suggested by this author in previousapers. We found that 65.50% of female patients scoring 5 or moread suffered spinal fractures, the scores being significantly higherp < 0.001) in older patients. All women with scores of 8 or more835 cases) had a previous diagnosis of vertebral fracture, and allf them presented more than one fracture. It was no possible toetermine if these fractures had been sustained after the initialiagnosis, due to insufficient information provided by the patientsr lack of previous radiographic studies.

The prevalence rates found in our survey were higher thanhose reported in the majority of internationally published papers3,6–12,14,15]; however, some authors have reported rates evenigher [13,16]. In our country, several authors have published lowerates of prevalence [17–19]; only one study conducted on thesteopenic female population [20] showed higher rates of vertebralracture than the present investigation. Nevertheless it is impor-ant to stress the difficulties of comparing the published worksue to marked differences found in age, methodology and sam-le size. There are heterogeneous data depending on the countryr even the region in several multicentric studies [8,9]. Moreover,he high prevalence of spinal fracture in our country, specificallyn the population older than 60 years, has been suggested toe related to the life conditions between 1936 and 1952, afterhe Spanish civil war (1936–1939) and the posterior isolation ofhe country from the rest of the world during the dictatorship.his situation led to a nutritional deficiency in a high percentagef the Spanish population, as was shown in the studies carriedut in Madrid during the civil war period. In that city, the dailyaloric intake diminished from 1514 kcal/day on August 1937 to52 kcal/day on February 1939. The lowest figures were recordedn December 1938, being 770 kcal/day [27]. This provoked anncrease of diseases related with starvation. The caloric deficien-ies were similar in all regions of the country. Several studies haveocumented growth failure and malnutrition-related diseases inhildren associated to the economic status of their families [28].he population segment older than 60 years in 2006 was the mostffected in terms of physical development and peak bone mass,ecause at that time they were in their second and third decades of

ife.This was documented in one study published in 1997, in which

igh rates of osteoporosis in women older than 50 years were foundith DXA measurements in hip and lumbar spine [29]. As we haveentioned, those women were aged 60 or older at the moment of

ur study in 2006.The following potential risk factors showed significant associa-

ion (p < 0.001) with vertebral fracture in our work: age, delayedenarche, premature menopause, diabetes mellitus, prolonged

Please cite this article in press as: Herrera A, et al. Prevalence of osteopo(2015), http://dx.doi.org/10.1016/j.maturitas.2014.12.004

reatment with steroids, sedentary lifestyle, previous diagnosisf fracture and previous diagnosis of osteoporosis; the same riskactors have been described in previous works [3,5,7,11,15]. BMIas similar in both groups (fracture/no fracture) and we think

PRESS xxx (2015) xxx–xxx 7

according with other authors that the determination of BMI notassociated with BMD loses its predictive value [22].

A decrease in body height was associated with the presence offracture (ratio of mean values of 3.8:1), as was described in [30].Calcium intake and solar exposition were similar in patients withor without vertebral fracture.

The initial diagnosis of vertebral fracture was performed by aradiologist in each center. The revision documented 372 cases ofinitial inadequate diagnosis (19.36%). Other published studies havereported higher rates of false positives [3], thus emphasizing theimportance of an adequate training for the radiologists involved inthese types of investigations. The highest rates of discrepancy wereobserved at the levels from T4 to T8 and in biconcave patterns offracture.

The severity of injury was significantly associated to the patientage (p < 0.001).

From a total of 4872 women included in the study, 1872 (38.42%)had a previous diagnosis of osteoporosis and 873 (46.36%) of themlater sustained a vertebral fracture. From the women with a previ-ous diagnosis of osteoporosis only 1020 (54.49%) had been treated,and this therapy had been adequate in only 536 (52.55%) cases.From the total of women with a previous diagnosis of vertebral frac-ture only 13.52% had received treatment. These data suggest that ahigh percentage of osteoporotic patients do not receive any treat-ment, and when they do, it may be inadequate or insufficient. Thismay be due to a suboptimal knowledge of the treatment protocolsfor osteoporosis.

Some limitations appear in the study. So, the revision of plainradiographs by the two expert radiologists was carried out in thecases where a fracture had initially been diagnosed. The false posi-tives were thus detected. On the contrary, not all the images labeledas “normal” were revised; only 1250 negative radiographs (42.36%of 2951) have been revised and any fracture was detected. Thegeneral trend in these studies is a overdiagnosis labeling as ver-tebral fracture any degenerative changes in vertebral bodies. Weshould note that the instructions given to the radiologists of differ-ent centers were to indicate as suspicion of fracture any vertebralbody deformity therefore we believe that there was any fractureundiagnosed

Other limitation was derived from the difficulties found in someregions of our country to gain access to DXA studies. The bone min-eral density (BMD) study would have improved the screening offractures in this work.

Finally, the evolution of the previously diagnosed fractures wasnot assessed due to the absence of previous image studies on thisgroup of patients.

5. Conclusion

Based on our results, we can conclude that vertebral osteo-porotic fracture in the female Spanish population represents afrequent and in many cases under-diagnosed disease. The highprevalence in the Spanish population older than 60 years is prob-ably related to malnutrition in the period from 1936 to 1952. Amarked percentage of patients with osteoporosis or vertebral frac-ture have not been adequately treated. And for all these reasons,special attention must be paid to the primary and secondary pre-vention of osteoporosis.

Contributors

rotic vertebral fracture in Spanish women over age 45. Maturitas

Study design: A Herrera, F López-Prats and M Mesa. Studycoordination: A Herrera. Data collection: J Mateo, J Gil-Albarova,A Lobo-Escolar and J M Artigas. Data analysis: L Gracia and EIbarz. Data interpretation: A Herrera, L Gracia and E Ibarz. Drafting

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anuscript: A Herrera, L Gracia and E Ibarz. Revising contents: alluthors. A Herrera and L Gracia take responsibility for the integrityf the data analysis.

ompeting interest

None declared.

unding

Vita and Procter & Gamble Laboratories financed all the logisticosts of this study.

onflict of interest statement

The authors declare no conflict of interest.

cknowledgements

We would like to thank the collaboration of our colleagues, the00 Orthopaedic and Trauma Surgeons who elaborated the proto-ols that allowed us to carry out this work. Special mention shouldlso be done to the radiologists in charge of the radiographic revi-ion.

eferences

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