Radiological guidance for the recognition and reporting of osteoporotic vertebral fragility fractures (VFFs)

Date of next review: 

Vertebral fragility fractures (VFF) are common and are frequently present on imaging, but are rarely reported. This missed opportunity has an impact not only on patient morbidity and quality of life but vertebral fractures themselves are associated with an increase in age-adjusted mortality and are a predictor of future osteoporotic fractures.

This dedicated guidance is designed to facilitate radiological recognition and actionable reporting of VFFs. The recommendations are applicable to all individuals who report imaging that may incorporate the spine, including radiologists reporting on- and offsite (including teleradiology) and reporting radiographers.

This guidance has been endorsed by the British Society of Skeletal Radiologists, the Royal College of Physicians and the Royal Osteoporosis Society. 

The key points highlighted in the guidance include:

  • Appointment of a radiology osteoporosis lead is desirable to support development, delivery and audit of policy and protocol in the identification and reporting of fragility fractures (including vertebral fragility fractures [VFFs]) and to act as part of a multidisciplinary team (within a local fracture liaison service [FLS] if available).
  • Agree local policies for the opportunistic reporting of VFFs from imaging that includes the spine.
  • Agree local policy for adopting a consistent approach to the identification and reporting of VFFs.
  • Implement a policy of automatic sagittal spinal reformatting, display and storage on picture archiving and communication systems (PACS) for cross-sectional imaging studies that include the spine.
  • Consider a policy for template reporting of cross-sectional imaging studies that include the spine to include bone integrity, presence of VFF, level and grade/severity.
  • Implement a policy for standardised use of terminology for VFFs – using the term ‘vertebral fracture’.
  • Implement routine audit processes around identification and reporting of VFFs.
  • Agree local policy for onward alerting of referrers or referral to fracture prevention pathways.
  • Agree service level agreements (SLA) with teleradiology contractors to adopt and adhere to VFF-reporting policies.
  • Consider the use of standard phrases or short codes to create actionable reports or alerts to referrers.
  • Where artificial intelligence (AI) technology is implemented to actively screen cross-sectional imaging, agree processes and policy for radiological correlation and alert reporting.
  • Discuss and agree the use of alerts, report content and automisation and clarify onward referral pathways. Clinical engagement is beneficial. Severe or multiple VFFs or cases with canal compromise will warrant urgent  clinical evaluation.