Reporting of Spinal Fractures

Transcription

1 Reporting of Spinal Fractures Poster No.: P-0026 Congress: ESSR 2014 Type: Authors: Keywords: DOI: Scientific Poster H. Al-Chalabi, C. Groves; Bradford/UK Osteoporosis, Structured reporting, Observer performance, Audit and standards, Conventional radiography, PACS, Musculoskeletal system, Musculoskeletal spine, Musculoskeletal bone /essr2014/P-0026 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 11

2 Purpose The wording of reports of spinal radiographs is crucial in the presence of a spinal fracture, expected or otherwise. There are national standards issued by the National Osteoporosis Society which are based on the semi-quantitative system outlined by Genant and Wu 1,2. The reporter should describe whether the fracture is a wedge, biconcave or crush and should grade it as mild, moderate or severe. The use of the word 'fracture' in the report is paramount. In the presence of an osteoporotic vertebral fracture, there is a significant risk of further spinal fractures, and subsequent hip fracture with all their attendant mortality and morbidity implications. The early recognition of spinal fracture ought to trigger investigation for osteoporosis and appropriate treatment with recognised benefits in preventing further damage. Studies have shown that a third of spinal radiograph reports do not mention spinal fractures 3, and of the reports identifying fractures, the fracture is mentioned in the report summary in less than half 4. The International Osteoporosis Foundation (IOF) recommends the use of clear, unambiguous terminology using the word 'fracture', and grading the fracture from mild to severe 5. Images for this section: Page 2 of 11

3 Page 3 of 11

4 Fig. 1: Multiple Fractures on Spinal X-Ray Page 4 of 11

5 Methods and Materials Spinal fracture reporting of plain radiographs in our regional teaching hospital was audited to determine accuracy and concordance with internationally accepted reporting standards. Standards used were based on the International Osteoporosis Foundation's recommendations on identification and reporting of vertebral fractures 5 in accordance with the Genant and Wu classification of spinal fractures 2 and can be found in Table 1. Plain thoracic and lumbar spine films for female patients aged over 45, during a 20 week period were reviewed for; Successful fracture identification Concordance of report with guidelines Recommendation for further assessment Concordance of the report with guidelines, required use of the word 'fracture', a grading to be given, a description of fracture morphology and recommendation for further assessment if no evidence of a previous diagnosis of osteoporosis was evident. The hospitals PACS system was used to retrospectively identify all reported plain film thoracic and/or lumbar spine studies, from female patients aged over 45 years, in a consecutive 20 week period. This cohort of patients was chosen in order to focus on the population most at risk of osteoporotic insufficiency fractures. If a patient had undergone both a thoracic and lumbar spine x-ray then both studies were assessed independently of one another. Grading and description of morphology are important in reporting of vertebral body fractures; severity of vertebral fractures is associated with the outcome independently from DEXA measurements 6 for example women with grade 1 vertebral fractures have a relative risk of further vertebral fractures within 4 years of 1.8%, compared to 2.7 in women with at leaset one grade 2 vertebral fracture 7 and biconcave fractures are a classic finding in osteoporosis. Reports were assessed for whether a grade and description of morphology, using correct terminology, was given; accuracy of fracture morphology and grading were not assessed in this study. An exact wording of clinical recommendation following identification of a vertebral fracture was not required; phrases considered acceptable included (but were not restricted to) "osteoporosis should be considered", "has osteoporosis been excluded?", "likely Page 5 of 11

6 secondary to osteoporosis" and "I suspect this may be osteoporotic" The determining factor was whether a report indicated to the referring clinician that osteoporosis was at least a potential cause of the vertebral fracture. Studies with accessable evidence indicating a prior diagnosis of osteoporosis, either from clinical details, previous reports or prior DEXA scanning, (n=21) were excluded from analysis. All films and reports were reviewed by a radiology specialist registrar following recent training in review of such films; any borderline films or films in which the registrar was uncertain were reviewed by an experienced muskuloskeletal radiology consultant. A total of 406 studies were reviewed with 103 studies containing one or more vertebral fractures. Images for this section: Fig. 2: Genant and Wu Classification of spinal fractures. Page 6 of 11

7 Table 1: Criteria and standards - based on the IOF publications (5) Page 7 of 11

8 Results A total of 406 studies were reviewed with 103 studies containing one or more vertebral fractures. Of these 103 studies, 97 had a demonstrated fracture mentioned in the report however the word "fracture" was only used in 80 of them (77.7%). 67 (65%) reports gave a grading classfication and 84 (81.6%) a morphological description. 82 of the cases had no evidence of a previous diagnosis of osteoporosis; only 18 (22%) of these reports mentioned any recommendation for further assessment or DEXA scanning. Present Report Applicable Cases in Fracture Identified Word fracture used (if identified) Grade Descriptor Recommendation if no previous evidence of osteoporosis available (80) (97) Percentage 94.2% 77.7% (82.5%) 65% 81.6% 22.0% Table 2 - Presence of fracture diagnosis and Contents of Reports Vertebral fracture identification rate at our centre compare well to others internationally however terminology used (i.e. the word 'fracture'), grading and description of morphology does not meet expected standards as recommended by the IOF. Although rates of fracture identification and description surpass those in the literature, as recognised globally, a sufficient number of reports in which fracture is identified are not containing recommendation regarding further action/assessment. Criterion Standard Results Fracture Identified 100% 97/103 = 94.2% Term "fracture" used if identified 100% 80/97 = 82.5% Grade given 100% 67/103 = 65% Correct Descriptor used 100% 84/103 = 81.6% Page 8 of 11

9 Recommendation if no previous evidence of osteoporosis Table 3 - Concordance with Standards 100% 18/82 = 22% Images for this section: Fig. 3: Concordance with standards. Page 9 of 11

10 Conclusion Audit of spinal fracture reports at our centre revealed a good rate of spinal fracture identification but showed there is room for improvement in the grading and classification of fractures and recommendations for DEXA assessments in reports. This supports multiple reviews in the literature that further emphasis needs to be placed on the structure and content of spinal fracture reporting, in order to reduce the rate of further fractures in those at risk. Recommendations following the results of this study: Reporters of spinal films (consultants, trainees, radiographers) should be aware of the requirement to use the word 'fracture' and to number, grade and describe their morphology. Identification of a fracture should lead to a recommendation for assessment of osteoporosis if no prior evidence for this exists. Terminology used in reports that is helpful; "Osteoporosis should be considered", "Has osteoporosis been excluded?" "I suspect this may be osteoporotic". The International Osteoporosis Foundation provide an online vertebral fracture teaching program for radiologists; References 1. WHO Scientific Group on the Assessment of Osteoporosis at Primary Health Care Level. Summary Meeting Report, Brussels, Belgium, 5-7 May Genant HK, Wu CY, van Kuijk C, Nevitt MC. Vertebral Fracture Assessment Using a Semiquantitative Technique. J. Bone Miner. Res. 1993;8(9): Delmas PD, van de Langerijt L, Watts NB, et al. Underdiagnosis of vertebral fractures is a worldwide problem: the IMPACT study. J. Bone Miner. Res. 2005;20(4): Gehlbach SH, Bigelow C, Heimisdottir M, May S, Walker M, Kirkwood JR. Recognition of Vertebral Fracture in a Clinical Setting. Osteoporos. Int. 2000;1. 5. Genant HK et al. International Osteoporosis Foundation Verebral Fracture Initiative Executive Summary. March [Online], Available: Executive_Summary-English.pdf ]26 Apr 2014]. Page 10 of 11

11 6. Grados F et al. Radiographic methods for evaluating osteoporotic vertebral fractures. Joint Bone Spine 2009; 76: Roux C et al. Mild prevalent and incident vertebral fractures are risk factors for new fractures. Osteoporos Int 2007; 18: Personal Information Hssein Al-Chalabi MBBS BSc. Department of Radiology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom and The Leeds Bradford Radiology Training Scheme, UK. Hssein.Al-Chalabi@leedsth.nhs.uk Page 11 of 11