The International Society for Clinical Densitometry VFR€¦ · Cleveland Clinic Foundation. His fellowship in musculoskeletal radiology was at the University of California, San Francisco

VFRVertebral Fracture

Recognition Course

The International Society for Clinical Densitometry

Version 2014 Copyright 2016 by the International Society for Clinical Densitometry

International Society for Clinical Densitometry

2017 Vertebral Fracture Recognition

Course Syllabus

This advanced densitometry and radiology course focuses on vertebral fracture

imaging, offering a significant advance in the diagnosis and management

of patients at risk for osteoporotic fractures. The importance of vertebral fractures

in the clinical management of osteoporosis, including the appearance of a normal

spine, vertebral fractures and other findings that may be confused with fractures

is detailed. Instruction is given regarding fracture recognition, analysis and

methods used for their definition and classification, patient positioning and image

acquisition.

Target Audience The content is designed for healthcare providers responsible for reading and

interpreting DXA scans, including specialists and generalists working in family

medicine, general and internal medicine, rheumatology, endocrinology,

obstetrics/gynecology, radiology, physical and occupational therapy, and

research, as well as technologists.

Overall Course Objectives As a result of this course, learners will be better prepared to:

1. Recognize quality imaging examinations.

2. Identify the appropriate complementary technologies.

3. Recall vertebral imaging as indicated in the 2013 Official Positions of the

ISCD.

4. Recognize vertebral fractures detected on spine imaging.

5. Compare and contrast the appearance of normal and fractured vertebrae.

6. Describe non-fracture abnormalities on spine image.


Accreditation Statement The International Society for Clinical Densitometry is accredited by the

Accreditation Council for Continuing Medical Education (ACCME) to provide

continuing medical education for physicians.

For information about the accreditation of this program, please contact ISCD at

+1.860.259.1000.

Credit Designation Clinicians: The International Society for Clinical Densitometry designates this

live educational activity for a maximum of 3.75 AMA PRA Category 1 Credits™.

Physicians should only claim credits commensurate with the extent of their

participation in the activity.

Technologists: The course qualifies for 4.5 Category A credits through the

ASRT. Technologists must check in and out each day through the mobile app to

verify attendance and receive credit. Partial credit will not be given.

Instructions to Receive Credit Physicians will be required to complete an evaluation of the activity online after

conclusion of the activity. As a part of that evaluation they will claim the amount

of credit commensurate with the extent of their participation in the activity. After

completing the evaluation, a certificate will be generated that the physician may

print to indicate credits earned.

Policy on Commercial Support and Conflict of Interest The ISCD maintains a policy on the use of commercial support, which ensures

that all educational activities sponsored by the ISCD provide in-depth

presentations that are fair, balanced, independent, and scientifically rigorous.

ISCD requires faculty, planners, managers and other individuals and their

spouse/life partner who are in a position to control the content of this activity to

disclose any real or apparent conflict of interest they may have as related to the

content of this activity. All identified conflicts of interest are thoroughly vetted

by ISCD for fair balance, scientific objectivity of studies mentioned in the

materials or used as the basis for content, and appropriateness of patient care

recommendations. Individual disclosures are included in course material.


Course Disclosures

Course Planning Committee

Tamara Vokes, MD, CCD No Financial Relationships to Disclose

Sarah Morgan, MD, RD, CCD No Financial Relationships to Disclose

John Schousboe, MD, PhD, CCD No Financial Relationships to Disclose

Harold Rosen, MD, CCD No Financial Relationships to Disclose

Course Content Reviewers

Glen Blake, PhD No Financial Relationships to Disclose

Robert Adler, MD, CCD No Financial Relationships to Disclose

2017 Course Faculty

John Schousboe, MD, PhD, CCD No Financial Relationships to Disclose

Bradford Richmond, MD, FACR, CCD No Financial Relationships to Disclose


International Society for Clinical Densitometry

2017 Vertebral Fracture Recognition

Course Schedule

Wednesday, April 19, 2017

2:00-2:40pm Lecture 1: Introduction to Vertebral Fracture Assessment (VFA)

2:40-3:25pm Lecture 2: Technical Aspects of VFA Imaging

3:25-4:15pm Lecture 3: VFA Indications and Interpretations

4:15-4:30pm Break

4:30-5:00pm Lecture 4: Principles of Reporting VFA

5:00-6:00pm Lecture 5: VFR Case Study Review and Workshop


Disclaimer The material presented in the ISCD Quality Bone Densitometry Course is

educational and does not constitute a medical or professional service. Great effort

has been made to assure that the course material is timely and accurate. However,

due to the rapidly changing nature of the field, some information provided may be

outdated or invalidated by subsequent developments.

The lecturers and authors shall not be held liable or responsible to any person or

entity with respect to any loss or damage alleged to be caused directly or

indirectly by the information presented at this program.

Disclosure of Unlabeled Use This educational activity may contain discussion of published and/or

investigational uses of agents that are not indicated by the FDA. Accredited

provider does not recommend the use of any agent outside of labeled indications.

The opinions expressed in this educational activity are those of the faculty and do

not necessarily represent views of any organization associated with this activity.

Please refer to the official prescribing information for each product for discussion

of approved indications, contra indications, and warnings.

Special Acknowledgement ISCD would like to express gratitude to the many people who over the last 10

years have contributed their vision, expertise, time and insight into the

development of the ISCD course curriculum.


2017 Faculty Bios

Brad Richmond, MD, CCD

Dr. Bradford Richmond is a staff physician at the Cleveland Clinic Foundation.

He is a native Clevelander and received a B.S. and M.S. in biology from

Cleveland State University. Dr. Richmond graduated from Case Western

Reserve University and completed residency in diagnostic radiology at the

Cleveland Clinic Foundation. His fellowship in musculoskeletal radiology was

at the University of California, San Francisco. At the Cleveland Clinic, Dr.

Richmond was Section Head of Musculoskeletal Radiology for 14 years, until

October 2002. He is Director of Bone Mineral Densitometry for the Metabolic

Bone Disease Clinic. He has been involved in osteoporosis research with the

Endocrinology and Rheumatology Departments since 1986. He has a joint

appointment in the Department of Orthopaedic Surgery and in the Women’s

Health Center and is currently an Associate Professor CCLCM of CWRU

School of Medicine. In 1992 Dr. Richmond co-chaired the ninth International

Bone Densitometry Workshop.

John T. Schousboe, MD, PhD, CCD

John Schousboe is a rheumatologist, health services researcher, and expert in the

diagnosis and management of osteoporosis. He is the Director of the

Osteoporosis Center at Park Nicollet Clinic, a subsidiary of HealthPartners. His

research interests are in the areas of vertebral fracture epidemiology and

assessment, abdominal aortic calcification, fracture risk assessment, health care

costs attributable to fractures, and cost-effectiveness of diagnostic procedures

for osteoporosis and fracture prevention interventions.

1

www.ISCD.org

ISCD Vertebral Fracture Assessment

Course

1

Must see box within a box both places.

Must see vertical repeated lines here.

Adjust

brightness

and contrast,

room lighting

and projector

resolution to

maximize

clarity of this

image.

www.ISCD.org


Course

2

Lecture 1: Introduction to

Vertebral Fracture Assessment

3

Learning Objectives

1. Describe the importance of vertebral fracture detection in osteoporosis diagnosis and fracture risk assessment.

2. Normal radiographic spine anatomy

3. Compare vertebral fracture detection by different methods:a. Qualitative visual

b. Semiquantitative visual

c. Morphometric measurement.

d. ABQ (algorithm-based qualitative)

4. Compare the advantages and disadvantages of vertebral fracture detection by radiographic vs. densitometric techniques

4

Osteoporosis Can Be

Diagnosed By:

• BMD – WHO criteria

• Fragility fracture with minimal trauma

▪ Spine

▪ hip

5

• 63 year old female

▪ Menopause age 52

▪ No other risk factors

▪ Routine DXA T-score

• spine -1.3

• total hip -1.8

“Osteopenia” with fragility

fracture = osteoporosis

“I don’t have osteoporosis,

I don’t need medication”

Why is Vertebral Imaging for

Fracture Detection Important?

• VCF are common, even with relatively

preserved BMD

• VCF are often unsuspected clinically and

unreported by Radiologists

• VCF predicts subsequent fractures,

independent of BMD

• VCF predict morbidity and mortality

Version 10.06

2

7

Vertebral Fractures are Common

in Both Men and WomenIncident morphometric fractures by age and sex

over 3.8 yrs (n = 14,011)

Adapted from Felsenberg for the EPOS group, J Bone Miner Res 2002; 17:716-724

0

5

10

15

20

25

30

All 50-54 55-59 60-64 65-69 70-74 75-79

Age Group (years)

Incid

ence p

er

1000 P

YR

S Men Women

15

25

5.7

10.7

Classification by BMD Alone Misses

Many Patients Who Will Fracture OFELY - prospective 9 year study, 671 PM♀

• Evaluation of clinical and radiographic fractures

• 158 fractures/116 women

Diagnosis by DXA

alone missed over

half of patients with

a clinical diagnosis

of osteoporosis

8

WH

O d

x in

fx p

ati

en

ts

Sornay-Rendu et al., J Bone Miner Res 2005; 20:1813-9

9

Problem: Vertebral Fractures

Often Not Recognized• Only about 1/3 of vertebral fractures found on

radiographs come to medical attention (Cooper et al., J

Bone Miner Res 1992;7:221, Fink et al., J Bone Miner Res 2005;20:1216)

• Majority of patients with vertebral fractures are

not aware of having a fracture (Vokes et al., Osteoporos Int

2003;14:871, Middleton et al., Osteoporos Int 2008;19:1167)

• Radiographs are usually not performed in the

course of evaluation of patients with

osteoporosis

• Routine radiographs - radiologists often do not

report vertebral fractures (Gehlbach et al., Osteoporos Int

2000;11:577)

10

Prevalent Vertebral Fractures Predict

Future Fractures Independent of BMD

• 25x risk if 1 vertebral fracture and low BMD

• 75x risk if multiple vertebral fractures and low BMD

75

25.1

14.910.2

7.4 4.41

Low BMD Med BMD Hi BMD

No Fx

1 Fx

> 1 Fx

Vertebral Fx + BMD = Improved Fracture Risk Assessment

Ross et al., Ann Intern Med 1991; 114:919

11

C

The Greater the Number of Prevalent Vertebral

Deformities, the Greater the Risk of Future

Fractures

Data from Black DM, et al. J Bone Miner Res. 1999;14:821-828.

0

1

2

3

No. of vertebral

deformities

at baseline

0

1

2

3

4

5

6

7

8

9

10

11

Vertebral

fracture

Nonvertebral

fracture (any)

Wrist

fracture

Rela

tive r

isk

Hip fracture

Fracture Severity Predicts Greater

Risk of Future Fractures

Version 10.012

Delmas et al., Bone 2003 33:522-532

3

13

VCF detected on VFA Also

Predict Future Fractures

• 5157 UK women ≥ 75 years

▪ Women with one or more fractures on VFA had a

RR for incident fractures of 2.01 (95% CI = 1.64-

2.47); RR for hip fracture = 2.29 (1.63-3.21)

▪ The presence of fractures on VFA predicted

future clinical fractures independently of age,

weight, and BMD.

McCloskey et al. J Bone Min Res 2008; 23:1561-8 14

Vertebral Fractures Are Diagnostic of

Osteoporosis and Indicate the Need for

Pharmacotherapy

• NOF recommends that presence of vertebral fractures (unless they result from severe trauma) in itself constitutes a diagnosis of osteoporosis.1

• Vertebral fractures suggest the need for aggressive therapy since:

▪ They predict future fractures

▪ They are associated with increased morbidity and mortality

▪ Treatment reduces future fracture risk

1NOF Physician’s Guide to Prevention and Treatment of Osteoporosis

15

All Vertebral Fractures Are

Associated with Morbidity (from

FIT trial)

Data from Nevitt MC et al., Arch Intern Med 2000; 160:77

Limited Activity

Bed Rest

0

25

50

75

100

Pa

tie

nts

(%

)

No Incident

Fracture

Radiographic

Fracture

Clinical

Fracture

36.8

3.9

76.2

26.9

93.2

52.7

Due to back pain

16

Vertebral Fractures Are Associated

With Increased Mortality

Adapted from Cooper C, et al. Am J Epidemiol. 1993;137:1001.© Johns Hopkins University School of Hygiene and Public Health,

used with permission

%

Survival

Time after fracture (years)

Expected

Observed100

80

60

40

20

0

1 2 3 4 5

Vertebral Fracture

(relative survival = 0.81)

100

80

60

40

20

0

1 2 3 4 5

Hip Fracture

(relative survival = 0.82)

17

Conclusion

Diagnosing the presence, number and severity of vertebral fractures is important in predicting the risk of future fractures and deciding the need for therapy.

Examples Where Finding an Unsuspected

Vertebral Fracture Will Change What is Done

• Patient with osteopenia and low fracture risk who

would not warrant Rx unless we document a

vertebral fracture, which upgrades diagnosis to

osteoporosis

• Patient with indication for Rx based on BMD or high

fracture risk; documentation of a vertebral fracture

may

▪ convince an otherwise hesitant patient to accept Rx

▪ affect the choice of Rx (anabolic over antiresorptive)

▪ affect the duration of antiresorptive Rx (10 vs 5 yrs)

18

4

“I have no symptoms of osteoporosis,

do not want treatment”

• 65 year old, asymptomatic

• Asthma, chronic steroids

• Routine DXA, T-score

▪ spine -3.9

▪ femoral neck -2.8

▪ total hip -2.3

• Not willing to consider therapy

– sent for consultation

• VFA with multiple fractures –

now accepts treatment19

Normal Vertebral Anatomy

20

Superior endplate

Vertebral body

Intravertebral

disc

Pedicle

Transverse

process

Spinous process

Appearance of the Lumbar Spine

on AP Radiograph• Lowest rib is usually on

T12.

Appearance of the Lumbar Spine

on AP Radiograph• Lowest rib is usually on

T12.

• Longest transverse

process is usually on L3

Appearance of the Lumbar

Spine on AP Radiograph

• T12 has the lowest rib

• Spinous processes

• Pedicles

• Intervertebral space

• sacrumIliac crest

Sacral alaSacral ala





• Pedicles


• sacrum

5





• Pedicles


• sacrum





• Pedicles


• sacrum

Appearance of the

Lumbar Spine on

Lateral Radiograph

• On this lateral view the patient is facing to your left, so anterior (front) is to the left.

• It really looks completely different from the AP view, even though you are looking at the very same structures

27

Appearance of the

Lumbar Spine on

Lateral Radiograph• Here you see the vertebral

bodies pointed out.

• In the lumbar spine they appear like squares.

• Recall that the appearance of vertebral bodies depends on how you view them; from above they look round, but from the side, they look like a square

28

Appearance of the

Lumbar Spine on

Lateral Radiograph

• Here you see the vertebral bodies numbered.

29

L5

L4

L3

L2

L1

sacrum

Appearance of the

Lumbar Spine on

Lateral Radiograph

• The pedicles are indicated by the arrows

30

6

Appearance of the

Lumbar Spine on

Lateral Radiograph

• Here you see the

intervertebral disk spaces.

• Recall that you cannot

actually see the disks, but

rather the SPACE

between vertebrae in

which the disks sit!

31

Appearance of the

Lumbar Spine on

Lateral Radiograph

• You can see the ribs on

the lateral view, but they

are subtle.

• Recall that on the lateral

view the ribs are coming

right out at you, so they

look very different than

they do on the AP view.

32

Appearance of the

Lumbar Spine on

Lateral Radiograph

• You can see the iliac

crests on the lateral view,

but they are subtle.

• Recall that on the lateral

view the iliac crests are

overlapping the lowest

vertebra (L5), so they look

very different than they do

on the AP view.

33

• When doing VFA

(vertebral fracture

analysis) you will see

AP and lateral

thoracolumbar views

• The AP thoracic spine

(or T-spine) view looks

very much like the AP

lumbar spine (L-spine)

view except

▪ The T-spine has ribs

coming off each of

the vertebrae, and

the L-spine doesn’t

▪ L-spine has

transverse processes

coming off, longest

on L3

• The AP thoracic spine

(or T-spine) view looks

very much like the AP

lumbar spine (L-spine)

view except

▪ The T-spine

vertebrae are shorter

than the L-spine

vertebrae.

7

• The lateral thoracic spine (or T-

spine) view looks very much

like the lateral lumbar spine (L-

spine) view except

▪ Note transition in shape and

size of vertebrae from top to

bottom.

▪ Note differing densities in

the thorax and abdomen

Diaphragm overlies T11, T12

38Image from Watts NB et al., Am Fam Phys 1988; 38:193

There is a Continuum Between

Normal and Fractured Vertebrae

Normal WedgeConcave Crush

Fractured vertebrae may have different appearances

39

Radiographic Diagnosis: Basic

Methods to Diagnose Vertebral

Fractures

• Qualitative visual

• Quantitative morphometric measurement of vertebral heights (QM)

• Semiquantitative visual method of Genant (SQ)

• Algorithm-based qualitative assessment (ABQ)

40



Fractures





41

Qualitative Visual Assessment:

The Interpreter (eg: radiologist) Decides

if a Vertebra is Normal or Fractured

Normal FractureRequires

trained

interpreter

Reports fractures

without

describing type

and severity T11 fx

42



Fractures





8

43

Quantitative Morphometry (QM):6 points on the image used to

quantify vertebral heights

Middle (Hm)

Anterior (Ha)

Posterior (Hp)

Note point placement in

mid-point of oblique vertebra

Measuring vertebral heights: anterior, middle and posterior

+

+

1. Software applies 6

points to each vertebra

▪ Superior and inferior

endplates

▪ Anterior and

posterior corners and

mid-point

2. Measures Ha, Hm, Hp

▪ Calculates ratios

Ha/Hp, Hm/Hp44

Quantitative morphometry

and VFA

Hp HaHm

Quantitative morphometry

and VFA report

46



Fractures





47

Semiquantitative (SQ) Analysis of GenantVisual Grading of Fracture Type and Severity

Combines the advantages of a quantitative

method with visual assessment48

Mild Fx (grade 1)

G1

G1

G3

G3

Severe FX (grade 3)

Examples of SQ Grading of Prevalent

Vertebral Fractures on Radiographs

9

49



Fractures





ABQ (Algorithm based

qualitative assessment)

• Diagnose a vertebral fracture if there is an

endplate fracture, i.e., discontinuity of the

endplate, or depression of vertebral

endplate below the vertebral ring

Version 10.050

A Grade 3 fracture

Loss of end-plate

definition

Due to Invagination of

end-plate (“Bowl”)

End Plate Fractures - Plate vs. Bowl

Clear end-plate

definition of the

normal vertebra

Genant and ABQ paradigms:

G

2

ABQABQ

0

20

40

60

80

100

120

T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4

Vert

eb

ral

frac

ture

Vertebral level

SQ-expert adjudicator, n=634

SQ-expert central, n=531

ABQ-expert, n=368

Distribution of Vertebral Fracture by

ABQ and SQ from the IMPACT Study

Courtesy to Dr Guirong Jiang

Correlation Between Methods of

Fracture Identification- QM vs SQ

• Good agreement for grade 2 and 3 fractures

• Poor agreement for grade 1 fractures

• Example from SOF, agreement between 3

radiologists

▪ Grade 2 and 3: 86-94%

▪ Grade 1: 22-30%

54Black et al., J Bone Miner Res 1995;10:890-902

10

55

Summary:

Diagnosis of Vertebral Fractures

• Multiple methods available

• All methods include a subjective visual

assessment

• Good agreement between different

methods and/or observers for moderate-

severe fractures

• Poor agreement for mild fractures

Prevalent vs Incident Fracture

• Prevalent = existing fracture on image

▪ Time of onset unknown e.g. could be old

traumatic fracture

• Incident = new fracture between serial

images

56

57

Diagnosing Incident Fractures

Baseline 20 Yr10 Yr

L1(G2)L1(G3)

L4(G3)

L2(G1)L2(G2)

L5(G2)

L5(G3)58

Defining Incident Fracture

• Diagnostic criteria (no consensus)

• Qualitative - Visually determine if difference in

appearance

• QM - >15-20% reduction in anterior, middle

and/or posterior height

• Genent - SQ change of 1 grade

• ABQ - With previous image for comparison,

subtle changes in the end-plate can suggest a

new fracture

59

Incident Vertebral Fracture

Baseline 6-months following

glucocorticoid therapy 60

National Osteoporosis

Foundation Working Group on

Vertebral Fractures

“Not all vertebral deformities

are vertebral fractures.”

J Bone Miner Res 1995; 6:518-523

11

61

• Normal anatomic variants

• Congenital anomaly

• Degenerative disease – disc space narrowing

• Infection – TB, osteomyelitis

• Paget’s disease

• Scheuermann’s disease (+/- Schmorl Nodes)

• Malignancy

Examples of Vertebral Deformities

That are Not Osteoporotic Fractures

Discussed in detail in lectures 3

Preferred method for

diagnosing and reporting

vertebral fractures

• Diagnosis of vertebral fracture –

▪ SQ method of Genant, if >20% deformity if

this is not due to another cause such as

Scheuermann, OR

▪ if there are features of endplate fracture or

discontinuity even without >20% deformity.

• Description of severity and type of vertebral

fracture – Use semiquantitative method of

GenantVersion 10.0

62

63

Diagnosing Vertebral Fractures

• Clinical (i.e. symptoms, confirmed by imaging)

• Review of previous CXR, CT, MRI to see if any unmentioned VCF can be identified

• Imaging:

• Radiographic

• Xrays (spine and chest)

• CTMRI

• Densitometric – VFA (Vertebral Fracture Assessment)

64

VFA: Imaging of the Spine For

Detection of Vertebral Fractures on

DXA MachineGE: DVA or LVA

Normal Fracture

Hologic: IVA or RVA

Normal Fracture

65

Comparison of Spine X-ray and VFA

*USA Specific-Medicare reimbursement

Spine X-ray VFA

Effective

Radiation Dose1800-2000 μSv 30-50 μSv

Access Separate visit Point of service

Cost Higher ($72*) Lower ($30*)

Resolution Higher Lower

Visualization Superior above T7Inferior above T7

(can be superior in LS)

Obliquity Common in LS Less parallax effect

Automated

morphometryNo

Yes

( ISCD discourages the

use of this feature)66

Although VFA Has Poor Visualization Above T7,

Isolated Fractures at T4 to T6 Are Not Common

van der Klift et al., J Bone Miner Res 2002;6:1051-1056

0

5

10

15

20

25

30

35

40

T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4

Vertebral Level

No

. o

f F

ractu

res Men Women

Incident fractures: 6.3 years, Rotterdam study

240 new fractures in 176 of 3469 persons

12

67

Agreement between VFA and

Radiographs

Binkley et al., Osteoporos Int 2005; 16:1513

80 PM females, VFA by 2 densitometrists

compared to SQ score by expert radiologists

94% agreement for

grade 2 and 3

50% agreement

for grade 1

68

VFA Had High Negative

Predictive Value

Of 794 non-fractured vertebral bodies evaluable by VFA, the

densitometrists correctly identified 764 as normal. Only 30

vertebra (3.8%) were incorrectly classified as fractured.

Binkley et al., Osteoporos Int 2005; 16:1513

The negative

predictive value

of VFA is good -

96.2% of non-

fractured

vertebrae

identified as

normal

69

Learning Objectives

1. Describe the importance of vertebral fracture detection in osteoporosis diagnosis and fracture risk assessment.

2. Normal radiographic spine anatomy

3. Compare vertebral fracture detection by different methods:a. Qualitative visual

b. Semiquantitative visual

c. Morphometric measurement.

d. ABQ (algorithm-based qualitative)

4. Compare the advantages and disadvantages of vertebral fracture detection by radiographic vs. densitometric techniques

www.ISCD.org


Course

70

Lecture 2:

Technical Considerations

Learning Objectives

1. Describe appropriate positioning imaging

2. Understand how to use adjustments to improve visual assessment – brightness, contrast, inversion, magnification.

3. Describe point placement for morphometric assessment in normal and abnormal vertebra

4. Recognize common problems with analysis

71

Technical aspects of spine

Radiography:

Lateral thoracic spine

• Voltage 60-70 kVp

• T4 – T12 with T-L overlap

• Centered on T7

• Patient instruction: quiet

breathing with 2 sec

exposure if possible*

Lateral lumbar spine

• Voltage 80-90 kVp

• T12 to S1 with T-L

overlap

• Centered on L4

• Patient instruction:

exhalation breath-holding

with exposure < 1.0 sec

Collimation to limit exposure to soft tissue anteriorly

*quiet breathing with 2 second

exposure will blur the ribs. Not

possible in new systems with

automated exposure

13

Patient Positioning

• True (left) lateral; Head support to keep spine

straight; Arms forward at right angle, elbows flexed

(for comfort)

• Supports between knees and ankles; Support in the

mid-lumbar region to position the spine parallel to

the table

Note pad under upper lumbar vertebrae at waist to keep

spine parallel to X-ray table (blue arrow)

Vertebral Fractures May be More

Obvious on Standing X-raysEspecially important for diagnosis of acute fracture

74

Standing Supine

Advantages of CT Technology

• Images can be

reconstructed in

three orthogonal

planes (usually

axial, sagittal and

coronal) and in 3D

• Improved

anatomical display

(no over-lapping

structures) sagittal section reconstruction

MRI Technology (1):

• Images the mobile nuclei of

hydrogen atoms using pulsed

microwave radiation to perturb

atomic alignment in a strong

magnetic field

• Mobile protons (as in water, fat,

protein) return a signal as they

come back to their prior state

• Relatively immobile protons

(hydroxyapatite of bone) return little

or no signal

MRI Technology (2):• Bone is seen as a negative space

visualized by virtue of adjacent

marrow, which is black or white

depending on pulse sequence (T1,

T2 etc)

• Pathologic bony lesions

(metastases, inflammation, etc.)

replace normal marrow and destroy

bone

• Pulse sequences can be optimized

to visualize specific pathology (eg.

malignant vs. osteoporotic fracture)

VFA Imaging:

Multiple terminology

• Hologic: IVA (Instant Vertebral Assessment); IVA-

HD (IVA-high definition)

• GE: LVA (Lateral Vertebral Assessment); DVA

(Dual-Energy Vertebral Assessment)

• Vertebral Fracture Assessment (VFA) is the

correct term to denote densitometric spine

imaging performed for the purpose of

detecting vertebral fractures (ISCD official

position)

• AMA CPT® code for VFA: 77082(USA)

78ISCD Offical position

14

VFA Technology - Varies by

Machine• Energy

• Single - Hologic

• Dual – GE

• Positioning

• Lateral decubitus – all GE, Hologic C

and W series

• Supine lateral Hologic A series with

rotating C-arm

• Analysis

79

VFA Technology:

Dual-energy or Single-energyGE

Dual energy with single energy option

Hologic

Single energy (dual not recommended)

80

Positioning for VFA

81

GE Prodigy

lateral decubitus

Hologic Supine

Hologic Positioning

82

Right Lateral decubitus C-arm - supine

Positioning for GE – left lateral

decubitus

83

Positioning on GE – Use Positioning

Devices to Ensure Spine Parallel to Table

84

Head

supported

in horizontal

position

Right fist

on tabletop or

arm parallel to

table

Alternate patient positioning

15

VFA – Basic Acquisition

85

Proper starting position enables more vertebrae to

be visualized

Verify Vertebral Level

86

L4-L5 normally at or near the pelvic crest

Lowest rib usually seen at anterior aspect of L1

Positioning and Acquisition

Problems • Shoulder rotation – difficult to visualize upper

thoracic vertebra

• Spine not parallel to table in lateral decubitus

(obliquity or parallax distortion)

• Scoliosis – may need to turn patient on

opposite side, use sponges to reposition

• Misidentifying levels – PA helpful

• Diaphragmatic shadow – can change with

inspiration/expiration

87

Positioning Problems: Shoulder Rotation

Reposition Patient

88

Scapular

shadow

Patient

rotated:

only one

side of rib

cage seen

behind

the spine

True

lateral:

right and

left side of

rib cage

super-

imposed

Obliquity (Parallax Distortion)

89

Cone

Beam

Parallel

Beam

Oblique Projection Orthogonal Projection

90

Orthograde Oblique

X-ray beam parallel to endplates X-ray beam oblique: biconcave

undplates

16

91

Positioning

Problems:Scoliosis

Same patient,

same day

Image on the right

provides improved

vertebral visualization.

WHY??

92

This is

“reverse VFA.”

When routine left decubitus

positioning does not afford

good visualization,

patient is repositioned

in right decubitus – improves

visualization of thoracic spine.

(Use reverse button on GE)

Acquisition Problems:

Misidentifying Vertebral Level

PA Helps Visualize Sacrum

93

5 or 6 Lumbar Vertebrae?

Acquisition

Problems:Diaphragmatic

Shadow

94

Inspiration Expiration

Eliminate with

expiration view

Analysis

• On-screen viewing in low-ambient light preferable to paper print-out

▪ Image enhancement (window, threshold)

▪ Manipulation

95

Common Problems in Point

Placement

• Obliquity

• Scoliosis

• Degenerative disc disease

• Osteophytes

• Hardware

• Vertebroplasty or kyphoplasty

96

17

Points Placement for

Different Projections of a Vertebral Body

97Genant et al J Bone Miner Res 1993; 8: 1137 98

Obliquity of Vertebrae

Midpoint

placed in

center of

oval

Scoliosis – Point Placement

Difficult

99

Degenerative DiseaseOsteophytic spurs complicate point placement

100DISH

Degenerative Disc Disease

Point Placement in

Degenerative Disease

101

Imagine parallel line through endplates

Vertebral Fractures Can

Have Secondary

Osteoarthritic Spurs -

Use Visual Assessment

102

18

DEMONSTRATION

103

Image Processing in DICOM- CXR

127

Normal CLACHE

contrast-limited adaptive histogram equalization (CLACHE

Changing brightness

and/or contrast allows

visualization of lumbar

spine on CXR

Morphometry software

128http://www.optasiamedical.com/opt-

content/uploads/SA4.0-X-ray-report.pdf129

Morphometry software

130

Summary

• Position patient correctly

• Analyze image – use image manipulation techniques

• Interpret the image – identify deformity and determine if it is due to a fracture▪ Must include visual assessment – cannot

rely on morphometry alone

•131

19

www.ISCD.org


Course

132

Lecture 3

Vertebral Fracture Recognition and

Interpretation

Learning Objectives

1. Identify the appearance of

▪ Normal vertebrae

▪ Normal anatomic variation

▪ Vertebral fractures

▪ Artifacts and distractions

▪ Other findings

2. Describe vertebral fracture shape and

severity

3. Describe when imaging techniques other

than VFA are indicated

133

Normal vertebral anatomy

Superior endplate

Vertebral body

Inferior endplate

Intervertebral disc

Pedicle

Transverse process

Spinous process

134

Normal radiographic vertebral

anatomy

Vertebral

body

Superior

endplate

Inferior

endplate

Pedicle

135Courtesy of Jiang ,G

Normal radiographic spinal

anatomy

L3T8

Lateral thoracic-

(T) spine

Lateral lumbar-

(L) spine

• Self-similarity between adjacent vertebrae

• Parallel endplates

• Smooth cortical margins

• Normal alignment

X-ray X-ray

T9

136

Normal vertebrae and spine by

VFA

L3T8

• Self-similarity between adjacent vertebrae

• Parallel endplates

• Smooth cortical margins

• Normal alignment

A B C

VFAVFA

137

20

VFA versus radiography

T6

VFA may not

visualize upper

thoracic spine as

well as X-ray

L3

X-ray subject to

more parallax in

lumbar spine

than VFA

138

VFA

NORMAL ANATOMIC VARIANTS

139

Normal anatomic variation

L4

L1

T6

Vertebral heights (cm) Vertebral height

gradually

increases from

T6 to L4

HpHa

The relationship

between Hp and

Ha changes from

T6 to L4

Normal thoracic

vertebrae are

wedge-like

Normal lumbar

vertebrae are

biconcave-like

Black DM, JBMR 1991;6:883-92. 140

Normal variant: Cupid’s Bow

• Bow shape of

posterior-inferior

endplates on AP

view

▪ L4 > L5 >> L3

▪ ♂ > ♀

▪ Af Am > Caucasian

▪ May be graded 1-3

• Mimics concave

VFx on lateral view

141

Note smooth end-plate contour

and posterior location

1. Dietz GW, Radiology 1976;121:577-9

2. Chan KK, Radiology 1997;202:253-6

Cupid’s Bow• Prevalence * 1

▪ Any Grade LS: 63%

▪ Grade 3 only: 8% (L4), 6% (L5), 1% (L3)

• Not associated with low bone mass 2

Coronal - CT - Sagittal VFA

1421. Dietz GW, Radiology 1976;121:577-9

2. Chan KK, Radiology 1997;202:253-6* In at least one lumbar vertebra

“Short anterior vertebral height”

1. Ferrar L, Bone 2007;41:5–12

2. Ferrar L, JBMR 2007;22:1434-41

3. Jiang G, Bone 2010;47:111-6

• “Reduced” anterior

height without loss of

endplate linearity▪ T-spine > L-spine

(~ 5:1)

▪ Several contiguous

vertebrae▪ ♂ > ♀

• Not associated with

low BMD

X-ray MRI

T9

143

21

VERTEBRAL FRACTURE BY

VARIOUS MODALITIES

144

Vertebral fractures by radiograph

145

X-ray X-rayX-ray

Acute back

pain after a fall

Vertebral fractures by

radiograph

Two weeks

later

Post-

augmentation

146

Acute vertebral fractures by MR

MRI-T1 MRI-STIR *MRI-T2

147

* STIR = Short Tau Inversion Recovery; a fat suppressing, fluid sensitive sequence

Multiple vertebral fractures by MR

MRI-T1 MRI-STIR

148

Multiple vertebral fractures by CT

Sagittal CT Coronal CT

T12T12

149

22

Multiple vertebral fractures by

Bone Scan/SPECT*

151

* Single Photon Emission Computed Tomography

Planar Axial Sagittal Coronal Axial Sagittal Coronal

Vertebral fracture by VFA

VFAVFA VFA152

Normal Vertebral Anatomy

L3T8

Seeing Vertebral Fractures

T12

T7

L3

X-ray VFA

• Make a visual sweep

from top to bottom

▪ Adjacent vertebra

should be similar

▪ VFx usually stand out

• Fractured endplates

▪ May not be parallel and

may show discontinuity

• Anterior cortical wall

▪ May show buckling

• Spinal misalignment

153

ARTIFACTS AND DISTRACTORS

154

Parallax can simulate VFx

Gantry angle parallel

to vertebral endplate

Gantry angle increasingly oblique

to vertebral endplate

En face visualization of both superior

and inferior endplates creates parallax155

Parallax can simulate VFx

L4

T12

Looks like a

biconcave

T12 VFx

because of

parallax

T12

T12

Patient

repositioning

indicates no

T12 VFx

T12

X-ray156

23

VFA

Parallax can occur with VFA

Automated

VFA software

detects L2

VFx

Patient

repositioning

corrects the

error

157

Artifacts and Distractors

T12 vertebral

augmentation

with poly-methyl-

methacrylate

(PMMA)

Large

osteophyte

Pedicle

screws

Endplate

sclerosis

158

VFAVFA

Artifacts and Distractors

Anterior cortex buckled?

Osteophytes

L2

VFA

159

This is anterior

cortical buckling

These are

osteophytes

The anterior spinal ligament line

Ignore bone

anterior to

this line when

assessing

vertebral shape

and dimensions

Radiograph Radiograph160

L1

VFA

Diaphragm shadow

VFA

L1

X-ray161 VFA

T12

Scapular shadow

T8 Schmorl

node?

Scapular

shadow

162

24

Kyphosis due to VFx

T12

T8

X-ray VFA

163

Kyphosis in absence of VFx

X-rayVFA

164

Degenerative disc disease accounts

for most kyphosis• Rancho Bernardo Study

▪ X-rays of 1407 kyphotic ♂/♀ ages 50-96

▪ Vertebral fracture identified• ~1/5th of all kyphotic ♂ and ♀• ~1/3rd of the most kyphotic (Q4)

Schneider DL, J Rheumatol 2004 ;31:747-52

Kado DM, Ann Int Med 2007;147:330-338

% w

ith V

Fx

<37º 37-45º 46-55º >55º

Q1 Q2 Q3 Q4

Quartile of Cobb Angle

165

X-ray MRI

Scoliosis confounds imaging

Morphometry

software detects

severe L1 wedge VFx

Incorrect

automated

point

placement

Manually

corrected

point

placement

VFA

166

Scoliosis

• C

VFA VFA167

“Reverse VFA”Technical tips to enhance VFA

imaging

• Equivocal T11 VFx

• Reversing patient

position may improve

visualization

• Not a vertebral fracture

• Be conservative with

mild (Gr1) VFx

168 VFA

T11

25

Technical tips to enhance VFA

imaging

• Imaging tool• Contrast

• Brightness

• Inverting the

image may help• Tools

• User options

• Image

• Invert

Summary of artifacts and

distractors

• Suboptimal positioning

• Parallax

• Patient motion

• Kypho-scoliosis

• Osteophytes,

syndesmophytes

• Bones, gas, diaphragm

• Instrumentation

• CalcificationsVFA

VFA170

VERTEBRAL FRACTURE

SHAPE AND SEVERITY

171

Genant visual Semi-Quantitative (SQ) Method

1. Visually scan from top to bottom

2. Identify abnormal vertebrae

3. Differentiate vertebral fracture from normal variant and non-fracture deformity

4. Determine fracture shape and grade

Genant HK, JBMR 1996;11:984-96

Radiograph172

Genant Visual SQ MethodFracture Shape

• Wedge, concave, crush

• Superior, inferior, both

Genant HK, JBMR 1996;11:984-96173

Genant Visual SQ MethodFracture Shape and Grade

Mild Gr 1 20-25%

Moderate Gr 2 25-40%

Severe * Gr 3 >40%

Genant HK, JBMR 1996;11:984-96174* Includes vertebra plana

26

The ABQ* method compliments

Genant SQ method

1. Visually scan from top to

bottom

▪ Identify abnormal

vertebrae

▪ Differentiate VFx from

variants and non-VFx

deformity

2. ABQ requires depression

of vertebral endplates

▪ By ABQ this is “short

anterior vertebral height”

Genant: VFx

ABQ: VFxGenant: VFx

ABQ: Not a VFx

Jiang G, Osteoporos Int 2004;15:887-96175

* ABQ = Algorithm Based Qualitative

They may change

shape over time…

June

20

X-ray

Vertebral fractures are dynamic

McKiernan FE, JBMR 2003;18:24-9

T12T12

June

26

Standing Supine

…and with axial

loading (standing)

“Dynamic mobility”

X-ray

176

Genant Grades 0-3 by VFA

No VFx Mild

Grade 1

L1 superior

concave

Moderate

Grade 2

T9 crush

Multiple

Grades

Severe

Grade 3

T12 wedge

Genant HK, JBMR 1996;11:984-96177

• There are technical issues with image acquisition

• There is subjectivity in visual assessment

• There is ambiguity in the descriptive language of vertebral fracture morphology

• There is disparity among results of SQ, ABQ and QM methods

• This is why clinical trials have complex processes for VFx adjudication

Even experts will disagree!

178

VERTEBRAL FRACTURES

179

Mild (Gr1) VFx on VFA

• Gr1 VFx may be difficult

to detect

▪ “Mild”, 20-25% height

loss

• Compared with Gr2 and

Gr3

▪ Poorer X-ray correlation

▪ Less predictive of

subsequent VFx

• Interpret Gr1 VFx

cautiously

L1

L1

X-rayVFA

180

27

Mild (Gr1) VFx on VFA

• Automated software

did not identify any VFx

• ABQ helps identify this

Gr1 superior concave

L1 VFx

• Interpret all mild (Gr1)

VFx cautiously

VFA

181

Moderate (Gr2) VFx on VFA

• Gr2 and Gr3 VFx

usually easy to

identify

▪ Loss of self-similarity

▪ Endplate deformity

▪ Lack of parallelism

▪ Cortical buckling

• Morphometry

software may help

with grade

• C

Gr2 superior

concave and

wedge L2 VFx

182

VFA

Moderate (Gr2) VFx on VFA

• Loss of self- similarity

• Endplate deformity

• Lack of endplate

parallelism

• Gr2 and Gr3 VFx▪ VFA 87-98% sensitive

▪ High correlation with

X-ray (κ=0.903)

▪ More predictive of

future VFx

Schousboe J, Osteoporos Int 2006;17:281-9 183

Moderate (Gr2) VFx

• T8 moderate (Gr2) crush

confirmed by X-rayT8

Lateral - VFA - PA

T8T8

Lateral - X-ray - AP184

Severe (Gr3) L1 wedge

L1

Chest X-ray

VFA185

Multiple VFx grades

T12 – Vertebra

plana

L3 – Gr3

biconcave

L5 – Gr3

crush

T12 – Gr3 crush

L1 – Vertebra plana

L2 – Gr3

biconcave

T10 – Gr2 crush

VFAVFA 186

28

Multiple VFx grades, kyphosis,

anterior bridging osteophytes

• T7, T8 - normal

• T9 - moderate crush

• T10 – moderate

wedge

• T11 – severe crush

• T12 – mild superior

wedge

• L1- normal

• L2 – moderate crushL1

T7

T11

187VFA

Moderate (Gr2) superior endplate

fractures

L1

L3

▪ Biconcave?

▪ Superior

concave?

▪ Wedge?

X-rayVFA

188

NON-FRACTURE AND

CONFOUNDING FINDINGS

189

Congenital vertebral

abnormalities

T7

T7

X-ray

VFA

190

Failure of

segmentation

X-ray

Limbus Vertebra

Congenital vertebral

abnormalities

X-ray

191Butterfly Vertebra

X-ray X-ray

Schmorl nodes

• Focal endplate

disruption due to

herniated disc

material through the

end-plate

• Not thought to be a

risk for osteoporotic

VFx

VFAVFA

192

29

Schmorl nodes and multiple VFx

• T5, T7, T10 – normal

• T6 – Schmorl node

• T8 – Superior VFx, Schmorl node

• T9 – Schmorl node

• T11 – Gr2 wedge, Schmorl node

• T12 – Gr3 wedge

• L1 – Gr2 crush

T10

T5

VFA193

Short Anterior Vertebral Height

T12

194

X-ray MRI VFA

Short Anterior Vertebral Height,

Schmorl node and VFx

195VFAMRI VFA

T5

L1

T10

VFA

“Degenerative remodeling”

• Mimics vertebral fracture,

but note

▪ Self-similarity of adjacent

vertebrae

▪ No depression of

vertebral endplate

• Resembles “Short

anterior vertebral height”, but

▪ Anterior osteophytes

▪ Disc narrowing 196

OTHER PATHOLOGY

VFA IS NOT A RADIOGRAPH

197

Calcified abdominal aortic

aneurysm

L1

Schousboe J, JBMR 2008;23:409-16

“Abdominal aortic calcification (AAC)

scored on VFA images is independently

associated with incident MI or stroke.”

Morphometry

software detects

Gr2 superior

concave L1 VFx

What else can

be seen?

CT CT Angio

VFA

VFA

198

30

Scheuermann Disease

▪ Multiple Schmorl nodes

▪ Irregular “undulating” endplate

▪ Wedge shaped vertebrae

▪ Kyphosis

▪ T > L-spine

▪ Demographic

▪ Males, onset age 13-17

▪ Prevalence 0.4 - 8.0% but may

be decreasing

X-ray

Makurthau AA, Spine 2013;38:1690-4 199

Scheuermann Disease

T7

T7

VFA X-ray200

X-ray

Scheuermann Disease

Intervertebral osteochondrosis

VFAX-ray MRI

T9T9

201

Diffuse Idiopathic Skeletal

Hyperostosis (DISH)

• Flowing ossification of

the anterior

longitudinal ligament

• Four contiguous

vertebrae

• Preserved inter-

vertebral disc height

• Features of Ankylosis

spondylitis absent

Resnick D, Seminar Arth Rheum 1978:7:153-87X-ray

202

Diffuse Idiopathic Skeletal

Hyperostosis (DISH)

T12

T12

X-ray Sagittal CT VFA

203

DISH and vertebral fracture

• Moderate L1 wedge

fracture caudal to a

long rigid construct

created by DISH

• Intra-vertebral cleft

seen beneath

superior endplate

X-ray204

31

• Syndesmophytes

▪ Neither osteophyte

or DISH

▪ Ossification of the

annulus

▪ “Bamboo spine”

• “Dagger sign”

▪ Ossification inter-

spinous ligament

Ankylosing spondylitis

DXA

VFA205

Paget’s disease with VFx

• Trabecular coarsening

• Boney expansion

X-ray MRIVFA

206

Metastatic prostate cancer

T12

T12

VFA

T12

207

X-ray

Rapid, synchronous VFxsConsider non-osteoporotic causes

Multiple Myeloma

OsteomalaciaOsteoporotic VFx tend to

occur in varying stages208

Indications for following VFA with

other imaging modalities

• The decision to perform additional imaging must be based on each patient’s overall clinical picture including the VFA result

• VFA is designed to detect vertebral fractures and not other abnormalities

Schousboe J, J Clin Densitom 2008;11:92-108

ISCD Official

Position

209



• ≥ 2 mild (Gr1) deformities and no moderate (Gr2) or severe (Gr3) deformity

• Vertebral lesions that cannot be attributed to benign causes

• Vertebral deformities in a patient with a history of malignancy


ISCD Official

Position

210

32



• Equivocal fractures

• Unidentifiable vertebrae between T7-L4

• Sclerotic or lytic changes, or findings suggestive of conditions other than osteoporosis


ISCD Official

Position

211

Summary: Vertebral Fracture

Recognition and Interpretation

• Judge technical

quality of image

▪ Use image tool to

change brightness

and contrast or invert

the image

▪ Reposition patient or

scan in opposite

decubitus position

• Make visual sweep

from top to bottom

▪ Adjacent vertebra

should be similar

▪ VFx usually stand out

• Fractured endplates

▪ Are not parallel

▪ May show

discontinuity

• Anterior cortical wall

▪ May show buckling 212



• Mild (Gr1) VFx may be difficult to detect and interpret

▪ Be conservative

▪ Quantitative morphometry is not a simple solution

• Moderate (Gr2) and severe (Gr3) fractures are usually easy to detect

• Be vigilant for non-osteoporotic vertebral deformity

213



• Report fractures of which you are certain

▪ Some Gr1 VFxs will be missed but these are

less predictive of future fractures

• Even experts can disagree

• Consider additional imaging

▪ If confirming VFx would change clinical

management

▪ The VFA image warrants additional

investigation

214

www.iscd.org

ISCD Vertebral Fracture Assessment Course

215

Lecture 4: Principles of Reporting VFA

216

Learning Objectives

1. List indications for imaging to detect spinal fractures

2. Describe components required in a VFA report

3. List information needed from the patient

4. Describe reporting of serial studies

5. Apply principles of reporting to clinical cases

6. Identify vertebral fractures on routine CXR or

abdominal/thoracic CT scans

33

ISCD Indications for Spinal Imaging

www.ISCD.org

ISCD Official Position

• Lateral spine imaging with standard radiography or densitometric VFA is indicated when T-score is ≤ -1.0 and one or more of the following is present:

▪ Women age ≥ 70 years or men ≥ age 80 years

▪ Historical height loss > 4 cm (>1.5 inches)

▪ Self-reported but undocumented prior vertebral fracture

▪ Glucocorticoid therapy equivalent to ≥ 5 mg of prednisone or equivalent per day for ≥ 3 months

218

Components of a VFA Report

• Patient identification, referring physician, indication(s) for study, technical quality and interpretation.

• A follow-up VFA report should also include comparability of studies and clinical significance of changes, if any.

• VFA should comment on the following

▪ Unevaluable vertebrae

▪ Deformed vertebrae, and whether or not the deformities are consistent with vertebral fracture

▪ Unexplained vertebral and extra-vertebral pathology

• Optional components include fracture risk and recommendations for additional studies.

Schousboe, et. al., J Clin Densitom 11:92-108, 2008


219

Information Needed From The

Patient• Demographic information: name, birth

date, gender, race, height and weight

• Requesting physician and other relevant

providers

• Indications for VFA study

• Previous spine imaging

• Risk factors for vertebral fractures

220

Risk Factors for Vertebral Fractures

• Height loss (height at age 25 by history/drivers license)

• Conditions and medications that increase risk of

vertebral fractures or affect spine imaging

(glucocorticoid or other medications, congenital &

developmental skeletal disorders, neoplasia, systemic

infections)

• Previous fractures (vertebral or nonvertebral, traumatic

vs. fragility, time of occurrence)

221

Technical Information About

The Scan

• Manufacturer

• DXA model

• VFA software version

• Scanning positions included

• PA position

• Lateral scan position

• Supine with rotating C-arm

• Lateral decubitus

222

Conditions influencing Technical Validity &

Interpretability of Scan

• Positioning adequate?

• Interpretable vertebral levels? (e.g. T5-L4)

• Confounding factors present?

• Developmental anomalies

• Scoliosis

• Calcification of organs and soft tissue

• Spine arthritis and degenerative disc disease

• Osteosclerotic and osteolytic lesions

34

223

Conditions Influencing Technical Validity &

Interpretability of Scan

• Artifacts? (internal/external)

• Previous spine surgery

• Motion artifact

• Rib, diaphragmatic, and scapular shadows

• Bowel gas

• Vena cava filter

• Spine surgery hardware

• Surgical clips

224

Reporting VFA Results

• Normal

• Abnormal

• Definite vertebral fracture

• Equivocal vertebral fracture

• Other vertebral deformities

• Comparison with previous

225

Method for Defining and Reporting Fractures

on VFA• The methodology utilized for vertebral fracture identification

should be similar to standard radiological approaches and be provided in the report.

• Fracture diagnosis should be based on visual evaluation and include assessment of grade/severity. Morphometry alone is not recommended because it is unreliable for diagnosis.

• The Genant visual semi-quantitative method is the current clinical technique of choice for diagnosing vertebral fracture with VFA.

• Severity of deformity may be confirmed by morphometricmeasurement if desired.

Schousboe, et. al., J Clin Densitom 11:92-108, 2008


226

Reporting Fractures

• Reporting level, type, and severity of fracture recommended because:

• Number and severity of vertebral fractures provides better stratification of future fracture risk (discussed in lecture 1)

• Permits comparison to prior imaging (plain films, VFA, MRI, CT etc)

• Can serve as a baseline for detection of incident fractures on future imaging

227

Case A

• 66 year-old healthy Caucasian woman

presents for routine DXA scan. VFA

obtained because of 2” height loss

• No history of fractures

• BMD results

▪ L1-L4 T-score: -1.0

▪ Total hip T-score: -2.4

▪ Femoral neck T-score: -2.2

228

Case A: VFA ReportingDemographics and Clinical Information

66 year old postmenopausal Caucasian female with

osteopenia on DXA and a history of height loss, referred

for VFA

35

229

• VFA was performed in the lateral

decubitus positions using a GE

Prodigy densitometer

• Positioning is good. There are no

obvious confounding factors. The

VFA scan was interpretable from

T6-L4

Case A: VFA ReportingTechnical Information

230

Case A: VFA ReportingFracture Results

• Using the semi-quantitative analysis of

Genant there was evidence of a grade 3

(severe) wedge fracture at T12.

231

Case A: Optional Reporting

Optional reporting of morphometry results

• Six-point morphometry confirmed severe

(grade 3) T12 deformity (53% reduction in

A/P ratio).

232

Case A: Reporting VFA (+BMD results)

• Mrs. AA has osteopenia by BMD criteria and) a severe T12 vertebral fracture identified on VFA.

• If alternative etiologies for vertebral fractures (prior trauma, pathologic fracture), are excluded, the diagnosis is osteoporosis

• Further evaluation may be warranted depending on the clinical situation.

233

Case A: Reporting Fracture Risk (Optional)

• The calculated 10-year absolute fracture risk

by FRAX® (version 3.8, based on a prior fragility

fracture)

▪ major osteoporotic fracture risk = 20%,

▪ hip fracture risk = 3.6%

234

• The patient was found to have

severe scoliosis and significant

amounts of bowel gas that prevent

adequate vertebral visualization.

• The VFA is uninterpretable.

• Further imaging would be needed

to identify vertebral fractures.

Case B: Reporting Confounding FactorsOccasionally, VFA or X-ray is Uninterpretable

36

Reporting ABQ Results ABQ Can Be Helpful When You Are Unsure

• Grade 1 fractures

▪ Difficult to diagnose because of normal variation in

vertebral shape

▪ Expert radiologists can disagree, even on x-ray

• Central endplate depression can be missed by

Genant’s method

235

X-Ray Example: Fracture by ABQ

• Parallax seen throughout the

lumbar spine makes it difficult to

assess vertebral ht

• However, superior endplate of L1

cannot be explained by obliquity

(note lack of similarity between

superior and inferior end-plates)

• Report: “ABQ documents

superior end-plate depression at

L1 diagnostic of fracture”

236

X-ray X-ray

VFA Example: Fracture by ABQ

• Morphometry normal

• However, on visual

inspection, superior

endplate depressed

• Report: “ABQ confirms

superior end-plate

depression diagnostic of

fracture”

237

CASE C: Identifying Fractures On Other

Imaging procedures

• 66 y/o Caucasian female started on high-dose

glucocorticoids for temporal arteritis in August 2012

• Low back pain after a fall a few days later, lumbar

spine x-ray normal

• CT scan documented a grade 1 fracture

• No further falls but complained of increased back

pain in October and again in January

238

C

CT Aug 2012 CXR Jan 2013

Case C: 66 y/o, high dose glucocorticoids

MRI Jan 2013

MRI: progression of fracture at T12, fx at T11, new fractures at L1(note change in signal suggesting a new fx) L2 and L4

CXR: fractures at T8, T9, T11, T12, L1, L2, L3

T12, G1

Case C: 66 y/o high dose glucocorticoids

• In retrospect, an

incident fracture at T12

(progression from

grade 1 to grade 3)

was seen on a CXR in

October 2012

• No other fractures were

seen at this time

Enlarged T12, L1, L2

CXR October 2012

37

Conclusion

• Multiple modalities can be used for identifying

vertebral fractures

• VFA is not needed if other imaging is available

• Reviewing previous images can be helpful in

determining when fractures occurred

241

C

Vertebral Fractures Can (and Should!) be

Assessed on Imaging for Other Indications

• Chest radiography (especially lateral CXR)

• Abdominal or thoracic whole-body computed

tomography

▪ Often not seen on axial sections but easily seen on

midline sagittal reformations

242

Vertebral Fractures Often Seen on Lateral

Chest Radiographs

243

X-ray X-ray

Whole Body CT Scans Can Reveal

Unsuspected Vertebral Fractures

244

Midline sagittal reformations of thoracic and abdominal CT scans

245

Indications for Repeat VFA(no official position)

• Repeat VFA when finding an incident

vertebral fracture would change patient

management

• Possible indications

▪ New back pain consistent with vertebral

fracture (although X-rays preferred for

evaluation of acute pain)

▪ Documented height loss ¾” (2 cm)

246

Reporting Serial Studies(Diagnosing incident fracture)

• Visually identify a change in the appearance of the vertebra

▪ Decide whether the change is due to an incident fracture (ABQ can be helpful)

• Use the SQ analysis of Genant to assign fracture grade on each exam. Incident fracture is a new fracture or an increase in severity and/or grade of an existing fracture

• Six-point morphometry may be used to quantitate deformity and/or its progression.

38

247

Case D

• 88 year old woman on oral bisphosphonates

for 6 years

• Known fractures at L1 and L2

• Follow-up DXA documents no bone loss

• Physical exam revealed worsening kyphosis

and a measured height loss of 1.5 inches

• Repeat VFA ordered

Case D:

Repeat VFA

248

L3

L3

T9 T9

Old Fractures:

arrows

New Fractures

(Also note

aortic calcification

and bra clips)

T12T12

2008

T9, L3

2007

249

Case D: Reporting of Serial Studies

• Mrs. DD was referred for a repeat BMD; VFA obtained because of a measured height loss

• VFA was performed using a Hologic Delphi densitometer. Bra clips and aortic calcification are noted but do not interfere with the identification of vertebral fractures

• VFA scan is interpretable from T6-L4• Comparison is made to the previous VFA scan

obtained in 2007 on the same densitometer

250

Case D: Reporting of Serial Studies

• Using the semi-quantitative analysis of

Genant there is evidence of multiple

moderate and severe fractures that were

present on the exam from 2007 (Grade 2 at

L2, Grade 3 at L1, Grade 2 at T11). In

addition, there are new fractures that were

not present in 2007: Grade 2 at L3 and Grade

3 at T9

251

Components of a VFA Report• Patient identification, referring physician, indication(s)

for study, technical quality and interpretation.

• A follow-up VFA report should also include comparability of studies and clinical significance of changes, if any.

• VFA should comment on the following

▪ Unevaluable vertebrae

▪ Deformed vertebrae, and whether or not the deformities are consistent with vertebral fracture

▪ Unexplained vertebral and extra-vertebral pathology

• Optional components include fracture risk and recommendations for additional studies.

Schousboe J et. al., J Clin Densitom 11:92-108, 2008


252

VFA Reporting

Work Sheet(For use in lecture 5)

• Assists in demographic

data gathering

• Clarification of vertebral

fracture classification

• Template for dictation

• Useful for reimbursement

submittal

• Considered as an intra-

office/clinic report

• Easy to use serial study

comparator

39

253

Vertebral Fracture

Recognition Work Shop

254Version 9.0

WORKSHOP

Case 1

T12

255

T12

WORKSHOP

Case 2

WORKSHOP

Case 3

256

T12

257

WORKSHOP

Case 4

T12

WORKSHOP

Case 5

April 2004 June 2005

L1

L2

L3

L4

L1

L2

L3

L4

40

259Version 9.0

WORKSHOP

Case 6

www.ISCD.org

ISCD Vertebral Fracture Assessment Course

260

Lecture 5: Case Study Review and

Workshop

261

Vertebral Fracture Recognition

Work Shop

262

VFA is for vertebral deformity assessment only. Further studies may be needed depending on results and clinical correlation

263Version 9.0

WORKSHOP

Case 1

T12

264Version 9.0

WORKSHOP

Case 1

T12

41

265

T12

WORKSHOP

Case 2

266

T7 G3 crush

& wedge

T9 G2 wedge

T12

WORKSHOP

Case 2

WORKSHOP

Case 3

267

T12

WORKSHOP

Case 3

268

Kyphoplasty L1

Scoliosis

DJD with vacuum

phenomena

Artifacts:

granuloma

bra fastener

button

Aortic calcification

T12

269

WORKSHOP

Case 4

T12

270

L2 G3 biconcave

& wedge

↑ density

T9 G3 crush & wedge

WORKSHOP

Case 4

T12

42

WORKSHOP

Case 5


L1

L2

L3

L4

L1

L2

L3

L4

WORKSHOP

Case 5


DJD, Incident G2 Fracture at L1

L1

L2

L3

L4

L1

L2

L3

L4

273Version 9.0

WORKSHOP

Case 6

274Version 9.0

WORKSHOP

Case 6

T7+T8 G3 Fracture

T11 G3 Fracture

L2 G3 Fracture

L3 G3 Fracture

L4 G2 Fracture

275

Learning Objectives

1. Practice reading spine images

2. Recognize normal variants

3. Recognize confounding factors

4. Identify and grade fractures

276

Case 1

T12

CONSIDER:

Positioning?correct

Confounding factors?mild DJD

Vertebrae identified?T6-L4

Fractures?none

43

277

Case 2

Scapular shadow

OsteophyteT12

Diaphragm

Normal L5 shape

T12

Positioning

good

Vertebrae visualized

T6-L5

Confounding factors

Fractures

none

278

Case 3

T4 G3 Crush

T12 G3 Wedge

T12

NOTE:Lack of self-similarity

Lack of parallelism

DJD

279

Case 4

T12 G2 Wedge

T12

NOTE:

Lack of self-similarity

End-plate deformity

Lack of parallelism

End plate fractures with (red)

and without (blue) abnormal

morphometry:

X-ray

Case 5

281

Elongated vertebrae,

osteophyte

no fracture(note end-plates

parallel)

T12

Lumbar obliquity,

no fracture

Case 6

←L2 G3 biconcave

T12

←T10 G1 wedge

←T11 G2 wedge

Greenfield filter NOTE:

Scoliosis and pulmonary markings

make visualization

of thoracic spine difficult

Case 7

44

283

Case 8

Right Lateral Decubitus

T12

Unable to visualize

lumbar vertebrae

What can you do?

Left lateral decubitus

284

Case 9

T10 G3 crush

T11 G2 wedge

T12 G2 biconcave

L2 G3 biconcave & wedge

L4 G3 biconcave

Multiple fractures

with typical

variability seen

with osteoporotic

fractures

Prosthetic

humerus→

285

Case 10

L1 G1 wedge,

G2 end-plate

T12

T12

Subtle end-plate

deformity

Note lack of

self-similarity

and lack of

parallelism

286

Case 11

Shape of L5

normal variant

NOTE:

poorly visualized

upper thoracic

spine

T8 G2 biconcave

287

Case 12

L3 G3 biconcave

L2 G2 wedge and inferior concave

T12

RW091009splenicHemato

ma• We see nothing

on the AP VFA,

so we know the

abnormality is

quite lateral.

• On lateral view

the abnormality is

anterior and right

under the

diaphragm,

suggesting

location in the

spleen.

Case 13

45

AP View Abdomen:

LUQ Calcification

CT: Calcified

Lesion in Spleen

Likely calcified granuloma

Case 13

290

Case 14

T11 G3 Crush

& Wedge

Vertebra plana T12

291

Case 15

T8 G2 crush

Loss of self-similarity

T10 G2 wedge

T12 T12

NOTE:

Typical DDD with

disc-space

narrowing ie

not DISH

292Version 9.0

Case 16

Multiple

fractures

Case 16: 35 y/oF with SLE:

steroids, enoxaparin, Lupron

293Version 9.0

CT June

2012

MRI May 2012

VFA June 2012

X-ray June 2012

Case 16: Progression of Vertebral Fractures

294Version 9.0

Sept 2012 – Xray Jan 2013 – X-raySept 2012 - MRI April 2013 -

VFA

46

DV 7/2/04 ap SPINE AND THEN ap+LAT Iva

SHOWING L3 biconcave, ?L5 wedge/T-Score

-3.8

-2.1

-3.2

-2.8

Case 17

296Version 9.0

Incorrect automatic point placement

by machine!

Case 18Kyphosis without fracture

297

Kyphosis

without

fractures

Kyphosis with

fractures

Case 19

298Version 9.0

VFA X-ray

Limbus Vertebra

Case 20

T12

Cupid’s bow

deformities,

most prominent in

lumbar spine

300Version 9.0

DISH DISH Ankylosing

spondilitis

Ankylosing

spondilitisCase 21

47

301

T12

T12

L1 G3 wedge→

Anything unusual

on AP???

Laminectomy T9-L5

Case 22

303Version 9.0

Case 24T7 G3 wedge

T12 G2 wedge

T12

T7 G3 wedge

(vertebra plana)

NOTE: ↑ density,

consider

pathologic fracture

T12

T12

T12Multiple G3 fx:

T8, T9,T10.T12

T11 vertebral

augmentation

L2 endplate

deformity

NOTE: scoliosis

does not preclude

visualization of thoracic

spine

Aortic calcification

Case 25

305

Case 26

T12 G3 wedge→

(vertebral

augmentation)

T7 G3 crush

T12

306Version 9.0

T12 G2 wedge and

superior endplate fracture

L1 inferior concave and wedge and

fracture

L3 superior

endplate fracture

Case 27

307Version 9.0

Case 28

T7 G2

endplate fracture

(not Schmorl’s)

T12 G2 wedge

L1 G2 Wedge

T12

Schmorl’s NodesT12

and schmorl’s

←T9 G2 superior

endplate fracture

T12

48

MRI Jan 2013

VFA May 2013

Case 29: Progression of vertebral fractures

311Version 9.0

Hypoplastic vertebrae due to

childhood radiation

Case 31

Unusual Vertebral Shape

What is This??

T12

T12

314

Learning Objectives

1. Practice reading VFA’s

2. Recognize normal variants

3. Recognize confounding factors

4. Identify and grade fractures on VFA

Extra cases for possible use

315Version 9.0

66 y/o HF treated with glucocorticoidsCase

Falsely elevated

spine BMD

5 MS

earlier

Multiple

vertebral

fractures

49

63 y/o Healthy Man with Sudden Onset of

Back Pain after Lifting a 400lb Cow

318Version 9.0

BMD T-scores:

FN= -0.8

TH= -1.0

1/3 radius =

+0.5

Further w/u?

Hgb = 7.5

Calcium=11

Cre=5.4

GFR=11

T Protein=9.9

Albumin=3.5

Fracture visualization on thoracic and

lumbar spine – 3 days later

319Version 9.0

321Version 9.0

Documents

The International Society for Clinical Densitometry VFR€¦ · Cleveland Clinic Foundation. His fellowship in musculoskeletal radiology was at the University of California, San Francisco