European Journal of Radiology 71 (2009) 385–387

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Editorial

The radiologist’s important roles and responsibilities in osteoporosis

a r t i c l e i n f o
Keywords:
Osteoporosis
Bone mineral density
Fractures
Imaging
Magnetic resonance imaging
Quantitative computed tomography
Trabecular bone structure

Fractures are the most significant complication of osteoporosis,
and account for the clinical morbidity, mortality and considerable
public health care burden of the disease. Osteoporotic fractures are
one of the most common causes of disability and a major con-
tributor to medical care costs in many regions of the world [1].
The social burden of fractures will increase throughout the world
as the population ages. However, there are now effective thera-
pies, which result in moderate increases in bone mineral density
(BMD) of 6–12% but more importantly reduce future fracture risk
by 40–70%. Early diagnosis of patients at risk of, or with (asymp-
tomatic), fractures is therefore important. As radiologists we are
involved, and have a central role, in many aspects of diagnosing
and treating osteoporosis. It is critical that we correctly
(i) interpret signs of osteoporosis using all imaging techniques,
(ii) diagnose osteoporosis using densitometric techniques, but
(iii) are also able to treat osteoporosis using vertebroplasty/
kyphoplasty or sacroplasty. Additionally
(iv) it is our responsibility to take a leadership role in developing
new imaging techniques to improve the diagnosis of those at
increased risk of osteoporotic fractures.
In this issue of the European Journal of Radiology we have assem-
bled international experts in the field of osteoporosis to provide
updated, pertinent information encompassing clinical, therapeutic
and diagnostic aspects of osteoporosis, including recent new devel-
opments in the field. After clinical introductions to the diagnosis
and treatment of osteoporosis this issue will focus on the imaging of
osteoporotic fractures, BMD methods, including dual energy X-ray
absorptiometry (DXA), quantitative computed tomography (QCT)
and quantitative ultrasound (QUS) with a chapter devoted to the
issues when these techniques are applied in children and applica-
tion of high resolution imaging techniques (computed tomography
CT and magnetic resonance imaging MRI) to quantitating trabec-
ular bone structure. In this editorial we provide some background
to the reader as a framework of osteoporosis and the important
role that radiologists have to contribute to diagnosis and manage-
ment.
1. Diagnosing insufficiency fractures
In recent years we have improved the use of imaging modal-
ities to diagnose osteoporotic fractures. There is evidence in
the past that there was under-diagnosis of vertebral fractures
on images such as the lateral chest radiograph [2–5]. This
prompted the collaborative Vertebral Fracture Initiative of the
International Osteoporosis Foundation (IOF) and the Osteo-
porosis Group of the European Society of Skeletal Radiology
(ESSR) through which the importance of radiologists reporting
vertebral fractures accurately and unambiguously was stressed
(http://www.iofbonehealth.org/health-professionals/educational-
tools-and-slide-kits/vertebral-fracture-teaching-program.html).
We also have learned how to use mid line sagittal reformations
from routine multi-detector CT examinations to identify fractures
which may be asymptomatic and which will not be evident on
the transverse axial sections [6,7]. In addition, we now know
that lesions, which we diagnosed previously as bone necroses (at
the knee and hip) actually represent osteoporotic insufficiency
fractures, and our interpretation of MR signs of insufficiency
fractures has improved [8–13]. This knowledge is critical in guiding
optimum patient management by our clinical colleagues.
2. Diagnostic quantitative techniques
Dual energy X-ray absorptiometry (DXA) ‘areal’ BMD in g/cm2
is currently the standard technique to quantify bone mass, and the
World Health Organisation’s (WHO) criterion to diagnose osteo-
porosis (T score at or below −2.5) only apply to DXA (lumbar
spine, femoral neck, total hip and distal third of radius). However,
a number of current developments, and results of recent studies,
of quantitative ultrasound (QUS) show the potential of this tech-
nique for fracture risk prediction [14–17]. Over the past 20 years

0720-048X/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2009.04.075
386 Editorial / European Journal of Radiology 71 (2009) 385–387
QCT, principally of the spinal trabecular BMD, had been sparsely
used and mostly applied in research studies. However, technical
developments in whole body CT (multi-detector volumetric CT)
have improved precision and extended the technique’s applica-
tion to the study of other clinically important sites such as the
hip. There is also increased appreciation of the advantages of CT
(separate measures of cortical and trabecular BMD; information on
size and shape of bones which also contribute to bone strength)
over DXA. As a consequence CT is being increasingly used to study
the skeleton and to better characterize osteoporotic fracture risk
[18–22].
3. New imaging techniques to diagnose and quantify
osteoporosis
To better describe entities not assessed with standard quanti-
tative, densitometric techniques which give additional information
on fracture risk the National Institute of Health in the US coined
the term “bone quality” [23]. Bone quality encompasses differ-
ent entities including trabecular architecture, bone turnover, and
mineralization of the bone matrix which will contribute to bone
strength in addition to bone mass and size. A major focus is on
structural measurements of cortical and trabecular bone, which
can be performed non-invasively. A number of new imaging tech-
niques to quantify cortical and trabecular bone structure have
been developed and validated including high resolution peripheral
QCT, multi-detector CT and MRI [24–35]. Recent research efforts
have focused on better understanding and quantifying the role of
cortical bone [25,36,37] and using new algorithms such as finite
element analysis [38–41] to better assess osteoporotic fracture
risk.
4. Conclusion
As radiologists we have tended to neglect our important role
in osteoporosis, which has been a rather ‘cinderella’ subject in our
interests and efforts in the past. Yet we play a vital role in the diag-
nosis and management of the disease through the identification
of the early radiographic features, and the detection of fractures,
which may be asymptomatic or undiagnosed. We therefore need
in the future to fulfill our responsibilities in detecting osteoporo-
sis and correctly assessing osteoporotic fracture risk. Osteoporotic
fractures are one of the major challenges to our health system today
and as radiologists we play a central role in guiding patient manage-
ment and therapy to prevent these fractures and their devastating
clinical consequences.
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 Editorial / European Journal of Radiology 71 (2009) 385–387 387

[39] Keaveny TM, Hoffmann PF, Singh M, et al. Femoral bone strength and its rela- Judith E. Adams ∗∗
tion to cortical and trabecular changes after treatment with PTH, alendronate, Department of Clinical Radiology, Manchester Royal
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scans. J Bone Miner Res 2008;23:1974–82. Infirmary, University of Manchester, Oxford Road,
[40] Mawatari T, Miura H, Hamai S, et al. Vertebral strength changes in rheumatoid Manchester M13 9WL, UK
arthritis patients treated with alendronate, as assessed by finite element anal-
ysis of clinical computed tomography scans: a prospective randomized clinical ∗ Correspondingauthor. Tel.: +1 415 353
trial. Arthritis Rheum 2008;58:3340–9.
[41] Orwoll ES, Marshall LM, Nielson CM, et al. Finite element analysis of the prox- 2450/8940; fax: +1 415 476 0616.
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475–83. ∗∗ Corresponding author. Tel.: +44 161 276 4457;
fax: +44 161 276 8916.
Thomas M. Link ∗ E-mail address: Thomas.Link@radiology.ucsf.edu
Department of Radiology of Biomedical Imaging, (T.M. Link)
University of California, 400 Parnassus Ave, A-367,
San Francisco, CA 94143, USA 4 April 2009