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Bone densitometry:

The ideal detector for Osteoporosis

By Dr Omar Hussein
Professor of Radiodiagnosis

Osteoporosis is a disease characterized by:

– Low bone mass

– Microarchitectural deterioration of the bone leading to Hip,

Colle’s, and vertebral fractures

– Microarchitectural Changes in Osteoporosis include

decreased Bone Mass,

Trabecular Thickness, Trabecular Number, Horizontal

Struts and Connectivity

– It is worth saying that Bone Resorption takes 7-10 days to

happen , while Bone formation takes 10-12 weeks

BMD Testing Techniques

A. Traditional methods

• Conventional radiography

• Radiographic absorptiometry (RA)

• Ultrasound densitometry

• Dual-energy X-ray absorptiometry(DEXA)

B. Non traditional methods

• New DEXA techniques

• Quantitative computed tomography (QCT) and Finite Element



The Basics of BMD Measurement
Measurement of BMD at any skeletal site has a value in predicting
fracture risk. A variety of densitometers are in clinical use and
provide reliable assessment of fracture risk.

However, hip BMD is the best predictor of hip fractures, and

spine BMD is the best predictor of spine fractures.

Dual energy X-ray Absorptiometry DXA

• Better than Isotope-based absorptiometry

• X-ray based

• Excellent precision and accuracy (1%)

• Reliable and versatile

• Economic exam cost

• High-intensity beam

• Fast scans, low dose

• High image quality

• Can measure all skeletal sites: central and peripheral

• Best Clinical Utility

Clinical uses:

• Site - specific measurements, essential for prediction of BMD,

fracture risk rate of loss.

• Comprehensive evaluation:

• Lumbar spine

• Proximal femur

• Total body is important in children, metabolic bone disease,

severe osteoporosis.

• DEXA allows us to determine :

A- Bone Tissue

• BMD (g/m²)

• Bone Mass (g)

• Area

A- Soft Tissue
• %Fat (R Value)
• Soft Tissue Mass (g) ( Fat Free Mass)
• Fat Mass (g)
• Lean Mass (g) (Fat free and Bone free Mass)
Problems in the interpretation of BMD by DEXA:

• Osteomalacia

• Osteoarthritis (especially the spine)

• Vascular calcification (especially the spine)

• Overlying metal objects

• Contrast media (spine)

• Previous fracture (spine, hip and wrist)

• Severe scoliosis

• Vertebral deformities due to osteoarthrosis, Scheuermann`s


Who should be tested?

1. All postmenopausal women under age 65 who have one or
more additional risk factor for osteoporosis.

2. All women aged 65 and older regardless of additional risk


3. Postmenopausal women who present with fractures (to

confirm diagnosis and determine disease severity)

4. Women who are considering therapy for osteoporosis, if BMD

testing would facilitate the decision.

5. Women who have been on hormone replacement therapy for
prolonged periods.

 Because absolute values can vary with different densitometers,

BMD is expressed as a relationship to two norms:

a. The expected BMD for the patient’s age and sex (Z-score)

b. The ‘young adult normal’ BMD for the same sex (T-score).

 The difference between the patient’s score and norm (T-score or

Z-score) is expressed as a standard deviation (SD) above or
below the mean.

 Usually, 1 SD equals a 10% to 12% difference in bone density.

 In general, when talking about fracture risk, we talk in terms of


 T-score is used because fracture risk increases as BMD declines

from young normal levels.

 Because in older adults, low BMD is very common, comparison

with age matched levels (Z-score) can be misleading

WHO definition of Osteoporosis:

Values of T score:

 > -1 SD is normal

 -2.5 to -1 SD equals osteopenia

 < -2.5 SD equals osteoporosis

Dual energy X-ray Absorptiometry DXA Interval
 Annual:

Post-menopausal osteoporosis, appropriate for age.

 Biannual:

Post-menopausal osteoporosis not appropriate for age.

Steroid induced Osteoporosis



Therapy other than HRT

Recommendations for extremely precise follow up

 To follow interval change in bone density, it is essential to
choose a measurement site that is responsive to treatment.

 Because BMD values in the forearm change very little with all
treatment for osteoporosis, the spine or proximal femur are the
preferred measurement sites. The important value to monitor
when assessing interval change is the absolute difference
between tests ( in gm/cm2), rather than the T- or Z-score.

 In addition, it is essential to have bone density test results

interpreted by an experienced practitioner. This is important
because many factors may influence test results, such as
osteoarthritis, scoliosis, and arterial calcification.

• Clinical Practice of Osteoporosis:

Where we are going tomorrow ?
Newer technologies that may help measure components of
bone quality and how they contribute to bone strength.

A- Specialized DEXA techniques:

➢ Lat. Vert. Morphometry

➢ Advanced Hip Assessment

➢ New Regions of Interest

B- QCT : Quantitative Computed Tomography

C- FEA : Finite Element Analysis
D- High Resolution MRI: Magnetic Resonance Imaging,
E- MRS : MR Spectroscopy

A- Specialized DEXA techniques:

Lateral DEXA Vertebral Morphometry

• A relatively new DXA technique has been developed to evaluate

vertebral deformity using a lateral DXA scan of the spine from T4
to L4.

• Compared with radiographs, this technique is potentially

advantageous with lower cost and lower radiation exposure, and

• Because it is quick and can be done in the same visit for BMD

• According to Hurxthal criteria, 6 measurement points are

selected in each vertebra between T4 and L4, corresponding
respectively to the four corners and the mid-points of the

• Computer measures anterior (Ha), middle (Hm) and posterior

(Hp) heights and calculates the following ratios:

• Ha/Hp (wedging), Hm/Hp (biconcavity) and Hp/Hp+1 or Hp/Hp–1

(crushing or compression), where Hp+1 and Hp–1 indicate the
posterior height of the vertebra above or below the one under
examination, respectively

• A vertebra is considered fractured if any of the three ratios of

vertebral body heights (Ha/Hp, Hm/Hp, Hp/Hp+1 or Hp/Hp–1) is :

<3 SD but >4 SD (grade 1 deformity)

or <4 SD (grade 2 deformity) below the gender-specific reference

mean ratio.

Advanced Hip Assessment (AHA)

Includes all the standard femoral regions of interest previously

available. In addition, AHA provides a measurement of two new
regions of interest-upper and lower femoral neck, automated
determination of hip axis length, and hip strength values.

1. Lower Femoral Neck

2. Trochanter

3. Ward's

4. Shaft

5. Total Hip (defined as the density of the combined region of the

femoral neck, trochanter, and shaft regions.

6. Upper Femoral Neck

7. Hip axis length (HAL)

Each centimeter (10%) increase in HAL increases hip fracture risk by

50-80%. For short-term prediction of hip fracture (within 2 years), HAL
was shown to predict hip fractures independent of BMD.

Bone around prosthesis

• (DXA) has proven to be a useful technique for quantifying

periprosthetic (BMD) changes around proximal femoral implants,
but relatively few studies have assessed BMD changes in bone
surrounding knee implants.

• Tibial bone loss may result from altered loading conditions

imposed by the implant (stress shielding) and periprosthetic
bone resorption caused by a variety of factors .

• These factors may contribute to aseptic loosening and ultimate

implant failure. Measurement of BMD change can detect any
biological change over time.

A- Quantitative Computed Tomography

• Advantages

• Flexible measurements: pure trabecular bone or mix of
cortical and trabecular

• Disadvantages

• spine .forearm .femur only

• relatively high radiation dose (100-1000 mR for spine)

• Low precision (2-5% error)

• expensive

• No validation of results (WHO, …)

- High Resolution- pQuantitative CT

- 3D QCT:
Evaluates Bone Geometry and Cancellous and Cortical Bone

- Finite Element Analysis:

An analytical method to predict bone strength that integrates

material and structural information

Uses QCT imaging data for geometry and density

Strengths of HR- pQCT:

• 3D assessment of architecture and density

• Short imaging time

• Low radiation dose

• Age-related changes and fracture discrimination studies


Limitations of HR- pQCT:

• Limited to radius and tibia only

• Requires specialized equipment

• No prospective fracture data

• Limited reference and therapy related data

A- Magnetic Resonance Imaging:
– Magnetic Resonance Microscopy (MMR):
High resolution images provide information about trabecular

– MR Spectroscopy of bone marrow:

• Provides information about bone marrow chemical composition
• MRS divides the global MR signal from bone into 2 major
segments: water and lipid.

• Water signal comes mostly from red marrow

• Most lipid stem from yellow marrow.

• The spectra of MRS have a water peak and a lipid peak

Strengths of HR- MRI

a. Non-invasive, non-ionizing radiation

b. 3D assessment of cortical and trabecular structure

c. Clinical scanners can be adapted

d. Treatment related effects ( calcitonin, testosterone)


a. Limited to appendicular skeleton

b. Limited Reference data, no prospective fracture data
c. Technically demanding