vertebral fracture assessment- vfa
TRANSCRIPT
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Vertebral Fracture Assessment- VFACalling a Fracture a Fracture
21 May 2019
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VFA: Calling a fracture a fracture
• Recap:
• Why are vertebral fracture an important finding?
• Identification of fractures in imaging
• Identification of fractures in DXA
• VFA
• VFA Case studies
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Why?
• Most common osteoporotic fracture
• Prevalence studies suggest that 12% of women aged 50–79 have vertebral fractures
• Strongly predict future fracture
risk- RR for NOF# 2.8
• Under-diagnosed (70%
undiagnosed)
Black et al., JBMR 1999; Melton et al., OI 1999; Lindsay et al., JAMA 2001
O’Neill TW, Felsenberg D, Varlow J, Cooper C, Kanis JA, Silman J. The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis
Study. J Bone Miner Res. 1996;11:1010-18
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Why?
19 Cauley JA, Risk of mortality following clinical fractures. Osteoporosis Int. 2000;11:556-61.
20 Kado DM, Vertebral fractures and mortality in older women: a prospective study. Arch Intern Med. 1999;159(11):1215-20.
21 Jalava T, et al. Association between vertebral fracture and increased mortality in osteoporotic patients. J Bone Miner Res. 2003;18(7):1254-60.
Increased morbidity and mortality
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Why?
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Why?
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Identification of vertebral fracture in imaging services
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Opportunities for the identification of VFx
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• Seek vertebral fractures apparent on
any imaging that includes the thoracic
and/or lumbar spine
• Report vertebral fractures clearly and
unambiguously
• Alert the referring clinician to the need
for further assessment of fracture risk,
via FLS where available
The Guidance
seek
report
alert
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Audit of CT CAP spine reporting
• Results of pilot 193 CT CAP men and women >50years
standards Audit reports
Comment on the spine in report
161 (83.4%)
Scans in which VFidentified
26 (13.5%) 15 (9.3%)
Scans with correct terminology
7 (46.6%)
Reports with VF recommending further assessment
0
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Identification of VFx in DXA
Think
• Is there a vertebral fracture
• Is this patient at risk of vertebral fractures?
Interrogate
• Patient questionnaire
• DXA scan image AND data
Act
• Flag
• report
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Interrogate
• Patient questionnaire• Any fractures in last 5
years?• Any episodes of back
pain with/without radiation
• Any documented height loss/kyphosis
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Interrogate
• DXA images and data• Appearances of
vertebral height
loss??
• Any unexplained
reduction in vertebral
area?
• Any previous
imaging?
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BMD Area
L1 0.703 9.11
L2 0.670 11.16
L3 0.745 12.05
L4 0.759 12.66
Interrogate
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Action
Non reporting practitioners
• Flag suspicion of vertebral fracture to the reporting clinician
Reporting practitioners
• Report suspicion of vertebral fracture
• Confirm vertebral fracture- request VFA/pain film or indicate this must be done in report
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Action
Non reporting practitioners
• Flag suspicion of vertebral fracture to the reporting clinician
Reporting practitioners
• Report suspicion of vertebral fracture
• Confirm vertebral fracture- request VFA/pain film or indicate this must be done in report
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Action
Non reporting practitioners
• Flag suspicion of vertebral fracture to the reporting clinician
Reporting practitioners
• Report suspicion of vertebral fracture
• Confirm vertebral fracture- request VFA/pain film or indicate this must be done in report
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VFA
• Clinical risk profiles have limited predictive ability
• High index of suspicion required to justify spine radiographs
• Radiation dose
• Cost
• Patient inconvenience
• VFA can be obtained at same time as BMD measurement
• Presence of fracture may access anabolic treatments
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Indications for VFA:
• T-score < -1.0 SD + 1 or more:
• Woman aged > 70 or man >80
• Historical height loss > 4 cm
• Self reported but undocumented prior vertebral fracture
• Glucocorticoid therapy >5 mg BD > 3 mo
ISCD 2015
VFA
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Indications for VFA:
• T-score < -1.0 SD + 1 or more:
• Woman aged > 70 or man >80
• Historical height loss > 4 cm
• Self reported but undocumented prior vertebral fracture
• Glucocorticoid therapy >5 mg BD > 3 mo
• Appearances on DXA suggestive of vertebral fracture
VFA
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• Should include part of L5 to top of T4
• Lateral – should be seen as rectangular
boxes with only one edge.
• L5 should usually sit between the iliac
crests
• L4 is frequently bisected by the iliac crests
• Thoracic vertebrae shorter, square and
have rib articulations.
VFA
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VFA
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VFA case studies:calling a fracture a fracture
Case 1
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L4
L3
L2
L1
T12
T11
T10
T9T8
T7
T8 Moderatewedge fracture
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L4
L3
L2
L1
T12
T11
T10
T9T8
T7
T8 Moderatewedge fracture
VFA 1 fracture identified
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VFA 1 fracture identified
plain film: vertebral fracture confirmed
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VFA case studies:calling a fracture a fracture
Case 2
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L4
L3
L2
L1
T12
T11
T10
T9T8
T7 Moderatecompression
Moderate compressionModerate compression
Mild Wedge
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L4
L3
L2
L1
T12
T11
T10
T9T8
T7 Moderatecompression
Moderate compressionModerate compression
Mild Wedge
VFA 4 fractures identified
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VFA 4 fractures identified
Plain film- Scheurmann’s
disease
No fractures
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VFA case studies:calling a fracture a fracture
Case 3
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L4
L3
L2
L1
T12
T11
T10
T9
Mild Wedge fracture
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L4
L3
L2
L1
T12
T11
T10
T9
VFA 1 fracture identified
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VFA 1 fracture identified
Plain film- Schmorl’s node
No fractures
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VFA case studies:calling a fracture a fracture
Case 4
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Mild Wedge fracture
Moderate biconcave fracture
Mild biconcavefracture
Mild biconcave fracure
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Mild Wedge fracture
Moderate biconcave fracture
Mild biconcavefracture
Mild biconcave fracure
VFA 9 fractures identified
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VFA 9 fractures identified
Plain film- osteomalacia
No fractures
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VFA case studies:calling a fracture a fracture
Summary:- VFA cannot differentiate between mild/grade 1 fractures
and non-fracture deformities