This document discusses the importance of detecting and properly reporting vertebral fractures seen on imaging studies. It notes that vertebral fractures are common but often go unreported, and early detection can help prevent future fractures and morbidity. The document describes audits conducted at Bradford Royal Infirmary that found low rates of vertebral fracture reporting and recommendations for osteoporosis screening. Actions taken include providing spine reconstructions for CTs, educating radiologists, and allowing direct referrals for bone density tests. A follow-up audit showed improvements in detection and reporting but also continued room for progress.

1. Dr. Amit Gupta
Dr. Clare Groves
Radiology Department
Bradford Royal Infirmary

2.  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’.

3.  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.

4. Hip FX
Vertebral Fx
Fragility Fx
Probability of
osteoporosis
in over 50’s
Very high
High
Moderate

5. Hip FX
Vertebral Fx
Fragility Fx
Probability of
osteoporosis
Very high
High
Moderate
FLS/FRAX
Hip Fractures
are preventable
Intervene
Here

6.  Detecting and treating vertebral fractures early
can:
1. Prevent new vertebral fractures
2. Prevent significant patient morbidity
3. Prevent hip fractures in the future
4. Save money for the NHS

7.  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

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

9.  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

10.  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.

11. 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 !

12.  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.

14.  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.

15.  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.

16. 16
Criterion Standar
d
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%

17.  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.

18.  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”.

19.  The International Osteoporosis Foundation
provide an online vertebral fracture teaching
program for radiologists;
http://www.iofbonehealth.org/vertebral-
fracture-teaching-program

20.  First Audit (plain film) was a consciousness-
raising exercise.
 Second Audit (CT) performed 12 months later

21.  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.

22.  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

25. • 37/163 patients had one or more vertebral fractures
(prevalence 22.7%)
37 fracture
Present
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%)

26. 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 categorized
Recommendation for DEXA
assessment should be included
in the report if there is no
previous evidence of
osteoporosis

27.  Vertebral fracture detection rate at BRI was
comparable to published figures, but very poor
 NOT utilising the available 3D reconstruction
software.

28.  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.

29.  This has also been audited AND presented at
clinical governance
……consciousness-raising

30.  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

31. • 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)

32.  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

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

34. Criterion 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%

36.  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!