Vertebral fractures – missed opportunities: The role of the

Radiology Department in correcting this!Andrew Pearson

NHS Borders, Scotland

Overview• Significance of vertebral fractures• Hip fracture audit• Poor performance of Radiology• Opportunities in Radiology to improve

fracture liaison• Input from DEXA

Requirements for effective Secondary Fracture prevention

• Effective mechanism for identification of first fragility fracture

• Effective communication with clinicians responsible for instigating treatment & follow up

Why is a Radiologist so ‘enthusiastic’ about vertebral fractures?

• Highly predictive of future fracture risk• Account for significant morbidity and

mortality• So common that they are often overlooked

as ‘incidental’ findings• Readily available golden opportunity to

identify patients requiring bone protecting medication

• Identification makes a real contribution to reducing incidence of hip fractures

• Fragility fracture progression can be halted by early identification, saving patient misery

• Represent a huge financial burden on NHS

Scottish Parliament. Written question in 2012 asking number of Hip & Vertebral Fractures, by health board• Answered by Health Minister Nicola Sturgeon

(now first minister)• Scottish Borders: 6 vertebral fractures per

year!• Real local experience: more like 6 a day!• Most insufficiency vertebral fractures are not

included in collected data

What makes vertebral fractures different?

• Most do not present acutely• Many go undiagnosed (50-70%, ref. NICE

TA161)• Inrcremental process• Often arise in absence of specific trauma• Highly predictive of skeletal ‘fragility’• Potentially the most important fractures to

identify• Account for chronic pain and morbidity• Must be actively ‘looked for’

Vertebral Fractures Substantially Increase

the Risk of New Fragility Fractures

A woman with one vertebral fracture has a 4.4 times increased risk of another vertebral fracture and 2.3 times increased risk of hip fracture (NICE TA161)

One woman in five will suffer from another vertebral fracture within a year (Lindsay et al., JAMA, 2001)

Women with low BMD and one fracture have a 25x risk of a women with normal BMD and no fracture

Incidence Rates for Vertebral, Wrist & Hip Fractures in Women

after Age 50

Wasnich RD, Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4th edition, 1999

50 60 70 80

40

30

20

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Vertebral

Hip

Wrist

Age (Years)

Ann

ual i

ncid

ence

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omen

Osteoporotic Fractures in Women:

Comparison with Other Diseases

Riggs BL, Melton LJ. Bone 1995Heart and Stroke Facts, 1996, American Heart

AssociationCancer Facts & Figures, 1996, American Cancer

Society

1 500 000*

0

500

1000

1500

2000

Osteoporotic Fractures

*annual incidence all ages † annual estimate women 29+

‡annual estimate women 30+ §1996 new cases, all ages

513 000†

228 000‡ 184 300§750 000

vertebral

250 000 other sites

250 000forearm

250 000hip

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All Types of Vertebral Fractures are Associated With Morbidity

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

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No IncidentFracture

RadiographicFracture

Clinical Fracture

36.8

3.9

76.2

26.9

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52.7Due to back pain

NICE TA161

Vertebral fractures are associated with a 4.4% increased mortality (UK specific data)

Mortality Rates by Number of Prevalent Vertebral Fractures

Kado DM et al., Arch Intern Med 1999,159:1215P for trend < 0.001

Mor

talit

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pers

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0

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Number of Vertebral Fractures

45

Vertebral fracture morbidity• Chronic pain from multiple ‘incremental’

fractures• Exaggerated kyphosis• Cause reduced mobility, leading to

further bone loss• Impact on respiratory reserve,

especially in COPD patients• Significant increase in GP visits

Vertebral Fractures in Summary

· are the most common osteoporotic fractures· are associated with excess mortality· are associated with significant morbidity, even if

they do not come to clinical attention· increase the risk of subsequent vertebral

fracture(s) by 5 fold and of other fragility fractures (including hip) by 2 fold

· highly predictive of future fracture risk due to the relative absence of trauma in their causation

A Retrospective Study Suggests that Vertebral Fractures are underdiagnosed

Gehlbach et al.,Osteoporos Int 2000, 11:577

934 hospitalised women with a lateral chest x-ray

0

20

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60

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120

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)132

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23 25

Fractureidentified by studyRadiologists

Fracturenoted in Radiologyreport

Fracturenoted inmedical record

ReceivedOsteoporosistreatment

Borders hip/vertebral fracture audit• 202 hip fractures in 2010• 56 (28%) had body CT in previous 5 years• 22 (39%) CTs showed vertebral fractures • 9 (40%) of 22 vert. fractures documented,

13 (60%) missed• 13 potentially preventable hip fractures in

2010 (£520,000!)

Missed vertebral fractures on whole body CT

Messages from audit• High prevalence (39%) of all CTs showed

vertebral fractures• 60% visible vertebral fractures were

overlooked• Radiologists need to do better at alerting

these fractures to the FLS team• Increasing general use of CT will further

increase opportunities to identify vertebral fractures

• Same opportunities available in MRI• This is opportunistic, without additional

resource requirement, using image data which is already available

• Change in practice of Borders Radiologists has contributed to 20% reduction in hip fractures between 2010 & 2014

Opportunities in Radiology• All clinical and many ‘occult’ vertebral

fractures pass through Radiology• Radiology has instant access to previous

fracture history and previous DEXAs (including referral forms)

• Easy imaging of spine (IVA, plain films, CSI)• Computerised records for easy searching• Opportunistic ‘cross sectional data’ : CT &

MRI• Identification of demineralisation on plain

films• Isotope Bone Scanning

• High fracture risk patients with cancer treatment induced bone loss

CT & MRI data• Large patient throughput• High Osteoporosis risk patients• No amendment to scanning protocol• Instant reconstructions when reporting• Access to previous records (fracture

history, DEXAs etc..)• Smart code referral to FLS or straight

to DEXA

CTPAs

DEXA SCANNING Importance of

Vertebral Morphometry

Lateral Vertebral Assessment

Combining BMD & Vertebral Fracture Assessment:

An Approach to Improve the Diagnosis Rate of Vertebral Fractures

· Improves risk assessment· Identification of occult fractures · Identification of scoliosis· Identification of artefacts

Poor quality IVA?• Plain films (at same attendance)• CT (baseline & follow up)

Differential diagnosis of vertebral fractures

• Osteoporotic fragility fracture• Myeloma• Metastases• Scheurmann’s disease• Schmorl’s nodes• Sickle cell disease, Gaucher’s disease

How can Radiology help reduce Osteoporotic

fractures?

Why in Radiology?• Only location for identification of all

vertebral fractures• Integration with non vertebral fractures

keeps all FLS data together• Access to previous imaging & DEXA to

assess age and significance of fractures• Assessment of alternative causes of

insufficiency fractures

Administrative process in Radiology, NHS Borders• Reporting Radiologist/Radiographer describes

fracture and dictates “insert fragility fracture”• Text string inserted as suffix to report indicating

that patient may be at increased risk of further fractures and will be assessed by the Osteoporosis team

• Radiology Office books these in as “Fracture Liaison” examinations, with other fracture liaison cases

• Osteoporosis Radiologist/Clinician assesses case (access to previous DEXA, fracture history, osteoporosis clinic attendances, current drug treaments) and decides on need to recall for DEXA or go straight to treatment

• Text string in report will automatically generate a DEXA referral or standard text recommending treatment

Requirements for success:

1. Understanding amongst Radiology team members of huge importance of identifying occult vertebral fractures

2. Simple mechanism for reporting Radiologist or Radiographer to identify and highlight presence of vertebral fractures on cross sectional and other imaging

3. Mechanism for ensuring that this information is passed to the Fracture Liaison team for further action

Message for Radiologists

• 11% of hip fractures are dead within 30 days

• 40% of hip fracture patients who previously lived independently in their own home end up in institutional care

• Hip fractures cost £40,000 each• Many hip fractures can be prevented

Why Radiology needs to act now!• Nobody else is in such a good position to help

identify patients at risk of hip fracture• Requires minimal time & effort• 30 seconds to save a life!• Failure to act when such obvious ‘incidental’

pathology is present on scan could be seen as a clinical incident

• All you need to do is:click of the mouse to show sagittal imagebrief look at this imagedictate a few words (e.g.: there are

several mid thoracic vertebral fractures, “insert fragility fracture”)

QUESTIONS