Vertebral Fracture Identification & Management Pathways

Vertebral FractureIdentification & ManagementPathwaysJill Griffin DCR (R)Clinical Lead Quality Improvement Royal Osteoporosis Society05 November 2019

Vertebral fracture identification

Summary The trouble with vertebralfactures: Associated with increasedmortality, morbidity, and costs ofhealthcare and treatment Increase risk of subsequentfracture Identification is problematic andsuboptimal Opportunities missedThis Photo by Unknown Author is licensed under CC BY

Why? only 30% come to medicalattention Only a minority result from falls Often asymptomatic Symptoms often attributed to othercauses by patients and healthcareprofessionals Routine imaging is discouraged for‘back pain’

Vertebral fracture identification pathway

Gap analysis

Challenge to Opportunity Secondary fracture prevention works Fracture Liaison/ investigation, treatment and follow-up- prevents further fractureGlasgow FLS 2000-2010Patients with fragility fractureassessed50,000Hip fracture rates-7.3%England hip fracture rates 17%Effective Secondary Prevention of Fragility Fractures: Clinical Standards for Fracture Liaison Services: National Osteoporosis Society 2015

Secondary fracture prevention-functions of an FLS service Identify people with fragilityfractures Investigate causes and risks(osteoporosis, fracture andfalls) Intervene- treatment andmanagement plan Follow upIdentifyassessmentTreatmentplanfollow-up

Secondary fracture prevention-functions of an FLS service Identify people with fragilityfracturesQUALITY Investigate causes and risks(osteoporosis, fracture andfalls) Intervene- treatment andmanagement plan Follow upIdentifyassessmentTreatmentplanIntegration &communicationfollow-up

Challenges and opportunities Opportunities to find the 70% In diagnostic imaging Clinical importance of VF poorly understood Imaging for other indications not routinelyscrutinised for incidental vertebral findings Reporting terminology for VF ambiguous Lack of pathways for further assessment

Clinical guidance for the effective identification ofvertebral fractures

The Guidance Seek vertebral fractures apparent on any imaging thatincludes the thoracic and/or lumbar spine Report vertebral fractures clearly and unambiguously Alert the referring clinician to the need for furtherassessment of fracture risk, via FLS where available

Finding Vertebral fractures via imaging reports

The Guidance: Seek VFx

The Guidance: Seek VFx

The Guidance: Seek VFxAre incidental vertebral fractures a significant unexpectedfinding?Yes3268No

Challenges and Opportunities Clinical importance poorly understood‘We do not routinely reportwedge fractures as incidental or alert findingsbecause they won’t be treated’‘Osteoporosis (and fracture)is a normal aging process’‘I report on the primary question asked in the referral’

The Guidance: Report VFxReport vertebral fractures clearly and unambiguously Comment on the spine Describe vertebral bodies as: Vertebral fracture Non fracture deformity Normal

The Guidance: AlertAlert the referring clinician the need for further assessment Use of failsafe alert system Agreed protocol and pathway

The Guidance: Seek VFx

Opportunities- terminology Calling fractures ‘fractures’ 122 scan reportsTerms usedn.Vertebral c wedge fracture/wedgefracture/anterior wedging337.5%End plate depression/end plate fracture/inferior end plate deformity4% explicitly using the term‘vertebral fracture’Osteoporotic crush/crush2Compression fracture110.5%Loss of vertebral height1Fracture2% using the ‘F’ word

Audit: Alerting referrer to significant finding of vertebral fractureIdentified at audit ReportedPatients withvertebral fracture21% (n.17)11.5% (n10)Patients referredonwardsn/a0

Finding Vertebral fractures via imaging reportsTerry 77 years:Nov 2014- CT CAP‘weight loss ? Upperabdominal massThis Photo by Unknown Author is licensed under CC BY-SA

Finding Vertebral fractures via imaging reportsTerry 77 years:Nov 2014- CT CAP‘weight loss ‘The? Upperbones are generallyabdominal massosteopenic with vertebralcollapse noted in the midthoracic region, no evidenceof bone destruction’This Photo by Unknown Author is licensed under CC BY-SA

Opportunities- Impact case studyNov 2014- CT CAP‘weight loss ? Upperabdominal mass‘The bones are generallyosteopenic with vertebralcollapse noted in the midthoracic region, noevidence of bonedestruction’

Opportunities- Impact case studyNov 2014- CT CAP ‘weight loss ?Upper abdominal mass‘The bones are generallyosteopenic with vertebral collapsenoted in the mid thoracic region,no evidence of bone destruction’June 2016- EDadmission fall at homecomminutedintertrochanteric fracture

Opportunities- Impact case studyNov 2014- CT CAP ‘weight loss ?Upper abdominal mass‘The bones are generally osteopenicwith vertebral collapse noted in themid thoracic region, no evidence ofbone destruction’June 2016- ED admission fall athome: comminuted intertrochantericfractureAugust 2016- DXA scan:osteoporosis

Opportunities- terminology Calling fractures ‘fractures’ 122 scan reportsTerms usedn.Vertebral c wedge fracture/wedgefracture/anterior wedging337.5%End plate depression/end plate fracture/inferior end plate deformity4% explicitly using the term‘vertebral fracture’Osteoporotic crush/crush2Compression fracture110.5%Loss of vertebral height1Fracture2% using the ‘F’ word

IdentifyassessmentTreatmentplanfollow-up

Vertebral fracture pathway designImaging foran rted as‘vertebralfracture andalerted to thereferrerReferrertakes action

Decision tree

ROS Incidental VFx - FLS demand model

Demand modelling

Demand modelling

Secondary fracture preventionAssessmentsDXA Fracture risk (FRAX Qfracture) Falls Where appropriate If note done in 24 months previous FRAX/NOGG guidanceFRAX BMD Bloods/ biochemistryOther testsManagement NICE 1st or 2nd line TREATMENT Follow-up 4 months & 12 months ( 3 year Zoledronic Acid & 5 Yearalendronate)

Supporting services

SupportRoyal Osteoporosis Society Guidance:

Education

Summary Seek- vertebral fractures Decipher Radiology Reports‘is this a vertebral fracture’ Implement secondaryfracture prevention Support and collaborate

Supporting YouJill Griffin DCR (R )Clinical Lead- QualityImprovementjill.griffin@theros.org.uk07912 295670

Fracture Liaison/ investigation, treatment and follow-up- prevents further fracture Glasgow FLS 2000-2010 Patients with fragility fracture assessed 50,000 Hip fracture rates -7.3% England hip fracture rates 17% Effective Secondary Prevention of Fragility Fractures: Clinical Standards for Fracture Liaison Services: National Osteoporosis .