NOS UK releases Guidance for effective identification of vertebral fractures

The National Osteoporosis Society, UK has released necessary guidelines to ensure that all vertebral fractures are systematically identified, reported using clear terminology for the referring clinician leading to appropriate management to avoid further fragility fractures.

There is no denial of the fact that treatment with pharmacological agents is highly effective in reducing the risk of further fracture within 6 to 12 months by 50–80%. But 20% of osteoporotic women with a recent vertebral fracture sustain a new vertebral fracture within the next 12 months. Therefore it is particularly important to identify those individuals with vertebral fractures who are osteopenic rather than osteoporotic, and who may otherwise not be considered for pharmacological treatment.

The society feels that under-diagnosis of vertebral fracture occurs due to several reasons because of following reasons-

• Unlike other fragility fractures, only a minority of vertebral fractures result from a fall


• Symptoms of a vertebral fracture are often attributed to another cause by both patient and healthcare professionals


• The need for spine imaging in a patient with risk factors for osteoporosis presenting with new back pain is often not recognised


• When imaging is undertaken for indications other than back pain, the spine may not be systematically scrutinised during the reporting process


• Vertebral fractures may be reported using ambiguous and confusing terminology


• The referring clinician may regard the finding of a vertebral fracture as incidental to the reason for the original referral, and fail to recognise its clinical importance

Recommendation for Identification of Vertebral fracture

• Vertebral fractures are most likely to be under-reported on imaging obtained for non-musculoskeletal indications. This includes images acquired using all modalities that involve any part of the thoracolumbar spine, with the greatest opportunity presented by the increasing number of computed tomography (CT) scans undertaken in older adults


• It is recommended that diagnostic imaging services establish local processes to ensure that the spine is routinely evaluated for the presence of vertebral fracture in all available imaging and that reports are actionable. Depending on local policies, this may involve:
  
  
  
  • routine sagittal reformating of CT images using bone algorithms, either by the operator or by the reporting clinician
  
  
  • scrutiny of lateral views of the spine on any relevant images (e.g. CT, magnetic resonance imaging (MRI), radiographs)
  
  
  • raising awareness among reporting clinicians of the importance of vertebral fracture identification
  
  
  • training and CPD to increase confidence in the recognition of vertebral fractures
  
  
  • inclusion on departmental audit programmes
  
  
  
  

Reporting of vertebral fractures

• Whenever imaging that includes the spine is reported, the report should indicate that the spine has been assessed


• Use of ambiguous and obscure terminology leads to confusion and the risk that vertebral fractures will be overlooked. Terms to be avoided describe vertebral fracture include:

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  • wedging
  
  
  • vertebral height loss
  
  
  • deformity
  
  
  • end-plate infraction or depression
  
  
  
  


• Where appearances are equivocal because the quality of images is sub-optimal, this should be reported

It is imperative that the appearance of the vertebral bodies is described clearly and unambiguously. A vertebra may be described in one of three ways.

1.Vertebral fracture

• Additional information should be given describing the vertebral level(s) involved and the severity of the fractures


• If previous imaging including the spine is available, this should be reviewed to identify the timing of the fracture

2. Non-fracture vertebral deformity

• If the cause of the deformity is clear, this should be described in the report. Common causes include degenerative change, Scheuermann’s disease and Schmorl’s nodes

3. Normal

Recommending further assessment

• The RCR endorses actionable reporting, written ‘in a way appropriate to the referrer’s expected level of familiarity with the issues raised.’ If a vertebral fracture is identified, the report should use the principles of fail-safe alerts (in line with RCR guidance and agreed locally) and flag to the referring clinician the need for further assessment and management to reduce the patient’s risk of further fracture. The presence of severe, multiple or recent vertebral fractures indicates that the patient is at very high fragility fracture risk, warranting an urgent evaluation


• The wording used will depend on the local service model and agreed pathways. A standard phrase may be saved as a shortcode that can be automatically inserted into the report. Examples include:

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  • appearances suggest osteoporosis—the patient should be offered assessment in the Fracture Liaison Service
  
  
  • appearances suggest osteoporosis. Further investigation and management to reduce the risk of further fracture is advised
  
  
  • appearances suggest a high risk of fragility fracture—referral for dual-energy X-ray (DXA) scan/referral to the metabolic bone clinic is advised
  
  
  
  

Integration with the fracture liaison service

• Localities with an established FLS should collaborate with their diagnostic imaging department to optimise case-finding into the service. Any additional activity will need to be scoped and appropriately resourced


• In most cases, the FLS will need to liaise with the referring clinician prior to offering assessment in the FLS or osteoporosis service. This allows the referrer to share information relevant to the patient’s referral and ensure that it is clinically appropriate for the patient to be offered an assessment. Assessment in the FLS may not be necessary or may not be in the patient’s best interests: the patient may already have been evaluated for osteoporosis, the vertebral fracture may be traumatic or due to pathology other than osteoporosis (such as malignancy), or the patient may have other conditions contra-indicating treatment (such as end-stage renal disease)

Identification of vertebral fractures during fracture risk assessment using DXA

• Dual-energy X-ray (DXA) measurement of bone mineral density (BMD) is undertaken as part of fracture risk assessment in patients with risk factors for osteoporosis. In addition to BMD measurement, DXA may also be used to acquire images of the thoracolumbar spine (usually from T4 to L4) using vertebral fracture assessment (VFA) scans


• It is recommended that VFA scans are targeted to patients at increased risk of vertebral fracture where identification of vertebral fracture will alter clinical management (i.e. lead to additional investigation, initiation or change in treatment)


• DXA scans are often reported by clinicians who are not radiologists or reporting radiographers. With training and experience, these clinicians may be confident to identify vertebral fractures from VFA images; however, this raises governance responsibilities that need to be addressed. Solutions may involve adjudication by a reporting practitioner or by confirmation of vertebral fracture using spine radiographs, which also enable more detailed evaluation of the differential diagnosis


• Systematic VFA imaging by DXA services should be regarded as an essential part of an integrated vertebral fracture identification pathway


• Redesign of existing FLS pathways to improve vertebral fracture identification in accordance with this guidance may require an additional resource, to include:

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  • systematic reporting of spine imaging and the introduction of a fail-safe alert process for vertebral fractures
  
  
  • case-finding of vertebral fracture patients
  
  
  • evaluation as to whether a vertebral fracture is a new finding in a patient already on treatment, and whether it is due to other pathology or trauma
  
  
  • assessment, management and follow-up by the FLS or osteoporosis service
  
  
  • audit of vertebral fracture identification
  
  
  
  

• The extra resource may include additional clinical and DXA assessments, as well as additional time for FLS nurses to establish whether an identified vertebral fracture is a new or old finding. Similarly, establishing whether a patient with a newly identified vertebral fracture needs to be seen in the FLS will in some cases take careful consideration and additional time

The guideline will help the clinicians to systematically identify all the vertebral fractures which will help to avoid future fragility fracture.

To read the guideline in full click on the link below:

https://www.guidelines.co.uk/musculoskeletal-and-joints-/nos-guideline-identification-of-vertebral-fractures/454148.article