Vertebral Fractures Frequently Underreported by Radiologists

Pam Harrison

September 26, 2017

Vertebral fragility fractures (VFFs) are largely underreported by radiologists, especially those who do not specialize in musculoskeletal imaging, thus missing an opportunity to offer treatment to patients with osteoporosis to prevent further fracture, a single center study in the United Kingdom suggests.

"Patients with osteoporosis vertebral fragility fractures are at increased risk of future fractures, including hip fractures," lead author Ruth Mitchell, MD, Merton College, University of Oxford, and colleagues observe in their paper, published online recently in the Archives of Osteoporosis.

"Our data demonstrate that VFFs are significantly underreported by radiologists, particularly by nonmusculoskeletal radiologists, [and] vigilance for vertebral fractures should be increased in a population such as this [one], where the mean age [was] over 80 and therefore a high incidence of vertebral fractures should be anticipated," they add.

Fewer Than Half of VFFs Were Logged at Time of Scan

Using data from the UK local Fracture Liaison Service, the researchers identified 157 evaluable patients who presented to the Oxford University Hospital NHS Trust in Oxford in 2013 with a hip fracture.

All had undergone some form of imaging of the spine in the preceding 5 years, including a CT scan, MRI, or plain film in which at least five thoracic or lumbar vertebrae were visible.

Almost two-thirds of the group were female, and the mean age at the time participants sustained their hip fracture was 82.5 years.

"Of the 157 individuals who had spinal imaging prior to their hip fracture…41% had detectable VFFs. Of these detectable VFFs, fewer than half, at 46%, were reported as 'fractured' by the radiologist at the time the image was taken," the researchers note.

However, satisfactory reporting at the time the image was taken varied substantially, depending on the type of radiology practiced, with 89% of musculoskeletal radiologists reporting the presence of a VFF on first imaging, compared with only 14% of nonmusculoskeletal radiologists.

Similarly, only 7% of grade 1 fractures — the least severe type of fracture — were reported on imaging compared with 68% of grade 2 fractures and 75% of grade 3 fractures; the latter is the most severe grade of fractures.

And "of those patients with a previously detectable VFF, only…25% were documented taking bone-specific therapy at the time of hip fracture," Dr Mitchell and colleagues note.

However, the database would not allow the researchers to determine whether treatment had been initiated because a vertebral fracture had been identified.

Lack of Awareness to Specifically Look for Fractures

Asked by Medscape Medical News to comment further, Dr Mitchell noted that most of the fractures that were successfully identified were reported by musculoskeletal radiologists reviewing imaging where the primary focus was the spine.

"Fewer fractures were picked up on imaging performed for other indications — for example, CT scans of the abdomen or pelvis," she noted in an email, "so it is probably not the detection of fractures that presents a challenge to the radiologist, but lack of awareness of the need to specifically look for them," she suggested.

This may be especially true when it comes to less severe fractures, which are often overlooked, she observed.

"We don't know how the levels of vertebral fracture reporting in our trust compared with other areas; however, this is not the first study to highlight underreporting [of VFFs]," Dr Mitchell said.

"But by reporting vertebral fractures, radiologists can help identify patients with osteoporosis who are at increased risk of hip fracture, and then the patient's general practitioner or local fracture prevention service can be alerted to this risk and offer follow-up investigations and osteoporosis treatment," she observed.

The International Osteoporosis Foundation has already recognized that the prevalence of vertebral fractures is underreported and has initiated a Vertebral Fracture Initiative to raise awareness among radiologists about the risk of vertebral fractures in the elderly and how to more effectively prevent further fractures through more thorough reporting.

Undiagnosed Vertebral Fractures Equate With Back Pain

In an unrelated investigation, US researchers evaluated the impact that clinically undiagnosed, incident radiographic vertebral fracture (VF) had on quality of life, including symptoms of back pain and associated limitations in usual activities, in older men enrolled in the Osteoporotic Fractures in Men (MrOS) study.

The data were published online September 7, 2017 in the Journal of Bone and Mineral Research.

Some 4396 men underwent spinal X-ray and filled out a symptom questionnaire at baseline and again at a second follow-up visit, at approximately 4.6 years later.

During the study interval, 3.8% of the cohort experienced a radiographic-only vertebral fracture while 0.6% had a documented radiographic plus clinical vertebral fracture.

Perhaps not surprisingly, "men with incident radiographic plus clinical VF were most likely to have back-pain symptoms and associated activity limitation at follow-up," lead author, Howard Fink, MD, MPH, Veterans Affairs Health Center, Minneapolis, Minnesota, and colleagues report.

Men with an incident radiographic plus clinical vertebral fracture were also significantly more likely to report any back pain or severe back pain, to be bothered most of the time by back pain, and to have limitations in their usual daily activities because of back pain, compared with men with no incident vertebral fracture.

MROS Quality-of-Life Indices at Follow-up

Index Incident radiographic plus clinical VF (%) No incident VF (%)
Any back pain 93 59
Severe back pain 18 4
Bothered most or all the time by back pain 50 13
Limited usual daily activities because of back pain 64 18

"In this cohort of community-dwelling older men, those with clinically undiagnosed incident radiographic VFs were significantly more likely to have back-pain symptoms and activity limitations due to back pain at follow-up than were men without incident VF," Dr Fink and colleagues observe.

Dr Mitchell and coauthors had no relevant financial relationships. Dr Fink had no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

Arch Osteoporos. Published online August 7, 2017. Article

J Bone Miner Res. Published online September 7, 2017. Abstract

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