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

Adding value in radiology-improved radiological diagnosis of osteoporotic vertebral fragility fractures following National UK Audit and Interventions

Vertebral fragility fractures (VFFs) are the most common osteoporotic fracture, with significant associated morbidity, mortality, and risk of future fractures. Unfortunately, VFFs are frequently underdiagnosed and underreported. With this background, The Royal College of Radiologists (RCR), in collaboration with the Royal College of Physicians (RCP) and Royal Osteoporosis Society (ROS), undertook a UK-wide retrospective audit in 2019 to assess radiology reporting of incidental VFFs present on CT studies. The audit standards were not achieved; however, following a series of interventions, a re-audit in 2022 demonstrated generalized improvement in compliance with the audit parameters, in particular a 6-percentage point increase in moderate/severe VFFs reported. This article examines the potential benefits in terms of reductions in patient morbidity, mortality, and costs that could be expected if the improvements identified were translated to a national level, acknowledging and discussing other improvements that need to occur, with particular reference to onward referral pathways.

Improved radiological diagnosis of osteoporotic vertebral fragility fractures following UK-wide interventions and re-audit-can this be maintained and translated into clinical practice?

To determine the potential economic, morbidity and mortality impact of improvements in reporting of vertebral fragility fractures (VFFs) following a complete audit cycle. Six percent interval increase in reporting of moderate/severe VFFs results in an additional 890 hip fractures predicted in year one and a potential cost saving of £13,207,000.

PURPOSE

To determine the potential economic, morbidity and mortality impact of improvements in reporting of vertebral fragility fractures (VFFs) following an initial UK-wide audit initiated by the Royal College of Radiologists (RCR), collaborating with the Royal Osteoporosis Society (ROS) and Royal College of Physicians (RCP) and subsequent re-audit in 2022.

METHODS

Patient-specific and organisational questionnaires in 2019 and 2022 involved retrospective analysis of between 50 and 100 consecutive, non-traumatic CT studies which included the thoracolumbar spine where the spine was not the area of clinical interest in patients > 70 years. VFFs were recorded and the severity graded using the Genant reporting system. A series of UK-wide interventions were initiated between the audits. Results of the re-audit were evaluated using a bespoke ROS calculator to identify potential patient related and economic benefits from any improvements demonstrated.

RESULTS

Widespread improvements were evident between the two audits across all audit parameters, both patient-related and organisational. Notably, there was a 6% interval increase in reporting of moderate/severe VFFs (26 to 32%). Extrapolating from NHS England data, approximately 1.8 million non-trauma CT studies including the thoracolumbar spine for patients > 70 years were performed in the UK in 2022. The incidence of VFFs in the 2022 audit was found to be 21.7%. Using these figures and the 6% increase, the number of additional patients potentially diagnosed with a VFF equates to 23,420. Applying the ROS Benefits Calculator, in this cohort of 23,420 patients with no treatment, 890 hip fractures can be predicted in year one. With initiation of treatment, this figure falls to 328 patients (562 hip fractures prevented in year one), a potential cost saving of £13,207,000.

CONCLUSION

The 2022 national re-audit confirmed improvements in radiology diagnostic performance and practice in VFF reporting. Ongoing work is required to build on this improvement and to further embed best practice. To realise this potential, there will need to be significant and maintained investment in onward referral and treatment systems (fracture liaison services or equivalent). Increasing availability of artificial intelligence will significantly increase the diagnoses of these fractures.

A retrospective service evaluation of patient awareness and engagement, and medication compliance and adherence, in patients with opportunistically identified vertebral fragility fractures in a local fracture liaison service

INTRODUCTION

Fracture liaison services (FLS), often staffed by radiographers, identify and treat patients over the age of 50 at high risk of future fractures by intervening after the first fracture. Vertebral fragility fractures (VFF) are particularly disabling and are highly predictive of future fracture but are underdiagnosed as they often do not come to clinical attention. To review the behaviour traits of patient with opportunistically identified VFF's (OIVFF), local FLS data can be used to compare outcomes of OIVFF's with acute VFF's (AVFF) and non-hip/spine fragility fractures (NHSFF).

METHODS

A retrospective service evaluation was completed using local FLS data from 1/1/22-31/12/22. A total of 1403 patients' data was included. Data was grouped by fracture cohort to evaluate patient engagement, fracture awareness, medication compliance and adherence.

RESULTS

The OIVFF cohort had the highest proportion of men at 32.4 %. There was little difference in engagement rates between cohorts but fracture awareness was low in the OIVFF cohort. Non-compliance to medication was highest in the NHSFF cohort. The OIVFF cohort had the highest number of patients no longer appropriate for treatment after 12 months (11.29 %). Medication adherence at 12 months was similar across cohorts.

CONCLUSION

Patients with OIVFF's do not appear to behave differently to other symptomatic fracture types within the FLS pathway in terms of engagement, compliance or adherence.

IMPLICATIONS FOR PRACTICE

Awareness of fracture was low for VFF's and future improvement of the patient diagnosis communication pathway is recommended. Further research into the increased number of men with OIVFF is recommended to ensure the pathway is efficient and to review potential barriers to diagnosis. Results suggest continued exploration of improving opportunistic identification of vertebral fractures is justified.

The potential role for artificial intelligence in fracture risk prediction

Osteoporotic fractures are a major health challenge in older adults. Despite the availability of safe and effective therapies for osteoporosis, these therapies are underused in individuals at high risk for fracture, calling for better case-finding and fracture risk assessment strategies. Artificial intelligence (AI) and machine learning (ML) hold promise for enhancing identification of individuals at high risk for fracture by distilling useful features from high-dimensional data derived from medical records, imaging, and wearable devices. AI-ML could enable automated opportunistic screening for vertebral fractures and osteoporosis, home-based monitoring and intervention targeting lifestyle factors, and integration of multimodal features to leverage fracture prediction, ultimately aiding improved fracture risk assessment and individualised treatment. Optimism must be balanced with consideration for the explainability of AI-ML models, biases (including information inequity in numerically under-represented populations), model limitations, and net clinical benefit and workload impact. Clinical integration of AI-ML algorithms has the potential to transform osteoporosis management, offering a more personalised approach to reduce the burden of osteoporotic fractures.

Reporting of paediatric osteoporotic vertebral fractures in Duchenne muscular dystrophy and potential impact on clinical management: the need for standardised and structured reporting

BACKGROUND

In boys with Duchenne muscular dystrophy (DMD), initiation of bisphosphonate is recommended upon identification of moderate or severe vertebral fractures, even if asymptomatic. Clear radiological reporting is important for consistency of clinical interpretation and management.

OBJECTIVES

To audit radiology reports of spine imaging for vertebral fracture assessment in DMD, and assess potential impact on diagnosis and management.

MATERIALS AND METHODS

Lateral thoracolumbar spine imaging (71 lateral spine radiographs and 13 lateral dual energy absorptiometry spine image) in 84 boys with DMD performed across two centres. Anonymised radiology reports by paediatric radiologists were circulated to two neuromuscular clinicians and two endocrinologists. Clinicians determined if there was vertebral fracture, no vertebral fracture, or unclear interpretation. Endocrinologists also determined if bisphosphonate was indicated. A single observer (a clinician with expertise in vertebral fracture assessment) performed vertebral fracture assessment in 37 images and re-reported using a structured format. Structured reports were re-circulated to the four clinicians to re-evaluate the degree of concordance in clinical diagnosis of vertebral fracture and treatment decisions with bisphosphonate.

RESULTS

The term "fracture" was used in 25/84 (30%) radiology reports and only in 8/43 (19%) with description of vertebral body abnormalities. Fracture grading was included in 7/43 (16%) radiology reports. Diagnostic concordance by the clinicians was noted in 36/84 (43%). Unclear interpretation was noted in 22% to 51% based on radiology reports. No unclear interpretation was noted with structured reports. Complete diagnostic (37/37, 100%) and treatment (37/37, 100%) concordance was noted with the structured reports, whereas complete diagnostic and treatment concordance was noted in only 16/37 (43%) and 17/37 (46%) of the radiology reports, respectively.

CONCLUSION

Only a third of radiology reports of spine imaging in DMD explicitly used the terminology "fracture". Grading was only noted in a small percentage. Variability in diagnostic interpretation by clinicians may lead to differing management plans. As identification of vertebral fracture is a trigger for treatment, developing reporting guidelines for paediatric vertebral fracture assessment will improve care. A structured template should be introduced for radiological reporting of paediatric vertebral fracture assessment.

Radiology reporting of incidental osteoporotic vertebral fragility fractures present on CT studies: results of UK national re-audit

AIM

To describe a UK-wide re-audit of the 2019 Royal College of Radiologists (RCR) audit evaluating patient-related data and organisational infrastructure in the radiological reporting of vertebral fragility fractures (VFFs) on computed tomography (CT) studies and to assess the impact of a series of RCR interventions, initiated to raise VFF awareness, on reporting practice and outcomes.

MATERIALS AND METHODS

Patient specific and organisational questionnaires largely replicated those utilised in 2019. The patient questionnaire involved retrospective analysis of between 50 and 100 consecutive, non-traumatic CT studies which included the thoracolumbar spine. All RCR radiology audit leads were invited to participate. Data collection commenced from 1 April 2022.

RESULTS

Data were supplied by 129/194 (67%) departments. One thousand five hundred and eighty-six of 7,316 patients (21.7%) had a VFF on auditor review. Overall improvements were demonstrated in key initial/provisional reporting results; comment on spine/bone (93.2%, 14.4% improvement, p<0.0002); fracture severity assessment (34.7%, 8.5% improvement, p=0.0007); use of recommended terminology (67.8%, 7.5% improvement, p=0.0034); recommendations for further management (11.7%, 9.1% improvement, p<0.0002).

CONCLUSIONS

The 2022 national re-audit confirms improvements in diagnostic performance and practice in VFF reporting. Continuing work is required to build on this improvement and to further embed best practice.

Using Artificial Intelligence to Diagnose Osteoporotic Vertebral Fractures on Plain Radiographs

Osteoporotic vertebral fracture (OVF) is a risk factor for morbidity and mortality in elderly population, and accurate diagnosis is important for improving treatment outcomes. OVF diagnosis suffers from high misdiagnosis and underdiagnosis rates, as well as high workload. Deep learning methods applied to plain radiographs, a simple, fast, and inexpensive examination, might solve this problem. We developed and validated a deep-learning-based vertebral fracture diagnostic system using area loss ratio, which assisted a multitasking network to perform skeletal position detection and segmentation and identify and grade vertebral fractures. As the training set and internal validation set, we used 11,397 plain radiographs from six community centers in Shanghai. For the external validation set, 1276 participants were recruited from the outpatient clinic of the Shanghai Sixth People's Hospital (1276 plain radiographs). Radiologists performed all X-ray images and used the Genant semiquantitative tool for fracture diagnosis and grading as the ground truth data. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were used to evaluate diagnostic performance. The AI_OVF_SH system demonstrated high accuracy and computational speed in skeletal position detection and segmentation. In the internal validation set, the accuracy, sensitivity, and specificity with the AI_OVF_SH model were 97.41%, 84.08%, and 97.25%, respectively, for all fractures. The sensitivity and specificity for moderate fractures were 88.55% and 99.74%, respectively, and for severe fractures, they were 92.30% and 99.92%. In the external validation set, the accuracy, sensitivity, and specificity for all fractures were 96.85%, 83.35%, and 94.70%, respectively. For moderate fractures, the sensitivity and specificity were 85.61% and 99.85%, respectively, and 93.46% and 99.92% for severe fractures. Therefore, the AI_OVF_SH system is an efficient tool to assist radiologists and clinicians to improve the diagnosing of vertebral fractures. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Fracture Risk in Men and Women With Vertebral Fractures Identified Opportunistically on Routine Computed Tomography Scans and Not Treated for Osteoporosis: An Observational Cohort Study

Vertebral fractures (VFs) have been associated with future fractures, yet few studies have evaluated whether this pertains to VFs available for identification on routine radiological imaging. We sought to evaluate the risk of subsequent fractures in subjects with VF identified opportunistically on computed tomography (CT) scans performed as part of routine clinical practice. From the radiology database of Holbæk Hospital we identified the first CT scan including the thorax and/or abdomen of 2000 consecutive men and women aged 50 years or older, performed from January 1, 2010 onward. The scans were assessed in a blinded approach to identify chest and lumbar VF, and these data linked to national Danish registers. Subjects were excluded if treated with an osteoporosis medication (OM) in the year prior to baseline (date of CT), and the remaining subjects with VF matched on age and sex in 1:2 ratio against subjects with no VF. We found that the risk of major osteoporotic fractures (hip, non-cervical vertebral, humerus, and distal forearm fractures) was higher for subjects with VF than without VF: incidence rates (IRs) were 32.88 and 19.59 fractures per 1000 subject-years, respectively, and the adjusted hazard ratio (HRadj) was 1.72 (95% confidence interval [CI], 1.03-2.86). Subsequent hip fracture IRs were 16.75 and 6.60; HRadj 3.02 (95% CI, 1.39-6.55). There were no significant differences in other fracture outcomes (including a pooled estimate of any subsequent fracture, except face, skull, and fingers: IRs 41.52 and 31.38; HRadj 1.31 [95% CI, 0.85-2.03]). Our findings suggest that subjects undergoing routine CT scans including the chest and/or abdomen are a high risk population in terms of fracture risk. Even within this group, subjects with VF are at higher risk of future major osteoporotic fracture (MOF), in particular hip fracture. Hence, systematic opportunistic screening for VF and subsequent fracture risk management is important to reduce the risk of new fractures. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Opportunistic screening for osteoporosis by abdominal CT in a British population

BACKGROUND

It has previously been shown that CT scans performed for other indications can be used to identify patients with osteoporosis. This has not yet been tested in a British population. We sought to evaluate the use of vertebral CT attenuation measures for predicting osteoporosis in a British cohort, using dual-energy X-ray absorptiometry (DEXA) as a reference standard.

METHODS

Patients who underwent abdominal CT in 2018 and concomitantly underwent DEXA within a six-month interval were retrospectively included. CT attenuation values in Hounsfield units (HU) were measured by placement of a region-of-interest at the central portion of the L1 vertebral body and then compared to their corresponding DEXA score. Receiver operating characteristic (ROC) curves were generated to evaluate the performance of a logistic regression model and to determine sensitivity and specificity thresholds.

RESULTS

536 patients (394 females, mean age 65.8) were included, of which 174 had DEXA-defined osteoporosis. L1 attenuation measures were significantly different (p < 0.01) between the three DEXA-defined groups of osteoporosis (118 HU), osteopenia (143 HU) and normal bone density (178 HU). The area under the ROC curve was 0.74 (95% CI 0.69-0.78). A threshold of 169 HU was 90% sensitive, and a threshold of 104 HU was 90% specific for diagnosing osteoporosis.

CONCLUSIONS

Routine abdominal CT can be used to opportunistically screen for osteoporosis without additional cost or radiation exposure. The thresholds identified in this study are comparable with previous studies in other populations. We recommend radiologists engage with primary care and rheumatology providers to determine appropriate cut-off values for further investigation.

Osteoporosis identification among previously undiagnosed individuals with vertebral fractures

Because osteoporosis is under-recognized in patients with vertebral fractures, we evaluated characteristics associated with osteoporosis identification. Most patients with vertebral fractures did not receive evaluation or treatment for osteoporosis. Black, younger, and male participants were particularly unlikely to have had recognized osteoporosis, which could increase their risk of negative outcomes.

INTRODUCTION

Vertebral fractures may be identified on imaging but fail to prompt evaluation for osteoporosis. Our objective was to evaluate characteristics associated with clinical osteoporosis recognition in patients who had vertebral fractures detected on their thoracolumbar spine imaging reports.

METHODS

We prospectively identified individuals who received imaging of the lower spine at primary care clinics in 4 large healthcare systems who were eligible for osteoporosis screening and lacked indications of osteoporosis diagnoses or treatments in the prior year. We evaluated characteristics of participants with identified vertebral fractures that were associated with recognition of osteoporosis (diagnosis code in the health record; receipt of bone mineral density scans; and/or prescriptions for anti-osteoporotic medications). We used mixed models to estimate adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

A total of 114,005 participants (47% female; mean age 65 (interquartile range: 57-72) years) were evaluated. Of the 8579 (7%) participants with vertebral fractures identified, 3784 (44%) had recognition of osteoporosis within the subsequent year. In adjusted regressions, Black participants (OR (95% CI): 0.74 (0.57, 0.97)), younger participants (age 50-60: 0.48 (0.42, 0.54); age 61-64: 0.70 (0.60, 0.81)), and males (0.39 (0.35, 0.43)) were less likely to have recognized osteoporosis compared to white participants, adults aged 65 + years, or females.

CONCLUSION

Individuals with identified vertebral fractures commonly did not have recognition of osteoporosis within a year, particularly those who were younger, Black, or male. Providers and healthcare systems should consider efforts to improve evaluation of osteoporosis in patients with vertebral fractures.

Post-fracture care programs for prevention of subsequent fragility fractures: a literature assessment of current trends

Post-fracture care (PFC) programs evaluate and manage patients with a minimal trauma or fragility fracture to prevent subsequent fractures. We conducted a literature review to understand current trends in PFC publications, evaluate key characteristics of PFC programs, and assess their clinical effectiveness, geographic variations, and cost-effectiveness. We performed a search for peer-reviewed articles published between January 2003 and December 2020 listed in PubMed or Google Scholar. We categorized identified articles into 4 non-mutually exclusive PFC subtopics based on keywords and abstract content: PFC Types, PFC Effectiveness/Success, PFC Geography, and PFC Economics. The literature search identified 784 eligible articles. Most articles fit into multiple PFC subtopics (PFC Types, 597; PFC Effectiveness/Success, 579; PFC Geography, 255; and PFC Economics, 98). The number of publications describing how PFC programs can improve osteoporosis treatment rates has markedly increased since 2003; however, publication gaps remain, including low numbers of publications from some countries with reported high rates of osteoporosis and/or hip fractures. Fracture liaison services and geriatric/orthogeriatric services were the most common models of PFC programs, and both were shown to be cost-effective. We identified a need to expand and refine PFC programs and to standardize patient identification and reporting on quality improvement measures. Although there is an increasing awareness of the importance of PFC programs, publication gaps remain in most countries. Improvements in established PFC programs and implementation of new PFC programs are still needed to enhance equitable patient care to prevent occurrence of subsequent fractures.

Understanding current UK practice for the incidental identification of vertebral fragility fractures from CT scans: an expert elicitation study

Background

There is an emerging interest in using automated approaches to enable the incidental identification of vertebral fragility fractures (VFFs) on existing medical images visualising the spine.

Aim

To quantify values, and the degree of uncertainty associated with them, for the incidental identification of VFFs from computed tomography (CT) scans in current practice.

Methods

An expert elicitation exercise was conducted to generate point estimates and measures of uncertainty for four values representing the probability of: VFF being correctly reported by the radiologist; the absence of VFF being correctly assessed by the radiologist; being referred for management when a VFF is identified; having a dual-energy X-ray absorptiometry (DXA) scan after general practitioner (GP) referral. Data from a sample of seven experts in the diagnosis and management of people with VFFs were pooled using mathematical aggregation.

Results

The estimated mean values for each probability parameter were: VFF being correctly reported by the radiologist = 0.25 (standard deviation (SD): 0.21); absence of VFF being correctly assessed by the radiologist = 0.89 (0.10); being referred for management when a VFF is identified by the radiologist = 0.15 (0.12); having a DXA scan after GP referral = 0.66 (0.28).

Discussion

These estimates could be used to facilitate the subsequent early economic evaluation of potential new approaches to improve the health outcomes of people with VFFs.

Conclusion

In the absence of epidemiological studies, this study produced point estimates and measures of uncertainty for key parameters needed to describe current pathways for the incidental diagnosis of VFFs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-022-02124-w.

UK clinical guideline for the prevention and treatment of osteoporosis

The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management.

INTRODUCTION

The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older.

METHODS

Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence.

RESULTS

Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement.

CONCLUSION

The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.

Epidemiology and reporting of osteoporotic vertebral fractures in patients with long-term hospital records based on routine clinical CT imaging

Osteoporotic vertebral fractures signify an increased risk of future fractures and mortality and can manifest the diagnosis of osteoporosis. We investigated the prevalence of vertebral fractures in routine CT of patients with long-term hospital records. Three out of ten patients showed osteoporotic vertebral fractures (VFs) corresponding to the highest rates reported in European population-based studies.

INTRODUCTION

VFs are a common manifestation of osteoporosis, which influences future fracture risk. Their epidemiology has been investigated in population-based studies. However, few studies report the prevalence of osteoporotic VF in patients seen in clinical routine and include all common fracture levels of the thoracolumbar spine. The purpose of this study was to investigate the prevalence of osteoporotic VF in patients with CT scans and long-term hospital records and identify clinical factors associated with prevalent VFs.

METHODS

All patients aged 45 years and older with a CT scan and prior hospital record of at least 5 years that were seen in the study period between September 2008 and May 2017 were reviewed. Imaging requirements were a CT scan with sagittal reformations including at least T6-L4. Patients with multiple myeloma were excluded. Fracture reading was performed using the Genant semi-quantitative method. Medical notes were reviewed for established diagnoses of osteoporosis and clinical information. Clinical factors (e.g. drug intake, chemotherapy, and mobility level) associated with prevalent VF were identified in logistic regression.

RESULTS

The study population consisted of 718 patients (228 women and 490 men; mean age 69.3 ± 10.1 years) with mainly cancer staging and angiography CT imaging. The overall prevalence of VFs was 30.5%, with non-significantly more men showing a fracture (32.5%) compared to women (26.3%; p > 0.05). Intake of metamizole for ≥ 3 months was significantly associated with a prevalent VF. Medical records did not include information about bone health in 90% of all patients. CT reports did mention a VF in only 24.7% of patients with a prevalent VF on CT review.

CONCLUSION

Approximately 30% of elderly patients with CT imaging and long-term hospital records showed VFs. Only one-quarter of these patients had VFs mentioned in CT reports. Osteoporosis management could be improved by consequent reporting of VFs in CT, opportunistic bone density measurements, and early involvement of fracture liaison services.

VerSe: A Vertebrae labelling and segmentation benchmark for multi-detector CT images

Vertebral labelling and segmentation are two fundamental tasks in an automated spine processing pipeline. Reliable and accurate processing of spine images is expected to benefit clinical decision support systems for diagnosis, surgery planning, and population-based analysis of spine and bone health. However, designing automated algorithms for spine processing is challenging predominantly due to considerable variations in anatomy and acquisition protocols and due to a severe shortage of publicly available data. Addressing these limitations, the Large Scale Vertebrae Segmentation Challenge (VerSe) was organised in conjunction with the International Conference on Medical Image Computing and Computer Assisted Intervention (MICCAI) in 2019 and 2020, with a call for algorithms tackling the labelling and segmentation of vertebrae. Two datasets containing a total of 374 multi-detector CT scans from 355 patients were prepared and 4505 vertebrae have individually been annotated at voxel level by a human-machine hybrid algorithm (https://osf.io/nqjyw/, https://osf.io/t98fz/). A total of 25 algorithms were benchmarked on these datasets. In this work, we present the results of this evaluation and further investigate the performance variation at the vertebra level, scan level, and different fields of view. We also evaluate the generalisability of the approaches to an implicit domain shift in data by evaluating the top-performing algorithms of one challenge iteration on data from the other iteration. The principal takeaway from VerSe: the performance of an algorithm in labelling and segmenting a spine scan hinges on its ability to correctly identify vertebrae in cases of rare anatomical variations. The VerSe content and code can be accessed at: https://github.com/anjany/verse.

Radiographer advanced and consultant practice and community diagnostic hubs - a vision for the future

OBJECTIVES

This article combines a brief narrative review of the Richards Report with an overview of current radiographer advanced and consultant clinical practice (ACCP) to provide suggestions for future ACCP within radiography.

KEY FINDINGS

The 'Diagnostics: Recovery and Renewal' report by Professor Sir Mike Richards, published in 2020, has identified a need for improvements to be made to diagnostic services. His recommendations include the introduction of Community Diagnostic Hubs (CDHs) that would provide quicker and easier access to diagnostic tests for patients⁽¹⁾ A narrative review around the concept of Advanced and Consultant Clinical Practice (ACCP) for radiographers demonstrates the capability of the radiographers to expand their role. The article concludes with a vision of how CDHs could potentially provide multiple career pathways for radiographers working at this level of practice.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

It is acknowledged that some of these concepts are a combination of visionary and aspirational in outlook rather than being entirely based on current practice. The intention of this article, and the implications for practice, are to support on-going discussions to enable radiography, as a profession, to seek ways and opportunities to do things differently whilst ensuring that the patient remains at the centre of the services delivered.

Pregnancy- and lactation-associated vertebral compression fractures: MRI prevalence and characteristics

The frequency of pregnancy- and lactation-associated vertebral compression fractures (PLVCFs) is not known. This study showed that MRI prevalence of PLVCFs was approximately 0.5% in females ≥ 15 and < 40 years of age over a 48-month period. PLVCFs did not display MRI features distinguishing them from other vertebral insufficiency fractures.

PURPOSE

We aimed to investigate the MRI prevalence and characteristics of pregnancy- and lactation-associated vertebral compression fractures (PLVCFs).

METHODS

This retrospective cross-sectional observational study included all thoracic, lumbar, or thoracolumbar MRI examinations performed in our hospital (or at outside centers and referred to us for consultation) of females ≥ 15 and < 40 years of age during a 48-month period. Two radiologists independently reviewed all images for vertebral compression fractures and their disagreement was resolved by a third blinded senior radiologist with 24 years of dedicated musculoskeletal radiology experience. MRI features of PLVCFs (early/late stage, height loss, endplate involvement, retropulsion) were noted.

RESULTS

A total of 1484 MRI examinations-including 50 consultations from outside centers-of 1260 females (mean age, 27.7 years; range, 15-39) were included. Interobserver agreement of the two junior radiologists was substantial (κ = 0.607; 95% CI, 0.545-0.669). Vertebral compression fractures were identified in 177 of thoracic (n = 210), lumbar (n = 900), or thoracolumbar MRI (n = 374) examinations. Six women (7 MRI examinations; 4.0% of MRIs with vertebral fractures) had PLVCFs diagnosed on MRI (prevalence, 0.47%; mean age, 31 years; age range, 25-37). Number of fractured vertebrae in cases with PLVCF ranged between 1 and 11 (mean, 5.6). DEXA, available in all patients with PLVCFs, verified osteopenia/osteoporosis in four of six patients.

CONCLUSION

PLVCFs have an MRI prevalence of approximately 0.5% in the target population and do not display distinguishing features from other insufficiency type vertebral compression fractures.

Integration of a vertebral fracture identification service into a fracture liaison service: a quality improvement project

Integration of a vertebral fracture identification service into a Fracture Liaison Service is possible. Almost one-fifth of computerised tomography scans performed identified an individual with a fracture. This increase in workload needs to be considered by any FLS that wants to utilise such a service.

INTRODUCTION

This service improvement project aimed to improve detection of incidental vertebral fractures on routine imaging. It embedded a vertebral fracture identification service (Optasia Medical, OM) on routine computerised tomography (CT) scans performed in this hospital as part of its Fracture Liaison Service (FLS).

METHODS

The service was integrated into the hospital's CT workstream. Scans of patients aged ≥ 50 years for 3 months were prospectively retrieved, alongside their clinical history and the CT report. Fractures were identified via OM's machine learning algorithm and cross-checked by the OM radiologist. Fractures identified were then added as an addendum to the original CT report and the hospital FLS informed. The FLS made recommendations based on an agreed algorithm.

RESULTS

In total, 4461 patients with CT scans were retrieved over the 3-month period of which 850 patients had vertebra fractures identified (19.1%). Only 49% had the fractures described on hospital radiology report. On average, 61 patients were identified each week with a median of two fractures. Thirty-six percent were identified by the FLS for further action and recommendations were made to either primary care or the community osteoporosis team within 3 months of fracture detection. Of the 64% not identified for further action, almost half was because the CT was part of cancer assessment or treatment. The remaining were due to a combination of only ≤ 2 mild fractures; already known to a bone health specialist; in the terminal stages of any chronic illness; significant dependency for activities of daily living; or a life expectancy of less than 12 months CONCLUSION: It was feasible to integrate a commercial vertebral fracture identification service into the daily working of a FLS. There was a significant increase in workload which needs to be considered by any future FLS planning to incorporate such a service into their clinical practice.

Supportive Care: An Indispensable Component of Modern Oncology

The advent of new cancer therapies, alongside expected growth and ageing of the population, better survival rates and associated costs of care, is uncovering a need to more clearly define and integrate supportive care services across the whole spectrum of the disease. The current focus of cancer care is on initial diagnosis and treatment, and end of life care. The Multinational Association of Supportive Care in Cancer defines supportive care as 'the prevention and management of the adverse effects of cancer and its treatment'. This encompasses the entire cancer journey, and necessitates involvement and integration of most clinical specialties. Optimal supportive care can assist in accurate diagnosis and management, and ultimately improve outcomes. A national strategy to implement supportive care is needed to acknowledge evolving oncology practice, changing disease patterns and the changing patient demographic.

Opportunistic osteoporosis screening: contrast-enhanced dual-layer spectral CT provides accurate measurements of vertebral bone mineral density

Objectives

Osteoporosis remains under-diagnosed, which may be improved by opportunistic bone mineral density (BMD) measurements on CT. However, correcting for the influence of intravenous iodine-based contrast agent is challenging. The purpose of this study was to assess the diagnostic accuracy of iodine-corrected vertebral BMD measurements derived from non-dedicated contrast-enhanced phantomless dual-layer spectral CT (DLCT) examinations.

Methods

Vertebral volumetric DLCT-BMD was measured in native, arterial, and portal-venous scans of 132 patients (63 ± 16 years; 32% women) using virtual monoenergetic images (50 and 200 keV). For comparison, conventional BMD was determined using an asynchronous QCT calibration. Additionally, iodine densities were measured in the abdominal aorta (AA), inferior vena cava, and vena portae (VP) on each CT phase to adjust for iodine-related measurement errors in multivariable linear regressions and a generalized estimated equation, and conversion equations were calculated.

Results

BMD values derived from contrast-enhanced phases using conversion equations adjusted for individual vessel iodine concentrations of VP and/or AA showed a high agreement with those from non-enhanced scans in Bland-Altman plots. Mean absolute errors (MAE) of DLCT-BMD were 3.57 mg/ml for the arterial (R² = 0.989) and 3.69 mg/ml for the portal-venous phase (R² = 0.987) (conventional BMD: 4.70 [R² = 0.983] and 5.15 mg/ml [R² = 0.981]). In the phase-independent analysis, MAE was 4.49 mg/ml for DLCT (R² = 0.989) (conventional BMD: 4.82 mg/ml [R² = 0.981]).

Conclusions

Converted BMD derived from contrast-enhanced DLCT examinations and adjusted for individual vessel iodine concentrations showed a high agreement with non-enhanced DLCT-BMD, suggesting that opportunistic BMD measurements are feasible even in non-dedicated contrast-enhanced DLCT examinations.

Key Points

• Accurate BMD values can be converted from contrast-enhanced DLCT scans, independent from the used scan phase.

• DLCT-BMD measurements from contrast-enhanced scans should be adjusted with iodine concentrations of portal vein and/or abdominal aorta, which significantly improves the goodness-of-fit of conversion models.

Hiding in plain sight-unreported osteoporotic vertebral fractures

KEY POINTS

• Reporting of vertebral fractures has important clinical consequences and can be improved by routinely performing sagittal reformating and by the use of a standard nomenclature and classification.

Detection of vertebral fracture in an acute hospital setting: an intervention to reduce future fracture risk through fracture liaison service intervention?

We introduced a standardised reporting system in the radiology department to highlight vertebral fractures and to signpost fracture prevention services. Our quality improvement project achieved improved fracture reporting, access to the FLS service, bone density assessment and anti-fracture treatment.

PURPOSE

Identification of vertebral fragility fractures (VF) provides an opportunity to identify individuals at high risk who might benefit from secondary fracture prevention. We sought to standardise VF reporting and to signpost fracture prevention services. Our aim was to improve rates of VF detection and access to our fracture liaison service (FLS).

METHODS

We introduced a standardised reporting tool within the radiology department to flag VFs with signposting for referral for bone densitometry (DXA) and osteoporosis assessment in line with Royal Osteoporosis Society guidelines. We monitored uptake of VF reporting during a quality improvement phase and case identification within the FLS service.

RESULTS

Recruitment of individuals with VF to the FLS service increased from a baseline of 63 cases in 2017 (6%) to 95 (8%) in 2018 and 157 (8%) in 2019 and to 102 (12%) in the first 6 months of 2020 (p = 0.001). One hundred fifty-three patients with VFs were identified during the QI period (56 males; 97 females). Use of the terminology 'fracture' increased to 100% (mean age 70 years; SD 13) in computed tomography (n = 110), plain X-ray (n = 37) or magnetic resonance imaging (n = 6) reports within the cohort. Signposting to DXA and osteoporosis assessment was included in all reports (100%). DXA was arranged for 103/153; 12 failed to attend. Diagnostic categories were osteoporosis (31%), osteopenia (36%) or normal bone density (33%). A new prescription for bone protection therapy was issued in 63/153. Twelve of the series died during follow-up.

CONCLUSIONS

Standardisation of radiology reporting systems facilitates reporting of prevalent vertebral fractures and supports secondary fracture prevention strategies.