Vertebral fracture assessments should be added to routine dual-energy X-ray absorptiometry (DXA) scans for people over the age of 50 years, according to a new National Institute for Health and Care Excellence (NICE) recommendation as part of its draft osteoporosis guidance.

Evidence shows that this assessment is a cost-effective measure to spot hidden fractures as it can be done on the same scanner during the same visit, the NICE committee agreed, noting that around 70% of spine fractures caused by osteoporosis currently go undiagnosed because they can initially cause no obvious symptoms.

Identifying more vertebral fractures is expected to ‘result in increased and better targeted treatment that will reduce fractures’, the committee added.

The draft guidance also recommends that DXA scans are automatically offered without the need for a risk assessment tool to people who have had either a previous hip or vertebral fragility fracture, or two or more fragility fractures.

In this group, a risk assessment tool – either FRAX or QFracture – is unnecessary because they will have a risk score of more than 10% anyway, the committee said.

These tools should be used to assess fragility fracture risk in people aged between 50 and 90 years who do not meet this criteria, while clinical judgement should be used in assessing risk in those over the age of 90 years, NICE said.

A full clinical assessment should also be done because the risk tools do not include all the factors that increase the chances of fracture, such as medicines that increase the chance of bone loss, and it should be taken into account that hormone replacement therapy decreases fragility fracture risk while on treatment.

The same risk tool should be used throughout an individual’s care because they calculate risk differently, the recommendations added.

It is thought that osteoporosis affects approximately 3.5 million people in the UK and spine fractures caused by osteoporosis are common, with an estimated 549,000 new fragility fractures each year, of which 105,000 are hip fractures, 86,000 vertebral fractures and 358,000 other fractures.

‘Vertebral fractures are common, silent and often missed’

Commenting on the draft guidance, Craig Jones, chief executive of the Royal Osteoporosis Society, said: ‘We welcome NICE’s recommendation to add vertebral fracture assessment to routine bone scans. Vertebral fractures are common, silent and often missed, yet when left undiagnosed they cause long-term pain, disability and loss of independence, with people losing 20 working days on average.

‘This guidance will only make a difference if results lead to treatment and follow-up. That’s why it must go hand in hand with the Government’s commitment to deliver high-quality Fracture Liaison Services across the country by 2030.  If we want to protect people from a cascade of preventable fractures that work really needs to start urgently.’

In January, a report by the All-Party Parliamentary Group (APPG) on Osteoporosis and Bone Health showed that more than half of people with osteoporosis said they’d had no contact from the NHS about their condition in the past year and nearly one in four had no contact for more than three years, exposing them to life-threatening hip and spinal fractures. 

The APPG said osteoporosis patients face a fragmented healthcare system that leaves most without basic diagnosis, treatment and monitoring. 

Helping healthcare professionals target care

Eric Power, interim director of the centre for guidelines at NICE, added: ‘Osteoporosis affects millions in England, and this guidance will help healthcare professionals target care towards those people at highest risk, improving their quality of life while making efficient use of NHS resources.’

A consultation on the new osteoporosis draft guidance, including the recommendation of adding vertebral fracture assessment to DXA scans, is open until 23 February, with an expected publication date for the final guidance of 15 July 2026.

In May last year, the Government announced that it was rolling out 13 new DXA bone scanners in hospitals across England, which would have capacity to deliver an extra 29,000 scans per year to help with the earlier diagnosis of conditions such as osteoporosis.