Opportunistic diagnosis of osteoporosis, fragile bone strength and vertebral fractures from routine CT scans; a review of approved technology systems and pathways to implementation

Abstract

Osteoporosis causes bones to become weak, porous and fracture more easily. While a vertebral fracture is the archetypal fracture of osteoporosis, it is also the most difficult to diagnose clinically. Patients often suffer further spine or other fractures, deformity, height loss and pain before diagnosis. There were an estimated 520,000 fragility fractures in the United Kingdom (UK) in 2017 (costing £4.5 billion), a figure set to increase 30% by 2030. One way to improve both vertebral fracture identification and the diagnosis of osteoporosis is to assess a patient’s spine or hips during routine computed tomography (CT) scans. Patients attend routine CT for diagnosis and monitoring of various medical conditions, but the skeleton can be overlooked as radiologists concentrate on the primary reason for scanning. More than half a million CT scans done each year in the National Health Service (NHS) could potentially be screened for osteoporosis (increasing 5% annually). If CT-based screening became embedded in practice, then the technique could have a positive clinical impact in the identification of fragility fracture and/or low bone density. Several companies have developed software methods to diagnose osteoporosis/fragile bone strength and/or identify vertebral fractures in CT datasets, using various methods that include image processing, computational modelling, artificial intelligence and biomechanical engineering concepts. Technology to evaluate Hounsfield units is used to calculate bone density, but not necessarily bone strength. In this rapid evidence review, we summarise the current literature underpinning approved technologies for opportunistic screening of routine CT images to identify fractures, bone density or strength information. We highlight how other new software technologies have become embedded in NHS clinical practice (having overcome barriers to implementation) and highlight how the novel osteoporosis technologies could follow suit. We define the key unanswered questions where further research is needed to enable the adoption of these technologies for maximal patient benefit.

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

“…There is emerging interest in improving the diagnosis of VFFs and various ML-CAD systems are currently in development. AI-based algorithms to identify VFFs on CT scans have previously been shown to be accurate and sensitive to identifying fractures [15,46]. These interventions access the medical images stored on Picture Archive and Communication Systems (PACS) and use AI to either identify and/ or grade VFFs, or provide a measure of the degree of confidence of a VFF being present on CT scans or radiographs.…”

“…Within this context, there is emerging interest in using automated approaches to enable the incidental identification of VFFs on existing medical images such as computed tomography (CT) scans visualising the spine [15]. The widespread availability of CT scans, offering high image resolution, provides an opportunity to develop an automated approach for the incidental identification of VFFs using machine learning (ML)-based computer-aided diagnostic (CAD) systems.…”

Imaging of Metabolic Bone Diseases: The Spine View, Part II

“…Currently, several methods for opportunistic osteoporosis screening are commercially available. 29 NanoxAI and Optasia target automated fracture detection, Mindways performs opportunistic QCT measurements, and ON.Diagnostics offers advanced bone strength analysis. All these methods can readily be used to enlarge the screening capabilities of our health care system.…”

“…All these methods can readily be used to enlarge the screening capabilities of our health care system. 29 However, most of them still require a large amount of manual interaction, limiting the broad and systematic application to all CTs performed.…”

World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (WCO-IOF-ESCEO 2021): ROS-IOF-ESCEO Symposium Abstracts

“…The Causes group have hosted two workshops, each of which was attended by a panel of international experts to explore research opportunities. The recommendations from a workshop on functional genomics of osteoporosis hosted by Prof Jon Tobias in October 2020 have now been published [1] and the recommendations from a workshop on the microbiome and osteoporosis hosted by Prof Sue Lanham-New and Dr Owen Cronin have been submitted for publication. The causes group has also initiated a UK-wide research study on the presentation, clinical features and treatment of pregnancy associated osteoporosis led by Professor Stuart H Ralston with initial results expected by the end of 2021.…”