VERTEBRAL FRACTURE DETECTION – WHY AND

HOW?

Dr. Amit Gupta Dr. Clare Groves

Radiology DepartmentBradford Royal Infirmary

Osteoporosis Bit of a Cinderella topic

Needs a ‘Champion’ in every Trust to show the world how interesting and important it is

Effective fracture prevention need the whole radiology team to ‘buy in’.

Osteoporotic fractures are VERY common

30% of post-menopausal women

Estimated lifetime risk of fracture at hip, lumbar spine or distal forearm is 30-40% in developed countries

Hip fractures are associated with significant increase in morbidity and mortality.

Background

Hip FX

Vertebral Fx

Fragility Fx

Probability of osteoporosis in over 50’s

Very high

High

Moderate

Hip FX

Vertebral Fx

Fragility Fx

Probability of osteoporosis

Very high

High

ModerateFLS/FRAX

Hip Fractures are preventable

InterveneHere

Hip Fractures are preventable

Detecting and treating vertebral fractures early can:

1. Prevent new vertebral fractures 2. Prevent significant patient morbidity3. Prevent hip fractures in the future4. Save money for the NHS

Financial burden Current annual UK estimate of hip fractures –

60,000 Increasing 1-3% per year Hospital costs for a hip fracture £3459 —

£33,264 (mean of £12,163)

Total annual financial burden £730 million*

* T M Lawrence, C T White, R Wenn et al. The current hospital cost of treating hip fractures. Injury, Int. J. Care Injured (2005) 36, 88-91

What can we do?

As health professionals, we are in an ideal position to identify and respond to both suspected and incidental findings of vertebral fractures.

Delayed diagnosis of vertebral fractures is a recognised

problem 2/3 of vertebral fractures don’t come to

clinical attention -‘silent fractures’ Be aware of ‘at risk’ patients Be aware of history of FFx Be aware of signs – dowger’s hump

Under reporting of spinal Fx- a recognised problem

Studies have shown a global 34% false negative rate in analysis of spinal radiographs by radiologists

For general CT, detection rates for spinal fracture have been reported at between 9-16%

Even when vertebral fracture is identified, only one-quarter of patients are started on treatment.

Sagittal reconstruction spine

• CT Abdomen performed for abdominal pain

• Spinal reconstruction not made at the time

• Multiple vertebral fractures unreported

• Two years later patient sustained a hip fracture

• We might have prevented that hip fracture !

Recommendations for plain film reporting vertebral fractures from the IOF:

Scrutinise all images for such fractures Use clear, unambiguous and accurate terminology –

the word ‘fracture’ not ‘collapse’ or other terms Give number and grades of fractures: mild=1,

moderate=2, severe=3. Indicate if osteoporotic, traumatic or pathological

and suggest further appropriate imaging, if relevant. If osteoporotic in origin, suggested measures should

be considered to reduce fracture risk.

Best Practice

Genant & Wu Classification (1993)

Fracture prevention- How were we doing at Bradford? Four years ago, no Fracture Liaison Service

Falls and Fragility fracture CQUIN

CJG decided that imaging could be a driver for change.

AUDIT to establish the the current state of play.

Objectives for first audit Plain film spine reports with regards to:

Fractures being identified Use of the word ‘Fracture’ in reports Grading of fracture Description of fracture morphology Recommendation for further assessment of

osteoporosis.

Audit Results

16

Criterion Standard

Results

Fracture Identified

100% 97/103 = 94.2%

Term “fracture” used if identified

100% 80/97 = 82.5%

Grade given 100% 67/103 = 65%Correct Descriptor used

100% 84/103 = 81.6%

Dexa recommended if no previous evidence of osteoporosis

100% 18/82 = 22%

Observations

Vertebral fracture identification rate at BRI was reasonable on plain film

Terminology used i.e. the word ‘fracture’ - did not meet expected standards

Grading and description of vertebral fractures did not meet expected standards

As recognised globally, a sufficient number of reports in which fracture is identified did not carry a recommendation regarding further action/assessment.

Recommendations from first audit

Reporters of spinal films (consultants, trainees, radiographers) should be aware of the requirement to use the word ‘fracture’ and to number, grade and describe their morphology.

Identification of a fracture should lead to a recommendation for assessment of osteoporosis if no prior evidence for this exists.

Terminology used in reports that is helpful; “Osteoporosis should be considered”, “Has osteoporosis been excluded?” “I suspect this may be osteoporotic”.

Nudge! The International Osteoporosis

Foundation provide an online vertebral fracture teaching program for radiologists; http://www.iofbonehealth.org/vertebral-fracture-teaching-program

Audit No.2 First Audit (plain film) was a

consciousness-raising exercise.

Second Audit (CT) performed 12 months later

To assess the detection rate and quality of radiological reporting of spinal fractures in CT in accordance to Genant & Wu gold standard

To encourage use of standardised language in reports according to Genant & Wu classification.

Audit No. 2 - Aims

Female patient aged over 45 167 consecutive CT examinations were

reviewed retrospectively including • CTPA • CT thorax and CT abdomen/Pelvis

4 examinations were excluded as no thin slices were available on PACS to construct sagittal reformat.

163 studies reviewed

Methods

• 37/163 patients had one or more vertebral fractures (prevalence 22.7%)

Results

37 fracturePresent

5 correctly identified (13.5%)

all 5 had used word 'fracture'

2 cases Grades given

2 cases Correct discriptors used

3 No grades and incorrect

descriptor used

32 not identified (86.5%)

Incidental Vertebral Fractures on CT

13.5% pick-up rate (in 103 positive cases)25% had DEXA recommended

Plan of Action

Introduction of an automated short code

Area for improvement

The term fracture should be used whenever a vertebral fracture is identified

Vertebral Fractures should be graded and categorizedRecommendation for DEXA assessment should be included in the report if there is no previous evidence of osteoporosis

Vertebral fracture detection rate at BRI was comparable to published figures, but very poor

NOT utilising the available 3D reconstruction software.

CT and vertebral fractures

What did we do next? Routine provision of sagittal spinal

reconstructions for all general CT studies.

Encouraging radiologists to refer directly for DEXA after finding spinal fractures in patients over 50y using a short code

Consciousness raising again – presentations, flyers, general nagging etc etc.

Direct ordering of DEXA This has also been audited AND

presented at clinical governance

……consciousness-raising

Third Audit – direct referral for DEXA

81 direct access DEXA referrals from radiology

between January and July 2014

All as a result of finding incidental spinal Fx on plain film; MR and CT

50 were randomly selected for review

Result of DEXA scans• 25 patients (50%) had a T score in the range

for osteoporosis (T Score below -2.5)

• 17 patients (34%) had T scores within the osteopenic range and were considered to be at risk of progression to osteoporosis

>80% of patients were considered to be at a significant risk for further fractures and advised treatment (lifestyle advice, calcium supplements

and anti-resorptive agents)

Direct DEXA referrals Clear benefits in highlighting possible

osteoporotic fractures in Radiology Reports

Direct DEXA referrals from radiologists has successfully aided the identification and treatment of high risk fracture patients

Final Audit = re-audit of CT and spinal FX

Same method as 2014 100 general CT scans in over 50’s January 2015

ResultsCriterion Results 2015 Results 2013

Fracture prevalence 20/100 = 20% 31/163 = 23%Fracture identified 17/20 = 85% 5/37 = 13.5%

Term “fracture” used, if identified

17/17 = 100% 5/5=100%

Grade given 5/17 = 29% 2/5=40%Correct description

used 5/17 = 29% 2/5=40%

DEXA recommendation

if no previous evidence of

osteoporosis

8/20 = 40% 1/4=25%

What Next?

What Next? Better but room for improvement

Gap analysis – how can we get detection rates up, how can we get more referrals for DEXA?

All about ‘buy in’ from colleagues!

Questions?