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N u c l e a r M e d i c i n e a n d M o l e c u l a r I m a g i n g P i c t o r i a l E s s ay

Lorente-Ramos et al.
DEXA of Osteoporosis

Nuclear Medicine and Molecular Imaging

Pictorial Essay

Dual-Energy X-Ray Absorptiometry

in the Diagnosis of Osteoporosis:
A Practical Guide
Rosa Lorente-Ramos1 OBJECTIVE. The purpose of this essay is a quick and comprehensive review of dual-
Javier Azpeitia-Armn energy x-ray absorptiometry in the diagnosis of osteoporosis that shows how to achieve the
Araceli Muoz-Hernndez best performance in three steps.
Jos Manuel Garca-Gmez CONCLUSION. The three-step procedure for dual-energy x-ray absorptiometry in-
Patricia Dez-Martnez cludes image acquisition emphasizing proper patient positioning and regions of interest; anal-
ysis, including areas to scan and detection of artifacts that should be excluded from the analy-
Miguel Grande-Brez
sis and noted in the report because they can necessitate additional imaging; and interpretation
American Journal of Roentgenology 2011.196:897-904.

Lorente-Ramos R, Azpeitia-Armn J, Muoz- of results.

Hernndez A, Garca-Gmez JM, Dez-Martnez P,
Grande-Brez M

ual-energy x-ray absorptiometry measured so that if one is unevaluable, the
(DEXA) is the technique of choice forearm can be imaged. For children (younger
in the assessment of bone mineral than 20 years) only the lumbar spine is stud-
density (BMD) [1], the average ied [7] because variability in femoral matura-
concentration of mineral in a defined section of tion results in lack of reproducibility in the hip
bone [2]. DEXA is a quick method that is accu- region, so the reference database is available
rate (exact measurement of BMD), precise (re- only for the spine.
producible), and flexible (different regions can Lumbar spinePosteroanterior images
be scanned) and is performed with a low radia- of the lumbar spine include vertebral bodies
tion dose [3, 4]. Although other factors, such as L1L4 (Fig. 1A).
trabecular bone structure, are important, cen- Proximal femurEither hip may be used for
tral BMD measurements are helpful in the diag- DEXA of the proximal femur. The lowest-level
nosis of osteoporosis for estimating the risk of data on the femoral neck and total hip are used
nontraumatic fracture and in choosing and for diagnosis (Fig. 1B). Total hip is the most
monitoring treatments. Understanding every reproducible measurement of the hip.
step of the procedure is important for maximiz- ForearmThe forearm is used in three con-
ing the usefulness of the imaging evaluation to ditions when the hip and spine cannot be mea-
patients and referring clinicians. sured or the data interpreted, in examinations
A DEXA scanner consists of a low-dose of patients with hyperparathyroidism and those
x-ray tube with two energies for separating whose weight exceeds the limit for the table.
Keywords: bone mineral density, DEXA, dual-energy mineral and soft-tissue components and a Primary hyperparathyroidism decreases
x-ray absorptiometry, osteoporosis high-resolution multidetector array. The de- BMD, which is greater in structures with pre-
vices have one of two different systems: a fan- dominantly cortical bone as opposed to trabec-
beam device that emits alternating high (140 ular bone. Recommendations include measure-
Received July 30, 2010; accepted after revision kVp) and low (70100 kVp) x-rays and sweeps ment at the three sites (hip, spine, and radius)
October 14, 2010. across a scan area or a constant x-ray beam for diagnosis and for follow-up after surgical
with a rare-earth filter and energy-specific ab- and medical treatment. The areas imaged are
All authors: Unidad Central de Radiodiagnstico de la
CAM, Hospital Infanta Leonor, Av gran Va del Este 80,
sorption, which separates photons of higher total bone, one third of the radius, the ultra-
28031 Madrid, Spain. Address correspondence to (70 keV) and lower (40 keV) energy [5]. distal radius, and the ulna. The most useful
R. Lorente-Ramos ( measurements are the ultradistal portion of
Image Acquisition the radius as an indicator of trabecular bone
AJR 2011; 196:897904 Areas Scanned loss and the distal one third of the radius (distal
In adult patients, central DEXA measure- radial diaphysis, excluding the ultradistal por-
ments of the lumbar spine and proximal femur tion) as an indicator of cortical bone mineral
American Roentgen Ray Society are recommended [6]. Two regions should be loss. According to the International Society

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for Clinical Densitometry [6], the distal one ROI [9]. Artifacts include dense objects such in evaluations of premenopausal women, men
third (33% radius) of the nondominant forearm as piercings (Fig. 5A), catheters (Fig. 5B), and younger than 50 years, and children and teen-
is the region of choice in the assessment of os- surgical material (Fig. 5C); retained contrast agers (younger than 20 years) [6]. Osteoporosis
teoporosis (Fig. 1C). medium, such as barium (Fig. 6A) and myel- should not be diagnosed on the basis of densi-
ographic agents (Fig. 6B);and vertebroplasty tometric criteria alone [5]. A Z-score less than
Appropriate Patient Positioning cement (Fig. 6C). Calcifications that do not 2 indicates the diagnosis is below the expect-
Appropriate patient positioning is essential affect the analysis, such as calcified kidneys ed range for age (adults) or low bone density for
for optimizing BMD measurement. The patients (Fig. 7A), hydatid cysts (Fig. 7B), myomas, chronologic age (children).
are placed in the supine position for posteroan- and lithiasis, should be noted in the report
terior imaging of the lumbar spine (Fig. 2A) and as incidental findings. Calcifications super- Conclusion
femoral neck (Fig. 2B) and sitting next to the ta- imposed on the ROI, such as dermatomyosi- DEXA is a quick, accurate, low-cost imag-
ble for imaging of the forearm (Fig. 2C). tis (Fig. 8) and bone grafts (Fig. 9), should be ing method for the diagnosis of osteoporosis.
noted as causes of increased BMD. It comprises adequate performance (symme-
Image Assessment DisordersMany diseases spuriously al- try, morphology, positioning), ROI placement,
Images are assessed for patient movement. ter BMD measurement. In analysis of the detection of artifacts, pathologic evaluation
The area of interest exceeding 12 cm and su- lumbar spine, a greater than 1 point differ- (incidental findings and those affecting analy-
perior and inferior limits should be included ence in T-score between two adjacent ver- sis), and evaluation of bone mineral density.
to verify that the complete anatomic region tebrae indicates a vertebra is abnormal, and
is scanned. The bone axis should be straight radiography is mandatory for diagnosis. De- References
and centered (Fig. 1), and the lesser trochanter generation due to osteoarthrosis artifactually 1. Lewiecki EM, Watts NB, McLung MR, et al. Of-
should not be seen on images of the proximal increases spinal BMD in elderly patients and ficial positions of the International Society for
causes several morphologic changes, such
American Journal of Roentgenology 2011.196:897-904.

femur (Fig. 1B). Clinical Densitometry. J Clin Endocrinol Metab

as osteophytes (bone growths) and verte- 2004; 89:36513655
Analysis bral endplate reactions to degenerative disks 2. Wahner H. Technical aspects and clinical inter-
Placement of Region of Interest (Fig. 10). In the presence of fractures, BMD pretation of bone mineral measurements. Public
Equipment from various manufacturers gen- is altered owing to higher bone density with a Health Rep 1989; 104[suppl]:2730
erates automatic ROIs, which should be re- smaller surface (Fig. 11). Lytic and sclerotic 3. Cummings SR, Bates D, Black DM. Clinical use
viewed. Correct numbering of vertebral bodies bone lesions, such as metastatic lesions, lym- of bone densitometry. JAMA 2002; 288:1889
is the main goal in DEXA of the lumbar spine. phoma, bone islands (Fig. 12), lesions due to 1897
The indicators of correct positioning are as fol- Paget disease, hemangiomas, and dense pedi- 4. Lentle BC, Prior JC. Osteoporosis: what a clini-
lows: the ribs appear at T12, the largest trans- cles (Fig. 13), also are impediments to BMD cian expects to learn from a patients bone density
verse processes are L3, the vertebral area values measurement. Diffuse diseases, such as an- examination. Radiology 2003; 228:620628
increase from L1 to L4, BMD increases from kylosing spondylitis and osteopetrosis, alter 5. Adams JE. Single and dual energy X-ray absorpti-
L1 to L3, and the BMD of L4 is similar to or osseous structure and bone density (Fig. 14). ometry. Eur Radiol 1997; 7:S20S31
slightly less than that of L3. Sometimes radio- 6. Baim S, Binkley N, Bilezikian JP, et al. Official
graphs are necessary for correlation. Altered Interpretation position of the International Society for Clinical
vertebrae (deformed or with lesions or artifacts The scanner calculates BMD in grams Densitometry and executive summary of the 2007
in them) should be excluded from the analysis. per square centimeter. A reference database ISCD position development conference. J Clin
If only one vertebral body is left, the region is is consulted, and values and curves are ob- Densitom 2008; 11:7591
not useful for diagnosis. In hip scanning, it is tained. The main parameters are T-score, 7. Baim S, Leonard MB, Bianchi ML, et al. Official
important to avoid undesired bone. The ana- which represents the SD by which the BMD positions of the International Society for Clinical
tomic landmark selected for femoral neck ROI differs from the mean BMD of a young adult Densitometry and executive summary of the 2007
placement is the greater trochanteric notch reference population of the same ethnicity and ISCD pediatric position development conference.
(Figs. 3A and 3B). sex, and Z-score, which is the SD by which J Clin Densitom 2008; 11:621
the BMD differs from the mean BMD of a 8. Orwoll ES, Oviatt SK. Longitudinal precision of
Pitfalls healthy population of the same ethnicity, sex, dual-energy x-ray absorptiometry in a multicenter
Inappropriate patient positioningThe and age as the person undergoing DEXA. study. The Nafarelin/Bone Study Group. J Bone
most important source of false BMD mea- For estimation of fracture risk, it is gener- Miner Res 1991; 6:191197
surements is inappropriate patient positioning ally accepted that each SD in T-score increas- 9. Jacobson JA, Jamadar DA, Hayes CW. Dual X-ray
(Figs. 4A and 4B). Longitudinal in vivo pre- es risk by a factor of 2 [10]. According to the absorptiometry: recognizing image artifacts and
cision reflects variability due to positioning: World Health Organization, among postmeno- pathology. AJR 2000; 174:16991705
spine, 1.1%; femoral neck, 1.2%; trochanter pausal women and men 50 years old and old- 10. [No authors listed]. Assessment of fracture risk and
1.3% [8]. er, diagnosis is based on T-score, normal being its application to screening for postmenopausal os-
ArtifactsImages should be assessed for greater than 1.0; osteopenia, 1 to 2.5; and teoporosis: report of a WHO study group. World
artifacts, which should be excluded from the osteoporosis, less than 2.5. Z-scores are used Health Organ Tech Rep Ser 1994;843:1129

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American Journal of Roentgenology 2011.196:897-904.

Fig. 152-year-old woman with hyperparathyroidism. Region of interest (ROI) and image assessment.
A, Posteroanterior dual-energy x-ray absorptiometric (DEXA) image of lumbar spine includes T12 and ribs, L5
and iliac bone, and straight and centered spine.
B, DEXA image of left proximal femur shows four ROIs are femoral neck, trochanter, intertrochanteric region,
and Ward triangle. Total hip image comprises four ROIs. Image includes all of femoral head and at least 1 cm
under region of lesser trochanter, which should not be seen owing to rotation. Femoral axis is straight.
C, DEXA image of left forearm. Most important ROI is one-third (1/3) radius (arrow). Image should include 2
cm of diaphysis over one third of forearm and part of carpal bones. Axis is straight and centered. BMD = bone
mineral density, UD = ultradistal.

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Fig. 2Patient positioning.
A, Photograph shows position for posteroanterior imaging of lumbar spine: supine
with hips and knees flexed over support to reduce lordosis.
B, Photograph shows position for imaging of proximal femur: supine with lower
extremity internally rotated 1530 and slightly abducted to keep femoral axis
C, Photograph shows position for imaging of forearm: sitting beside table with
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forearm resting on table, hand pronated and held by straps.

Fig. 358-year-old menopausal woman with osteopenia. Green = normal, yellow = osteopenia; red = osteoporosis, BMD = bone mineral density, BMC = bone mineral
content, Sup = superior, Inf = inferior, Ward = Ward triangle.
A, Dual-energy x-ray absorptiometric (DEXA) image shows incorrect placement of region of interest (ROI) in which boundary includes bone other than area of interest
(femoral neck T-score, 2,6; total femur, 2).
B, DEXA image shows correct ROI placement. Equipment allows operator to reduce ROI size and change angulation according to morphologic features of femoral neck or
exclude area from analysis. T-score decreases with correct ROI placement (femoral neck T-score, 2.1; total femur, 1.8).

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Fig. 473-year-old woman with osteopenia. Green = normal, yellow = osteopenia; red = osteoporosis, BMD = bone mineral density, BMC = bone mineral content, Sup =
superior, Inf = inferior, Ward = Ward triangle.
A, Dual-energy x-ray absorptiometric (DEXA) image of proximal femur shows inappropriate positioning of femoral head resulting in depiction of lesser trochanter (arrow)
and normal femoral neck T-score of 0.9.
B, DEXA image shows appropriate rotation in that lesser trochanter is not depicted (arrow). Modification of hip rotation to proper position results in femoral neck T-score
of 1.3, indicating presence of osteopenia.
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Fig. 5Artifacts caused by dense objects.

A, 18-year-old girl with anorexia nervosa. Dual-
energy x-ray absorptiometric (DEXA) image
shows density superimposed on L4 (arrow) found
to be metallic removable piercing not noticed by
technologist. Examination was repeated after
removal of object, and L4 Z-score decreased from 1.6
to 3 and L1L4 Z-score from 1.7 to 3.
B, 65-year-old woman with enteric tube. DEXA image
shows dense structure (arrow) superimposed over L1
vertebral body. Exclusion of L1 from analysis changed
T-score from 1 for L1L4 to 1.2 for L2L4.
C, 68-year-old woman with spinal fixation. DEXA
image shows presence of surgical material over L4
L5 increases bone mineral density values (L3 T-score,
2.8; L4, 1.2). Exclusion of L4 changes T-score from
1.8 for L1L4 to 2.7 for L1L3. Green = normal,
yellow = osteopenia; red = osteoporosis, BMD = bone
mineral density, BMC = bone mineral content, D11
and D12 = T11 and T12.


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Fig. 6Artifacts caused by contrast material.
Green = normal, yellow = osteopenia; red = osteoporosis, BMD = bone mineral density.
A, 65-year-old woman who underwent barium examination of upper gastrointestinal tract day before dual-energy x-ray absorptiometric (DEXA). DEXA image shows
higher of T-score in L3 (1.6) than in adjacent vertebrae (L2, 3.3; L4, 1.1). Exclusion of L3 changes L1L4 T-score from 1.4 to 2.3. Because artifacts can be caused by
retained contrast material from previous examinations, every patient should be asked whether barium examination has been performed within past few days, and DEXA
should be postponed if it has.
B, 72-year-old woman with remote history of myelography. DEXA image shows densities overlying L3 and L5 caused by retained myelographic contrast medium from
examination performed 25 years ago. Area should be excluded from analysis. With exclusion of L3, L1L4 T-score changes from 2.1 to 2.5.
C, 75-year-old woman with osteoporotic L1 and L3 fractures sustained 1 year ago and managed with vertebroplasty. DEXA image shows T-scores are higher than for
adjacent vertebrae (L1, 0.2; L2, 3.5; L3, 1.2; L4, 4). Excluding L1 and L3 from analysis changes L1L4 T-score from 2.1 to 3.8.

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Fig. 7Calcifications not affecting analysis.
A, 67-year-old-woman with calcified kidney. Dual-energy x-ray absorptiometric (DEXA) image shows previously unknown calcified nonfunctioning kidney. Radiograph
confirms finding.
B, 54-year-old woman with calcified hydatid cyst. DEXA image and radiograph show calcification that proved to be hepatic hydatid cyst.
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Fig. 870-year-old woman with dermatomyositis. Dual-energy x-ray Fig. 967-year-old woman with bone graft. Dual-energy x-ray absorptiometric
absorptiometric image and radiograph show multiple seeming calcifications image and radiograph show area of laminectomy and calcified bone graft over
superimposed on left hip. Erroneous increase in bone mineral density (arrow) L4L5 vertebral bodies. Exclusion of L3 and L4 changes L1L4 T-score of 1.8 to
precludes analysis. L1L2 T-score of 1.6.

Fig. 1072-year-old woman with osteoarthrosis. Dual-energy x-ray absorptiometric Fig. 1166-year-old woman with vertebral fracture. Dual-energy x-ray
image shows artifactual increase in bone mineral density (arrow) in affected absorptiometric image shows high-density L1 vertebral body of reduced size
vertebrae due to osteophytes and vertebral endplate reaction to degenerative disk. consistent with vertebral fracture (arrow). Lateral radiograph of lumbar spine
Affected vertebrae have higher bone mineral density and T-score (L2, 1.0; L3, 0.8) confirms presence of fracture (arrow). Top = normal, center = osteopenia;
than adjacent vertebral bodies (L1, 1.7; L4, 2.4). BMD = bone mineral density, bottom = osteoporosis, BMD = bone mineral density.
green = normal, yellow = osteopenia; red = osteoporosis.

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Fig. 1256-year-old woman with sclerotic bone island. Dual-energy x-ray

absorptiometric image and radiograph depict dense round area in trochanteric
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Fig. 1379-year-old woman with sclerotic vertebral pedicle. Dual-energy Fig. 1450-year-old woman with osteopetrosis. Posteroanterior dual-energy
x-ray absorptiometric image and radiograph show dense round area overlying x-ray absorptiometric (DXA) image of lumbar spine shows dense vertebrae with
L4 vertebral body (solid arrows) that turned out to be left L4 sclerotic pedicle. high T-score at all levels. BMC = bone mineral content, BMD = bone mineral
Cholecystectomy clips (open arrows) are evident. Green = normal, yellow = density, CV = coefficient of variation, ACF = autocorrelation function, BCF = bias
osteopenia; red = osteoporosis, BMD = bone mineral density. correction factor, TH = total hip.

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