g logo ipb green

Clinical guidance for the effective identification of vertebral fractures

Purpose and objectives of this guidance

  • The purpose of this guidance is to ensure that all vertebral fractures are systematically identified, reported using clear terminology to the referring clinician, and lead to appropriate management to avoid further fragility fractures
  • The key objectives of this guidance:
    • to raise awareness among all healthcare professionals of the clinical significance of vertebral fractures and the importance of implementing timely investigation and management to reduce the risk of further fragility fractures.
    • to enable services to identify all patients with vertebral fractures and offer management in the fracture prevention pathway
    • to raise awareness among reporting clinicians to ensure that vertebral fractures are reported clearly and unambiguously, and that the route to appropriate management is signposted within the report
    • to highlight to commissioners or those with responsibility for the allocation of resources, the clinical, financial and ethical case for a fully funded vertebral fracture identification pathway
    • to facilitate audit to inform service development and monitor progress

Why do vertebral fractures remain undiagnosed?

  • Under-diagnosis of vertebral fracture occurs for a number of reasons:
    • unlike other fragility fractures, only a minority of vertebral fractures result from a fall
    • symptoms from 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

Clinically treatable and preventable

  • A multidisciplinary approach should be used to manage patients’ symptoms caused by a vertebral fracture. There is a range of pharmacological agents that are highly effective in reducing the risk of further fracture. Treatment reduces the risk of fracture within 6 to 12 months by 50–80%. Timely treatment is essential given that 20% of osteoporotic women with a recent vertebral fracture will sustain a new vertebral fracture within the next 12 months. 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

Fracture Liaison Services

  • A Fracture Liaison Service (FLS) prevents secondary fractures by identifying patients with a fragility fracture using dedicated case-finding. It provides assessment for osteoporosis and where appropriate, treatment and follow-up. FLS designed to the national Clinical Standards offer the best model for effective secondary fracture prevention. The standards specifically require FLS to identify systematically all patients over 50 years of age with a newly reported vertebral fracture

The role of diagnostic imaging departments in the vertebral fracture pathway*

  • Effective case-finding and management of patients with osteoporotic vertebral fractures requires an integrated approach across the whole fracture prevention pathway, with diagnostic imaging departments being uniquely placed to bring about the most substantial improvements by:
    • actively seeking vertebral fractures apparent on any imaging that includes the thoracic and/or lumbar spine
    • reporting vertebral fractures clearly and unambiguously
    • alerting the referring clinician to the need for further assessment of fracture risk, via the FLS where available

*Please see full guideline for a definition and classification of a vertebral fracture.

Vertebral fracture identification

  • 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
    • agreement between diagnostic imaging departments, referring clinical teams and Trust management of a fail-safe alert mechanism in respect of vertebral fractures as ‘significant, important, unexpected and actionable findings’ in accordance with the Royal College of Radiology (RCR) standards guidance

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 to describe vertebral fracture include:
    • 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 urgent evaluation
  • The wording used will depend on the local service model and agreed pathways. A standard phrase may be saved as a short code that can be automatically inserted into the report. Examples include:
    • 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 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

Implementation of the vertebral fracture pathway

Vertebral-fracture-pathway

  • Redesign of existing FLS pathways to improve vertebral fracture identification in accordance with this guidance may require additional resource, to include:
    • systematic reporting of spine imaging and 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
  • 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

National Osteoporosis Society support for service development

  • The NOS can support sites aiming to establish a new vertebral fracture pathway or augment their existing pathway to better meet the national clinical standards for FLS in respect of vertebral fractures. Please see the FLS implementation toolkit for more details

full guideline available from…

nos.org.uk/publications

National Osteoporosis Society. Clinical guidance for the effective identification of vertebral fractures. November 2017.

First included: April 2018.