Which Central Dual X-ray Absorptiometry Skeletal Sites and Regions of Interest Should Be Used to Determine the Diagnosis of Osteoporosis?

doi:10.1385/JCD:5:3S:S11

Journal of Clinical Densitometry

Volume 5, Issue 3, Supplement, Autumn 2002, Pages s11-s17

https://doi.org/10.1385/JCD:5:3S:S11 Get rights and content

Abstract

Although central measurement of bone mass by dual X-ray absorptiometry (DXA) is viewed by many as the “gold standard” for the diagnosis of osteoporosis in patients without previous fragility fracture, controversy remains on how best to use central DXA as a tool for diagnosis. Questions concerning the measurement of bone mass of the central skeleton were addressed at the International Society for Clinical Densitometry Position Development Conference. An expert panel agreed on the following positions: First, the diagnosis of osteoporosis should be based on the lowest T-score of either the PA spine or hip. Second, both the PA spine and hip should be measured. Third, whenever possible, bone mineral density (BMD) of the first four lumbar vertebrae should be measured. Fourth, DXA manufacturers should use L1–L4 as the default region of interest for their printouts. Fifth, BMD of either hip may be measured. Sixth, the lowest T-score of the three sites total hip, femoral neck, or trochanter should be considered. Seventh, Ward's area should not be used for diagnostic purposes; DXA manufacturers should not include this region in the default printout. Eighth, BMD of the forearm should be measured if the hip or spine cannot be accurately measured. Finally, lateral spine BMD should not be used to diagnose osteoporosis.

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Cited by (127)

Bilateral hip DXA Reporting: 2023 Official Positions of the International Society for Clinical Densitometry
2024, Journal of Clinical Densitometry
Introduction: This position development conference (PDC) Task Force examined the use and reporting of bilateral hip bone mineral density (BMD) measurements. This was deemed appropriate as increased availability of Dual-energy X-ray Absorptiometry (DXA) technology offering bilateral hip measurement resulted in more routine clinical use. The International Society for Clinical Densitometry Official Positions accept bilateral hip BMD measurement for clinical use but currently do not include recommendations for reporting those studies. Methods: Four key questions regarding bilateral hip reporting were proposed by the PDC Steering Committee. Relevant literature was identified using PubMed. Questions included whether bilateral hip measurements are appropriate for diagnostic classification or monitoring, as well as which bilateral hip regions of interest should be reported for diagnosis and monitoring. Additionally, the appropriate nomenclature for bilateral hip acquisition was defined. Results: The literature review demonstrated that bilateral hip measurement is appropriate and diagnostic classification should be based on the lowest T-score at the right or left side femoral neck or total hip; the mean T-score should not be used for diagnostic purposes. Mean bilateral total hip is preferred for BMD monitoring. The terms hip, or total hip were deemed appropriate nomenclature instead of femur or total proximal femur. Conclusion: Bilateral hip acquisition is clinically appropriate and reporting and nomenclature standards are offered herein when a bilateral hip study is acquired. In terms of future research, the impact of discordant hips on diagnosis and monitoring was identified as a significant knowledge gap.
Hounsfield Unit for Evaluating Bone Mineral Density and Strength: Variations in Measurement Methods
2023, World Neurosurgery
To assess the consistency and accuracy of various measurements of the Hounsfield unit (HU) in lumbar vertebrae.
The study reviewed lumbar spine computed tomography images of 60 postmenopausal women aged >50 years. A total of 240 vertebrae were measured and analyzed for the variations of HU values in different sections and regions. Investigated the relationship between HU values of the lumbar spine under different measurements and dual-energy X-ray absorptiometry results and the ability to identify patients with osteoporosis.
HU values measured in midsagittal (r = 0.763), midcoronal (r = 0.768), and midaxial (r = 0.786) sections exhibited a strong positive correlation with dual-energy X-ray absorptiometry T-scores. HU values measured in midsagittal and midaxial sections of the vertebral body were in good agreement (P > 0.1), but decreased in the midcoronal (P < 0.001). HU values in the middle of the vertebral body were significantly higher than in the near end plate (P < 0.001). HU values varied between L1 and L4 vertebrae, but all had a good ability to identify osteoporosis and did not differ significantly in screening ability (P > 0.05).
An averaged HU value in axial multilevel is a comprehensive assessment of vertebral bone density. Using the HU value of the lumbar spine can help identify patients with osteoporosis, and the screening ability does not differ significantly across vertebral segments.
Preoperative glenoid bone density is associated with systemic osteoporosis in primary shoulder arthroplasty
2023, Seminars in Arthroplasty JSES
In shoulder arthroplasty, poor bone mineral density can impact humeral and glenoid fixation, as well as increase the risk of periprosthetic fracture. The purposes of this study were to (1) determine the association between preoperative glenoid and humeral Hounsfield units (HUs) with systemic bone density in primary shoulder arthroplasty, (2) determine a threshold for HU on preoperative shoulder computed tomography (CT) to classify patients as osteoporotic, and (3) identify which anatomic T-score locations were significantly associated with glenoid and/or humeral HU measurements.
Consecutive patients who had both a preoperative shoulder CT and a dual-energy x-ray absorptiometry (DEXA) scan were included. HU measurements of the glenoid vault and proximal humerus were recorded. DEXA T-scores from the spine, hip, and femoral neck were recorded, and osteoporosis was defined as a T-score of −2.5 or lower in any of the anatomic sites. Patients were grouped into osteoporosis and nonosteoporosis cohorts and these cohorts were compared using standard statistical tests. To assess the association between HUs and DEXA T-score, linear regression analysis was performed. Additional receiver operating characteristic analysis was performed to evaluate the ability of HUs to classify patients as osteoporotic.
A total of 162 patients undergoing primary shoulder arthroplasty with both preoperative CT and DEXA scores were included. The osteoporosis cohort had significantly lower body mass index (P = .001), although no other significant differences in demographics were found between the 2 cohorts. The osteoporosis cohort was associated with significantly lower glenoid vault bone density in HUs (183 ± 104 vs. 303 ± 157, P = .004) and trended toward significantly lower proximal humeral bone density in HUs (34.3 ± 54.8 vs. 64.5 ± 58.2, P = .058). Glenoid HU threshold of 175 had an area under the curve of 0.75, with sensitivity of 80.8% and specificity of 62.5% for classifying systemic osteoporosis. HUs of both the glenoid (P = .031) and proximal humerus (P = .003) were significantly associated with femoral neck T-scores on linear regression analysis. Similarly, HUs of both the glenoid (P < .001) and proximal humerus (P = .009) were significantly associated with spine T-scores on linear regression analysis.
This study found that glenoid vault HU is significantly associated with systemic osteoporosis and can be used as a screening tool for detecting osteoporosis preoperatively. In addition to implications for component fixation and periprosthetic fracture, local bone density evaluation on shoulder CT prior to shoulder arthroplasty represents an opportunity for osteoporosis screening.
Positions of The International Society for Clinical Densitometry and Their Etiology: A Scoping Review
2023, Journal of Clinical Densitometry
The International Society for Clinical Densitometry convenes a Position Development Conference (PDC) every 2 to 3 years to make recommendations for guidelines and standards in the field of musculoskeletal measurement and assessment. The recommendations pertain to clinically relevant issues regarding the acquisition, quality control, interpretation, and reporting of measures of various aspects of musculoskeletal health. These PDCs have been meeting since 2002 and have generated 214 Adult, 26 FRAX, 41 pediatric, and 9 general nomenclature consideration positions, for a total of 290 positions. All positions are justified by detailed documents that present the background and rationale for each position. However, the linkage to these publications is not maintained by the ISCD or any other publication such that physicians cannot easily understand the etiology of the positions. Further, the wording of many positions has changed over the years after being reviewed by subsequent PDCs. This scoping review captures the references, changes, and timeline associated with each position through the 2019 PDC. It is meant to serve as a guide to clinicians and researchers for intelligent use and application of the positions.
Evaluation of factors related to the occurrence of new fragility fractures: A case–control study
2023, Revista Espanola de Cirugia Ortopedica y Traumatologia
Las fracturas por fragilidad (FF) son frecuentes en pacientes osteoporóticos. Existen una serie de factores de riesgo y variables clínicas, que podrían predecir su aparición.
Se realizó un estudio observacional retrospectivo de casos y controles. Los casos estuvieron definidos por la presencia de una FF (326 participantes) y los controles por pacientes de similares características sin FF (629 participantes).
Ciertos factores aumentan el riesgo de FF, como un diagnóstico previo de DM tipo 2 (OR: 2,001), las elevaciones de 1 ng/mL del CTX (OR: 1,88), tener antecedentes parentales de fractura de cadera (OR: 1,667), el aumento en 5 años en la edad (OR: 1,39) y los incrementos de 1 kg/m² del IMC (OR: 1,041). Por el contrario, otros factores evaluados disminuyen ese riesgo, como mantener unos niveles de 25(OH)D ≥ 30 ng/mL (OR: 0,686) y una T-score ≥ −2,5 (OR: 0,642).
Niveles de 25(OH)D ≥ 30 ng/mL y una T-score en el cuello femoral ≥ −2,5 son factores protectores de las FF, mientras que el diagnóstico previo de DM tipo 2, un CTX elevado, el antecedente parental de fractura de cadera, un incremento de 1 kg/m² del IMC y el aumento de la edad en 5 años serían predisponentes a padecer FF.
Fragility fractures (FF) are frequent in osteoporotic patients. There are a series of risk factors and clinical variables that could predict their appearance.
A retrospective observational study of cases and controls was carried out. Cases were defined by the presence of FF (326 participants) and controls by patients with similar characteristics without FF (629 participants).
Certain factors increase the risk of FF, such as a previous diagnosis of type 2 DM (OR: 2.001), 1 ng/mL elevations of CTX (OR: 1.88), having a parental history of hip fracture (OR: 1.667), 5-year increase in age (OR: 1.39), and 1 kg/m² increases in BMI (OR: 1.041). In contrast, other factors evaluated decreased this risk, such as maintaining 25(OH)D levels ≥ 30 ng/mL (OR: 0.686) and a T-score ≥ −2.5 (OR: 0.642).
Levels of 25(OH)D ≥ 30 ng/mL and a T-score at the femoral neck ≥ −2.5 are protective factors for FF, while a previous diagnosis of type 2 DM, an elevated CTX, a parental history of hip fracture, an increase of 1 kg/m² in BMI and an increase in age by 5 years would be predisposing to FF.
Cervical and First Thoracic Spine Hounsfield Units Assessment and Relationship to Clinical Outcomes and Cervical Sagittal Parameters in Patients Undergoing Anterior Cervical Spine Surgery
2022, World Neurosurgery
This study had 3 objectives: to compare bone mineral density (BMD) from 3 axial slices, subchondral trabecular bone 2 mm inferior to the cranial endplate, middle of the vertebral body, and subchondral trabecular bone 2 mm superior to the caudal endplate; assess BMD variations and correlations of C1-T1 vertebrae; and correlate BMD with clinical outcomes and cervical sagittal parameters in patients undergoing anterior cervical discectomy and fusion.
The study enrolled 71 patients who underwent anterior cervical discectomy and fusion between March 2017 and January 2020. Patient demographics, clinical outcomes, cervical sagittal parameters, and Hounsfield units (HUs) of C1-T1 vertebrae were recorded. Analysis of variance was performed to compare HUs from the axial slices. Pearson correlation coefficient was performed to calculate the relationship between mean HUs of C1-T1 and to assess correlations of mean HUs with clinical outcomes and cervical sagittal parameters.
There were no significant differences between HUs of 3 axial levels. Mean HUs were highest in the mid-cervical spine (C4). Significant correlations in mean HUs among all measured spinal levels were observed. Age, sex, and body mass index were not related to mean HUs. Visual analog scale, Neck Disability Index, and Patient Health Questionnaire-9 scores were not related to HUs before and after surgery. There were significant correlations among mean HUs of C2-T1 vertebrae, C2-C7 sagittal vertical axis, and cranial tilt. Mean HUs of C4 had the strongest correlation with C2-C7 sagittal vertical axis.
To our knowledge, this is the first study of cranial and caudal subchondral trabecular BMD using HUs and comparing them with the middle of the vertebral body and study of correlations between mean HUs of C1-T1 vertebrae and clinical outcomes and cervical sagittal parameters. Correcting C2-C7 sagittal vertical axis and cranial tilt would improve BMD of C1-T1 vertebrae.

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Position StatementWhich Central Dual X-ray Absorptiometry Skeletal Sites and Regions of Interest Should Be Used to Determine the Diagnosis of Osteoporosis?

Abstract

Bone

Endocr Pract

J Clin Densitom

J Clin Densitom

J Clin Densitom

J Clin Densitom

Appl Radiat Isot

J Clin Densitom

J Clin Densitom

J Clin Densitom

Do we need to change the WHO definition of osteoporosis?

Osteoporos Int

An update on the diagnosis and assessment of osteoporosis with densitometry. Committee of Scientific Advisors, International Osteoporosis Foundation

Osteoporos Int

Guidelines for the use of bone densitometry

DXA remains gold standard for assessing spine and femoral head

Diagn Imaging (San Francisco) Bone Mass

Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report

Osteoporos Int

Position Statement
Which Central Dual X-ray Absorptiometry Skeletal Sites and Regions of Interest Should Be Used to Determine the Diagnosis of Osteoporosis?