Radiographic diagnosis of osteoporotic vertebral fractures. An updated review

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Una revisión actualizada" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1151 "Ancho" => 1405 "Tamanyo" => 209279 ] ] "descripcion" => array:1 [ "en" => "Examples of expanded semi-quantitative (eSQ) OVF (osteoporotic vertebral fracture) classification by Wang et al.<a class="elsevierStyleCrossRef" href="#bib0435">35</a> (A) Grade I, minimal; (B) Grade II, mild; (C) Grade III, moderate; (D) Grade IV, moderate-severe; (E) Grade V, severe; (F) Grade VI, collapsed." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Daniel López Zúñiga, Antonio Jesús Láinez-Ramos-Bossini, Fernando Ruiz Santiago" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Daniel" "apellidos" => "López Zúñiga" ] 1 => array:2 [ "nombre" => "Antonio Jesús" "apellidos" => "Láinez-Ramos-Bossini" ] 2 => array:2 [ "nombre" => "Fernando" "apellidos" => "Ruiz Santiago" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0025775321004280" "doi" => "10.1016/j.medcli.2021.06.019" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775321004280?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622000225?idApp=UINPBA00004N" "url" => "/23870206/0000015800000003/v1_202202040749/S2387020622000225/v1_202202040749/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S0025775321005352" "issn" => "00257753" "doi" => "10.1016/j.medcli.2021.08.004" "estado" => "S300" "fechaPublicacion" => "2022-02-11" "aid" => "5815" "copyright" => "The Authors" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Med Clin. 2022;158:133-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Clinical report" "titulo" => "Diffuse alveolar hemorrhage in a patient with anti-neutrophil cytoplasm antibody-associated vasculitis successfully treated with immunoadsorption combined with methylprednisolone" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "133" "paginaFinal" => "136" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemorragia alveolar difusa en un paciente con vasculitis asociada a anticuerpos contra el citoplasma de neutrófilos tratada con éxito con inmunoadsorción combinada con metilprednisolona" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 467 "Ancho" => 1750 "Tamanyo" => 131704 ] ] "descripcion" => array:1 [ "en" => "The pulmonary imaging before and after IA. 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Una revisión actualizada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 447 "Ancho" => 1305 "Tamanyo" => 81550 ] ] "descripcion" => array:1 [ "en" => "Examples of morphometric measurements and their associated morphological parameters. (A) Anterior wedging; (b) posterior wedging; (c) biconcavity; (d) crush fracture. Red points mark the vertebral height which is decreased." ] ] ] "textoCompleto" => "IntroductionOsteoporosis is characterised by the deterioration of bone mass and micro-architecture, which increases the risk of fragility fractures.<a class="elsevierStyleCrossRef" href="#bib0265">1</a> It is the most common metabolic bone disease in the world, representing a major health concern with 27.6 million people affected in the European Union.<a class="elsevierStyleCrossRefs" href="#bib0270">2–4</a> Its prevalence is higher in women and increases with age, being 3–4 times more frequent above the age of 50.<a class="elsevierStyleCrossRef" href="#bib0275">3</a>Vertebral fractures are the most frequent location in osteoporotic patients.<a class="elsevierStyleCrossRef" href="#bib0275">3</a> Detecting one or more osteoporotic vertebral fractures (OVFs) is sufficient to make the diagnosis of osteoporosis, even in the absence of bone mineral density (BMD) determination.<a class="elsevierStyleCrossRef" href="#bib0270">2</a> Moreover, the presence of one or more OVFs significantly increases the risk of suffering other fractures in the future, regardless of the patient's BMD, and the associated morbidity and mortality are similar to osteoporotic hip fractures at 5 years.<a class="elsevierStyleCrossRefs" href="#bib0265">1,3,5–8</a>As highlighted by Lentle et al.,<a class="elsevierStyleCrossRefs" href="#bib0290">6,9</a> OVFs are a special type of fracture due to several factors, including lack of consensus criteria on their definition, coexistence of bone consolidation and destruction with subsequent gradual fracture development, and paucity or even absence of symptoms. In fact, many OVFs are incidentally detected on imaging exams performed for unrelated reasons. It is estimated that only 30% of OVFs come to medical attention,<a class="elsevierStyleCrossRef" href="#bib0280">4</a> which has been attributed to various factors such as clinical focus on other findings of greater severity, lack of familiarity with OVFs<a class="elsevierStyleCrossRef" href="#bib0310">10</a> or ambiguous terminology in radiology reports.<a class="elsevierStyleCrossRef" href="#bib0315">11</a> However, an accurate diagnosis of OVFs is needed to initiate appropriate drug treatment and thus reduce the risk of future fractures.<a class="elsevierStyleCrossRef" href="#bib0310">10</a> Moreover, describing the severity of the OVF is essential because severe fractures are associated with greater deterioration of bone quality and higher risk of new fractures.<a class="elsevierStyleCrossRef" href="#bib0320">12</a>Although radiologists have a central role in the diagnosis of OVFs, interpretation of chest and spine radiographs is a basic skill for all clinicians, thus recommendations for assessing OVFs should be known. However, with the development of more sophisticated imaging exams (e.g., CT, MRI), clinicians and even radiologists are losing interest in recognising the features and classification systems of OVFs on conventional radiography. The purpose of this article is to review the main radiographic approaches available regarding the diagnosis of OVFs, their advantages and limitations, as well as the anatomical variants that most frequently lead to diagnostic pitfalls.Radiographic techniques to assess osteoporotic vertebral fracturesConventional or plain radiography is a fast, widely available and inexpensive technique that involves relatively low effective radiation doses (0.3–0.7mSv).<a class="elsevierStyleCrossRef" href="#bib0325">13</a> For these reasons, it is considered by some authors to be the best imaging technique to assess the presence of low-energy vertebral fractures.<a class="elsevierStyleCrossRef" href="#bib0330">14</a> Although spine radiographs are the optimal radiographic technique to make an accurate diagnosis of OVF, chest radiography also allows their detection, thus cautious examination of the spine should always be carried out, even in patients without pain.Conventional spine radiographyConventional radiography of the thoracolumbar spine, in both anterior–posterior (AP) and lateral projections, is the initial imaging exam of choice in patients with symptoms suggestive of low-energy vertebral fracture (localised pain, height reduction, or thoracic kyphosis), especially if there is associated trauma.<a class="elsevierStyleCrossRefs" href="#bib0335">15,16</a>Performing an adequate radiographic technique is necessary to avoid diagnostic errors due to incorrect positioning of the patient or inadequate acquisition parameters.<a class="elsevierStyleCrossRef" href="#bib0265">1</a> Parallel positioning of the patient's spine on the table and adequate centring, collimation and physical parameters must be ensured to avoid poor image quality.<a class="elsevierStyleCrossRef" href="#bib0345">17</a> The coverage should include the spinal segment between C7 and S1.<a class="elsevierStyleCrossRef" href="#bib0330">14</a>Although specific projections centred at the thoracolumbar junction may be used,<a class="elsevierStyleCrossRef" href="#bib0350">18</a> the AP and lateral projections are usually sufficient for correct assessment of the height of vertebral bodies and for detection of fracture lines. Although assessment based on both projections increases diagnostic sensitivity, the AP projection is less sensitive, being the lateral projection the only one used in most epidemiological studies.<a class="elsevierStyleCrossRef" href="#bib0265">1</a> In this projection, the two main parameters to be assessed are vertebral height and the degree of kyphotic deformity. It should be stressed that the decrease in these parameters over time may allow the diagnosis of incident OVFs, thus radiographic follow-up is essential to spot new OVFs. On the other hand, Wáng et al.<a class="elsevierStyleCrossRef" href="#bib0355">19</a> suggest that the majority of moderate and severe vertebral fractures can be detected on AP projections in patients at high risk of osteoporosis.Conventional chest radiographyAlthough not the initial imaging technique of choice, chest radiography is undoubtedly one of the most widely used imaging exams and generally covers all or part of the thoracolumbar junction in the lateral projection, allowing the diagnosis of OVFs both in symptomatic and asymptomatic patients. Therefore, this examination can be a valuable screening method for OVFs. However, it has been found that only one third of OVFs are described in radiologic reports of chest radiographs.<a class="elsevierStyleCrossRef" href="#bib0335">15</a> In general, the same technical quality requirements and measures as in spine radiography are applicable. Although few literature is available on the utility of the AP projection and further studies are needed to demonstrate its positive predictive value and cost-effectiveness in real-world practice, it opens up a great opportunity for the diagnosis of OVFs in patients with radiographs performed for other reasons (e.g. abdomen or chest radiography).Classification systems used in the diagnosis of osteoporotic vertebral fractures on conventional radiographyFor more than half a century, numerous classification systems have been developed with the aim to classify OVFs based on imaging features on conventional radiography. Nevertheless, only a few classifications have gained international acceptance, and the criteria for the diagnosis and classification of OVFs remain a subject of debate among experts.<a class="elsevierStyleCrossRefs" href="#bib0360">20–22</a> In this sense, OVF has traditionally been considered to involve a loss of at least 20% of the vertebral height.<a class="elsevierStyleCrossRef" href="#bib0330">14</a> However, with progressive understanding of the pathophysiology of OVFs, many authors have recognised that this classic definition is neither necessary nor sufficient to diagnose OVFs,<a class="elsevierStyleCrossRefs" href="#bib0265">1,23</a> because there are other signs that can be indicative of OVF in the absence of significant reduction of vertebral height. Accordingly, loss of parallelism between adjacent vertebrae or vertebral endplates (VEs), impaction of the VE on the vertebral body (VB), cortical discontinuities of the VB or VE, or indentation of vertebral surfaces, particularly in the anterior cortex, are currently considered signs of OVF in the appropriate clinical setting.<a class="elsevierStyleCrossRefs" href="#bib0265">1,6,22</a>A review of the literature on this topic reveals various radiographic diagnostic criteria for OVF, but all or most of them can be classified into three main categories: quantitative, qualitative and combined (semiquantitative) methods. Each of these approaches has certain advantages and limitations that must be known in order to apply the most appropriate one according to the clinical context.Quantitative or morphometric methodsQuantitative or morphometric methods are based on the measurement of the anterior, medial and posterior vertebral height (AVH, MVH and PVH, respectively). The comparison of these measurements with reference values allows determining the presence of fracture. Other aspects such as vertebral morphology are not assessed directly, although some of them can be actually inferred from the ratios obtained. For instance, the relationship between the AVH and the PVH reflects the degree of fracture wedging (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0350">18,24</a> Numerous morphometric algorithms have been developed with different degrees of complexity. The Eastell-Melton method<a class="elsevierStyleCrossRef" href="#bib0385">25</a> distinguishes three types of fractures (wedge, biconcavity, compression or crush fracture) depending on the vertebral height which is decreased, while the McCloskey-Kanis method further classifies the wedge type into anterior and posterior. Posterior wedge includes loss of PVH and MVH. Of note, isolated loss of the PVH was considered a variant which typically occurs at L5.<a class="elsevierStyleCrossRef" href="#bib0390">26</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>One of the main advantages of quantitative methods is that they are based on objective and reproducible measurements, particularly in healthy individuals.<a class="elsevierStyleCrossRef" href="#bib0380">24</a> In addition, the agreement with semi-quantitative methods is very high for intermediate and severe OVFs. Moreover, because of their simplicity, most of these methods can be applied by inexperienced observers, which is of particular interest to clinicians with little experience, or even to non-physicians in the research field. Furthermore, they can be used to implement ad hoc software and evaluate the efficiency of automated diagnostic algorithms using different methods (e.g., based on statistics or artificial intelligence).One of the main limitations of these methods is that they do not consider morphological alterations that may indicate OVF in the absence of vertebral height loss. In addition, it is not possible to ascertain whether the vertebral height loss is due to OVFs or other non-fracture causes, resulting in a high number of false positives. Moreover, there is low agreement with the semi-quantitative methods for mild or low-grade OVFs, with a higher rate of false positives using morphometric methods. Finally, these methods are time consuming for clinical practice and show a relatively high inter- and intra-observer variability.<a class="elsevierStyleCrossRef" href="#bib0330">14</a> In particular, the selected points for the measurement of each vertebral height (mainly the MVH) are quite subjective, particularly in cases of poor quality radiographs, spinal rotation or blurred vertebral edges.<a class="elsevierStyleCrossRef" href="#bib0395">27</a>Qualitative methodsClassification of osteoporotic vertebral fractures proposed by Jiang et al.Some OVFs do not display significant alterations of vertebral height or area, thus morphometric and combined methods are not appropriate.<a class="elsevierStyleCrossRefs" href="#bib0265">1,28</a> To diagnose these OVFs, several methods have been developed based on a step-by-step analysis focused on abnormalities of the VE. The main approach within this group is the algorithm-based qualitative (ABQ) method and its modified versions proposed by Jiang et al.<a class="elsevierStyleCrossRefs" href="#bib0395">27,28</a>, although this consideration has been overlooked in some clinical guidelines<a class="elsevierStyleCrossRef" href="#bib0405">29</a>.The ABQ method is designed to detect alterations in the VEs that are present in OVFs and exclude other potential causes for such alterations, (e.g. anatomical variants, diseases or poor radiographic technique). The steps of this algorithm lead to one of the following conclusions: (a) normal vertebra, (b) OVF (VE depression±loss of vertebral height), or (c) non-osteoporotic deformity (>15% loss of vertebral height without VE depression).Classification of osteoporotic vertebral fractures proposed by Sugita et al.According to this classification,<a class="elsevierStyleCrossRef" href="#bib0410">30</a> five types of OVF are distinguished based on the morphology of the VB in the lateral projection (performed in an acute setting) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>): type I (swelled-front): >50% bulge of the anterior wall; type II (bow-shaped): focal depression of the anterior wall and upper VE; type III (projecting): focal prominence<50% of the anterior wall; type IV (concave): depression of the upper VE without affecting the anterior wall; and type V (indented): indentation of the centre of the anterior wall with fracture line.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Types I, II and III have a worse prognosis and are associated with higher incidence of late vertebral collapse, while types IV and V have a better prognosis. The former group frequently show an intravertebral cleft that can be detected in radiographs as an intravertebral vacuum phenomenon. This observation has been partially supported by the work of Ha et al.,<a class="elsevierStyleCrossRef" href="#bib0415">31</a> who developed a simplified classification of OVFs with two groups: end plate or midportion types. In the endplate type fracture, cortical disruption of the VB is located at the endplate area or the anterior cortex adjacent to the endplate with confined signal changes on MRI around the endplate. In the mid-portion type, cortical disruptions of the VB and signal changes on MRI occur around the mid-portion of the vertebra. The authors noted that mid-portion type fractures and injury to the posterior vertebral wall are relative risk factors for progressive collapse following the acute fracture event.The main advantage of qualitative methods is that they allow the diagnosis of OVF without significant loss of vertebral height. In addition, prospective studies with large sample sizes have recently demonstrated an inverse correlation between OVFs diagnosed with qualitative methods and BMD, which is significantly higher compared to that of morphometric methods.<a class="elsevierStyleCrossRef" href="#bib0420">32</a> The main limitation of qualitative methods lies in the need for qualified observers who can discern among the possible causes of an abnormal VE morphology.<a class="elsevierStyleCrossRef" href="#bib0420">32</a> Furthermore, in cases of old fractures, remodelling of the VE over time can make discontinuities or depression of the VE unidentifiable, resulting in an increased number of false negatives.<a class="elsevierStyleCrossRef" href="#bib0395">27</a>Combined methodsCombined methods are based on both the description of the vertebral morphology and the quantification of height or surface loss. Although several classification systems have been reported, those proposed by Genant et al.,<a class="elsevierStyleCrossRef" href="#bib0425">33</a> and the German Society for Orthopaedics and Trauma (DGOU)<a class="elsevierStyleCrossRef" href="#bib0360">20</a> will be described because of their interest and applicability.Classification of osteoporotic vertebral fractures proposed by Genant et al.This is one of the most widely used systems for the diagnosis of OVFs based on conventional radiography in epidemiological studies.<a class="elsevierStyleCrossRef" href="#bib0430">34</a> It is based on the determination of vertebral height or surface loss (degrees 0–3) and the morphology of the vertebra, depending on the vertebral body height affected (anterior, middle or posterior). The estimation of height loss is based on visual assessment instead of direct measurements of the VB. The observer must then compare the actual vertebral height with the theoretical height that the vertebra should have, which requires previous experience.<a class="elsevierStyleCrossRefs" href="#bib0330">14,27</a> In fact, the inter-observer agreement for osteoporotic vertebral deformity according to Genant's grading system may show disparities.<a class="elsevierStyleCrossRef" href="#bib0430">34</a>Depending on the percentage of height and/or surface loss, the following degrees of deformity are established: grade 0 or normal vertebra (height loss<20% and surface loss<10%); grade 0.5 or borderline deformity (height loss 15–20%); grade 1 or mild deformity (height loss 20–25% and surface loss 10–20%); grade 2 or moderate deformity (height loss 25–40% and surface loss 20–40%) and grade 3 or severe deformity (height and surface loss>40%).Depending on the morphology of the vertebra, the following OVF types are distinguished: wedge fracture (involvement of the anterior wall); biconcave fracture (involvement of the middle wall; and crush fracture (involvement of the posterior wall).Other morphological changes such as VE deformities or disruption of the cortical outline must be considered as defining criteria for OVF. Recently, Wang et al.,<a class="elsevierStyleCrossRef" href="#bib0435">35</a> emphasized the importance of recognising the presence of endplate and/or cortex fracture (ECF), and proposed an expanded semi-quantitative (eSQ) OVF classification into six degrees for a more accurate reporting in follow-up research studies. Accordingly, the eSQ considers Genant's borderline deformity as grade I or minimal. This grade may be important when there is associated ECF. Genant's grade I deformity is equivalent to eSQ mild grade (grade 2); Genant's moderate grade (grade 2) is subdivided into eSQ grade 3 OVF (moderate, >25%–<1/3 height loss) and eSQ grade 4 OVF (moderately-severe, >1/3–<40% height loss). The rationale for this division is that OVFs with >1/3 height loss are always associated with positive ECF sign radiographically,<a class="elsevierStyleCrossRef" href="#bib0440">36</a> and that the presence of ECF is associated with further vertebral collapse and risk of new fractures.<a class="elsevierStyleCrossRef" href="#bib0445">37</a> Finally, Genant's severe grade 3 is subdivided into eSQ grade 5 (severe, >40%–<2/3 height loss) and eSQ grade 6 (collapsed, >2/3 height loss) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Nevertheless, for daily clinical practice, Wang also proposed to simplify Genant's classification into three categories: <1/5 vertebral height loss, 1/5–1/3 vertebral height loss and >1/3 vertebral height loss. OVFs of >1/3 of height loss are always associated with ECF.<a class="elsevierStyleCrossRefs" href="#bib0450">38,39</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>In general, combined methods can be easily applied in clinical practice and research, showing excellent inter-observer agreement.<a class="elsevierStyleCrossRef" href="#bib0330">14</a> In addition, the spinal deformity index proposed by Minne et al.,<a class="elsevierStyleCrossRef" href="#bib0460">40</a> which is obtained by adding up the degrees of the fractures present in the T4-L4 segment, has demonstrated prognostic value in estimating the severity of OVFs using the Genant's method.<a class="elsevierStyleCrossRef" href="#bib0425">33</a> One of the main advantages of the latter system over qualitative methods lies in the possibility of grading fractures by quantifying height loss, which allows a more accurate estimation of the patient's prognosis.The Genant's classification is insufficiently sensitive to detect OVFs that do not exceed 15–20% height loss (false negatives). In addition, slight vertebral height loss can be secondary to alterations other than osteoporosis (e.g. developmental abnormalities, normal aging, postural changes) especially in men (false positives).<a class="elsevierStyleCrossRefs" href="#bib0265">1,6</a> On the other hand, the correlation between Genant's grade I deformities and the development of OVFs is low.<a class="elsevierStyleCrossRef" href="#bib0465">41</a> In comparison with Sugita's classification, it is more focused on the degree of vertebral height loss. Conversely, Sugita's classification focuses on the shape of vertebral deformity, although it does not consider the involvement of the posterior wall.Classification of osteoporotic vertebral fracture proposed by the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)This classification aims to be a reliable and simple approach to be implemented in daily clinical practice, facilitating decision-making on the most appropriate treatment for vertebral fractures.<a class="elsevierStyleCrossRefs" href="#bib0360">20,42</a> This classification considers both the morphological pattern and the biomechanical stability of the fracture. It is not exclusively based on radiography, but also on CT and MRI. This system divides vertebral fractures into the following types (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>): type 1: no vertebral deformity, exclusively oedema in the VB (detected by MRI); type 2: deformity without or with<1/5 involvement of the posterior vertebral wall; type 3: deformity with involvement of the posterior vertebral wall; type 4: loss of integrity of the VB, collapse of the VB or “pincer” type fracture; and type 5: injuries with rotation or distraction.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>The main advantage of this classification lies in its simplicity, which facilitates its use in daily clinical practice. In addition, it includes recommendations on the appropriate treatment for each type of fracture (i.e., conservative vs. surgical). Regarding the limitations of this classification, no proper validation has been performed so far and, as stated above, a major drawback for non-radiologists is the need for an MRI exam to diagnose type 1 fractures. Furthermore, it does not take into consideration that height loss or deformities can be secondary to causes other than fractures.Compared to the classification by Ha et al.,<a class="elsevierStyleCrossRef" href="#bib0415">31</a> the DGOU's system (similarly to that proposed by Wang et al.<a class="elsevierStyleCrossRef" href="#bib0435">35</a>) is relatively complex. Therefore, further research is still required to develop a classification that optimizes both simplicity and clinical efficiency, with relevant clues that ensure the most appropriate management and prognosis for OVFs.A summary of the main classification methods for the diagnosis of osteoporotic vertebral fractures (OVF) is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Imaging findings that can be mistaken for osteoporotic vertebral fracturesThere are several causes other than OVF that can lead to reduced vertebral height and they should be known to avoid diagnostic errors. The most relevant ones<a class="elsevierStyleCrossRefs" href="#bib0330">14,43</a> are described below with some illustrative examples shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0005">-Physiological wedging: In normal children and adults, the VB is anteriorly wedged from T1 through L2 (peak at T7), non-wedged at L3, and posteriorly wedged at L4–L5 (peak at L5). In physiologic vertebral wedging thoracic kyphosis values are within the normal range and Schmorl's nodes are absent.<a class="elsevierStyleCrossRef" href="#bib0480">44</a></li><li class="elsevierStyleListItem" id="lsti0010">-Short vertebral height: term introduced by Jiang et al.,<a class="elsevierStyleCrossRef" href="#bib0375">23</a> to explain the low percentage of fractures found when applying the ABQ method in comparison with morphometric methods. It consists of abnormal morphometric measurements, i.e. reduced vertebral height, without alterations of the VE.<a class="elsevierStyleCrossRef" href="#bib0485">45</a> Up to 20% of height loss can be normal with aging, but it may be difficult to differentiate it from mild vertebral fractures.</li><li class="elsevierStyleListItem" id="lsti0015">-Cupid's bow deformity: This is a developmental variant characterised by a focal defect of the parasagittal cartilage of the VE, normally affecting the lower endplate of L4 and L5.<a class="elsevierStyleCrossRef" href="#bib0490">46</a> In the lateral projection it is observed as an indentation of the posterior region of the lower endplate, simulating a VE depression fracture.<a class="elsevierStyleCrossRef" href="#bib0330">14</a></li><li class="elsevierStyleListItem" id="lsti0020">-Scheuermann's disease: This is a rare disease which predominantly affects young males. It is characterised by alterations of the thoracolumbar spine coexisting with a height reduction of the intervertebral space and increased AP diameter. The most frequently used diagnostic criterion in clinical practice is the presence of a kyphotic angulation of at least 5° in three or more adjacent VBs.<a class="elsevierStyleCrossRef" href="#bib0495">47</a></li><li class="elsevierStyleListItem" id="lsti0025">-Schmorl's nodes or intraspongeal disc herniations: These represent a common finding, especially in patients with a degenerative spine, such as those with Scheuermann's disease. Schmorl's nodes are focal depressions of the VE due to weakness of the intervertebral disc, usually by degenerative phenomena. Although usually small in size, they are sometimes larger and can simulate OVFs. In these cases, it should be remembered that Schmorl's nodes have well-defined, rounded, sclerotic contours and do not extend through the entire endplate.<a class="elsevierStyleCrossRef" href="#bib0330">14</a></li><li class="elsevierStyleListItem" id="lsti0030">-Degenerative scoliosis: Due to the rotational effect of scoliosis on the VBs, these may acquire a biconcave appearance and be misinterpreted as an OVF. The AP projection allows to verify the presence of scoliosis, specifically the incurvation of the spinal axis and the decrease in size of the VBs in the concavity of the curve in comparison with the convexity.</li><li class="elsevierStyleListItem" id="lsti0035">-Pathological vertebral fracture: Most of the literature aimed at differentiating benign osteoporotic from pathological vertebral fractures secondary to metastases or primary tumours is based on MRI findings. Nevertheless, although less sensitive, there are several plain radiograph signs that may orientate in this challenging differential diagnosis. As stated above, OVFs usually present 3 morphologic patterns, namely wedge, concave (fish vertebra or diabolo-shaped vertebra) and, in advanced cases, crush. Involvement of the posterior vertebral wall in crush fractures appears as retropulsion of the posterior margin, either superior or inferior, of the vertebral body (VB). The presence of gas collections within the latter is considered a sign of vertebral necrosis and/or intravertebral instability and suggests benign osteoporotic fracture.<a class="elsevierStyleCrossRefs" href="#bib0500">48,49</a></li></ul><elsevierMultimedia ident="fig0025"></elsevierMultimedia>In pathological fractures, the osteolytic pattern in the VB can be detected, although 30–50% of bone loss is usually required for this pattern to be visible on plain-film radiography.<a class="elsevierStyleCrossRefs" href="#bib0510">50,51</a> Expansion of the cortex due to tumour growth inside the fractured body manifests as a convex wall while extension of the tumour to the paravertebral space can be detected as a paravertebral mass. Finally, unilateral destruction of the pedicle is usually responsible for the “winking owl” or “one-eyed vertebra” sign. Occasionally, destruction of both pedicles may lead to the “blind vertebra sign” in which there is no rounded shape of any of the pedicles in the AP view.<a class="elsevierStyleCrossRef" href="#bib0520">52</a>ConclusionsWe have reviewed the three main different approaches for classifying OVFs using conventional radiography. Quantitative or morphometric methods offer high reproducibility and objectivity but have low sensitivity for the detection of fractures characterised by subtle morphological alterations in which there is no significant vertebral height loss. Qualitative methods offer greater sensitivity for the diagnosis of OVFs that do not have significant vertebral height loss, but they require highly trained observers capable of discriminating the specific and sometimes very subtle imaging findings. Combined methods consider both loss of vertebral height or surface and vertebral morphology. The most suitable approach depends on context, familiarity and ease of use for the reader. Finally, it is important to acknowledge the most frequent non-fracture causes for vertebral abnormalities that can be mistaken for vertebral fractures on conventional radiography.Conflict of interestNothing to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1657736" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1473381" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1657737" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1473382" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Radiographic techniques to assess osteoporotic vertebral fractures" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Conventional spine radiography" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Conventional chest radiography" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Classification systems used in the diagnosis of osteoporotic vertebral fractures on conventional radiography" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Quantitative or morphometric methods" ] 1 => array:3 [ "identificador" => "sec0035" "titulo" => "Qualitative methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Classification of osteoporotic vertebral fractures proposed by Jiang et al." ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Classification of osteoporotic vertebral fractures proposed by Sugita et al." ] ] ] 2 => array:3 [ "identificador" => "sec0050" "titulo" => "Combined methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Classification of osteoporotic vertebral fractures proposed by Genant et al." ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Classification of osteoporotic vertebral fracture proposed by the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Imaging findings that can be mistaken for osteoporotic vertebral fractures" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-03-20" "fechaAceptado" => "2021-06-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1473381" "palabras" => array:4 [ 0 => "Osteoporosis" 1 => "Vertebral fracture" 2 => "Conventional radiography" 3 => "Radiological diagnosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1473382" "palabras" => array:4 [ 0 => "Osteoporosis" 1 => "Fractura vertebral" 2 => "Radiografía simple" 3 => "Diagnóstico radiológico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The radiological diagnosis of osteoporotic vertebral fractures (OVFs) is of major importance considering its therapeutic and prognostic implications. Both radiologists and clinicians have the opportunity to diagnose OVFs in daily clinical practice due to the widespread use of spine and chest radiography. However, several studies have reported an under-diagnosis of OVFs, particularly by a lack of consensus on the diagnostic criteria. Therefore, up-to-date knowledge of the most relevant approaches for the diagnosis of OVFs is necessary for many physicians. This article aims to review the most commonly used classification systems in the diagnosis of OVFs based on conventional radiography. We discuss their rationale, advantages and limitations, as well as their utility according to the context. This review will provide a concise yet useful understanding of the typology of OVFs, their clinical significance and prognosis. Finally, we include anatomical variations that can be confused with OVFs by non-experts." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El diagnóstico radiológico de las fracturas vertebrales osteoporóticas (FVO) es de gran importancia, considerando sus implicaciones terapéuticas y pronósticas. Tanto los radiólogos como los facultativos tienen la oportunidad de diagnosticar las FVO en la práctica clínica diaria debido al uso extendido de las radiografías de columna y tórax. Sin embargo, diversos estudios han reportado el infradiagnóstico de las FVO, particularmente debido a la falta de consenso sobre los criterios diagnósticos. Por tanto, es necesario actualizar el conocimiento de los enfoques más relevantes en cuanto al diagnóstico de las FVO de muchos médicos. El objetivo del presente artículo es revisar los sistemas de clasificación más comúnmente utilizados para diagnosticar las FVO sobre la base de la radiografía convencional. Debatimos sus fundamentos, ventajas y limitaciones, así como su utilidad con respecto al contexto. Esta revisión aportará una comprensión concisa y útil de la tipología de las FVO, su significación clínica y pronóstico. Por último, incluimos variaciones anatómicas que pueden ser confundidas con las FVO por los no expertos." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 447 "Ancho" => 1305 "Tamanyo" => 81550 ] ] "descripcion" => array:1 [ "en" => "Examples of morphometric measurements and their associated morphological parameters. (A) Anterior wedging; (b) posterior wedging; (c) biconcavity; (d) crush fracture. Red points mark the vertebral height which is decreased." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 915 "Ancho" => 1405 "Tamanyo" => 172995 ] ] "descripcion" => array:1 [ "en" => "Examples of OVF (osteoporotic vertebral fracture) according to the classification proposed by Sugita et al.31. (A) Normal vertebra. (B) Type I (swelled-front fracture). C) Type II (bow-shaped fracture). (D) Type III (projecting fracture). (E) Type IV (concave fracture). (F) Type V (indented fracture)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1151 "Ancho" => 1405 "Tamanyo" => 209279 ] ] "descripcion" => array:1 [ "en" => "Examples of expanded semi-quantitative (eSQ) OVF (osteoporotic vertebral fracture) classification by Wang et al.<a class="elsevierStyleCrossRef" href="#bib0435">35</a> (A) Grade I, minimal; (B) Grade II, mild; (C) Grade III, moderate; (D) Grade IV, moderate-severe; (E) Grade V, severe; (F) Grade VI, collapsed." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1016 "Ancho" => 1405 "Tamanyo" => 194803 ] ] "descripcion" => array:1 [ "en" => "Examples of OVFs (osteoporotic vertebral fractures) according to the DGOU's classification: (A) Type 1. (B) Type 2. (C) Type 3. (D) Types 4. (E) Type 5. Adapted from Schnake KJ et al.<a class="elsevierStyleCrossRef" href="#bib0360">20</a>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1136 "Ancho" => 1405 "Tamanyo" => 144979 ] ] "descripcion" => array:1 [ "en" => "Examples of non-osteoporotic vertebral height loss (A) Short vertebral height. (B and C) Cupid's bow deformity which causes indentation of the vertebral endplate in the lateral projection (arrows). (D) Scheuermann's disease. (E) Wedging and sclerosis in degenerative scoliosis. (F) Pathologic fracture in osteolytic metastasis." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "VE: vertebral endplate; BMI: bone mass index." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Quantitative methods \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Qualitative methods \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Combined methods \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Main characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Measurement of height or surface without assessment of vertebral morphology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Exclusion of VE abnormalities caused by conditions other than OVF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Estimation of height loss combined with vertebral morphology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advantages \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reproducibility (healthy subjects), Objective, Automatization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Excludes potential confounders (anatomical variants, other conditions). Better correlation with BMI and incidence of new OVFs. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Traditionally considered the best method due to its simplicity. High inter and intra-observer agreement. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Limitations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">False positives (height loss due to non-fracture causes), False negatives (OVF without height loss) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Need for highly-trained or expert observers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Confusion with anatomical variants and other conditions. It requires training and experience \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Applicability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Automated diagnosis, research \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Daily clinical practice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Daily clinical practice, research \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Examples \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eastell et al.,<a class="elsevierStyleCrossRef" href="#bib0385">25</a> McCloskey et al.<a class="elsevierStyleCrossRef" href="#bib0390">26</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Jiang et al.,<a class="elsevierStyleCrossRef" href="#bib0375">23</a> Sugita et al.<a class="elsevierStyleCrossRef" href="#bib0410">30</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Genant et al.,<a class="elsevierStyleCrossRef" href="#bib0425">33</a> DGOU<a class="elsevierStyleCrossRef" href="#bib0360">20</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2822422.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of the main classification methods for the diagnosis of osteoporotic vertebral fractures (OVF)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:52 [ 0 => array:3 [ "identificador" => "bib0265" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Identifying osteoporotic vertebral endplate and cortex fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y.X.J. Wáng" 1 => "F.R. Santiago" 2 => "M. Deng" 3 => "M.H. Nogueira-Barbosa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.21037/qims.2017.10.05" "Revista" => array:6 [ "tituloSerie" => "Quant Imaging Med Surg" "fecha" => "2017" "volumen" => "7" "paginaInicial" => "555" "paginaFinal" => "591" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29184768" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0270" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinician's guide to prevention and treatment of osteoporosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Cosman" 1 => "S.J. de Beur" 2 => "M.S. LeBoff" 3 => "E.M. Lewiecki" 4 => "B. Tanner" 5 => "S. Randall" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00198-014-2794-2" "Revista" => array:6 [ "tituloSerie" => "Osteoporos Int" "fecha" => "2014" "volumen" => "25" "paginaInicial" => "2359" "paginaFinal" => "2381" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25182228" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0275" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteoporosis in the European Union: medical management, epidemiology and economic burden" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Hernlund" 1 => "A. Svedbom" 2 => "M. Ivergård" 3 => "J. Compston" 4 => "C. Cooper" 5 => "J. Stenmark" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11657-013-0136-1" "Revista" => array:5 [ "tituloSerie" => "Arch Osteoporos" "fecha" => "2013" "volumen" => "8" "paginaInicial" => "136" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24113837" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0280" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Under-reporting of osteoporotic vertebral fractures on computed tomography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.L. Williams" 1 => "A. Al-Busaidi" 2 => "P.J. Sparrow" 3 => "J.E. Adams" 4 => "R.W. Whitehouse" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ejrad.2007.08.028" "Revista" => array:6 [ "tituloSerie" => "Eur J Radiol" "fecha" => "2009" "volumen" => "69" "paginaInicial" => "179" "paginaFinal" => "183" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17913429" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0285" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical consequences of vertebral fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P.D. Ross" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Med" "fecha" => "1997" "volumen" => "103" "paginaInicial" => "S30" "paginaFinal" => "S43" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0290" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The radiology of osteoporotic vertebral fractures redux" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Lentle" 1 => "J. Trollip" 2 => "K. Lian" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jocd.2015.08.009" "Revista" => array:6 [ "tituloSerie" => "J Clin Densitom" "fecha" => "2016" "volumen" => "19" "paginaInicial" => "40" "paginaFinal" => "47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26428658" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0295" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Excess mortality after hospitalisation for vertebral fracture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.A. Kanis" 1 => "A. Oden" 2 => "O. Johnell" 3 => "C. De Laet" 4 => "B. Jonsson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00198-003-1516-y" "Revista" => array:6 [ "tituloSerie" => "Osteoporos Int" "fecha" => "2004" "volumen" => "15" "paginaInicial" => "108" "paginaFinal" => "112" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14598026" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0300" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Population-based study of survival after osteoporotic fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Cooper" 1 => "E.J. Atkinson" 2 => "S.J. Jacobsen" 3 => "W.M. O’fallon" 4 => "L.J. Melton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/oxfordjournals.aje.a116756" "Revista" => array:6 [ "tituloSerie" => "Am J Epidemiol" "fecha" => "1993" "volumen" => "137" "paginaInicial" => "1001" "paginaFinal" => "1005" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8317445" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0305" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Imaging of osteoporotic fractures on XR CT, and MR" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B.C. Lentle" 1 => "I. Hammond" 2 => "G.B. Firth" 3 => "R.A.L. Sutton" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Curr Radiol Rep" "fecha" => "2014" "volumen" => "2" "paginaInicial" => "32" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0310" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The prevalence and under-diagnosis of vertebral fractures on chest radiograph" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Y. Li" 1 => "L. Yan" 2 => "S. Cai" 3 => "P. Wang" 4 => "H. Zhuang" 5 => "H. Yu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12891-018-2171-y" "Revista" => array:5 [ "tituloSerie" => "BMC Musculoskelet Disord" "fecha" => "2018" "volumen" => "19" "paginaInicial" => "235" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30021567" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0315" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Underdiagnosis of vertebral fractures is a worldwide problem: the IMPACT study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.D. Delmas" 1 => "L. van de Langerijt" 2 => "N.B. Watts" 3 => "R. Eastell" 4 => "H. Genant" 5 => "A. Grauer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Bone Miner Res" "fecha" => "2004" "volumen" => "20" "paginaInicial" => "557" "paginaFinal" => "563" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0320" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severity of vertebral fracture reflects deterioration of bone microarchitecture" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.K. Genant" 1 => "P.D. Delmas" 2 => "P. Chen" 3 => "Y. Jiang" 4 => "E.F. Eriksen" 5 => "G.P. Dalsky" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Osteoporos Int" "fecha" => "2007" "volumen" => "18" "paginaInicial" => "69" "paginaFinal" => "76" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0325" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiation exposure in X-ray-based imaging techniques used in osteoporosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Damilakis" 1 => "J.E. Adams" 2 => "G. Guglielmi" 3 => "T.M. Link" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur Radiol" "fecha" => "2010" "volumen" => "20" "paginaInicial" => "2707" "paginaFinal" => "2714" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0330" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Identifying osteoporotic vertebral fracture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.F. Griffith" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3978/j.issn.2223-4292.2015.08.01" "Revista" => array:6 [ "tituloSerie" => "Quant Imaging Med Surg" "fecha" => "2015" "volumen" => "5" "paginaInicial" => "592" "paginaFinal" => "602" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26435923" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0335" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of specific training in detecting osteoporotic vertebral fractures on routine chest radiographs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Gruber" 1 => "J. Dinges" 2 => "D. Müller" 3 => "T. Baum" 4 => "E. Rummeny" 5 => "J. Bauer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "RöFo – Fortschritte auf dem Gebiet der Röntgenstrahlen und der Bildgeb Verfahren" "fecha" => "2013" "volumen" => "185" "paginaInicial" => "1074" "paginaFinal" => "1080" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0340" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteoporotic thoracolumbar fractures—how are they different?.—Classification and treatment algorithm" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Rajasekaran" 1 => "R.M. Kanna" 2 => "K.J. Schnake" 3 => "A.R. Vaccaro" 4 => "G.D. Schroeder" 5 => "S. Sadiqi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/BOT.0000000000000949" "Revista" => array:6 [ "tituloSerie" => "J Orthop Trauma" "fecha" => "2017" "volumen" => "31" "paginaInicial" => "S49" "paginaFinal" => "S56" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28816876" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0345" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The use of reference image criteria in X-ray diagnostics: an application for the optimisation of lumbar spine radiographs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Almén" 1 => "A. Tingberg" 2 => "J. Besjakov" 3 => "S. Mattsson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00330-004-2320-6" "Revista" => array:3 [ "tituloSerie" => "Eur Radiol" "fecha" => "2004" "paginaInicial" => "14" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0350" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Review of radiological scoring methods of osteoporotic vertebral fractures for clinical and research settings" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Oei" 1 => "F. Rivadeneira" 2 => "F. Ly" 3 => "S.J. Breda" 4 => "M.C. Zillikens" 5 => "A. Hofman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur Radiol" "fecha" => "2013" "volumen" => "23" "paginaInicial" => "476" "paginaFinal" => "486" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0355" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recognizing osteoporotic vertebral deformity on frontal view radiograph: a cohort analysis and a pictorial review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y.X.J. Wáng" 1 => "M.M. Du" 2 => "N. Che-Nordin" 3 => "P.P. Ye" 4 => "S.W. Qiu" 5 => "J.F. Griffith" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11657-020-00716-5" "Revista" => array:3 [ "tituloSerie" => "Arch Osteoporos" "fecha" => "2020" "paginaInicial" => "15" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0360" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classification of osteoporotic thoracolumbar spine fractures: recommendations of the spine section of the German Society for Orthopaedics and Trauma (DGOU)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.J. Schnake" 1 => "T.R. Blattert" 2 => "P. Hahn" 3 => "A. Franck" 4 => "F. Hartmann" 5 => "B. Ullrich" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Glob Spine J" "fecha" => "2018" "volumen" => "8" "paginaInicial" => "46S" "paginaFinal" => "49S" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0365" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiologic assessment of osteoporotic vertebral fractures: diagnostic and prognostic implications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T.M. Link" 1 => "G. Guglielmi" 2 => "C. van Kuijk" 3 => "J.E. Adams" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00330-005-2773-2" "Revista" => array:6 [ "tituloSerie" => "Eur Radiol" "fecha" => "2005" "volumen" => "15" "paginaInicial" => "1521" "paginaFinal" => "1532" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15841380" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0370" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteoporotic vertebral endplate and cortex fractures: a pictorial review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Y.X.J. Wáng" 1 => "M. Deng" 2 => "L.-C. He" 3 => "N. Che-Nordin" 4 => "F.R. Santiago" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Orthop Transl" "fecha" => "2018" "volumen" => "15" "paginaInicial" => "35" "paginaFinal" => "49" ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0375" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of methods for the visual identification of prevalent vertebral fracture in osteoporosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G. Jiang" 1 => "R. Eastell" 2 => "N.A. Barrington" 3 => "L. Ferrar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00198-004-1626-1" "Revista" => array:6 [ "tituloSerie" => "Osteoporos Int" "fecha" => "2004" "volumen" => "15" "paginaInicial" => "887" "paginaFinal" => "896" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15071725" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0380" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiographic methods for evaluating osteoporotic vertebral fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. Grados" 1 => "J. Fechtenbaum" 2 => "E. Flipon" 3 => "S. Kolta" 4 => "C. Roux" 5 => "P. Fardellone" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Jt Bone Spine" "fecha" => "2009" "volumen" => "76" "paginaInicial" => "241" "paginaFinal" => "247" ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0385" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classification of vertebral fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R. Eastell" 1 => "S.L. Cedel" 2 => "H.W. Wahner" 3 => "B.L. Riggs" 4 => "L.J. Melton" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Bone Miner Res" "fecha" => "1991" "volumen" => "6" "paginaInicial" => "207" "paginaFinal" => "215" ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0390" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The assessment of vertebral deformity: a method for use in population studies and clinical trials" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.V. McCloskey" 1 => "T.D. Spector" 2 => "K.S. Eyres" 3 => "E.D. Fern" 4 => "N. O’Rourke" 5 => "S. Vasikaran" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Osteoporos Int" "fecha" => "1993" "volumen" => "3" "paginaInicial" => "138" "paginaFinal" => "147" ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0395" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vertebral fracture: diagnostic difficulties of a major medical problem" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. Szulc" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/jbmr.3404" "Revista" => array:7 [ "tituloSerie" => "J Bone Miner Res" "fecha" => "2018" "volumen" => "33" "paginaInicial" => "553" "paginaFinal" => "559" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29419882" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109799004684" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0400" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The broadening spectrum of osteoporotic vertebral fracture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F.E. McKiernan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00256-008-0632-3" "Revista" => array:6 [ "tituloSerie" => "Skeletal Radiol" "fecha" => "2009" "volumen" => "38" "paginaInicial" => "303" "paginaFinal" => "308" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19183993" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0405" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteoporosis Canada 2010 guidelines for the assessment of fracture risk" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Lentle" 1 => "A.M. Cheung" 2 => "D.A. Hanley" 3 => "W.D. Leslie" 4 => "D. Lyons" 5 => "A. Papaioannou" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.carj.2011.05.001" "Revista" => array:6 [ "tituloSerie" => "Can Assoc Radiol J" "fecha" => "2011" "volumen" => "62" "paginaInicial" => "243" "paginaFinal" => "250" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21852066" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0410" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classification of vertebral compression fractures in the osteoporotic spine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Sugita" 1 => "N. Watanabe" 2 => "Y. Mikami" 3 => "H. Hase" 4 => "T. Kubo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.bsd.0000168716.23440.61" "Revista" => array:5 [ "tituloSerie" => "J Spinal Disord Tech" "fecha" => "2005" "volumen" => "18" "paginaInicial" => "376" "paginaFinal" => "381" ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0415" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors affecting progressive collapse of acute osteoporotic spinal fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K.Y. Ha" 1 => "Y.H. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Osteoporos Int" "fecha" => "2013" "volumen" => "24" "paginaInicial" => "1207" "paginaFinal" => "1213" ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0420" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The radiology of osteoporotic vertebral fractures revisited" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Lentle" 1 => "F. Koromani" 2 => "J.P. Brown" 3 => "L. Oei" 4 => "L. Ward" 5 => "D. Goltzman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "J Bone Miner Res" "fecha" => "2019" "volumen" => "34" "paginaInicial" => "e3669" ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0425" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vertebral fracture assessment using a semiquantitative technique" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H.K. Genant" 1 => "C.Y. Wu" 2 => "C. van Kuijk" 3 => "M.C. Nevitt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/jbmr.5650080915" "Revista" => array:6 [ "tituloSerie" => "J Bone Miner Res" "fecha" => "1993" "volumen" => "8" "paginaInicial" => "1137" "paginaFinal" => "1148" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8237484" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0430" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Difficulties in the diagnosis of vertebral fracture in men: agreement between doctors" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Fechtenbaum" 1 => "K. Briot" 2 => "S. Paternotte" 3 => "M. Audran" 4 => "V. Breuil" 5 => "B. Cortet" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Jt Bone Spine" "fecha" => "2014" "volumen" => "81" "paginaInicial" => "169" "paginaFinal" => "174" ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0435" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Semi-quantitative grading and extended semi-quantitative grading for osteoporotic vertebral deformity: a radiographic image database for education and calibration" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y.X.J. Wáng" 1 => "D. Diacinti" 2 => "W. Yu" 3 => "X.-G. Cheng" 4 => "M.H. Nogueira-Barbosa" 5 => "N. Che-Nordin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Ann Transl Med" "fecha" => "2020" "volumen" => "8" ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0440" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "All osteoporotically deformed vertebrae with>34% height loss have radiographically identifiable endplate/cortex fracture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Deng" 1 => "T.C.Y. Kwok" 2 => "J.C.S. Leung" 3 => "P.C. Leung" 4 => "Y.X.J. Wáng" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Orthop Transl" "fecha" => "2018" "volumen" => "14" "paginaInicial" => "63" "paginaFinal" => "66" ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0445" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteoporotic vertebral deformity with endplate/cortex fracture is associated with higher further vertebral fracture risk: the Ms OS (Hong Kong) study results" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y.X.J. Wáng" 1 => "N. Che-Nordin" 2 => "M. Deng" 3 => "J.C.S. Leung" 4 => "A.W.L. Kwok" 5 => "L.C. He" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00198-019-04856-4" "Revista" => array:6 [ "tituloSerie" => "Osteoporos Int" "fecha" => "2019" "volumen" => "30" "paginaInicial" => "897" "paginaFinal" => "905" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30666373" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0450" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A modified semi-quantitative (mSQ) grading scheme for osteoporotic vertebral fracture in elderly women" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Y.X.J. Wáng" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.21037/qims.2019.02.04" "Revista" => array:6 [ "tituloSerie" => "Quant Imaging Med Surg" "fecha" => "2019" "volumen" => "9" "paginaInicial" => "146" "paginaFinal" => "150" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30976538" "web" => "Medline" ] ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0455" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of radiography in the study of spinal disorders" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F. Ruiz Santiago" 1 => "A.J. Láinez Ramos-Bossini" 2 => "Y.X.J. Wáng" 3 => "D. López Zúñiga" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.21037/qims-20-1014" "Revista" => array:7 [ "tituloSerie" => "Quant Imaging Med Surg" "fecha" => "2020" "volumen" => "10" "paginaInicial" => "2322" "paginaFinal" => "2355" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33269230" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0022347615005545" "estado" => "S300" "issn" => "00223476" ] ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0460" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A newly developed spine deformity index (SDI) to quantitate vertebral crush fractures in patients with osteoporosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.W. Minne" 1 => "G. Leidig" 2 => "C. Wüster" 3 => "L. Siromachkostov" 4 => "G. Baldauf" 5 => "R. Bickel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Bone Miner" "fecha" => "1988" "volumen" => "3" "paginaInicial" => "335" "paginaFinal" => "349" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2852512" "web" => "Medline" ] ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0465" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mild morphometric vertebral fractures predict vertebral fractures but not non-vertebral fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. Johansson" 1 => "A. Odén" 2 => "E.V. McCloskey" 3 => "J.A. Kanis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00198-013-2460-0" "Revista" => array:6 [ "tituloSerie" => "Osteoporos Int" "fecha" => "2014" "volumen" => "25" "paginaInicial" => "235" "paginaFinal" => "241" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23974856" "web" => "Medline" ] ] ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0470" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nonsurgical and surgical management of osteoporotic vertebral body fractures: recommendations of the spine Section of the German Society for Orthopaedics and Trauma (DGOU)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.R. Blattert" 1 => "K.J. Schnake" 2 => "O. Gonschorek" 3 => "E. Gercek" 4 => "F. Hartmann" 5 => "S. Katscher" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Glob Spine J" "fecha" => "2018" "volumen" => "8" "paginaInicial" => "50S" "paginaFinal" => "55S" ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0475" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classifying thoracolumbar fractures: role of quantitative imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. Ruiz Santiago" 1 => "P. Tomás Muñoz" 2 => "E. Moya Sánchez" 3 => "M. Revelles Paniza" 4 => "A. Martínez Martínez" 5 => "A.L. Pérez Abela" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.21037/qims.2016.12.04" "Revista" => array:6 [ "tituloSerie" => "Quant Imaging Med Surg" "fecha" => "2016" "volumen" => "6" "paginaInicial" => "772" "paginaFinal" => "784" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28090452" "web" => "Medline" ] ] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0480" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vertebral body shape variation in the thoracic and lumbar spine: Characterization of its asymmetry and wedging" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Masharawi" 1 => "K. Salame" 2 => "Y. Mirovsky" 3 => "S. Peleg" 4 => "G. Dar" 5 => "N. Steinberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ca.20532" "Revista" => array:7 [ "tituloSerie" => "Clin Anat" "fecha" => "2008" "volumen" => "21" "paginaInicial" => "46" "paginaFinal" => "54" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17729333" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S016882271630153X" "estado" => "S300" "issn" => "01688227" ] ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0485" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is short vertebral height always an osteoporotic fracture? The Osteoporosis and Ultrasound Study (OPUS)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Ferrar" 1 => "G. Jiang" 2 => "G. Armbrecht" 3 => "D.M. Reid" 4 => "C. Roux" 5 => "C.C. Glüer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.bone.2007.03.015" "Revista" => array:6 [ "tituloSerie" => "Bone" "fecha" => "2007" "volumen" => "41" "paginaInicial" => "5" "paginaFinal" => "12" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17499570" "web" => "Medline" ] ] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0490" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cupid's bow contour of the vertebral body: Evaluation of pathogenesis with bone densitometry and imaging-histopathologic correlation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.K. Chan" 1 => "D.J. Sartoris" 2 => "P. Haghighi" 3 => "P. Sledge" 4 => "E. Barrett-Connor" 5 => "D.T. Trudell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiology.202.1.8988219" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "1997" "volumen" => "202" "paginaInicial" => "253" "paginaFinal" => "256" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8988219" "web" => "Medline" ] ] ] ] ] ] ] ] 46 => array:3 [ "identificador" => "bib0495" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scheuermann's disease: current diagnosis and treatment approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Bezalel" 1 => "E. Carmeli" 2 => "E. Been" 3 => "L. Kalichman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3233/BMR-140483" "Revista" => array:6 [ "tituloSerie" => "J Back Musculoskelet Rehabil" "fecha" => "2014" "volumen" => "27" "paginaInicial" => "383" "paginaFinal" => "390" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24898440" "web" => "Medline" ] ] ] ] ] ] ] ] 47 => array:3 [ "identificador" => "bib0500" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Usefulness of prone cross-table lateral radiographs in vertebral compression fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.H. Cho" 1 => "S.I. Shin" 2 => "J.H. Lee" 3 => "J.S. Yeom" 4 => "B.S. Chang" 5 => "C.K. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Orthop Surg" "fecha" => "2013" "volumen" => "5" "paginaInicial" => "195" "paginaFinal" => "201" "itemHostRev" => array:3 [ "pii" => "S0026049514003126" "estado" => "S300" "issn" => "00260495" ] ] ] ] ] ] ] 48 => array:3 [ "identificador" => "bib0505" "etiqueta" => "49" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Plain-film radiography in the study of spinal pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F. Ruiz Santiago" 1 => "L. Guzmán Alvarez" 2 => "M. Tello Moreno" 3 => "P.J. Navarrete González" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rx.2009.12.010" "Revista" => array:6 [ "tituloSerie" => "Radiologia" "fecha" => "2010" "volumen" => "52" "paginaInicial" => "126" "paginaFinal" => "137" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20227735" "web" => "Medline" ] ] ] ] ] ] ] ] 49 => array:3 [ "identificador" => "bib0510" "etiqueta" => "50" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current imaging in spinal metastatic disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Kamholtz" 1 => "G. 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Radiographic diagnosis of osteoporotic vertebral fractures. An updated review

Diagnóstico radiológico de las fracturas vertebrales osteoporóticas. Una revisión actualizada

Daniel López Zúñigaa, Antonio Jesús Láinez-Ramos-Bossinia,b, Fernando Ruiz Santiagoa,b,

Corresponding author

ferusan12@gmail.com

Corresponding author.

a Department of Radiology, “Virgen de las Nieves” University Hospital, Granada, Spain

b Department of Radiology and Physical Medicine, University of Granada, Granada, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Osteoporosis is characterised by the deterioration of bone mass and micro-architecture&#44; which increases the risk of fragility fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">1</span></a> It is the most common metabolic bone disease in the world&#44; representing a major health concern with 27&#46;6 million people affected in the European Union&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">2&#8211;4</span></a> Its prevalence is higher in women and increases with age&#44; being 3&#8211;4 times more frequent above the age of 50&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Vertebral fractures are the most frequent location in osteoporotic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">3</span></a> Detecting one or more osteoporotic vertebral fractures &#40;OVFs&#41; is sufficient to make the diagnosis of osteoporosis&#44; even in the absence of bone mineral density &#40;BMD&#41; determination&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">2</span></a> Moreover&#44; the presence of one or more OVFs significantly increases the risk of suffering other fractures in the future&#44; regardless of the patient&#39;s BMD&#44; and the associated morbidity and mortality are similar to osteoporotic hip fractures at 5 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">1&#44;3&#44;5&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">As highlighted by Lentle et al&#46;&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">6&#44;9</span></a> OVFs are a special type of fracture due to several factors&#44; including lack of consensus criteria on their definition&#44; coexistence of bone consolidation and destruction with subsequent gradual fracture development&#44; and paucity or even absence of symptoms&#46; In fact&#44; many OVFs are incidentally detected on imaging exams performed for unrelated reasons&#46; It is estimated that only 30&#37; of OVFs come to medical attention&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">4</span></a> which has been attributed to various factors such as clinical focus on other findings of greater severity&#44; lack of familiarity with OVFs<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">10</span></a> or ambiguous terminology in radiology reports&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">11</span></a> However&#44; an accurate diagnosis of OVFs is needed to initiate appropriate drug treatment and thus reduce the risk of future fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">10</span></a> Moreover&#44; describing the severity of the OVF is essential because severe fractures are associated with greater deterioration of bone quality and higher risk of new fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although radiologists have a central role in the diagnosis of OVFs&#44; interpretation of chest and spine radiographs is a basic skill for all clinicians&#44; thus recommendations for assessing OVFs should be known&#46; However&#44; with the development of more sophisticated imaging exams &#40;e&#46;g&#46;&#44; CT&#44; MRI&#41;&#44; clinicians and even radiologists are losing interest in recognising the features and classification systems of OVFs on conventional radiography&#46; The purpose of this article is to review the main radiographic approaches available regarding the diagnosis of OVFs&#44; their advantages and limitations&#44; as well as the anatomical variants that most frequently lead to diagnostic pitfalls&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Radiographic techniques to assess osteoporotic vertebral fractures</span><p id="par0025" class="elsevierStylePara elsevierViewall">Conventional or plain radiography is a fast&#44; widely available and inexpensive technique that involves relatively low effective radiation doses &#40;0&#46;3&#8211;0&#46;7<span class="elsevierStyleHsp" style=""></span>mSv&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">13</span></a> For these reasons&#44; it is considered by some authors to be the best imaging technique to assess the presence of low-energy vertebral fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">14</span></a> Although spine radiographs are the optimal radiographic technique to make an accurate diagnosis of OVF&#44; chest radiography also allows their detection&#44; thus cautious examination of the spine should always be carried out&#44; even in patients without pain&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conventional spine radiography</span><p id="par0030" class="elsevierStylePara elsevierViewall">Conventional radiography of the thoracolumbar spine&#44; in both anterior&#8211;posterior &#40;AP&#41; and lateral projections&#44; is the initial imaging exam of choice in patients with symptoms suggestive of low-energy vertebral fracture &#40;localised pain&#44; height reduction&#44; or thoracic kyphosis&#41;&#44; especially if there is associated trauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Performing an adequate radiographic technique is necessary to avoid diagnostic errors due to incorrect positioning of the patient or inadequate acquisition parameters&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">1</span></a> Parallel positioning of the patient&#39;s spine on the table and adequate centring&#44; collimation and physical parameters must be ensured to avoid poor image quality&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">17</span></a> The coverage should include the spinal segment between C7 and S1&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Although specific projections centred at the thoracolumbar junction may be used&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">18</span></a> the AP and lateral projections are usually sufficient for correct assessment of the height of vertebral bodies and for detection of fracture lines&#46; Although assessment based on both projections increases diagnostic sensitivity&#44; the AP projection is less sensitive&#44; being the lateral projection the only one used in most epidemiological studies&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">1</span></a> In this projection&#44; the two main parameters to be assessed are vertebral height and the degree of kyphotic deformity&#46; It should be stressed that the decrease in these parameters over time may allow the diagnosis of incident OVFs&#44; thus radiographic follow-up is essential to spot new OVFs&#46; On the other hand&#44; W&#225;ng et al&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">19</span></a> suggest that the majority of moderate and severe vertebral fractures can be detected on AP projections in patients at high risk of osteoporosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conventional chest radiography</span><p id="par0045" class="elsevierStylePara elsevierViewall">Although not the initial imaging technique of choice&#44; chest radiography is undoubtedly one of the most widely used imaging exams and generally covers all or part of the thoracolumbar junction in the lateral projection&#44; allowing the diagnosis of OVFs both in symptomatic and asymptomatic patients&#46; Therefore&#44; this examination can be a valuable screening method for OVFs&#46; However&#44; it has been found that only one third of OVFs are described in radiologic reports of chest radiographs&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">15</span></a> In general&#44; the same technical quality requirements and measures as in spine radiography are applicable&#46; Although few literature is available on the utility of the AP projection and further studies are needed to demonstrate its positive predictive value and cost-effectiveness in real-world practice&#44; it opens up a great opportunity for the diagnosis of OVFs in patients with radiographs performed for other reasons &#40;e&#46;g&#46; abdomen or chest radiography&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Classification systems used in the diagnosis of osteoporotic vertebral fractures on conventional radiography</span><p id="par0050" class="elsevierStylePara elsevierViewall">For more than half a century&#44; numerous classification systems have been developed with the aim to classify OVFs based on imaging features on conventional radiography&#46; Nevertheless&#44; only a few classifications have gained international acceptance&#44; and the criteria for the diagnosis and classification of OVFs remain a subject of debate among experts&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">20&#8211;22</span></a> In this sense&#44; OVF has traditionally been considered to involve a loss of at least 20&#37; of the vertebral height&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">14</span></a> However&#44; with progressive understanding of the pathophysiology of OVFs&#44; many authors have recognised that this classic definition is neither necessary nor sufficient to diagnose OVFs&#44;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">1&#44;23</span></a> because there are other signs that can be indicative of OVF in the absence of significant reduction of vertebral height&#46; Accordingly&#44; loss of parallelism between adjacent vertebrae or vertebral endplates &#40;VEs&#41;&#44; impaction of the VE on the vertebral body &#40;VB&#41;&#44; cortical discontinuities of the VB or VE&#44; or indentation of vertebral surfaces&#44; particularly in the anterior cortex&#44; are currently considered signs of OVF in the appropriate clinical setting&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">1&#44;6&#44;22</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A review of the literature on this topic reveals various radiographic diagnostic criteria for OVF&#44; but all or most of them can be classified into three main categories&#58; quantitative&#44; qualitative and combined &#40;semiquantitative&#41; methods&#46; Each of these approaches has certain advantages and limitations that must be known in order to apply the most appropriate one according to the clinical context&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Quantitative or morphometric methods</span><p id="par0060" class="elsevierStylePara elsevierViewall">Quantitative or morphometric methods are based on the measurement of the anterior&#44; medial and posterior vertebral height &#40;AVH&#44; MVH and PVH&#44; respectively&#41;&#46; The comparison of these measurements with reference values allows determining the presence of fracture&#46; Other aspects such as vertebral morphology are not assessed directly&#44; although some of them can be actually inferred from the ratios obtained&#46; For instance&#44; the relationship between the AVH and the PVH reflects the degree of fracture wedging &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">18&#44;24</span></a> Numerous morphometric algorithms have been developed with different degrees of complexity&#46; The Eastell-Melton method<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">25</span></a> distinguishes three types of fractures &#40;wedge&#44; biconcavity&#44; compression or crush fracture&#41; depending on the vertebral height which is decreased&#44; while the McCloskey-Kanis method further classifies the wedge type into anterior and posterior&#46; Posterior wedge includes loss of PVH and MVH&#46; Of note&#44; isolated loss of the PVH was considered a variant which typically occurs at L5&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">26</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">One of the main advantages of quantitative methods is that they are based on objective and reproducible measurements&#44; particularly in healthy individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">24</span></a> In addition&#44; the agreement with semi-quantitative methods is very high for intermediate and severe OVFs&#46; Moreover&#44; because of their simplicity&#44; most of these methods can be applied by inexperienced observers&#44; which is of particular interest to clinicians with little experience&#44; or even to non-physicians in the research field&#46; Furthermore&#44; they can be used to implement ad hoc software and evaluate the efficiency of automated diagnostic algorithms using different methods &#40;e&#46;g&#46;&#44; based on statistics or artificial intelligence&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">One of the main limitations of these methods is that they do not consider morphological alterations that may indicate OVF in the absence of vertebral height loss&#46; In addition&#44; it is not possible to ascertain whether the vertebral height loss is due to OVFs or other non-fracture causes&#44; resulting in a high number of false positives&#46; Moreover&#44; there is low agreement with the semi-quantitative methods for mild or low-grade OVFs&#44; with a higher rate of false positives using morphometric methods&#46; Finally&#44; these methods are time consuming for clinical practice and show a relatively high inter- and intra-observer variability&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">14</span></a> In particular&#44; the selected points for the measurement of each vertebral height &#40;mainly the MVH&#41; are quite subjective&#44; particularly in cases of poor quality radiographs&#44; spinal rotation or blurred vertebral edges&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Qualitative methods</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Classification of osteoporotic vertebral fractures proposed by Jiang et al&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Some OVFs do not display significant alterations of vertebral height or area&#44; thus morphometric and combined methods are not appropriate&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">1&#44;28</span></a> To diagnose these OVFs&#44; several methods have been developed based on a step-by-step analysis focused on abnormalities of the VE&#46; The main approach within this group is the algorithm-based qualitative &#40;ABQ&#41; method and its modified versions proposed by Jiang et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">27&#44;28</span></a>&#44; although this consideration has been overlooked in some clinical guidelines<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">29</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The ABQ method is designed to detect alterations in the VEs that are present in OVFs and exclude other potential causes for such alterations&#44; &#40;e&#46;g&#46; anatomical variants&#44; diseases or poor radiographic technique&#41;&#46; The steps of this algorithm lead to one of the following conclusions&#58; &#40;a&#41; normal vertebra&#44; &#40;b&#41; OVF &#40;VE depression<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>loss of vertebral height&#41;&#44; or &#40;c&#41; non-osteoporotic deformity &#40;&#62;15&#37; loss of vertebral height without VE depression&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Classification of osteoporotic vertebral fractures proposed by Sugita et al&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall">According to this classification&#44;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">30</span></a> five types of OVF are distinguished based on the morphology of the VB in the lateral projection &#40;performed in an acute setting&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#58; type I &#40;swelled-front&#41;&#58; &#62;50&#37; bulge of the anterior wall&#59; type II &#40;bow-shaped&#41;&#58; focal depression of the anterior wall and upper VE&#59; type III &#40;projecting&#41;&#58; focal prominence<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37; of the anterior wall&#59; type IV &#40;concave&#41;&#58; depression of the upper VE without affecting the anterior wall&#59; and type V &#40;indented&#41;&#58; indentation of the centre of the anterior wall with fracture line&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Types I&#44; II and III have a worse prognosis and are associated with higher incidence of late vertebral collapse&#44; while types IV and V have a better prognosis&#46; The former group frequently show an intravertebral cleft that can be detected in radiographs as an intravertebral vacuum phenomenon&#46; This observation has been partially supported by the work of Ha et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">31</span></a> who developed a simplified classification of OVFs with two groups&#58; end plate or midportion types&#46; In the endplate type fracture&#44; cortical disruption of the VB is located at the endplate area or the anterior cortex adjacent to the endplate with confined signal changes on MRI around the endplate&#46; In the mid-portion type&#44; cortical disruptions of the VB and signal changes on MRI occur around the mid-portion of the vertebra&#46; The authors noted that mid-portion type fractures and injury to the posterior vertebral wall are relative risk factors for progressive collapse following the acute fracture event&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The main advantage of qualitative methods is that they allow the diagnosis of OVF without significant loss of vertebral height&#46; In addition&#44; prospective studies with large sample sizes have recently demonstrated an inverse correlation between OVFs diagnosed with qualitative methods and BMD&#44; which is significantly higher compared to that of morphometric methods&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">32</span></a> The main limitation of qualitative methods lies in the need for qualified observers who can discern among the possible causes of an abnormal VE morphology&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">32</span></a> Furthermore&#44; in cases of old fractures&#44; remodelling of the VE over time can make discontinuities or depression of the VE unidentifiable&#44; resulting in an increased number of false negatives&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">27</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Combined methods</span><p id="par0100" class="elsevierStylePara elsevierViewall">Combined methods are based on both the description of the vertebral morphology and the quantification of height or surface loss&#46; Although several classification systems have been reported&#44; those proposed by Genant et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">33</span></a> and the German Society for Orthopaedics and Trauma &#40;DGOU&#41;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">20</span></a> will be described because of their interest and applicability&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Classification of osteoporotic vertebral fractures proposed by Genant et al&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">This is one of the most widely used systems for the diagnosis of OVFs based on conventional radiography in epidemiological studies&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">34</span></a> It is based on the determination of vertebral height or surface loss &#40;degrees 0&#8211;3&#41; and the morphology of the vertebra&#44; depending on the vertebral body height affected &#40;anterior&#44; middle or posterior&#41;&#46; The estimation of height loss is based on visual assessment instead of direct measurements of the VB&#46; The observer must then compare the actual vertebral height with the theoretical height that the vertebra should have&#44; which requires previous experience&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">14&#44;27</span></a> In fact&#44; the inter-observer agreement for osteoporotic vertebral deformity according to Genant&#39;s grading system may show disparities&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">34</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Depending on the percentage of height and&#47;or surface loss&#44; the following degrees of deformity are established&#58; grade 0 or normal vertebra &#40;height loss<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20&#37; and surface loss<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10&#37;&#41;&#59; grade 0&#46;5 or borderline deformity &#40;height loss 15&#8211;20&#37;&#41;&#59; grade 1 or mild deformity &#40;height loss 20&#8211;25&#37; and surface loss 10&#8211;20&#37;&#41;&#59; grade 2 or moderate deformity &#40;height loss 25&#8211;40&#37; and surface loss 20&#8211;40&#37;&#41; and grade 3 or severe deformity &#40;height and surface loss<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Depending on the morphology of the vertebra&#44; the following OVF types are distinguished&#58; wedge fracture &#40;involvement of the anterior wall&#41;&#59; biconcave fracture &#40;involvement of the middle wall&#59; and crush fracture &#40;involvement of the posterior wall&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Other morphological changes such as VE deformities or disruption of the cortical outline must be considered as defining criteria for OVF&#46; Recently&#44; Wang et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">35</span></a> emphasized the importance of recognising the presence of endplate and&#47;or cortex fracture &#40;ECF&#41;&#44; and proposed an expanded semi-quantitative &#40;eSQ&#41; OVF classification into six degrees for a more accurate reporting in follow-up research studies&#46; Accordingly&#44; the eSQ considers Genant&#39;s borderline deformity as grade I or minimal&#46; This grade may be important when there is associated ECF&#46; Genant&#39;s grade I deformity is equivalent to eSQ mild grade &#40;grade 2&#41;&#59; Genant&#39;s moderate grade &#40;grade 2&#41; is subdivided into eSQ grade 3 OVF &#40;moderate&#44; &#62;25&#37;&#8211;&#60;1&#47;3 height loss&#41; and eSQ grade 4 OVF &#40;moderately-severe&#44; &#62;1&#47;3&#8211;&#60;40&#37; height loss&#41;&#46; The rationale for this division is that OVFs with &#62;1&#47;3 height loss are always associated with positive ECF sign radiographically&#44;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">36</span></a> and that the presence of ECF is associated with further vertebral collapse and risk of new fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">37</span></a> Finally&#44; Genant&#39;s severe grade 3 is subdivided into eSQ grade 5 &#40;severe&#44; &#62;40&#37;&#8211;&#60;2&#47;3 height loss&#41; and eSQ grade 6 &#40;collapsed&#44; &#62;2&#47;3 height loss&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Nevertheless&#44; for daily clinical practice&#44; Wang also proposed to simplify Genant&#39;s classification into three categories&#58; &#60;1&#47;5 vertebral height loss&#44; 1&#47;5&#8211;1&#47;3 vertebral height loss and &#62;1&#47;3 vertebral height loss&#46; OVFs of &#62;1&#47;3 of height loss are always associated with ECF&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">38&#44;39</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">In general&#44; combined methods can be easily applied in clinical practice and research&#44; showing excellent inter-observer agreement&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">14</span></a> In addition&#44; the spinal deformity index proposed by Minne et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">40</span></a> which is obtained by adding up the degrees of the fractures present in the T4-L4 segment&#44; has demonstrated prognostic value in estimating the severity of OVFs using the Genant&#39;s method&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">33</span></a> One of the main advantages of the latter system over qualitative methods lies in the possibility of grading fractures by quantifying height loss&#44; which allows a more accurate estimation of the patient&#39;s prognosis&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The Genant&#39;s classification is insufficiently sensitive to detect OVFs that do not exceed 15&#8211;20&#37; height loss &#40;false negatives&#41;&#46; In addition&#44; slight vertebral height loss can be secondary to alterations other than osteoporosis &#40;e&#46;g&#46; developmental abnormalities&#44; normal aging&#44; postural changes&#41; especially in men &#40;false positives&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">1&#44;6</span></a> On the other hand&#44; the correlation between Genant&#39;s grade I deformities and the development of OVFs is low&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">41</span></a> In comparison with Sugita&#39;s classification&#44; it is more focused on the degree of vertebral height loss&#46; Conversely&#44; Sugita&#39;s classification focuses on the shape of vertebral deformity&#44; although it does not consider the involvement of the posterior wall&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Classification of osteoporotic vertebral fracture proposed by the Spine Section of the German Society for Orthopaedics and Trauma &#40;DGOU&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">This classification aims to be a reliable and simple approach to be implemented in daily clinical practice&#44; facilitating decision-making on the most appropriate treatment for vertebral fractures&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">20&#44;42</span></a> This classification considers both the morphological pattern and the biomechanical stability of the fracture&#46; It is not exclusively based on radiography&#44; but also on CT and MRI&#46; This system divides vertebral fractures into the following types &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#58; type 1&#58; no vertebral deformity&#44; exclusively oedema in the VB &#40;detected by MRI&#41;&#59; type 2&#58; deformity without or with<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#47;5 involvement of the posterior vertebral wall&#59; type 3&#58; deformity with involvement of the posterior vertebral wall&#59; type 4&#58; loss of integrity of the VB&#44; collapse of the VB or &#8220;pincer&#8221; type fracture&#59; and type 5&#58; injuries with rotation or distraction&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">The main advantage of this classification lies in its simplicity&#44; which facilitates its use in daily clinical practice&#46; In addition&#44; it includes recommendations on the appropriate treatment for each type of fracture &#40;i&#46;e&#46;&#44; conservative vs&#46; surgical&#41;&#46; Regarding the limitations of this classification&#44; no proper validation has been performed so far and&#44; as stated above&#44; a major drawback for non-radiologists is the need for an MRI exam to diagnose type 1 fractures&#46; Furthermore&#44; it does not take into consideration that height loss or deformities can be secondary to causes other than fractures&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Compared to the classification by Ha et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">31</span></a> the DGOU&#39;s system &#40;similarly to that proposed by Wang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">35</span></a>&#41; is relatively complex&#46; Therefore&#44; further research is still required to develop a classification that optimizes both simplicity and clinical efficiency&#44; with relevant clues that ensure the most appropriate management and prognosis for OVFs&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">A summary of the main classification methods for the diagnosis of osteoporotic vertebral fractures &#40;OVF&#41; is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Imaging findings that can be mistaken for osteoporotic vertebral fractures</span><p id="par0155" class="elsevierStylePara elsevierViewall">There are several causes other than OVF that can lead to reduced vertebral height and they should be known to avoid diagnostic errors&#46; The most relevant ones<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">14&#44;43</span></a> are described below with some illustrative examples shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Physiological wedging</span>&#58; In normal children and adults&#44; the VB is anteriorly wedged from T1 through L2 &#40;peak at T7&#41;&#44; non-wedged at L3&#44; and posteriorly wedged at L4&#8211;L5 &#40;peak at L5&#41;&#46; In physiologic vertebral wedging thoracic kyphosis values are within the normal range and Schmorl&#39;s nodes are absent&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">44</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Short vertebral height</span>&#58; term introduced by Jiang et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">23</span></a> to explain the low percentage of fractures found when applying the ABQ method in comparison with morphometric methods&#46; It consists of abnormal morphometric measurements&#44; i&#46;e&#46; reduced vertebral height&#44; without alterations of the VE&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">45</span></a> Up to 20&#37; of height loss can be normal with aging&#44; but it may be difficult to differentiate it from mild vertebral fractures&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Cupid&#39;s bow deformity</span>&#58; This is a developmental variant characterised by a focal defect of the parasagittal cartilage of the VE&#44; normally affecting the lower endplate of L4 and L5&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">46</span></a> In the lateral projection it is observed as an indentation of the posterior region of the lower endplate&#44; simulating a VE depression fracture&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Scheuermann&#39;s disease</span>&#58; This is a rare disease which predominantly affects young males&#46; It is characterised by alterations of the thoracolumbar spine coexisting with a height reduction of the intervertebral space and increased AP diameter&#46; The most frequently used diagnostic criterion in clinical practice is the presence of a kyphotic angulation of at least 5&#176; in three or more adjacent VBs&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">47</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Schmorl&#39;s nodes or intraspongeal disc herniations&#58;</span> These represent a common finding&#44; especially in patients with a degenerative spine&#44; such as those with Scheuermann&#39;s disease&#46; Schmorl&#39;s nodes are focal depressions of the VE due to weakness of the intervertebral disc&#44; usually by degenerative phenomena&#46; Although usually small in size&#44; they are sometimes larger and can simulate OVFs&#46; In these cases&#44; it should be remembered that Schmorl&#39;s nodes have well-defined&#44; rounded&#44; sclerotic contours and do not extend through the entire endplate&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Degenerative scoliosis</span>&#58; Due to the rotational effect of scoliosis on the VBs&#44; these may acquire a biconcave appearance and be misinterpreted as an OVF&#46; The AP projection allows to verify the presence of scoliosis&#44; specifically the incurvation of the spinal axis and the decrease in size of the VBs in the concavity of the curve in comparison with the convexity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Pathological vertebral fracture&#58;</span> Most of the literature aimed at differentiating benign osteoporotic from pathological vertebral fractures secondary to metastases or primary tumours is based on MRI findings&#46; Nevertheless&#44; although less sensitive&#44; there are several plain radiograph signs that may orientate in this challenging differential diagnosis&#46; As stated above&#44; OVFs usually present 3 morphologic patterns&#44; namely wedge&#44; concave &#40;fish vertebra or diabolo-shaped vertebra&#41; and&#44; in advanced cases&#44; crush&#46; Involvement of the posterior vertebral wall in crush fractures appears as retropulsion of the posterior margin&#44; either superior or inferior&#44; of the vertebral body &#40;VB&#41;&#46; The presence of gas collections within the latter is considered a sign of vertebral necrosis and&#47;or intravertebral instability and suggests benign osteoporotic fracture&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">48&#44;49</span></a></p></li></ul></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">In pathological fractures&#44; the osteolytic pattern in the VB can be detected&#44; although 30&#8211;50&#37; of bone loss is usually required for this pattern to be visible on plain-film radiography&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">50&#44;51</span></a> Expansion of the cortex due to tumour growth inside the fractured body manifests as a convex wall while extension of the tumour to the paravertebral space can be detected as a paravertebral mass&#46; Finally&#44; unilateral destruction of the pedicle is usually responsible for the &#8220;winking owl&#8221; or &#8220;one-eyed vertebra&#8221; sign&#46; Occasionally&#44; destruction of both pedicles may lead to the &#8220;blind vertebra sign&#8221; in which there is no rounded shape of any of the pedicles in the AP view&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">52</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">We have reviewed the three main different approaches for classifying OVFs using conventional radiography&#46; Quantitative or morphometric methods offer high reproducibility and objectivity but have low sensitivity for the detection of fractures characterised by subtle morphological alterations in which there is no significant vertebral height loss&#46; Qualitative methods offer greater sensitivity for the diagnosis of OVFs that do not have significant vertebral height loss&#44; but they require highly trained observers capable of discriminating the specific and sometimes very subtle imaging findings&#46; Combined methods consider both loss of vertebral height or surface and vertebral morphology&#46; The most suitable approach depends on context&#44; familiarity and ease of use for the reader&#46; Finally&#44; it is important to acknowledge the most frequent non-fracture causes for vertebral abnormalities that can be mistaken for vertebral fractures on conventional radiography&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">Nothing to declare&#46;</p></span></span>"
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          "titulo" => "Radiographic techniques to assess osteoporotic vertebral fractures"
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          "titulo" => "Classification systems used in the diagnosis of osteoporotic vertebral fractures on conventional radiography"
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                  "titulo" => "Classification of osteoporotic vertebral fractures proposed by Jiang et al&#46;"
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                  "titulo" => "Classification of osteoporotic vertebral fractures proposed by Sugita et al&#46;"
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              "titulo" => "Combined methods"
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                  "titulo" => "Classification of osteoporotic vertebral fractures proposed by Genant et al&#46;"
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                  "titulo" => "Classification of osteoporotic vertebral fracture proposed by the Spine Section of the German Society for Orthopaedics and Trauma &#40;DGOU&#41;"
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          "identificador" => "sec0065"
          "titulo" => "Imaging findings that can be mistaken for osteoporotic vertebral fractures"
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    "fechaRecibido" => "2021-03-20"
    "fechaAceptado" => "2021-06-01"
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            0 => "Osteoporosis"
            1 => "Fractura vertebral"
            2 => "Radiograf&#237;a simple"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The radiological diagnosis of osteoporotic vertebral fractures &#40;OVFs&#41; is of major importance considering its therapeutic and prognostic implications&#46; Both radiologists and clinicians have the opportunity to diagnose OVFs in daily clinical practice due to the widespread use of spine and chest radiography&#46; However&#44; several studies have reported an under-diagnosis of OVFs&#44; particularly by a lack of consensus on the diagnostic criteria&#46; Therefore&#44; up-to-date knowledge of the most relevant approaches for the diagnosis of OVFs is necessary for many physicians&#46; This article aims to review the most commonly used classification systems in the diagnosis of OVFs based on conventional radiography&#46; We discuss their rationale&#44; advantages and limitations&#44; as well as their utility according to the context&#46; This review will provide a concise yet useful understanding of the typology of OVFs&#44; their clinical significance and prognosis&#46; Finally&#44; we include anatomical variations that can be confused with OVFs by non-experts&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico radiol&#243;gico de las fracturas vertebrales osteopor&#243;ticas &#40;FVO&#41; es de gran importancia&#44; considerando sus implicaciones terap&#233;uticas y pron&#243;sticas&#46; Tanto los radi&#243;logos como los facultativos tienen la oportunidad de diagnosticar las FVO en la pr&#225;ctica cl&#237;nica diaria debido al uso extendido de las radiograf&#237;as de columna y t&#243;rax&#46; Sin embargo&#44; diversos estudios han reportado el infradiagn&#243;stico de las FVO&#44; particularmente debido a la falta de consenso sobre los criterios diagn&#243;sticos&#46; Por tanto&#44; es necesario actualizar el conocimiento de los enfoques m&#225;s relevantes en cuanto al diagn&#243;stico de las FVO de muchos m&#233;dicos&#46; El objetivo del presente art&#237;culo es revisar los sistemas de clasificaci&#243;n m&#225;s com&#250;nmente utilizados para diagnosticar las FVO sobre la base de la radiograf&#237;a convencional&#46; Debatimos sus fundamentos&#44; ventajas y limitaciones&#44; as&#237; como su utilidad con respecto al contexto&#46; Esta revisi&#243;n aportar&#225; una comprensi&#243;n concisa y &#250;til de la tipolog&#237;a de las FVO&#44; su significaci&#243;n cl&#237;nica y pron&#243;stico&#46; Por &#250;ltimo&#44; incluimos variaciones anat&#243;micas que pueden ser confundidas con las FVO por los no expertos&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Examples of morphometric measurements and their associated morphological parameters&#46; &#40;A&#41; Anterior wedging&#59; &#40;b&#41; posterior wedging&#59; &#40;c&#41; biconcavity&#59; &#40;d&#41; crush fracture&#46; Red points mark the vertebral height which is decreased&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Examples of OVF &#40;osteoporotic vertebral fracture&#41; according to the classification proposed by Sugita et al&#46;<span class="elsevierStyleSup">31</span>&#46; &#40;A&#41; Normal vertebra&#46; &#40;B&#41; Type I &#40;swelled-front fracture&#41;&#46; C&#41; Type II &#40;bow-shaped fracture&#41;&#46; &#40;D&#41; Type III &#40;projecting fracture&#41;&#46; &#40;E&#41; Type IV &#40;concave fracture&#41;&#46; &#40;F&#41; Type V &#40;indented fracture&#41;&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Examples of expanded semi-quantitative &#40;eSQ&#41; OVF &#40;osteoporotic vertebral fracture&#41; classification by Wang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">35</span></a> &#40;A&#41; Grade I&#44; minimal&#59; &#40;B&#41; Grade II&#44; mild&#59; &#40;C&#41; Grade III&#44; moderate&#59; &#40;D&#41; Grade IV&#44; moderate-severe&#59; &#40;E&#41; Grade V&#44; severe&#59; &#40;F&#41; Grade VI&#44; collapsed&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Examples of OVFs &#40;osteoporotic vertebral fractures&#41; according to the DGOU&#39;s classification&#58; &#40;A&#41; Type 1&#46; &#40;B&#41; Type 2&#46; &#40;C&#41; Type 3&#46; &#40;D&#41; Types 4&#46; &#40;E&#41; Type 5&#46; Adapted from Schnake KJ et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">20</span></a></p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Examples of non-osteoporotic vertebral height loss &#40;A&#41; Short vertebral height&#46; &#40;B and C&#41; Cupid&#39;s bow deformity which causes indentation of the vertebral endplate in the lateral projection &#40;arrows&#41;&#46; &#40;D&#41; Scheuermann&#39;s disease&#46; &#40;E&#41; Wedging and sclerosis in degenerative scoliosis&#46; &#40;F&#41; Pathologic fracture in osteolytic metastasis&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Quantitative methods&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Qualitative methods&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Combined methods&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Main characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Measurement of height or surface without assessment of vertebral morphology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Exclusion of VE abnormalities caused by conditions other than OVF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Estimation of height loss combined with vertebral morphology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reproducibility &#40;healthy subjects&#41;&#44; Objective&#44; Automatization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excludes potential confounders &#40;anatomical variants&#44; other conditions&#41;&#46; Better correlation with BMI and incidence of new OVFs&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Traditionally considered the best method due to its simplicity&#46; High inter and intra-observer agreement&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Limitations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">False positives &#40;height loss due to non-fracture causes&#41;&#44; False negatives &#40;OVF without height loss&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Need for highly-trained or expert observers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Confusion with anatomical variants and other conditions&#46; It requires training and experience&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Applicability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Automated diagnosis&#44; research&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Daily clinical practice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Daily clinical practice&#44; research&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Examples&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eastell et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">25</span></a> McCloskey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Jiang et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">23</span></a> Sugita et al&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Genant et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">33</span></a> DGOU<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Summary of the main classification methods for the diagnosis of osteoporotic vertebral fractures &#40;OVF&#41;&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:52 [
            0 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Identifying osteoporotic vertebral endplate and cortex fractures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Y&#46;X&#46;J&#46; W&#225;ng"
                            1 => "F&#46;R&#46; Santiago"
                            2 => "M&#46; Deng"
                            3 => "M&#46;H&#46; Nogueira-Barbosa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.21037/qims.2017.10.05"
                      "Revista" => array:6 [
                        "tituloSerie" => "Quant Imaging Med Surg"
                        "fecha" => "2017"
                        "volumen" => "7"
                        "paginaInicial" => "555"
                        "paginaFinal" => "591"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29184768"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinician&#39;s guide to prevention and treatment of osteoporosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; Cosman"
                            1 => "S&#46;J&#46; de Beur"
                            2 => "M&#46;S&#46; LeBoff"
                            3 => "E&#46;M&#46; Lewiecki"
                            4 => "B&#46; Tanner"
                            5 => "S&#46; Randall"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00198-014-2794-2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Osteoporos Int"
                        "fecha" => "2014"
                        "volumen" => "25"
                        "paginaInicial" => "2359"
                        "paginaFinal" => "2381"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25182228"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0275"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoporosis in the European Union&#58; medical management&#44; epidemiology and economic burden"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46; Hernlund"
                            1 => "A&#46; Svedbom"
                            2 => "M&#46; Iverg&#229;rd"
                            3 => "J&#46; Compston"
                            4 => "C&#46; Cooper"
                            5 => "J&#46; Stenmark"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11657-013-0136-1"
                      "Revista" => array:5 [
                        "tituloSerie" => "Arch Osteoporos"
                        "fecha" => "2013"
                        "volumen" => "8"
                        "paginaInicial" => "136"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24113837"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Under-reporting of osteoporotic vertebral fractures on computed tomography"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46;L&#46; Williams"
                            1 => "A&#46; Al-Busaidi"
                            2 => "P&#46;J&#46; Sparrow"
                            3 => "J&#46;E&#46; Adams"
                            4 => "R&#46;W&#46; Whitehouse"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ejrad.2007.08.028"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Radiol"
                        "fecha" => "2009"
                        "volumen" => "69"
                        "paginaInicial" => "179"
                        "paginaFinal" => "183"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17913429"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0285"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical consequences of vertebral fractures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P&#46;D&#46; Ross"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am J Med"
                        "fecha" => "1997"
                        "volumen" => "103"
                        "paginaInicial" => "S30"
                        "paginaFinal" => "S43"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The radiology of osteoporotic vertebral fractures redux"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "B&#46; Lentle"
                            1 => "J&#46; Trollip"
                            2 => "K&#46; Lian"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jocd.2015.08.009"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Densitom"
                        "fecha" => "2016"
                        "volumen" => "19"
                        "paginaInicial" => "40"
                        "paginaFinal" => "47"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26428658"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0295"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Excess mortality after hospitalisation for vertebral fracture"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;A&#46; Kanis"
                            1 => "A&#46; Oden"
                            2 => "O&#46; Johnell"
                            3 => "C&#46; De Laet"
                            4 => "B&#46; Jonsson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00198-003-1516-y"
                      "Revista" => array:6 [
                        "tituloSerie" => "Osteoporos Int"
                        "fecha" => "2004"
                        "volumen" => "15"
                        "paginaInicial" => "108"
                        "paginaFinal" => "112"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14598026"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Population-based study of survival after osteoporotic fractures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46; Cooper"
                            1 => "E&#46;J&#46; Atkinson"
                            2 => "S&#46;J&#46; Jacobsen"
                            3 => "W&#46;M&#46; O&#8217;fallon"
                            4 => "L&#46;J&#46; Melton"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/oxfordjournals.aje.a116756"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Epidemiol"
                        "fecha" => "1993"
                        "volumen" => "137"
                        "paginaInicial" => "1001"
                        "paginaFinal" => "1005"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8317445"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Imaging of osteoporotic fractures on XR CT&#44; and MR"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "B&#46;C&#46; Lentle"
                            1 => "I&#46; Hammond"
                            2 => "G&#46;B&#46; Firth"
                            3 => "R&#46;A&#46;L&#46; Sutton"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Curr Radiol Rep"
                        "fecha" => "2014"
                        "volumen" => "2"
                        "paginaInicial" => "32"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The prevalence and under-diagnosis of vertebral fractures on chest radiograph"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Y&#46; Li"
                            1 => "L&#46; Yan"
                            2 => "S&#46; Cai"
                            3 => "P&#46; Wang"
                            4 => "H&#46; Zhuang"
                            5 => "H&#46; Yu"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s12891-018-2171-y"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Musculoskelet Disord"
                        "fecha" => "2018"
                        "volumen" => "19"
                        "paginaInicial" => "235"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30021567"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Underdiagnosis of vertebral fractures is a worldwide problem&#58; the IMPACT study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;D&#46; Delmas"
                            1 => "L&#46; van de Langerijt"
                            2 => "N&#46;B&#46; Watts"
                            3 => "R&#46; Eastell"
                            4 => "H&#46; Genant"
                            5 => "A&#46; Grauer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Bone Miner Res"
                        "fecha" => "2004"
                        "volumen" => "20"
                        "paginaInicial" => "557"
                        "paginaFinal" => "563"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Severity of vertebral fracture reflects deterioration of bone microarchitecture"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;K&#46; Genant"
                            1 => "P&#46;D&#46; Delmas"
                            2 => "P&#46; Chen"
                            3 => "Y&#46; Jiang"
                            4 => "E&#46;F&#46; Eriksen"
                            5 => "G&#46;P&#46; Dalsky"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Osteoporos Int"
                        "fecha" => "2007"
                        "volumen" => "18"
                        "paginaInicial" => "69"
                        "paginaFinal" => "76"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Radiation exposure in X-ray-based imaging techniques used in osteoporosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Damilakis"
                            1 => "J&#46;E&#46; Adams"
                            2 => "G&#46; Guglielmi"
                            3 => "T&#46;M&#46; Link"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur Radiol"
                        "fecha" => "2010"
                        "volumen" => "20"
                        "paginaInicial" => "2707"
                        "paginaFinal" => "2714"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Identifying osteoporotic vertebral fracture"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;F&#46; Griffith"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3978/j.issn.2223-4292.2015.08.01"
                      "Revista" => array:6 [
                        "tituloSerie" => "Quant Imaging Med Surg"
                        "fecha" => "2015"
                        "volumen" => "5"
                        "paginaInicial" => "592"
                        "paginaFinal" => "602"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26435923"
                            "web" => "Medline"
                          ]
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                      ]
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                  ]
                ]
              ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of specific training in detecting osteoporotic vertebral fractures on routine chest radiographs"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Gruber"
                            1 => "J&#46; Dinges"
                            2 => "D&#46; M&#252;ller"
                            3 => "T&#46; Baum"
                            4 => "E&#46; Rummeny"
                            5 => "J&#46; Bauer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "R&#246;Fo &#8211; Fortschritte auf dem Gebiet der R&#246;ntgenstrahlen und der Bildgeb Verfahren"
                        "fecha" => "2013"
                        "volumen" => "185"
                        "paginaInicial" => "1074"
                        "paginaFinal" => "1080"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoporotic thoracolumbar fractures&#8212;how are they different&#63;&#46;&#8212;Classification and treatment algorithm"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Rajasekaran"
                            1 => "R&#46;M&#46; Kanna"
                            2 => "K&#46;J&#46; Schnake"
                            3 => "A&#46;R&#46; Vaccaro"
                            4 => "G&#46;D&#46; Schroeder"
                            5 => "S&#46; Sadiqi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/BOT.0000000000000949"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Orthop Trauma"
                        "fecha" => "2017"
                        "volumen" => "31"
                        "paginaInicial" => "S49"
                        "paginaFinal" => "S56"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28816876"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0345"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The use of reference image criteria in X-ray diagnostics&#58; an application for the optimisation of lumbar spine radiographs"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Alm&#233;n"
                            1 => "A&#46; Tingberg"
                            2 => "J&#46; Besjakov"
                            3 => "S&#46; Mattsson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00330-004-2320-6"
                      "Revista" => array:3 [
                        "tituloSerie" => "Eur Radiol"
                        "fecha" => "2004"
                        "paginaInicial" => "14"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Review of radiological scoring methods of osteoporotic vertebral fractures for clinical and research settings"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Oei"
                            1 => "F&#46; Rivadeneira"
                            2 => "F&#46; Ly"
                            3 => "S&#46;J&#46; Breda"
                            4 => "M&#46;C&#46; Zillikens"
                            5 => "A&#46; Hofman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur Radiol"
                        "fecha" => "2013"
                        "volumen" => "23"
                        "paginaInicial" => "476"
                        "paginaFinal" => "486"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recognizing osteoporotic vertebral deformity on frontal view radiograph&#58; a cohort analysis and a pictorial review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Y&#46;X&#46;J&#46; W&#225;ng"
                            1 => "M&#46;M&#46; Du"
                            2 => "N&#46; Che-Nordin"
                            3 => "P&#46;P&#46; Ye"
                            4 => "S&#46;W&#46; Qiu"
                            5 => "J&#46;F&#46; Griffith"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11657-020-00716-5"
                      "Revista" => array:3 [
                        "tituloSerie" => "Arch Osteoporos"
                        "fecha" => "2020"
                        "paginaInicial" => "15"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0360"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification of osteoporotic thoracolumbar spine fractures&#58; recommendations of the spine section of the German Society for Orthopaedics and Trauma &#40;DGOU&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46;J&#46; Schnake"
                            1 => "T&#46;R&#46; Blattert"
                            2 => "P&#46; Hahn"
                            3 => "A&#46; Franck"
                            4 => "F&#46; Hartmann"
                            5 => "B&#46; Ullrich"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Glob Spine J"
                        "fecha" => "2018"
                        "volumen" => "8"
                        "paginaInicial" => "46S"
                        "paginaFinal" => "49S"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Radiologic assessment of osteoporotic vertebral fractures&#58; diagnostic and prognostic implications"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "T&#46;M&#46; Link"
                            1 => "G&#46; Guglielmi"
                            2 => "C&#46; van Kuijk"
                            3 => "J&#46;E&#46; Adams"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00330-005-2773-2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Radiol"
                        "fecha" => "2005"
                        "volumen" => "15"
                        "paginaInicial" => "1521"
                        "paginaFinal" => "1532"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15841380"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoporotic vertebral endplate and cortex fractures&#58; a pictorial review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Y&#46;X&#46;J&#46; W&#225;ng"
                            1 => "M&#46; Deng"
                            2 => "L&#46;-C&#46; He"
                            3 => "N&#46; Che-Nordin"
                            4 => "F&#46;R&#46; Santiago"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Orthop Transl"
                        "fecha" => "2018"
                        "volumen" => "15"
                        "paginaInicial" => "35"
                        "paginaFinal" => "49"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0375"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of methods for the visual identification of prevalent vertebral fracture in osteoporosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G&#46; Jiang"
                            1 => "R&#46; Eastell"
                            2 => "N&#46;A&#46; Barrington"
                            3 => "L&#46; Ferrar"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00198-004-1626-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Osteoporos Int"
                        "fecha" => "2004"
                        "volumen" => "15"
                        "paginaInicial" => "887"
                        "paginaFinal" => "896"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15071725"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0380"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Radiographic methods for evaluating osteoporotic vertebral fractures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46; Grados"
                            1 => "J&#46; Fechtenbaum"
                            2 => "E&#46; Flipon"
                            3 => "S&#46; Kolta"
                            4 => "C&#46; Roux"
                            5 => "P&#46; Fardellone"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Jt Bone Spine"
                        "fecha" => "2009"
                        "volumen" => "76"
                        "paginaInicial" => "241"
                        "paginaFinal" => "247"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0385"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification of vertebral fractures"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46; Eastell"
                            1 => "S&#46;L&#46; Cedel"
                            2 => "H&#46;W&#46; Wahner"
                            3 => "B&#46;L&#46; Riggs"
                            4 => "L&#46;J&#46; Melton"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Bone Miner Res"
                        "fecha" => "1991"
                        "volumen" => "6"
                        "paginaInicial" => "207"
                        "paginaFinal" => "215"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0390"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The assessment of vertebral deformity&#58; a method for use in population studies and clinical trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46;V&#46; McCloskey"
                            1 => "T&#46;D&#46; Spector"
                            2 => "K&#46;S&#46; Eyres"
                            3 => "E&#46;D&#46; Fern"
                            4 => "N&#46; O&#8217;Rourke"
                            5 => "S&#46; Vasikaran"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Osteoporos Int"
                        "fecha" => "1993"
                        "volumen" => "3"
                        "paginaInicial" => "138"
                        "paginaFinal" => "147"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0395"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vertebral fracture&#58; diagnostic difficulties of a major medical problem"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P&#46; Szulc"
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                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/jbmr.3404"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Bone Miner Res"
                        "fecha" => "2018"
                        "volumen" => "33"
                        "paginaInicial" => "553"
                        "paginaFinal" => "559"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29419882"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109799004684"
                          "estado" => "S300"
                          "issn" => "07351097"
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0400"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The broadening spectrum of osteoporotic vertebral fracture"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "F&#46;E&#46; McKiernan"
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                    0 => array:2 [
                      "doi" => "10.1007/s00256-008-0632-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Skeletal Radiol"
                        "fecha" => "2009"
                        "volumen" => "38"
                        "paginaInicial" => "303"
                        "paginaFinal" => "308"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19183993"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "29"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteoporosis Canada 2010 guidelines for the assessment of fracture risk"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46; Lentle"
                            1 => "A&#46;M&#46; Cheung"
                            2 => "D&#46;A&#46; Hanley"
                            3 => "W&#46;D&#46; Leslie"
                            4 => "D&#46; Lyons"
                            5 => "A&#46; Papaioannou"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.carj.2011.05.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Can Assoc Radiol J"
                        "fecha" => "2011"
                        "volumen" => "62"
                        "paginaInicial" => "243"
                        "paginaFinal" => "250"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21852066"
                            "web" => "Medline"
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                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0410"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification of vertebral compression fractures in the osteoporotic spine"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Sugita"
                            1 => "N&#46; Watanabe"
                            2 => "Y&#46; Mikami"
                            3 => "H&#46; Hase"
                            4 => "T&#46; Kubo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.bsd.0000168716.23440.61"
                      "Revista" => array:5 [
                        "tituloSerie" => "J Spinal Disord Tech"
                        "fecha" => "2005"
                        "volumen" => "18"
                        "paginaInicial" => "376"
                        "paginaFinal" => "381"
                      ]
                    ]
                  ]
                ]
              ]
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            30 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk factors affecting progressive collapse of acute osteoporotic spinal fractures"
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                          "autores" => array:2 [
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                            1 => "Y&#46;H&#46; Kim"
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                    0 => array:1 [
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                        "tituloSerie" => "Osteoporos Int"
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                        "paginaInicial" => "1207"
                        "paginaFinal" => "1213"
                      ]
                    ]
                  ]
                ]
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              "identificador" => "bib0420"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The radiology of osteoporotic vertebral fractures revisited"
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                            1 => "F&#46; Koromani"
                            2 => "J&#46;P&#46; Brown"
                            3 => "L&#46; Oei"
                            4 => "L&#46; Ward"
                            5 => "D&#46; Goltzman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "J Bone Miner Res"
                        "fecha" => "2019"
                        "volumen" => "34"
                        "paginaInicial" => "e3669"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0425"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vertebral fracture assessment using a semiquantitative technique"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46;K&#46; Genant"
                            1 => "C&#46;Y&#46; Wu"
                            2 => "C&#46; van Kuijk"
                            3 => "M&#46;C&#46; Nevitt"
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                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/jbmr.5650080915"
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                        "tituloSerie" => "J Bone Miner Res"
                        "fecha" => "1993"
                        "volumen" => "8"
                        "paginaInicial" => "1137"
                        "paginaFinal" => "1148"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8237484"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0430"
              "etiqueta" => "34"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Difficulties in the diagnosis of vertebral fracture in men&#58; agreement between doctors"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Fechtenbaum"
                            1 => "K&#46; Briot"
                            2 => "S&#46; Paternotte"
                            3 => "M&#46; Audran"
                            4 => "V&#46; Breuil"
                            5 => "B&#46; Cortet"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Jt Bone Spine"
                        "fecha" => "2014"
                        "volumen" => "81"
                        "paginaInicial" => "169"
                        "paginaFinal" => "174"
                      ]
                    ]
                  ]
                ]
              ]
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            34 => array:3 [
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                      "titulo" => "Semi-quantitative grading and extended semi-quantitative grading for osteoporotic vertebral deformity&#58; a radiographic image database for education and calibration"
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                        "tituloSerie" => "Ann Transl Med"
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                        "volumen" => "8"
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                ]
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            35 => array:3 [
              "identificador" => "bib0440"
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                      "titulo" => "All osteoporotically deformed vertebrae with<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>34&#37; height loss have radiographically identifiable endplate&#47;cortex fracture"
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                            3 => "P&#46;C&#46; Leung"
                            4 => "Y&#46;X&#46;J&#46; W&#225;ng"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Orthop Transl"
                        "fecha" => "2018"
                        "volumen" => "14"
                        "paginaInicial" => "63"
                        "paginaFinal" => "66"
                      ]
                    ]
                  ]
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                      "titulo" => "Osteoporotic vertebral deformity with endplate&#47;cortex fracture is associated with higher further vertebral fracture risk&#58; the Ms OS &#40;Hong Kong&#41; study results"
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                            4 => "A&#46;W&#46;L&#46; Kwok"
                            5 => "L&#46;C&#46; He"
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                        "fecha" => "2019"
                        "volumen" => "30"
                        "paginaInicial" => "897"
                        "paginaFinal" => "905"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30666373"
                            "web" => "Medline"
                          ]
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                    0 => array:2 [
                      "titulo" => "A modified semi-quantitative &#40;mSQ&#41; grading scheme for osteoporotic vertebral fracture in elderly women"
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                          "etal" => false
                          "autores" => array:1 [
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                        "tituloSerie" => "Quant Imaging Med Surg"
                        "fecha" => "2019"
                        "volumen" => "9"
                        "paginaInicial" => "146"
                        "paginaFinal" => "150"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30976538"
                            "web" => "Medline"
                          ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of radiography in the study of spinal disorders"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "F&#46; Ruiz Santiago"
                            1 => "A&#46;J&#46; L&#225;inez Ramos-Bossini"
                            2 => "Y&#46;X&#46;J&#46; W&#225;ng"
                            3 => "D&#46; L&#243;pez Z&#250;&#241;iga"
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                        "tituloSerie" => "Quant Imaging Med Surg"
                        "fecha" => "2020"
                        "volumen" => "10"
                        "paginaInicial" => "2322"
                        "paginaFinal" => "2355"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33269230"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0022347615005545"
                          "estado" => "S300"
                          "issn" => "00223476"
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              "identificador" => "bib0460"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "A newly developed spine deformity index &#40;SDI&#41; to quantitate vertebral crush fractures in patients with osteoporosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;W&#46; Minne"
                            1 => "G&#46; Leidig"
                            2 => "C&#46; W&#252;ster"
                            3 => "L&#46; Siromachkostov"
                            4 => "G&#46; Baldauf"
                            5 => "R&#46; Bickel"
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                    0 => array:1 [
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                        "tituloSerie" => "Bone Miner"
                        "fecha" => "1988"
                        "volumen" => "3"
                        "paginaInicial" => "335"
                        "paginaFinal" => "349"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2852512"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mild morphometric vertebral fractures predict vertebral fractures but not non-vertebral fractures"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46; Johansson"
                            1 => "A&#46; Od&#233;n"
                            2 => "E&#46;V&#46; McCloskey"
                            3 => "J&#46;A&#46; Kanis"
                          ]
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1007/s00198-013-2460-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Osteoporos Int"
                        "fecha" => "2014"
                        "volumen" => "25"
                        "paginaInicial" => "235"
                        "paginaFinal" => "241"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23974856"
                            "web" => "Medline"
                          ]
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                    0 => array:2 [
                      "titulo" => "Nonsurgical and surgical management of osteoporotic vertebral body fractures&#58; recommendations of the spine Section of the German Society for Orthopaedics and Trauma &#40;DGOU&#41;"
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                          "autores" => array:6 [
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                            1 => "K&#46;J&#46; Schnake"
                            2 => "O&#46; Gonschorek"
                            3 => "E&#46; Gercek"
                            4 => "F&#46; Hartmann"
                            5 => "S&#46; Katscher"
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                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Glob Spine J"
                        "fecha" => "2018"
                        "volumen" => "8"
                        "paginaInicial" => "50S"
                        "paginaFinal" => "55S"
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                    ]
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                ]
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            42 => array:3 [
              "identificador" => "bib0475"
              "etiqueta" => "43"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classifying thoracolumbar fractures&#58; role of quantitative imaging"
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                          "autores" => array:6 [
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                            2 => "E&#46; Moya S&#225;nchez"
                            3 => "M&#46; Revelles Paniza"
                            4 => "A&#46; Mart&#237;nez Mart&#237;nez"
                            5 => "A&#46;L&#46; P&#233;rez Abela"
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                        "tituloSerie" => "Quant Imaging Med Surg"
                        "fecha" => "2016"
                        "volumen" => "6"
                        "paginaInicial" => "772"
                        "paginaFinal" => "784"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28090452"
                            "web" => "Medline"
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              "identificador" => "bib0480"
              "etiqueta" => "44"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vertebral body shape variation in the thoracic and lumbar spine&#58; Characterization of its asymmetry and wedging"
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                          "etal" => true
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                            2 => "Y&#46; Mirovsky"
                            3 => "S&#46; Peleg"
                            4 => "G&#46; Dar"
                            5 => "N&#46; Steinberg"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ca.20532"
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                        "tituloSerie" => "Clin Anat"
                        "fecha" => "2008"
                        "volumen" => "21"
                        "paginaInicial" => "46"
                        "paginaFinal" => "54"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17729333"
                            "web" => "Medline"
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                        "itemHostRev" => array:3 [
                          "pii" => "S016882271630153X"
                          "estado" => "S300"
                          "issn" => "01688227"
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                ]
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            44 => array:3 [
              "identificador" => "bib0485"
              "etiqueta" => "45"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Is short vertebral height always an osteoporotic fracture&#63; The Osteoporosis and Ultrasound Study &#40;OPUS&#41;"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "G&#46; Jiang"
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                            3 => "D&#46;M&#46; Reid"
                            4 => "C&#46; Roux"
                            5 => "C&#46;C&#46; Gl&#252;er"
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                        ]
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                    0 => array:2 [
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                        "tituloSerie" => "Bone"
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                        "volumen" => "41"
                        "paginaInicial" => "5"
                        "paginaFinal" => "12"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17499570"
                            "web" => "Medline"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Cupid&#39;s bow contour of the vertebral body&#58; Evaluation of pathogenesis with bone densitometry and imaging-histopathologic correlation"
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                          "etal" => true
                          "autores" => array:6 [
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                            2 => "P&#46; Haghighi"
                            3 => "P&#46; Sledge"
                            4 => "E&#46; Barrett-Connor"
                            5 => "D&#46;T&#46; Trudell"
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                        "tituloSerie" => "Radiology"
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                        "volumen" => "202"
                        "paginaInicial" => "253"
                        "paginaFinal" => "256"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8988219"
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                        "tituloSerie" => "J Back Musculoskelet Rehabil"
                        "fecha" => "2014"
                        "volumen" => "27"
                        "paginaInicial" => "383"
                        "paginaFinal" => "390"
                        "link" => array:1 [
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Usefulness of prone cross-table lateral radiographs in vertebral compression fractures"
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                            4 => "B&#46;S&#46; Chang"
                            5 => "C&#46;K&#46; Lee"
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                  "host" => array:1 [
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                        "tituloSerie" => "Clin Orthop Surg"
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                        "paginaInicial" => "195"
                        "paginaFinal" => "201"
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                          "issn" => "00260495"
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              "identificador" => "bib0505"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Plain-film radiography in the study of spinal pain"
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                          "autores" => array:4 [
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                            3 => "P&#46;J&#46; Navarrete Gonz&#225;lez"
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                        ]
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                    ]
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                    0 => array:2 [
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                        "tituloSerie" => "Radiologia"
                        "fecha" => "2010"
                        "volumen" => "52"
                        "paginaInicial" => "126"
                        "paginaFinal" => "137"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20227735"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0510"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current imaging in spinal metastatic disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46; Kamholtz"
                            1 => "G&#46; Sze"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Oncol"
                        "fecha" => "1991"
                        "volumen" => "18"
                        "paginaInicial" => "158"
                        "paginaFinal" => "159"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2014400"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0515"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Bone scans with one or two new abnormalities in cancer patients with no known metastases&#58; reliability of interpretation of initial correlative radiographs"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
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                            2 => "E&#46;B&#46; Cronin"
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                        ]
                      ]
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                        "tituloSerie" => "Radiology"
                        "fecha" => "1990"
                        "volumen" => "174"
                        "paginaInicial" => "503"
                        "paginaFinal" => "507"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2296659"
                            "web" => "Medline"
                          ]
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                ]
              ]
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              "identificador" => "bib0520"
              "etiqueta" => "52"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Evaluation and treatment of spinal metastases&#58; an overview"
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "W&#46;B&#46; Jacobs"
                            1 => "R&#46;G&#46; Perrin"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Neurosurg Focus"
                        "fecha" => "2001"
                        "volumen" => "11"
                        "paginaInicial" => "e10"
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                ]
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