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How to Read a DXA Scan

Presentation · September 2020

DOI: 10.13140/RG.2.2.27865.34407

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Ibrahim Alali
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How to Read a DXA Scan

Ibrahim Alali
Master’s Degree in Endocrinology
Damascus University
Outline
• Introduction
• DXA Indications
• Technical issues
• Patient instructions
• Regions of interest
• Reference database
• Diagnosis
• Follow-up
• Vertebral fracture assessment
• DXA report & VFA report
• Body composition
• Examples
• MCQs
Introduction

• DXA provides the unique ability to diagnose disease, assess fracture

risk, and monitor therapy.
• The WHO criteria is applicable only on central DXA
• Other modalities of imaging pDXA, QCT, QpCT, QUS are analogs for
central DXA
• Bone density measurements from different devices cannot be directly
compared.
Indications for Bone Mineral Density (BMD)
Testing

• Women aged 65 and older.

• For post-menopausal women younger than age 65 if they have a risk
factor for low bone mass such as;
• Low body weight
• Prior fracture
• High risk medication use
• Disease or condition associated with bone loss.
• Women during the menopausal transition with clinical risk factors for
fracture.
Indications for Bone Mineral Density (BMD)
Testing

• Men aged 70 and older.

• For men < 70 years age if they have a risk factor for low bone
mass such as;
• Low body weight
• Prior fracture
• High risk medication use
• Disease or condition associated with bone loss.
Indications for Bone Mineral Density (BMD)
Testing

• Adults with a fragility fracture.

• Adults with a disease or condition associated with low bone mass or
bone loss.
• Adults taking medications associated with low bone mass or bone
loss.
• Anyone being considered for pharmacologic therapy.
• Anyone being treated, to monitor treatment effect.
• Women discontinuing estrogen should be considered.
 Bone Mineral Density Patient Instructions

• You can not take this test if you are pregnant.

• Eat a normal diet on the day of the test.
• Take your medications as you normally would.
• DO NOT take calcium supplements for 24 hours before the test.
• The test should be performed prior to oral, rectal, or IV contrast
studies or at least 7 days after any of these studies.
 Skeletal sites for Diagnosis

• Measure BMD at both the PA spine and hip in all patients

• Forearm BMD should be measured under the following
circumstances:
• Hip and/or spine cannot be measured or interpreted.
• Hyperparathyroidism
• Very obese patients (over the weight limit for DXA table)
Skeletal sites for Diagnosis
 Spine Region of Interest

• Use PA L1-L4 for spine BMD measurement

• Use all evaluable vertebrae and only exclude vertebrae that are
affected by local structural change or artifact.
• Use three vertebrae if four cannot be used and two if three cannot be
used
• BMD based diagnostic classification should not be made using a
single vertebra.
• If only one evaluable vertebra remains after excluding other
vertebrae, diagnosis should be based on a different valid skeletal site
 Spine Region of Interest

• Anatomically abnormal vertebrae may be excluded from analysis if:

• They are clearly abnormal and non-assessable within the
resolution of the system
• There is more than a 1.0 T-score difference between the vertebra
in question and adjacent vertebrae
• Inappropriate Area, or BMC
• When vertebrae are excluded, the BMD of the remaining vertebrae is
used to derive the T-score
• The lateral spine should not be used for diagnosis, but may have a
role in monitoring
 Hip Region of Interest

• Use femoral neck, or total proximal femur whichever is lowest.

• BMD may be measured at either hip
• There are insufficient data to determine whether mean T-scores for
bilateral hip BMD can be used for diagnosis
• The mean hip BMD can be used for monitoring, with total hip being
preferred
 Forearm Region of Interest

• Use 33% radius (sometimes called one-third radius) of the non-

dominant forearm for diagnosis.
• Other forearm ROI are not recommended
Forearm Region of Interest
 Reference Database for T-Scores

• Use a uniform Caucasian (non-race adjusted) female

normative database for women/Men of all ethnic groups.
• If local reference data are available they should be used to
calculate only Z-scores but not T-scores.
 Reference Database for Z-Scores

• Z-scores should be population specific where adequate

reference data exist.
• For the purpose of Z-score calculation, the patient’s self-
reported ethnicity should be used.
 BMD Reporting in Postmenopausal
Women and in Men Age 50 and Older

• T-scores are preferred.

• The WHO densitometric classification is applicable
 Central DXA for Diagnosis

• The WHO international reference standard for osteoporosis diagnosis is

a T-score of -2.5 or less at the femoral neck.
• Osteoporosis may be diagnosed in postmenopausal women and in
men age 50 and older if the T-score of the lumbar spine, total hip, or
femoral neck is -2.5 or less.
• Low Bone mass/density may be diagnosed if T-score is between -1 and
-2.5
 BMD Reporting in Females Prior to
Menopause and in Males Younger Than
Age 50

• Z-scores, not T-scores, are preferred. This is particularly important in

children.
• A Z-score of -2.0 or lower is defined as “below the expected range
for age”, and a Z-score above -2.0 is “within the expected range for
age.”
 BMD Reporting in Females Prior to
Menopause and in Males Younger Than
Age 50

• Osteoporosis cannot be diagnosed in men under age 50 on the basis

of BMD alone.
• The WHO diagnostic criteria may be applied to women in the
menopausal transition.
 High BMD! Is There a Limit ?

• Artifacts
• High spine BMD is common, likely reflecting spinal Degenerative
disease, and often not associated with similarly changes in hip and
radius.
• T-score cut-point of +2.5 SD at both spine and hip were utilized
• More imaging studies
 Serial BMD Measurements
• Can be used to determine whether treatment should be started on
untreated patients.
• Can monitor response to therapy by finding an increase or stability of
bone density.
• Can evaluate individuals for non-response by finding loss of bone
density.
• Serial BMD testing can detect loss of bone density, indicating the
need for assessment of treatment adherence, evaluation of
secondary causes of osteoporosis, and re-evaluation of treatment
options
 Serial BMD Measurements

• Intervals between BMD testing should be determined according to

each patient’s clinical status ; typically one year after initiation or
change of therapy is appropriate.
• In conditions associated with rapid bone loss, such as glucocorticoid
therapy, testing more frequently is appropriate.
 Serial BMD Measurements

• T-scores and Z-scores can not be used to define changes in bone

density
• Only BMD should be used for comparing
• The “least significant change” must be determined for each DXA site
and is specific to the machine and the technologist(s)
 Serial BMD Measurements
• LSC is determined by conducting a precision assessment that includes
15 patients scanned 3 times or 30 patients scanned twice with
repositioning between scans
• In the perfect world, the least significant change is 2.8 %, often the
LSC will be between 3 and 5 %.
• Changes in bone mineral density of 3 % or less are not a true change
in BMD
• Using a different machine for a follow-up DXA presents complex
challenges in data interpretation
 Vertebral Fracture Assessment
• The densitometric spine imaging performed for the purpose
of detecting vertebral fractures.
• Indications for VFA
Lateral Spine imaging with Standard Radiography or Densitometric
VFA is indicated when T-score is < -1.0 and of one or more of the
following is present:
1.Women age ≥ 70 years or men ≥ age 80 years
2.Historical height loss > 4 cm (>1.5 inches)
3.Self-reported but undocumented prior vertebral fracture
4.Glucocorticoid therapy equivalent to ≥ 5 mg of prednisone or equivalent
per day for ≥ 3 months
 Methods for Defining and Reporting
Fractures on VFA

• Fracture diagnosis should be based on visual evaluation and include

assessment of grade/severity.
• Morphometry alone is not recommended because it is unreliable for
diagnosis.
• The Genant visual semi-quantitative method is the current clinical
technique of choice for diagnosing vertebral fracture with VFA.
 Methods for Defining and Reporting
Fractures on VFA

• Severity of deformity may be confirmed by morphometric

measurement if desired.
• VFA is designed to detect vertebral fractures and not other
abnormalities.
Vertebral Fracture Assessment
 Trabecular Bone Score (TBS)

• TBS is associated with vertebral, hip and major osteoporotic fracture

risk in postmenopausal women.
• TBS is associated with hip fracture risk and major osteoporotic
fracture risk in men over the age of 50 years.
• TBS should not be used alone to determine treatment
recommendations in clinical practice.
• TBS can be used in association with FRAX and BMD to adjust FRAX-
probability of fracture in postmenopausal women and older men.
 Trabecular Bone Score (TBS)
• In patients receiving anti-fracture therapy:
• The role of TBS in monitoring antiresorptive therapy is unclear.
• TBS is potentially useful for monitoring anabolic therapy.
 Baseline DXA Report: Minimum
Requirements

• Demographics (name, medical record identifying number, date of

birth, sex).
• Requesting provider.
• Indications for the test.
• Manufacturer and model of instrument used
• Technical quality and limitations of the study, stating why a specific
site or ROI is invalid or not included.
 Baseline DXA Report: Minimum
Requirements

• BMD in g/cm2 for each site.

• The skeletal sites, ROI, and, if appropriate, the side, that
were scanned.
• The T-score and/or Z-score where appropriate.
 Baseline DXA Report: Minimum
Requirements
• WHO criteria for diagnosis in postmenopausal females and in
men age 50 and over.
• Risk factors including information regarding previous non-
traumatic fractures.
• A statement about fracture risk.
• A general statement that a medical evaluation for secondary
causes of low BMD may be appropriate.
• Recommendations for the necessity and timing of the next
BMD study
 DXA Report: Optional Items

• Recommendation for further non-BMD testing, such as X-ray,

magnetic resonance imaging, computed tomography, etc.
• Recommendations for pharmacological and non-pharmacological
interventions.
• Specific recommendations for evaluation of secondary osteoporosis.
 Follow-Up DXA Report

• Statement regarding which previous or baseline study and ROI is

being used for comparison.
• Comments on any outside study including manufacturer and model
on which previous studies were performed and the appropriateness
of the comparison.
• Recommendations for the necessity and timing of the next BMD
study.
 DXA Report: Items That Should not be
Included

• A statement that there is bone loss without knowledge of previous

bone density.
• Mention of “mild,” “moderate,” or “marked” osteopenia or
osteoporosis.
• Separate diagnoses for different ROI (e.g., osteopenia at the hip and
osteoporosis at the spine).
 DXA Report: Items That Should not be
Included

• Expressions such as “She has the bones of an 80-year-old,” if the

patient is not 80 years old.
• Results from skeletal sites that are not technically valid.
• The term “osteopenia” is retained, but “low bone mass” or “low bone
density” is preferred
 Components of a VFA Report

• VFA reports should comment on the following

• Unevaluable vertebrae
• Deformed vertebrae, and whether or not the deformities are
consistent with vertebral fracture
• Unexplained vertebral and extra-vertebral pathology
• Optional components include fracture risk and
recommendations for additional studies.
 Body Composition: Indications

• In patients living with HIV to assess fat distribution in those using

anti-retroviral agents associated with a risk of lipoatrophy.
• In patients with muscle weakness or poor physical functioning to
assess fat and lean mass.
• In obese patients undergoing (bariatric surgery, or medical, diet, or
weight loss regimens with anticipated large weight loss) to assess fat
and lean mass changes when weight loss exceeds approximately 10%.
Body Composition
Body Composition
Practical Section
MCQs
 Thanks for listening

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