Radiol med (2012) 117:1347–1354

DOI 10.1007/s11547-012-0881-z

MUSCULOSKELETAL RADIOLOGY
RADIOLOGIA MUSCOLO-SCHELETRICA

Quality assurance of imaging techniques used in the clinical

management of osteoporosis

Controllo di qualità delle tecniche di imaging nella gestione clinica

dell’osteoporosi

G. Guglielmi1, 2 • J. Damilakis3, 4 • G. Solomou3, 4 • A. Bazzocchi5, 6

1
Department of Radiology, University of Foggia, Viale Luigi Pinto 1, 71100 Foggia, Italy
2
Department of Radiology, Scientific Institute “Casa Sollievo della Sofferenza” Hospital, Viale Cappuccini 1, 71013 San Giovanni
Rotondo (FG), Italy
3
University of Crete, Faculty of Medicine, Department of Medical Physics, P.O. Box 2208, 71003 Heraklion, Crete, Greece
4
University Hospital of Heraklion, Department of Medical Physics, P.O. Box 1352, 71110 Heraklion, Crete, Greece
5
Imaging Division, Clinical Department of Radiological and Histocytopathological Sciences, University of Bologna, Sant’Orsola,
Malpighi Hospital, Via G. Massarenti 9, 40138 Bologna, Italy
6
Diagnostic and Interventional Radiology, “Rizzoli” Orthopaedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
Correspondence to: G. Guglielmi, Department of Radiology, University of Foggia, Viale L. Pinto 1, 71100 Foggia, Italy, Tel.: +39-
0881-733866, Fax: +39-0881-350368, e-mail: g.guglielmi@unifg.it

Received: 12 July 2012 / Accepted: 24 July 2012 / Published online: 22 October 2012
© Springer-Verlag 2012

Abstract
Recent advances in the densitometric and imaging
techniques involved in the management of osteoporosis are
associated with increasing accuracy and precision as well
as with higher exposure to ionising radiation. Therefore,
special attention to quality assurance (QA) procedures
is needed in this field. The development of effective and
efficient QA programmes is mandatory to guarantee
optimal image quality while reducing radiation exposure
levels to the ALARA principle (as low as reasonably
achievable). In this review article, the basic QA procedures
are discussed for the techniques applied to everyday
clinical practice.
Keywords Osteoporosis · Bone densitometry · DXA ·
QCT · QUS · Bone structure
Riassunto
I recenti progressi nelle tecniche di densitometria e di
imaging nella diagnosi dell’osteoporosi sono associati ad
una crescente accuratezza e precisione così come ad una
maggiore esposizione a radiazioni ionizzanti.
In questo campo è pertanto richiesta una particolare
attenzione alle procedure di controllo di qualità (Quality
Assurance, QA). Lo sviluppo di programmi di QA efficaci
ed efficienti è necessario al fine di garantire una qualità
dell’immagine ottimale e al contempo di ridurre i livelli
di esposizione alle radiazioni secondo il principio ALARA
(cioè al livello più basso ragionevolmente ottenibile). In
questa review sono trattate le procedure base di QA per
le metodiche di imaging adoperate nella pratica clinica
quotidiana.

Parole chiave Osteoporosi · Densitometria ossea · DXA ·

QCT · QUS ·Struttura ossea

Introduction

Osteoporosis is a skeletal disease, characterised by low sceptibility to fracture [1]. This disease is widely recognised
bone mass and micro-architectural deterioration of bone as an important public health problem because of the signi-
tissue, with a consequent increase in bone fragility and su- ficant morbidity, mortality and economic and social costs
1348
associated with its complications, i.e., fractures at different
skeletal sites [2]. The percentage of patients with osteoporo-
sis increases progressively with age and the disease occurs
more frequently among females. Fractures tend to occur in
those bone parts, such as the vertebral body, hip and wrist,
which rely heavily on trabecular bone for their strength [3,
4]. It is estimated that every year 9 million osteoporotic
fractures affect the worldwide population, and more than
half of these occur in Europe and in the Americas [5, 6].
Osteoporotic fractures cost 36 billion euro in Europe and 18
billion dollars in the US every year, and these are expected
to increase twofold or more by 2050 unless treatments are
pursued that have a significant impact on the global burden
of fractures [7, 8].
Quality assurance (QA) is by definition a programme
for the systematic monitoring and evaluation of the various
aspects of a service or facility to ensure that standards of
quality are being met. QA in bone densitometry and asso-
ciated methods is composed of those actions aiming to (1)
maintain adequate equipment performance with the lowest
possible radiation dose to patients consistent with clinical
imaging requirements and (2) assure that adequate diagno-
stic information is provided at the lowest possible cost. A
QA programme should include (a) guidelines and requi-
rements for equipment installation and its clinical use, (b)
standardised periodic tests developed to maintain diagnostic
quality (quality control, QC), (c) radiation safety policies
and procedures, (d) preventive maintenance procedures and
(e) staff training and education.
Several methods have been developed to assess bone mi-
neral status. Dual-energy X-ray absorptiometry (DXA) is
currently the most widely used method for the measurement
of areal bone mineral density (BMDa) (g/cm2). Quantitative
computed tomography (QCT) allows separate assessment
of cortical and trabecular bone, providing volumetric bone
mineral density (BMD) (mg/cm3). Peripheral QCT (pQCT),
and high-resolution pQCT (HR pQCT) are CT-based tech-
niques dedicated to the study of appendicular sites of the
skeleton, with the aim of analysing both density and micro-
architectural bone properties. Moreover, quantitative ul-
trasound (QUS) and magnetic resonance (MR) techniques
have been developed to assess bone quantity and quality.
However, MR imaging is not discussed in this manuscript,
since it is mainly limited to research fields. Vertebral fractu-
res are usually diagnosed on spine radiographs or images of
the spine acquired by DXA devices.
The use of diagnostic imaging methods for the assessment
of bone status has constantly and quickly increased, so that
QA in bone densitometry deserves special attention [9]. The
purpose of this review article is to summarise the current
practice of QA in bone densitometry and related techniques
and to discuss the magnitude of radiation exposure from the
X-ray methods used for the assessment of bone status.
Radiol med (2012) 117:1347–1354
Equipment and installation
The technical features of bone densitometry and other re-
lated medical devices should satisfy clinical requirements.
The supplier of the equipment should describe all clinical
applications of the system and specify the performance in
terms of accuracy and precision. DXA and QCT should
be supplemented with a reference database to compare pa-
tients’ measured BMD with that of age- and sex-matched
normal subjects and with normal young adults. Equipment
packages should include not only the specific application
software package but also dedicated phantoms for calibra-
tion and quality control procedures.
The installation of the equipment should be followed by
procedures that ensure proper functioning, satisfy all current
radiation protection requirements and manufacturer speci-
fications. Radiation safety checks should be performed by
a medical physics expert. Electrical safety tests, equipment
tests and staff training should be provided by the supplier
of the equipment; the employer should verify if equipment
tests and staff training have been performed on the newly
installed equipment [9].
Quality control
An important issue in the study of bone status is the esta-
blishment of sufficient QC procedures, performed to ensure
that a manufactured product meets a defined and standardi-
sed set of quality criteria. These procedures include monito-
ring of the stability and performance of the devices as well
as guidelines for the handling of error sources in order to
guarantee reliable quantitative information to clinicians and
patients as an aid to diagnosis and management of osteo-
porosis.
Dual-energy X-ray absorptiometry
DXA has a relevant and central role in the evaluation of
individuals at risk of osteoporosis, in helping clinicians to
assess fracture risk and in patients with osteoporosis to se-
lect pharmacological therapy and to monitor treatment or
disease progression [10].
Steps should be taken to make sure that a DXA device is
of sufficiently high quality and that its accuracy and preci-
sion is consistent with the manufacturer guidelines. Accura-
cy is the ability of a measurement to match the actual value
of the quantity being measured and is expressed in terms of
accuracy error. Precision is the degree to which repeated
measurements under unchanged conditions show the same
results. This is influenced by several parameters, such as
skill and training of the technician performing the scan, the
site of measurement and the clinical features of patients [9].
Radiol med (2012) 117:1347–1354
To determine the accuracy of a DXA densitometer, a
phantom containing tissue-mimicking materials of known
and different densities is scanned to ensure that measured
values are truly assessed for all quantities under investiga-
tion [11]. The phantom represents the typical density ran-
ge and size of normal human spine. The accuracy error of
DXA bone densitometers is better than 10% [12]. Phantom
measurements have to be performed every day, or at least 3
times a week. Results are entered into the QC database to
enable compensation of calibration changes.
To determine in-vitro precision of a DXA densitometer,
the phantom provided by the manufacturer for routine DXA
QC tests should be scanned multiple times. Precision is de-
pendent on population age and health status and is affected
by errors when BMD is evaluated in longitudinal studies.
To overcome this limit and reduce precision errors, the ima-
ges of previous DXA examinations should be used in mo-
nitoring the accuracy of patient positioning. Of note, howe-
ver, is that the precision error estimated by the manufacturer
does not usually represent the error in the clinical setting.
Thus, every facility should determine in vivo reproducibili-
ty for each DXA device [13, 14].
It is well known that DXA devices developed by different
manufacturers and even by the same manufacturer provide
different BMD results when used to measure the same ske-
letal site of a patient because of differences in scanner de-
sign, data acquisition, algorithms and method of calibration.
To minimise differences between different DXA systems
cross-calibration techniques have been developed. The stan-
dardised BMD (sBMD) has been introduced to distinguish
interchangeable BMD from manufacturer-specific BMD
[15, 16]. Although sBMD values can reduce the differences
between measurements performed by systems developed by
different manufacturers to less than 6%, the use of different
DXA systems to longitudinally monitor the bone status of
an individual is not recommended.
Quantitative CT
The QA of CT systems is recognised as an important to-
pic and scientific and professional organisations have de-
veloped guidelines for equipment specifications, equipment
QC tests and radiation safety [17]. Radiation safety in CT
is emphasised because patient radiation doses from CT are
considerably higher than those from DXA.
The measurement of precision is influenced by the CT
scanner model, QCT method, skill of the radiological
technologist, patient positioning and movement. Each faci-
lity should perform precision testing to determine precision
error and calculate the least significant change. If a facility
has more than one user technologist, these values should
represent an average of pooled data from all technologists.
1349
Precision is better for 3D multidetector QCT than for single-
slice 2D QCT [17].
QCT is based on analysis of the trabecular bone com-
partment in the spine or proximal femur. Calibration is
needed to convert CT numbers (Hounsfield Units, HU) to
grams per cubic centimeter. Most calibration approaches
consist of a calcium hydroxyapatite-based bone mineral re-
ference phantom that is scanned with the patient and placed
underneath the lumbar spine or between the hips. Several
manufacturers have provided calibration standards along
with special software to define regions of interest and quan-
tify BMD. The Image Analysis (Columbia, KY, USA) stan-
dard consists of rods with varying concentrations of calcium
hydroxyapatite mixed in a water-equivalent solid resin ma-
trix [18]. Another approach, phantomless calibration, uses
histograms of HU values placed in regions of subcutaneous
fat and skeletal muscle, assuming fixed properties for each
tissue types to determine a HU calibration [17].
Quantitative US
Many QUS techniques have been developed for the mea-
surement of broadband ultrasound attenuation (BUA) and
speed of sound (SOS). Also an index indicative of bone
stiffness is calculated from BUA and SOS. QUS measure-
ments are affected by precision errors due to patient posi-
tioning, coupling between the transducer and the skin of the
patients, and the effect of soft tissue properties. Therefore
QC procedures regularly performed with specific phantoms
are required for performance monitoring and stability check
of the devices [9, 19, 20]. A phantom should emulate the in
vivo measurement as much as possible in terms of geometry
and acoustic properties.
The differences in measurements between available QUS
equipment are greater than those between DXA devices;
this is due to the different transducers and frequency ranges
[21].
Radiation dosimetry
A bone densitometry QA programme should involve perio-
dic checks and measurements to maintain diagnostic image
quality at the lowest possible radiation exposure.
Quantities and units
The two most frequently used radiation quantities in dia-
gnostic radiology are absorbed dose (AD) and effective
dose (ED). The AD, expressed in grays (Gy), is a measure
of the energy per unit of mass deposited in the tissue and
organs of the exposed body. The ED, expressed in sieverts
1350
(Sv), is calculated using organ or tissue absorbed doses and
the relative radiosensitivity assigned to each of these organs
or tissues, defined by the International Commission on Ra-
diological Protection (ICRP) [22].
The ED was introduced to allow comparison of the risk
estimates from different sources of ionising radiation, for
example from DXA and QCT, or from imaging techniques
and natural background radiation. The annual worldwide
average ED from natural background radiation is 2.4 mSv
[9].
Dosimetric quantities used in CT are the CT dose index
(CTDI) and the dose-length product (DLP) [9]. The CTDI
represents the average absorbed dose, along the z axis, from
a series of contiguous exposures. CTDI measurements are
performed at the periphery and at the centre of cylindrical
phantoms representing the human head and body by using
a pencil ionisation chamber with a length of 100 mm. From
these measurements, a weighted CTDI (CTDIw) represen-
ting the average dose to a single slice is obtained. Moreo-
ver, CTDI volume (CTDIv) has been introduced to take into
account the effect of pitch on radiation dose, for imaging
performed in the spiral mode, which is defined as CTDIw
divided by pitch. The DLP is defined as the CTDIv multi-
plied by the imaging length (mGy×cm). Thus, DLP is an
indicator of the integrated dose of an entire CT examination.
Broad estimates of effective dose E can be derived from
DLP values using conversion coefficients: E=DLP×k whe-
re k is body region–specific normalised ED factors (mSv*
mGy−1*cm−1) [23].
Patient exposure
DXA
Children and adult doses from DXA have been reported in
several studies [24-28]. The increased field size of fan-beam
scanners (linear-array detector) and more recently of cone
beam densitometers (bi-dimensional detector), compared
to pencil beam devices, has resulted in shorter scan times
allowing greater patient compliance and better image qua-
lity. However, patient doses associated with state-of-the-art
DXA scanners have also been increased [29].
Patient doses from pencil-beam DXA is 1 μSv or less.
This dose level is lower than the average daily dose from na-
tural background radiation. Patient doses up to 15 μSv and
10 μSv for spine and hip scans, respectively, have been re-
ported for fan-beam DXA examinations performed on adult
patients [26]. For paediatric patients doses are higher and
can exceed 50 μSv if adult acquisition protocols are used
[26].
There are many variables affecting patient dose from
DXA, such as the site of measurement (e.g. lumbar spine,
forearm, hip and total body), patient body size, acquisition
Radiol med (2012) 117:1347–1354
Table 1 Adult effective doses for spine radiographs (from Damilakis et al.
[9], with permission)
Tabella 1 Dosi effettive nei soggetti adulti per radiogrammi del rachide
dorso-lombare (da Damilakis et al. [9], con autorizzazione)
Effective dose
(μSv)
Thoracic spine AP 0.4
Thoracic spine LAT 0.3
Lumbar spine AP 0.7
Lumbar spine LAT 0.3
AP, anterior-posterior; LAT, lateral
Table 2 Adult effective doses for various diagnostic X-ray examinations
(from Mettler et al. [31], with permission)
Tabella 2 Dosi effettive nei soggetti adulti per vari esami di diagnostica a
raggi X (da Mettler et al. [31], con autorizzazione)
Examination Effective
dose
(μSv)
Panoramic dental radiography 0.01
Chest radiography (posterior-anterior) 0.02
Chest radiography (posterior-anterior and lateral) 0.1
Mammography 0.4
Abdominal radiography 0.7
Chest CT 7
Abdominal CT 8
Coronary percutaneous transluminal angioplasty,
stent placement, or radiofrequency ablation 15
CT, computed tomography
technique, X-ray tube filtration, efficiency of detection sy-
stem, number of scans, exposure parameters, scan speed and
scan size. Most of these parameters cannot be controlled by
the operator performing the DXA examination. Table 1 pre-
sents the effective dose from spine radiographs, while Ta-
ble 2 delineates doses associated with different diagnostic
X-ray examinations as derived from the literature. Table 3
shows doses from PA spine, proximal femur and total body
DXA scans [26, 30, 31].
Children may require densitometry to assess and moni-
tor BMD for chronic diseases (e.g. endocrine disorders) or
pharmacological treatments (e.g. chemotherapy). The use of
an adult standardised scan protocol in imaging of paediatric
patients is a common cause for excessive radiation to these
patients. This may be attributed to the fact that the exposure
parameters and the image size selected in these protocols
are optimised for standard-sized adults. Specifically, pae-
diatric patients will receive about two to three times higher
ED than adults due to (a) the larger field size and (b) higher
dose to internal organs because of less attenuation of X-rays
by overlying tissue [26]. DXA systems require different
software for paediatrics, for both scanning adjustments and
Radiol med (2012) 117:1347–1354
Table 3 Adult effective doses for examinations performed on Hologic Discovery/QDR4500 DXA devices (from Blake et al. [26], with permission)
Tabella 3 Dosi effettive nei soggetti adulti per esami eseguiti su scanner DXA Hologic Discovery/QDR4500 (da Blake et al. [26], con autorizzazione)
Examinations Scan modes
PA spine Array
Fast
Express
Hip Array
Fast
Express
Whole body
(Discovery-A/ Discovery-W)
PA, posterior-anterior; N/A, not available
appropriate database comparison. A lumbar spine or total
body scan generally provides sufficient information about
the bone status in children. Additional skeletal sites should
be scanned only when the radiation dose is justified by the
potential clinical benefit.
Bone densitometry is rarely necessary in a pregnant pa-
tient. BMD measurements may help to diagnose pregnancy-
associated osteoporosis and exclude the presence of patho-
logy with characteristics similar to those of osteoporosis.
Damilakis et al. estimated conceptus doses and risks related
to DXA acquisitions performed during pregnancy [32]. To
minimise the number of accidental exposures of pregnant
patients from DXA careful screening for pregnancy is nee-
ded. When a patient is found to be pregnant after having
undergone a DXA examination, communication with the
woman is very important to give her an assessment of con-
ceptus dose. Published research shows that conceptus doses
and potential radiogenic risks from DXA are negligible and,
therefore, abortion due to radiation exposure is not recom-
mended [22, 32].
In the case of serial DXA scans, as in follow-up studies,
the radiation burden is increased. Justification of these exa-
minations should be performed with special care to ensure
that the expected benefits exceed the potential risks.
QCT
Assessment of BMD is possible using CT scanners. This
method allows a separate assessment of cortical and tra-
becular BMD, expressed in mg/cm3. A typical single-slice
2D spine QCT protocol consists of a scout image and th-
ree slices in the midplane of vertebral bodies between T12
and L3. An examination acquired at 80 kVp tube potential
1351
Effective dose
(μSv)
ICRP 60 ICRP 103
13.3 N/A
6.7 N/A
4.4 4.4
9.3 N/A
4.7 N/A
3.1 2.4
4.2/8.4 N/A
and 125 mAs tube load delivers a radiation dose to a patient
from 60 to approximately 300 μSv, depending on protocol
parameters and CT scanner model [25, 33]. Recently, 3D
QCT protocols have been developed based on multidetector
CT (MDCT) imaging, providing accurate measurements of
BMD and new insights into bone geometry. However, QCT
examinations using MDCT are associated with high radia-
tion doses (1.5 mSv and 2.9 mSv for the spine and the hip
3D scans, respectively) [34, 35]. On the other hand, QCT of
the appendicular skeleton, is associated with low patient ED
(lower than 10 μSv) [34].
The analysis of MDCT high resolution (HR) images
provides important information about the trabecular bone
network [36, 37]. However, patient doses associated with
HRCT (with isotropic spatial resolution, submillimetre ran-
ge) are high , reaching about 3 mSv [38].
Several factors play a role in the reduction of radiation
dose to the patient. The use of newly developed reconstruc-
tion algorithms can decrease image noise, providing better
image quality at lower radiation burden. Proper selection of
protocol settings, including the selection of minimal scan
length, is very important to limit the dose. The use of adap-
tive section collimation, available in new-generation MDCT
scanners, allows reduction of exposure due to z-over scan-
ning associated with helical scanning [39]. Moreover, ul-
trathin (i.e., 1.2 and 2 mm) beam collimations should not be
used unless strictly necessary for specific clinical purpose,
due to their contribution to dose increase. Optimising the
X-ray beam spectrum or activating the automatic exposu-
re control system of the CT scanner is also helpful in de-
creasing the radiation dose. Nevertheless, studies are still
needed to maximise the diagnostic information provided by
the new technologies with the lowest radiation dose to the
1352 Radiol med (2012) 117:1347–1354

patient. The use of CTDI to ED conversion coefficients may
provide an estimate of patient exposure on modern MDCT
scanners [40, 41]. However, more accurate calculation of
patient ED is possible using patient-specific Monte Carlo
software packages for CT dosimetry [42].
Peripheral QCT (pQCT) scanners are dedicated units ca-
pable of assessing bone architecture and BMD at appendi-
cular bones. Using a recently developed HR pQCT scanner,
in vivo images have been obtained with an isotropic spatial
resolution of 82 μm [43]. The ED from pQCT examinations
is on the order of few μSv [34, 43].
Occupational radiation doses and shielding
The scan type and mode, the workload and the relative po-
sition of the workstation to the scanning table are factors
influencing exposure to the operator. The ICRP recommen-
ds that the ED to a radiation worker should be limited to 20
mSv per year [22].
The radiation exposure of DXA operators is usually very
low, when all procedures are performed following the gui-
delines. The Ministry of Health Service in British Columbia
has found that the exposure per 1000 scans to the bone den-
sitometry operator was 56.0 mR for Hologic QDR4500W,
7.0 mR for Norland Eclipse XE and 21.0 mR for GE Pro-
digy Lunar [44]. In a more recent study, Larkin et al. [27]
found that the annual effective dose from fan-beam systems
at a distance of 1 m ranges from 0.5 to 1.5 mSv, depending
on the DXA model.
An increase in the operator’s distance from the patient
and the use of mobile or immobile shielding can reduce the
operator’s ED [27]. The need for shielding mainly depends
on patient workload, the size of the examination room, and
the type of DXA scanner (especially for fan-beam techno-
logy). Generally, no additional shielding is required in the
walls of a properly designed DXA facility [9]. When plan-
ning a bone densitometry facility, however, several para-
meters should be taken into account so that the exposure
in adjoining areas is at a level acceptable for members of
the public. A shielding study should be performed by me-
dical radiation physicists to assess shielding requirements
associated with DXA. If the room configuration does not
provide the necessary distance between DXA and operator,
a transparent lead-acrylic shielding may be required to pro-
tect healthcare personnel while viewing the patient during
the examination.
Preventive maintenance procedures
In addition to QC and dose measurements, a periodic as-
sessment of the condition of the bone densitometry device
is of primary importance (i.e. checking of electrical safety,
equipment emergency stop, radiation warning lights, the
availability and adequacy of patient support tools). Moreo-
ver all resulting test results should be recorded and periodi-
cally reviewed to detect needed changes [9].
Education and staff training
The performance of a bone densitometry facility is greatly
influenced by the education and training of the staff deli-
vering the services. Radiologists should be fully trained in
pathophysiology, treatment of osteoporosis and bone me-
tabolic diseases. They should also be acquainted with the
application of all radiological techniques employed for the
diagnosis of osteoporosis and familiar with the bone densi-
tometry diagnostic activity [45]. Medical physicists should
have competency and knowledge of QC and dosimetry
techniques in bone densitometry to minimise exposure of
patients and optimise examinations [46]. The American
Society of Radiologic Technologists recently released the
Bone Densitometry Curriculum to provide guidelines on
the standards for the training of technologists dealing with
bone densitometry. Continuing medical education is of gre-
at importance for all medical professionals involved in bone
densitometry to ensure that knowledge and skills are up to
date. Several national and international societies such as the
International Society for Clinical Densitometry provide trai-
ning courses for both physicians and technologists [47].

Conflict of interest None

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