Skip to main content
SpringerLink
Log in

Radiology reporting of osteoporotic vertebral fragility fractures on computed tomography studies: results of a UK national audit

  • Musculoskeletal
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

To evaluate organisational reporting infrastructure and patient-related reporting data in the diagnosis of vertebral fragility fractures (VFFs) as demonstrated on computed tomography (CT).

Methods

Organisational and patient-specific questionnaires were developed by consensus between The Royal College of Radiologists, the Royal College of Physicians, and the Royal Osteoporosis Society. The patient-specific component of the audit involved analysis of CT reporting data acquired from 50 consecutive non-traumatic studies including the thoracolumbar spine. Ethical approval for this type of study is not required in the UK. All UK radiology departments with an audit lead (auditor) registered with The Royal College of Radiologists (RCR) were invited to participate in this retrospective audit.

Results

In total, 127 out of 202 departments (63%) supplied data to the study, with inclusion of 6357 patients. Overall, 1362/6357 patients (21.4%) had a fracture present on auditor review of the CT imaging. There was a lack of compliance with all audit standards: 79% of reports commented on the vertebrae (target 100%), fracture severity was mentioned in 26.2% (target 100%), the recommended terminology ‘vertebral fracture’ was used in 60.1% (target 100%), and appropriate onward referral was recommended in 2.6% (target 100%).

Conclusions

The findings from this study should be used to provide impetus to improve the diagnosis and care for patients with osteoporotic VFFs. Solutions are multifactorial, but radiologist and local osteoporosis/fracture liaison service engagement is fundamental, combined with necessary development of electronic report notification systems and expansion of supporting fracture services.

Key Points

• Early detection and diagnosis of vertebral fragility fractures (VFFs) significantly reduce patient morbidity and mortality. This study describes the results of a retrospective UK-wide audit evaluating current radiology reporting practice in the opportunistic diagnosis of VFFs as demonstrated on computed tomography (CT) studies including the spine.

• Key audit standards included comment made on bone integrity in primary report (target 100%), comment made on severity of fractures (90%), report used recommended terminology ‘fracture’ (100%), and report made appropriate recommendations for referral/further assessment (100%). The audit results demonstrated a lack of compliance with all audit standards; lack of compliance was most marked in the use of recommended terminology (achieved 60.3%), in relation to comment on fracture severity (achieved 26.2%) and for recommendation for referral/further assessment (achieved 2.6%).

• Solutions are challenging and multifactorial but the opportunity exists for all radiologists to examine their practice and directly improve patient care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Abbreviations

ABQ:

Algorithm-based qualitative

AI:

Artificial intelligence

CT:

Computed tomography

FLS:

Fracture liaison service

MPR:

Multiplanar reconstruction

MR:

Magnetic resonance

QM:

Quantitative morphometry

RCP:

Royal College of Physicians

RCR:

The Royal College of Radiologists

RIS:

Radiology information system

ROS:

Royal Osteoporosis Society

SQ:

Semi-quantitative

VFF:

Vertebral fragility fracture

References

  1. Kanis JA, Johnell O, Oden A et al (2000) Long-term risk of osteoporotic fracture in Malmö. Osteoporos Int 11:669–674

    CAS  PubMed  Google Scholar 

  2. Samelson EJ, Hannan MT, Zhang Y, Genant HK, Felson DT, Kiel DP (2006) Incidence and risk factors for vertebral fracture in women and men: 25-year follow-up results from the population-based Framingham study. J Bone Miner Res 21:1207–1214

    PubMed  Google Scholar 

  3. O'Neill TW, Felsenberg D, Varlow J, Cooper C, Kanis JA, Silman AJ (1996) The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study. J Bone Miner Res 11:1010–1018

    CAS  PubMed  Google Scholar 

  4. Cooper C, Atkinson EJ, O'Fallon WM, Melton JM (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985-1989. J Bone Miner Res 7:221–227

    CAS  PubMed  Google Scholar 

  5. Curtis EM, van der Velde R, Moon RJ et al (2016) Epidemiology of fractures in the United Kingdom 1988-2012: variation with age, sex, geography, ethnicity and socioeconomic status. Bone 87:19–26

    PubMed  PubMed Central  Google Scholar 

  6. Adams J, Clark E, Clunie G et al (2017) Clinical guidance for the effective identification of vertebral fractures. National Osteoporosis Society, London

    Google Scholar 

  7. Ross PD, Davis JW, Epstein RS, Wasnich RD (1991) Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med 114:919–923

    CAS  PubMed  Google Scholar 

  8. Melton LJ 3rd, Atkinson EJ, Cooper C, O’Fallon WM, Riggs BL (1999) Vertebral fractures predict subsequent fractures. Osteoporos Int 10:214–221

    PubMed  Google Scholar 

  9. McCloskey EV, Vasireddy S, Threlkeld J et al (2008) Vertebral fracture assessment (VFA) with a densitometer predicts future fractures in elderly women unselected for osteoporosis. J Bone Miner Res 23:1561–1568

    PubMed  Google Scholar 

  10. Gonnelli S, Caffarelli C, Maggi S et al (2013) The assessment of vertebral fractures in elderly women with recent hip fractures: the BREAK Study. Osteoporos Int 24:1151–1159

    CAS  PubMed  Google Scholar 

  11. Cauley JA, Thompson DE, Ensrud KC, Scott JC, Black D (2000) Risk of mortality following clinical fractures. Osteoporos Int 11:556–561

    CAS  PubMed  Google Scholar 

  12. Jalava T, Sarna S, Pylkkänen L et al (2003) Association between vertebral fracture and increased mortality in osteoporotic patients. J Bone Miner Res 18:1254–1260

    PubMed  Google Scholar 

  13. Lenchik L, Rogers LF, Delmas PD, Genant HK (2004) Diagnosis of osteoporotic vertebral fractures: importance of recognition and description by radiologists. AJR Am J Roentgenol 183:949–958

    PubMed  Google Scholar 

  14. Delmas PD, van de Langerijt L, Watts NB et al (2005) Underdiagnosis of vertebral fractures is a worldwide problem: the IMPACT study. J Bone Miner Res 20:557–563

    PubMed  Google Scholar 

  15. Carberry GA, Pooler BD, Binkley N, Lauder TB, Bruce RJ, Pickhardt PJ (2016) Unreported vertebral body compression fractures at abdominal multidetector CT. Radiology 268:120–126

  16. Mitchell RM, Jewell P, Javaid MK, McKean D, Ostlere SJ (2017) Reporting of vertebral fragility fractures: can radiologists help reduce the number of hip fractures? Arch Osteoporos 12:71. https://doi.org/10.1007/s11657-017-0363-y

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Lentle B, Koromani F, Brown JP et al (2019) The radiology of osteoporotic vertebral fractures revisited. J Bone Miner Res 34:409–418

    PubMed  Google Scholar 

  18. Oei L, Rivadeneira F, Ly F et al (2013) Review of radiological scoring methods of osteoporotic vertebral fractures for clinical and research settings. Eur Radiol 23:476–486

    PubMed  Google Scholar 

  19. Genant HK, Wu CY, van Kuijk NMC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148

    CAS  PubMed  Google Scholar 

  20. Wasnik R (1996) Epidemiology of osteoporosis. In: Flavus M (ed) Primer on the metabolic bone diseases and disorders of mineral metabolism. Lipincott-Raven, Philadelphia, pp 249–251

    Google Scholar 

  21. Bazzocchi A, Spinnato P, Garzillo G et al (2012) Detection of incidental vertebral fractures in breast imaging: the potential role of MR localisers. Eur Radiol 22:2617–2623

    PubMed  Google Scholar 

  22. Williams AL, Al-Busaidi A, Sparrow PJ, Adams JE, Whitehouse RW (2009) Under-reporting of osteoporotic vertebral fractures on computed tomography. Eur J Radiol 69:179–183

    PubMed  Google Scholar 

  23. Adams JE (2016) Opportunistic identification of vertebral fractures. J Clin Densitom 19:54–62

    PubMed  Google Scholar 

  24. Müller D, Bauer JS, Zeile M, Ernst JR, Link TM (2008) Significance of sagittal reformations in routine thoracic and abdominal multislice CT studies for detecting osteoporotic fractures and other spine abnormalities. Eur Radiol 18:1696–1702

    PubMed  Google Scholar 

  25. Lee SJ, Binkley N, Lubner MG, Bruce RJ, Ziemlewicz TJ, Pickhardt PJ (2016) Opportunistic screening for osteoporosis using the sagittal reconstruction from routine abdominal CT for combined assessment of vertebral fractures and density. Osteoporos Int 27:1131–1136

    CAS  PubMed  Google Scholar 

  26. Lentle BC, Berger C, Probyn L et al (2018) Comparative analysis of the radiology of osteoporotic vertebral fractures in women and men: cross-sectional and longitudinal observations from the Canadian Multicentre Osteoporosis Study (CaMos). J Bone Miner Res 33:569–579

    CAS  PubMed  Google Scholar 

  27. Royal College of Radiologists (2016) Standards for the communication of radiological reports and fail-safe alert notification. London

  28. Duncan KA, Drinkwater KJ, Dugar N, Howlett DC (2016) Audit of radiology communication systems for critical, urgent, and unexpected significant findings. Clin Radiol 71:265–270

    CAS  PubMed  Google Scholar 

  29. Eccles E, Thompson JD, Roddam H (2018) An evaluation of fracture liaison services in the detection and management of osteoporotic fragility fractures: a narrative review. Radiography (Lond) 24:392–395

    CAS  Google Scholar 

  30. Walters S, Khan T, Ong T, Sahota O (2017) Fracture liaison services: improving outcomes for patients with osteoporosis. Clin Interv Aging 10:117–127

    Google Scholar 

  31. Wasfie T, Jackson A, Brock C, Galovska S, McCullough JR, Burgess JA (2019) Does a fracture liaison service program minimize recurrent fragility fractures in the elderly with osteoporotic vertebral compression fractures? Am J Surg 217:557–560

    PubMed  Google Scholar 

  32. De Bruin IJA, Wyers CE, van den Bergh JPW, Geusens PMM (2017) Fracture liaison services: do they reduce fracture rates? Ther Adv Musculoskelet Dis 9:157–164

    PubMed  PubMed Central  Google Scholar 

  33. Akesson K, Marsh D, Mitchell PJ et al (2013) Capture the fracture: a best practice framework and global campaign to break the fragility fracture cycle. Osteoporos Int 24:2135–2152

    CAS  PubMed  PubMed Central  Google Scholar 

  34. Ferizi U, Honig S, Chang G (2019) Artificial intelligence, osteoporosis and fragility fractures. Curr Opin Rheumatol 31:368–375

    PubMed  PubMed Central  Google Scholar 

  35. Burns JE, Yao J, Summers RM (2017) Vertebral body compression fractures and bone density: automated detection and classification on CT images. Radiology 284:788–797

    PubMed  PubMed Central  Google Scholar 

  36. Muehlematter UJ, Mannil M, Becker AS et al (2019) Vertebral body insufficiency fractures: detection of vertebrae at risk on standard CT images using texture analysis and machine learning. Eur Radiol 29:2207–2217

    PubMed  Google Scholar 

  37. Tomita N, Cheung YY, Hassanpour S (2018) Deep neural networks for automatic detection of osteoporotic vertebral fractures on CT scans. Comput Biol Med 19:8–15

    Google Scholar 

  38. Howlett DC, Drinkwater KJ, Lawrence D, Barter S, Nicholson T (2013) Findings of the UK national audit evaluating image-guided or image-assisted liver biopsy. Part II. Minor and major complications and procedure-related mortality. Radiology 266:26–35

    Google Scholar 

  39. Chalmers N, Jones K, Drinkwater K, Uberoi R, Tawn J (2008) The UK nephrostomy audit. Can a voluntary registry produce robust performance data? Clin Radiol 63:888–894

    CAS  PubMed  Google Scholar 

  40. Polit DF, Hungler BP (1999) Nursing research: principles and methods. Lippincott-Raven, Philadelphia

    Google Scholar 

  41. Papadakis AE, Karantanas AH, Papadokostakis G, Petinellis E, Damilakis J (2009) Can abdominal multi-detector CT diagnose spinal osteoporosis? Eur Radiol 19:172–176

    PubMed  Google Scholar 

  42. Pickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ, Binkley N (2013) Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med 158:588–595

    PubMed  PubMed Central  Google Scholar 

  43. Buckens CF, Dijkhuis G, de Keizer B, Verhaar HJ, de Jong PA (2015) Opportunistic screening for osteoporosis on routine computed tomography? An external validation study. Eur Radiol 25:2074–2079

    PubMed  Google Scholar 

  44. Alacreu E, Moratal D, Arana E (2017) Opportunistic screening for osteoporosis by routine CT in Southern Europe. Osteporos Int 28:983–990

    Google Scholar 

  45. Li YL, Wong KH, Law MW et al (2018) Opportunistic screening for osteoporosis in abdominal computed tomography for Chinese population. Arch Osteoporos 13:76. https://doi.org/10.1007/s11657-018-0492-y

    Article  PubMed  Google Scholar 

  46. Löffler MT, Sollmann N, Mei K et al (2020) X-ray-based quantitative osteoporosis imaging at the spine. Osteoporos Int 31(2):233–250

    PubMed  Google Scholar 

  47. Lentle BC, Brown JP, Khan A et al (2007) Recognizing and reporting vertebral fractures: reducing the risk of future osteoporotic fractures. Can Assoc Radiol J 58:27–36

    PubMed  Google Scholar 

Download references

Acknowledgements

This work was undertaken on behalf of The Royal College of Radiologists (RCR) Clinical Audit and Quality Improvement Committee. The authors gratefully acknowledge all the RCR audit leads who participated in the project and supplied data. The authors also thank Bonnie Wiles, Royal College of Physicians, London; and Anne Thurston, Royal Osteoporosis Society, for their advice and assistance.

Funding

The authors state that this work has not received any funding.

Author information

Authors and Affiliations

  1. Eastbourne Hospital, Eastbourne, UK

    David C. Howlett & Nadia Mahmood

  2. The Royal College of Radiologists, 63 Lincoln’s Inn Fields, London, WC2A 3JW, UK

    Karl J. Drinkwater

  3. Dorset County Hospital, Dorchester, UK

    Jozsef Illes

  4. The Royal Osteoporosis Society, Bath, UK

    Jill Griffin

  5. The Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK

    Kassim Javaid

Authors
  1. David C. Howlett
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Karl J. Drinkwater
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nadia Mahmood
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jozsef Illes
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jill Griffin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kassim Javaid
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Karl J. Drinkwater.

Ethics declarations

Guarantor

The scientific guarantor of this publication is Professor David C Howlett.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was not required for this study because approval for this type of study is not required in the UK, as patient data are anonymised and are used only to further best medical practice.

Ethical approval

Institutional Review Board approval was not required because ethical approval is not required for clinical audit in the UK.

Methodology

• Retrospective

• Cross-sectional study

• Multicentre study

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Howlett, D.C., Drinkwater, K.J., Mahmood, N. et al. Radiology reporting of osteoporotic vertebral fragility fractures on computed tomography studies: results of a UK national audit. Eur Radiol 30, 4713–4723 (2020). https://doi.org/10.1007/s00330-020-06845-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-020-06845-2

Keywords

Search

Navigation