Imaging evaluation of osteoporotic vertebral fracture.

As the world's population ages, the incidence of osteoporosis defined by decreased bone mass and alteration of microarchitecture has inevitably increased. This results in osteoporosis-associated fracture and leads to debilitating health outcomes and a considerable economic burden on the health care system. In this issue of the Journal of the Chinese Medical Association, Lin and colleagues have contributed an interesting article entitled Determination of the painful level in osteoporotic vertebral fractures: retrospective comparison between plain film, bone scan, and magnetic resonance imaging. The authors studied 52 patients with osteoporotic vertebral fracture (OVF) treated by vertebroplasty in a single institute in Northern Taiwan and found that the pain level of single-level compression vertebral fracture could be identified accurately by either plain film or bone scan; however, the pain level of multiple-level compression vertebral fractures should necessitate the use of magnetic resonance imaging (MRI) to provide an improved and more sensitive diagnosis to localize multiple sites of vertebral fractures. In addition, when a vacuum cleft sign appeared on plain film in patients with supposed vertebral fractures, two other diagnostic tools, bone scan and MRI, both showed positive findings. Although we applaud the successful publication of this article, there are several controversial issues that require further discussion. First, what is the aim of this study? In our understanding, the authors would like to localize the fracture sites of the osteoporotic vertebral bones more precisely by comparing the detection accuracy of three commonly used tools: plain film, bone scan, and MRI. However, it is unknown why the authors compared pain score (visual analog scale) of these 52 patients with OVF treated by vertebroplasty, preoperatively and postoperatively. As would be expected, patients after treatment had a significant decline of pain score from 7.6 to 2.8. However, this reduced pain score might in fact represent the benefits or effectiveness of the use of vertebroplasty in the management of patients with OVF. However, this was not a main outcome of the study and, furthermore, was not a conclusion presented by the authors. A recent meta-analysis from Tian et al showed that patients with OVF treated by vertebroplasty had statistically significant improvements in pain relief compared with the traditional treatment. Additionally, there was the similar incidence of adjacent vertebral fracture between those patients