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Research ArticleArticle

Vertebral Fractures in Ankylosing Spondylitis Are Associated with Lower Bone Mineral Density in Both Central and Peripheral Skeleton

Eva Klingberg, Mats Geijer, Jan Göthlin, Dan Mellström, Mattias Lorentzon, Elisabet Hilme, Martin Hedberg, Hans Carlsten and Helena Forsblad-d'Elia
The Journal of Rheumatology August 2012, jrheum.120316; DOI: https://doi.org/10.3899/jrheum.120316
Eva Klingberg
From the Department of Rheumatology and Inflammation Research and the Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg; Centre for Medical Imaging and Physiology, Skåne University Hospital, and Lund University, Lund; Department of Radiology, Sahlgrenska University Hospital, Mölndal; Department of Rheumatology, Hospital of Alingsås, Alingsås; and Department of Rheumatology, Hospital of Borås, Borås, Sweden. Supported by grants from The Health and Medical Care Executive Board of the Västra Götaland, Rune and Ulla Amlövs foundation for Rheumatology Research, Gothenburg’s Association Against Rheumatism, The Medical Society of Gothenburg, and the Region Västra Götaland (agreement concerning research and education of doctors), COMBINE, Inger Bendix foundation, and the Margareta Rheuma research foundation. E. Klingberg, MD, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg; M. Geijer, MD, PhD, Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund University; J. Göthlin, MD, Professor, Department of Radiology, Sahlgrenska University Hospital/Mölndal; D. Mellström, MD, Professor; M. Lorentzon, MD, Associate Professor, Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg; E. Hilme, MD, PhD, Department of Rheumatology, Alingsås; M. Hedberg, MD, Department of Rheumatology, Borås; H. Carlsten, MD, Professor; H. Forsblad-d’Elia, MD, Associate Professor, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg. Address correspondence to Dr. E. Klingberg, Department of Rheumatology, Sahlgrenska/SU, Gröna stråket 14, S-413 45 Gothenburg, Sweden. E-mail: Eva.Klingberg@vgregion.se Accepted for publication June 1, 2012.
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Mats Geijer
From the Department of Rheumatology and Inflammation Research and the Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg; Centre for Medical Imaging and Physiology, Skåne University Hospital, and Lund University, Lund; Department of Radiology, Sahlgrenska University Hospital, Mölndal; Department of Rheumatology, Hospital of Alingsås, Alingsås; and Department of Rheumatology, Hospital of Borås, Borås, Sweden. Supported by grants from The Health and Medical Care Executive Board of the Västra Götaland, Rune and Ulla Amlövs foundation for Rheumatology Research, Gothenburg’s Association Against Rheumatism, The Medical Society of Gothenburg, and the Region Västra Götaland (agreement concerning research and education of doctors), COMBINE, Inger Bendix foundation, and the Margareta Rheuma research foundation. E. Klingberg, MD, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg; M. Geijer, MD, PhD, Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund University; J. Göthlin, MD, Professor, Department of Radiology, Sahlgrenska University Hospital/Mölndal; D. Mellström, MD, Professor; M. Lorentzon, MD, Associate Professor, Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg; E. Hilme, MD, PhD, Department of Rheumatology, Alingsås; M. Hedberg, MD, Department of Rheumatology, Borås; H. Carlsten, MD, Professor; H. Forsblad-d’Elia, MD, Associate Professor, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg. Address correspondence to Dr. E. Klingberg, Department of Rheumatology, Sahlgrenska/SU, Gröna stråket 14, S-413 45 Gothenburg, Sweden. E-mail: Eva.Klingberg@vgregion.se Accepted for publication June 1, 2012.
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Jan Göthlin
From the Department of Rheumatology and Inflammation Research and the Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg; Centre for Medical Imaging and Physiology, Skåne University Hospital, and Lund University, Lund; Department of Radiology, Sahlgrenska University Hospital, Mölndal; Department of Rheumatology, Hospital of Alingsås, Alingsås; and Department of Rheumatology, Hospital of Borås, Borås, Sweden. Supported by grants from The Health and Medical Care Executive Board of the Västra Götaland, Rune and Ulla Amlövs foundation for Rheumatology Research, Gothenburg’s Association Against Rheumatism, The Medical Society of Gothenburg, and the Region Västra Götaland (agreement concerning research and education of doctors), COMBINE, Inger Bendix foundation, and the Margareta Rheuma research foundation. E. Klingberg, MD, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg; M. Geijer, MD, PhD, Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund University; J. Göthlin, MD, Professor, Department of Radiology, Sahlgrenska University Hospital/Mölndal; D. Mellström, MD, Professor; M. Lorentzon, MD, Associate Professor, Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg; E. Hilme, MD, PhD, Department of Rheumatology, Alingsås; M. Hedberg, MD, Department of Rheumatology, Borås; H. Carlsten, MD, Professor; H. Forsblad-d’Elia, MD, Associate Professor, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg. Address correspondence to Dr. E. Klingberg, Department of Rheumatology, Sahlgrenska/SU, Gröna stråket 14, S-413 45 Gothenburg, Sweden. E-mail: Eva.Klingberg@vgregion.se Accepted for publication June 1, 2012.
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Dan Mellström
From the Department of Rheumatology and Inflammation Research and the Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg; Centre for Medical Imaging and Physiology, Skåne University Hospital, and Lund University, Lund; Department of Radiology, Sahlgrenska University Hospital, Mölndal; Department of Rheumatology, Hospital of Alingsås, Alingsås; and Department of Rheumatology, Hospital of Borås, Borås, Sweden. Supported by grants from The Health and Medical Care Executive Board of the Västra Götaland, Rune and Ulla Amlövs foundation for Rheumatology Research, Gothenburg’s Association Against Rheumatism, The Medical Society of Gothenburg, and the Region Västra Götaland (agreement concerning research and education of doctors), COMBINE, Inger Bendix foundation, and the Margareta Rheuma research foundation. E. Klingberg, MD, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg; M. Geijer, MD, PhD, Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund University; J. Göthlin, MD, Professor, Department of Radiology, Sahlgrenska University Hospital/Mölndal; D. Mellström, MD, Professor; M. Lorentzon, MD, Associate Professor, Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg; E. Hilme, MD, PhD, Department of Rheumatology, Alingsås; M. Hedberg, MD, Department of Rheumatology, Borås; H. Carlsten, MD, Professor; H. Forsblad-d’Elia, MD, Associate Professor, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg. Address correspondence to Dr. E. Klingberg, Department of Rheumatology, Sahlgrenska/SU, Gröna stråket 14, S-413 45 Gothenburg, Sweden. E-mail: Eva.Klingberg@vgregion.se Accepted for publication June 1, 2012.
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Mattias Lorentzon
From the Department of Rheumatology and Inflammation Research and the Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg; Centre for Medical Imaging and Physiology, Skåne University Hospital, and Lund University, Lund; Department of Radiology, Sahlgrenska University Hospital, Mölndal; Department of Rheumatology, Hospital of Alingsås, Alingsås; and Department of Rheumatology, Hospital of Borås, Borås, Sweden. Supported by grants from The Health and Medical Care Executive Board of the Västra Götaland, Rune and Ulla Amlövs foundation for Rheumatology Research, Gothenburg’s Association Against Rheumatism, The Medical Society of Gothenburg, and the Region Västra Götaland (agreement concerning research and education of doctors), COMBINE, Inger Bendix foundation, and the Margareta Rheuma research foundation. E. Klingberg, MD, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg; M. Geijer, MD, PhD, Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund University; J. Göthlin, MD, Professor, Department of Radiology, Sahlgrenska University Hospital/Mölndal; D. Mellström, MD, Professor; M. Lorentzon, MD, Associate Professor, Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg; E. Hilme, MD, PhD, Department of Rheumatology, Alingsås; M. Hedberg, MD, Department of Rheumatology, Borås; H. Carlsten, MD, Professor; H. Forsblad-d’Elia, MD, Associate Professor, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg. Address correspondence to Dr. E. Klingberg, Department of Rheumatology, Sahlgrenska/SU, Gröna stråket 14, S-413 45 Gothenburg, Sweden. E-mail: Eva.Klingberg@vgregion.se Accepted for publication June 1, 2012.
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Elisabet Hilme
From the Department of Rheumatology and Inflammation Research and the Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg; Centre for Medical Imaging and Physiology, Skåne University Hospital, and Lund University, Lund; Department of Radiology, Sahlgrenska University Hospital, Mölndal; Department of Rheumatology, Hospital of Alingsås, Alingsås; and Department of Rheumatology, Hospital of Borås, Borås, Sweden. Supported by grants from The Health and Medical Care Executive Board of the Västra Götaland, Rune and Ulla Amlövs foundation for Rheumatology Research, Gothenburg’s Association Against Rheumatism, The Medical Society of Gothenburg, and the Region Västra Götaland (agreement concerning research and education of doctors), COMBINE, Inger Bendix foundation, and the Margareta Rheuma research foundation. E. Klingberg, MD, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg; M. Geijer, MD, PhD, Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund University; J. Göthlin, MD, Professor, Department of Radiology, Sahlgrenska University Hospital/Mölndal; D. Mellström, MD, Professor; M. Lorentzon, MD, Associate Professor, Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg; E. Hilme, MD, PhD, Department of Rheumatology, Alingsås; M. Hedberg, MD, Department of Rheumatology, Borås; H. Carlsten, MD, Professor; H. Forsblad-d’Elia, MD, Associate Professor, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg. Address correspondence to Dr. E. Klingberg, Department of Rheumatology, Sahlgrenska/SU, Gröna stråket 14, S-413 45 Gothenburg, Sweden. E-mail: Eva.Klingberg@vgregion.se Accepted for publication June 1, 2012.
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Martin Hedberg
From the Department of Rheumatology and Inflammation Research and the Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg; Centre for Medical Imaging and Physiology, Skåne University Hospital, and Lund University, Lund; Department of Radiology, Sahlgrenska University Hospital, Mölndal; Department of Rheumatology, Hospital of Alingsås, Alingsås; and Department of Rheumatology, Hospital of Borås, Borås, Sweden. Supported by grants from The Health and Medical Care Executive Board of the Västra Götaland, Rune and Ulla Amlövs foundation for Rheumatology Research, Gothenburg’s Association Against Rheumatism, The Medical Society of Gothenburg, and the Region Västra Götaland (agreement concerning research and education of doctors), COMBINE, Inger Bendix foundation, and the Margareta Rheuma research foundation. E. Klingberg, MD, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg; M. Geijer, MD, PhD, Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund University; J. Göthlin, MD, Professor, Department of Radiology, Sahlgrenska University Hospital/Mölndal; D. Mellström, MD, Professor; M. Lorentzon, MD, Associate Professor, Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg; E. Hilme, MD, PhD, Department of Rheumatology, Alingsås; M. Hedberg, MD, Department of Rheumatology, Borås; H. Carlsten, MD, Professor; H. Forsblad-d’Elia, MD, Associate Professor, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg. Address correspondence to Dr. E. Klingberg, Department of Rheumatology, Sahlgrenska/SU, Gröna stråket 14, S-413 45 Gothenburg, Sweden. E-mail: Eva.Klingberg@vgregion.se Accepted for publication June 1, 2012.
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Hans Carlsten
From the Department of Rheumatology and Inflammation Research and the Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg; Centre for Medical Imaging and Physiology, Skåne University Hospital, and Lund University, Lund; Department of Radiology, Sahlgrenska University Hospital, Mölndal; Department of Rheumatology, Hospital of Alingsås, Alingsås; and Department of Rheumatology, Hospital of Borås, Borås, Sweden. Supported by grants from The Health and Medical Care Executive Board of the Västra Götaland, Rune and Ulla Amlövs foundation for Rheumatology Research, Gothenburg’s Association Against Rheumatism, The Medical Society of Gothenburg, and the Region Västra Götaland (agreement concerning research and education of doctors), COMBINE, Inger Bendix foundation, and the Margareta Rheuma research foundation. E. Klingberg, MD, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg; M. Geijer, MD, PhD, Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund University; J. Göthlin, MD, Professor, Department of Radiology, Sahlgrenska University Hospital/Mölndal; D. Mellström, MD, Professor; M. Lorentzon, MD, Associate Professor, Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg; E. Hilme, MD, PhD, Department of Rheumatology, Alingsås; M. Hedberg, MD, Department of Rheumatology, Borås; H. Carlsten, MD, Professor; H. Forsblad-d’Elia, MD, Associate Professor, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg. Address correspondence to Dr. E. Klingberg, Department of Rheumatology, Sahlgrenska/SU, Gröna stråket 14, S-413 45 Gothenburg, Sweden. E-mail: Eva.Klingberg@vgregion.se Accepted for publication June 1, 2012.
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Helena Forsblad-d'Elia
From the Department of Rheumatology and Inflammation Research and the Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg; Centre for Medical Imaging and Physiology, Skåne University Hospital, and Lund University, Lund; Department of Radiology, Sahlgrenska University Hospital, Mölndal; Department of Rheumatology, Hospital of Alingsås, Alingsås; and Department of Rheumatology, Hospital of Borås, Borås, Sweden. Supported by grants from The Health and Medical Care Executive Board of the Västra Götaland, Rune and Ulla Amlövs foundation for Rheumatology Research, Gothenburg’s Association Against Rheumatism, The Medical Society of Gothenburg, and the Region Västra Götaland (agreement concerning research and education of doctors), COMBINE, Inger Bendix foundation, and the Margareta Rheuma research foundation. E. Klingberg, MD, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg; M. Geijer, MD, PhD, Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund University; J. Göthlin, MD, Professor, Department of Radiology, Sahlgrenska University Hospital/Mölndal; D. Mellström, MD, Professor; M. Lorentzon, MD, Associate Professor, Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg; E. Hilme, MD, PhD, Department of Rheumatology, Alingsås; M. Hedberg, MD, Department of Rheumatology, Borås; H. Carlsten, MD, Professor; H. Forsblad-d’Elia, MD, Associate Professor, Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg. Address correspondence to Dr. E. Klingberg, Department of Rheumatology, Sahlgrenska/SU, Gröna stråket 14, S-413 45 Gothenburg, Sweden. E-mail: Eva.Klingberg@vgregion.se Accepted for publication June 1, 2012.
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Abstract

Objective To study the prevalence and risk factors for vertebral fractures (VF) in ankylosing spondylitis (AS) and the relation between VF, measures of disease activity, and bone mineral density (BMD) in different measurement sites.

Methods Patients with AS (modified New York criteria) underwent examination, answered questionnaires, and gave blood samples. Lateral spine radiographs were scored for VF (Genant score) and syndesmophyte formation through modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). BMD was measured with dual-energy x-ray absorptiometry in the hip, radius, and lumbar spine in anteroposterior and lateral projections with estimation of volumetric BMD (vBMD).

Results Two hundred four patients (57% men) with a mean age of 50 ± 13 years and disease duration 15 ± 11 years were included. VF were diagnosed in 24 patients (12%), but were previously noted clinically in only 3 of the 24. Patients with VF were significantly older (p = 0.004), had longer disease duration (p = 0.011), higher Bath Ankylosing Spondylitis Metrology Index (p = 0.011), mSASSS (p = 0.035), and Bath Ankylosing Spondylitis patient global score-2 (BASG-2) (p = 0.032) and were more often smokers (p = 0.032). All women with a VF were postmenopausal. BMD was significantly lower at all measuring sites in the patients with VF. In logistic regression, high BASG- 2, low BMD in femoral neck, and low lumbar vBMD were independently associated with presence of VF.

Conclusion VF in AS are common but are often not diagnosed. VF are associated with advanced age, longstanding disease, impaired back mobility, syndesmophyte formation, and lower BMD in both the central and peripheral skeleton. BMD in the femoral neck, total hip, and estimated vBMD showed the strongest association with VF.

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Vertebral Fractures in Ankylosing Spondylitis Are Associated with Lower Bone Mineral Density in Both Central and Peripheral Skeleton
Eva Klingberg, Mats Geijer, Jan Göthlin, Dan Mellström, Mattias Lorentzon, Elisabet Hilme, Martin Hedberg, Hans Carlsten, Helena Forsblad-d'Elia
The Journal of Rheumatology Aug 2012, jrheum.120316; DOI: 10.3899/jrheum.120316

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Vertebral Fractures in Ankylosing Spondylitis Are Associated with Lower Bone Mineral Density in Both Central and Peripheral Skeleton
Eva Klingberg, Mats Geijer, Jan Göthlin, Dan Mellström, Mattias Lorentzon, Elisabet Hilme, Martin Hedberg, Hans Carlsten, Helena Forsblad-d'Elia
The Journal of Rheumatology Aug 2012, jrheum.120316; DOI: 10.3899/jrheum.120316
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