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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?