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Genant

visual semiquantitative vertebral fracture grading

Per-vertebra visual fracture assessment from T4 through L4 using morphology plus anterior, middle or posterior height loss and projected-area loss; morphometry confirms severity but cannot diagnose fracture alone.

vigenteGenant et al. / International Society for Clinical Densitometry1993 original; 2023 ISCD VFA technique of choice1993XR, DXA, CT
Fonte primária5 categorias
0Grade 0, normal0.5Grade 0.5, borderline or questionable deformity1Grade 1, mild fracture2Grade 2, moderate fracture3Grade 3, severe fracture

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Categorias

Reescritas a partir da fonte e citadas
0
1 de 5

Grade 0, normal

Grade 0: the identified vertebra has expected regional shape and no visual endplate, cortical or configuration change consistent with fracture. Height loss below 20% supports Grade 0 only when morphology is normal; a definite subthreshold endplate fracture or a questionable deformity must not be hidden in this category.

CondutaList the vertebral level and technical evaluability. Grade 0 at one level requires no fracture-specific action from this scale, but it does not exclude fracture at another level, low bone density or another cause of symptoms and cannot determine osteoporosis care.
RiscoGrade 0 means no visual fracture at the assessed level, not zero future fracture risk. Risk still depends on age, bone density, prior fractures, medications and clinical factors, which the Genant code does not quantify.
verificadoRecognizing and reporting osteoporotic vertebral fracturesGrigoryan et al. 2003, PMC3591834, Genant visual semiquantitative assessment and Figs. 1-3: normal Grade 0 requires visual assessment against adjacent and expected regional morphology; the text warns that normal wedging, biconcavity and degenerative remodeling can mimic mild fracture.
0.5
2 de 5

Grade 0.5, borderline or questionable deformity

Optional Grade 0.5: a borderline vertebra shows some deformation but cannot be clearly assigned a definite Grade 1 fracture. Preserve the observed endplate, cortex, shape and height findings; Grade 0.5 is an uncertainty category, not a definitive mild osteoporotic fracture.

CondutaCompare prior imaging and clinical context and consider diagnostic radiography or other imaging when confirmation would change care, especially with malignancy, a lytic or sclerotic feature, an unidentifiable level or another non-benign concern. Do not initiate grade-specific treatment from 0.5 alone.
RiscoBorderline and mild deformities have the greatest reader subjectivity and may reflect normal variation or non-osteoporotic disease. The 0.5 label carries no calibrated probability that the vertebra is fractured or that another fracture will occur.
verificadoRecognizing and reporting osteoporotic vertebral fracturesGrigoryan et al. 2003, PMC3591834, visual semiquantitative description states that Grade 0.5 is sometimes used for deformation not clearly assignable to Grade 1 and discusses subjectivity of borderline and mild deformities. ISCD 2023 lists equivocal fracture as an indication for follow-up imaging based on the clinical picture.
1
3 de 5

Grade 1, mild fracture

Grade 1 mild fracture: a visually credible vertebral fracture with approximately 20-25% reduction in anterior, middle or posterior height and approximately 10-20% reduction in projected vertebral-body area. Report wedge, biconcave or crush shape separately and exclude a normal or degenerative mimic.

CondutaClearly report the mild fracture and integrate age, symptoms, BMD, prior fractures, glucocorticoids and secondary causes under local osteoporosis guidance. The grade alone does not choose medication, vertebral augmentation, surgery or follow-up timing; equivocal Grade 1 morphology may require confirmation.
RiscoA prevalent vertebral fracture is clinically relevant and associated with later fracture and morbidity, but Grade 1 does not supply an individual risk percentage. Mild grades are the most vulnerable to projection, regional shape and reader variation.
verificadoRecognizing and reporting osteoporotic vertebral fracturesGrigoryan et al. 2003, PMC3591834, visual SQ section: Grade 1 is 20-25% height and 10-20% projected-area reduction; the article explains morphology, nonfracture differentials, mild-grade subjectivity and future-fracture association. ISCD 2023 requires visual fracture diagnosis rather than morphometry alone.
2
4 de 5

Grade 2, moderate fracture

Grade 2 moderate fracture: a visually credible fracture with approximately 26-40% reduction in anterior, middle or posterior height and approximately 21-40% reduction in projected vertebral-body area. Preserve exact level, measurements and morphology and distinguish osteoporosis from trauma, neoplasm or another deforming process.

CondutaCommunicate the moderate vertebral fracture and any acuity or pathologic features and support appropriate osteoporosis or secondary-cause evaluation. Genant Grade 2 alone cannot select a drug, brace, procedure or surgical pathway; neurologic or malignant features require their own urgent assessment.
RiscoModerate vertebral fracture indicates greater structural deformity and contributes to clinical fracture-risk assessment, but it is not a stand-alone probability model. Patient risk remains dependent on the full fracture history, BMD and clinical context.
verificadoRecognizing and reporting osteoporotic vertebral fracturesGrigoryan et al. 2003, PMC3591834, visual SQ section defines Grade 2 as 26-40% height and 21-40% area reduction and details visual morphology and differential diagnosis. ISCD 2023 retains the method for VFA and specifies follow-up imaging for malignant, equivocal, lytic or sclerotic concerns.
3
5 de 5

Grade 3, severe fracture

Grade 3 severe fracture: a visually credible vertebral fracture with greater than 40% reduction in vertebral height and projected area. The configuration may be wedge, biconcave or crush; severe collapse still requires assessment for traumatic, neoplastic, infectious and other non-osteoporotic causes.

CondutaReport severe collapse, level, canal or neurologic implications, acuity features and any suspicious bone destruction separately and prompt appropriate specialist evaluation. The grade does not autonomously determine osteoporosis therapy, augmentation, stabilization or oncologic care.
RiscoGrade 3 is the maximum Genant severity category and represents substantial structural loss, but the classification gives no patient-specific mortality, neurologic or future-fracture probability. Etiology, acuity, multiplicity and clinical risk factors remain decisive.
verificadoRecognizing and reporting osteoporotic vertebral fracturesGrigoryan et al. 2003, PMC3591834, visual SQ section defines Grade 3 as greater than 40% height and projected-area reduction and separates severity from wedge, biconcave or crush shape; differential-diagnosis sections require visual exclusion of non-osteoporotic deformity.
Lógica de decisão estruturada

Diagnose fracture visually before grading severity. Preserve level, morphology, measurements, borderline or subthreshold states, differential diagnosis and modality; never infer osteoporosis treatment or acuity from the grade alone.

{
  "categories": [
    {
      "outcome_code": "0",
      "label": "normal",
      "fracture_status": "no_visual_fracture",
      "height_reduction": "below_20_percent_only_if_morphology_is_normal"
    },
    {
      "outcome_code": "0.5",
      "label": "borderline_or_questionable",
      "fracture_status": "deformation_present_but_not_clearly_grade_1",
      "role": "optional_Genant_borderline_category_not_a_definite_fracture_grade"
    },
    {
      "outcome_code": "1",
      "label": "mild",
      "fracture_status": "definite_visual_fracture",
      "height_reduction_any_of_anterior_middle_or_posterior": "approximately_20_to_25_percent",
      "projected_area_reduction": "approximately_10_to_20_percent"
    },
    {
      "outcome_code": "2",
      "label": "moderate",
      "fracture_status": "definite_visual_fracture",
      "height_reduction_any_of_anterior_middle_or_posterior": "approximately_26_to_40_percent",
      "projected_area_reduction": "approximately_21_to_40_percent"
    },
    {
      "outcome_code": "3",
      "label": "severe",
      "fracture_status": "definite_visual_fracture",
      "height_reduction_any_of_anterior_middle_or_posterior": "greater_than_40_percent",
      "projected_area_reduction": "greater_than_40_percent"
    }
  ],
  "applicability": {
    "use_for": "Visual semiquantitative identification and severity grading of vertebral fractures, one vertebral body at a time, primarily on lateral thoracic and lumbar radiographs or densitometric vertebral fracture assessment.",
    "classification_unit": "one_identified_vertebral_body_from_T4_through_L4",
    "required_inputs": [
      "vertebral_level",
      "diagnostic_lateral_view_or_sagittal_reformation",
      "technical_evaluability",
      "anterior_middle_and_posterior_height",
      "projected_area_or_visual_area_loss",
      "endplate_and_cortex_morphology",
      "adjacent_vertebral_context",
      "alternative_deformity_assessment"
    ],
    "outside_scope": [
      "acute_fracture_age_without_MRI_or_prior_imaging",
      "etiology_from_grade_alone",
      "spinal_instability",
      "neurologic_compression",
      "bone_mineral_density_diagnosis",
      "treatment_selection",
      "individual_future_fracture_probability"
    ]
  },
  "modality_and_quality_gate": {
    "original_method": "Visual assessment on standardized lateral thoracic and lumbar radiographs from T4 through L4, without requiring direct caliper measurement for every vertebra.",
    "VFA_rule": "For densitometric VFA, the 2023 ISCD positions identify Genant visual semiquantitative assessment as the clinical technique of choice. Diagnosis remains visual; morphometry alone is unreliable.",
    "CT_rule": "Sagittal CT reformations can reveal and characterize vertebral deformity, but the report must retain CT as the modality and apply the visual fracture and differential-diagnosis gate before using height thresholds.",
    "adequacy_rule": "Mark a vertebra unevaluable when rotation, projection, overlap, poor exposure, severe scoliosis, hardware or limited coverage prevents confident identification of its endplates and height. Never assign Grade 0 to an unseen vertebra.",
    "comparison_rule": "For incident change, compare technically similar studies side by side and confirm vertebral numbering before assigning a new or increased grade."
  },
  "visual_diagnosis_before_morphometry": {
    "core_rule": "First decide whether the contour and endplate or cortical change is consistent with fracture. Use height and area loss to grade a visually credible fracture, not to convert every short vertebra into osteoporosis.",
    "fracture_features": [
      "endplate_depression_or_loss_of_parallelism",
      "anterior_cortex_buckling_or_interruption",
      "wedge_biconcave_or_crush_configuration_with_credible_fracture_morphology",
      "change_from_prior_or_adjacent_expected_shape"
    ],
    "normal_variation_guard": "Midthoracic vertebrae and the thoracolumbar junction can be physiologically wedged, and lower lumbar bodies may be mildly biconcave. Compare with adjacent levels and expected regional anatomy.",
    "nonfracture_differential": [
      "degenerative_remodeling",
      "Scheuermann_disease",
      "congenital_or_developmental_variant",
      "prior_high_energy_trauma",
      "neoplastic_deformity",
      "Paget_disease",
      "infection",
      "postoperative_or_treatment_change"
    ],
    "subthreshold_fracture_rule": "A definite endplate or cortical fracture can be visually recognized with less than 20 percent height loss. Describe it as a fracture below the Grade 1 morphometric threshold rather than mislabeling it Grade 0 or rounding it to Grade 1."
  },
  "severity_assignment_algorithm": [
    {
      "if": "normal_expected_shape_without_visual_fracture_or_pathologic_deformity",
      "output_code": "0"
    },
    {
      "if": "some_deformation_but_not_confidently_a_definite_grade_1_fracture",
      "output_code": "0.5"
    },
    {
      "if": "definite_visual_fracture_with_approximately_20_to_25_percent_loss_in_any_height_and_approximately_10_to_20_percent_area_loss",
      "output_code": "1"
    },
    {
      "if": "definite_visual_fracture_with_approximately_26_to_40_percent_loss_in_any_height_and_approximately_21_to_40_percent_area_loss",
      "output_code": "2"
    },
    {
      "if": "definite_visual_fracture_with_greater_than_40_percent_loss_in_height_and_projected_area",
      "output_code": "3"
    }
  ],
  "morphology_and_measurement_model": {
    "anterior_height": "Anterior vertebral-body height, interpreted against posterior height, adjacent vertebrae and expected regional shape.",
    "middle_height": "Central vertebral-body height; predominant loss supports a biconcave deformity.",
    "posterior_height": "Posterior vertebral-body height; substantial posterior and generalized loss supports a crush deformity.",
    "projected_area": "Visual or measured lateral projected vertebral-body area. The original system includes area reduction even though later clinical use often emphasizes height.",
    "grade_rule": "Use the greatest credible loss among anterior, middle and posterior heights together with area and morphology. Preserve exact measurements and any threshold discordance.",
    "shape_rule": "Report wedge, biconcave or crush morphology separately. Shape is not tied to a particular severity grade and does not replace the 0-3 score.",
    "area_height_conflict": "If height and area suggest different grades, return the supported range and expert review rather than selecting the more severe number silently."
  },
  "borderline_and_serial_rules": {
    "grade_0_5": "Grade 0.5 is an optional borderline designation sometimes used for a deformed vertebra that cannot be clearly assigned Grade 1. It must not be presented as a definite mild fracture or collapsed into Grade 0 without explanation.",
    "incident_fracture": "A new incident semiquantitative fracture generally requires progression by a full grade or from a previously questionable 0.5 vertebra to a definite fracture on comparable serial imaging.",
    "remodeling_guard": "Settling or remodeling of a known fracture can reduce height without representing a distinct new fracture. Correlate symptoms, interval and marrow edema or fracture line when acuity matters.",
    "multi_level_rule": "Grade every evaluable level independently and list unevaluable levels. Do not average grades across the spine as a patient-level severity class."
  },
  "current_ISCD_context": {
    "endorsed_use": "ISCD 2023 retains Genant visual semiquantitative assessment as the clinical technique of choice for diagnosing vertebral fracture on VFA and allows morphometry to confirm severity.",
    "follow_up_imaging_triggers": [
      "lesion_not_attributable_to_a_benign_cause",
      "vertebral_deformity_with_relevant_malignancy_history",
      "equivocal_fracture",
      "unidentifiable_vertebra_between_T7_and_L4",
      "sclerotic_lytic_or_other_nonosteoporotic_feature"
    ],
    "report_elements": [
      "technical_quality",
      "unevaluable_levels",
      "deformed_levels",
      "whether_each_deformity_is_consistent_with_fracture",
      "unexplained_vertebral_or_extravertebral_pathology"
    ]
  },
  "management_and_risk_context": {
    "management_rule": "A confirmed vertebral fragility fracture should be clearly reported and can prompt osteoporosis and secondary-cause evaluation under local clinical guidance, but Genant grade alone does not select medication, vertebral augmentation, surgery or follow-up interval.",
    "risk_rule": "Prevalent vertebral fractures are associated with future fracture and morbidity, but the semiquantitative grade is not a patient-specific risk calculator. Integrate age, BMD, prior fractures, glucocorticoids and a validated clinical risk model.",
    "acuity_rule": "The morphology grade does not establish acute versus chronic. Use marrow edema, fracture line, soft-tissue findings, prior imaging and symptoms when acuity changes care."
  },
  "output_contract": [
    "modality_view_and_technical_adequacy",
    "every_evaluable_and_unevaluable_level_T4_to_L4",
    "visual_fracture_or_nonfracture_deformity_assessment",
    "anterior_middle_posterior_height_and_projected_area_loss",
    "wedge_biconcave_or_crush_shape",
    "Genant_0_0_5_1_2_3_or_ungraded_subthreshold_fracture",
    "comparison_with_prior_and_change_in_grade",
    "alternative_pathologic_degenerative_congenital_or_traumatic_cause",
    "acuity_features_reported_separately",
    "osteoporosis_evaluation_flag_without_autonomous_treatment"
  ],
  "missing_input_behavior": [
    "If a vertebral level is not visible or not confidently numbered, mark it unevaluable rather than Grade 0.",
    "If morphometry shows height loss but visual fracture morphology is absent, report a nonfracture deformity or unresolved cause instead of assigning a Genant fracture automatically.",
    "If deformation is visible but does not clearly meet Grade 1, preserve Grade 0.5 or explicit borderline uncertainty.",
    "If a definite endplate or cortical fracture has less than 20 percent height loss, describe the subthreshold fracture and do not force Grade 0 or 1.",
    "If height and area thresholds conflict, retain the measurements and adjacent-grade range for expert adjudication."
  ],
  "interpretation_limits": [
    "The original validation cohort comprised postmenopausal women and the system requires training and standardized visual interpretation, especially for Grade 0.5-1.",
    "The grade does not diagnose osteoporosis etiology, fracture acuity, instability, malignancy or neurologic compromise.",
    "Projection, normal regional shape and degenerative remodeling can create false mild fractures; morphometry without visual adjudication is insufficient."
  ],
  "supporting_sources": [
    {
      "role": "primary_method",
      "citation": "Genant et al. J Bone Miner Res. 1993;8:1137-1148",
      "doi": "10.1002/jbmr.5650080915",
      "pmid": "8237484"
    },
    {
      "role": "open_visual_method_and_differential",
      "citation": "Grigoryan et al. Eur Spine J. 2003;12 Suppl 2:S104-S112",
      "doi": "10.1007/s00586-003-0613-0",
      "pmcid": "PMC3591834"
    },
    {
      "role": "current_VFA_position",
      "citation": "International Society for Clinical Densitometry 2023 Official Adult Positions",
      "url": "https://iscd.org/official-positions-2023/"
    }
  ],
  "source_locator": "Genant et al. 1993, PMID 8237484, DOI 10.1002/jbmr.5650080915, original semiquantitative method; Grigoryan et al. 2003, PMC3591834, visual SQ thresholds, Grade 0.5, morphology, differential diagnosis and serial assessment; ISCD 2023 Official Adult Positions, Methods for Defining and Reporting Fractures on VFA and follow-up imaging indications."
}

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