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==Overview==
==Overview==
The most important [[modality]] for measuring [[Bone mineral density|bone mineral density (BMD)]], on which every osteoporosis diagnostic and [[therapeutic]] decision is based on, is [[Dual energy X-ray absorptiometry|dual energy X-ray absorptiometry (DEXA)]]. [[Dual energy X-ray absorptiometry|DEXA]] is a 2-dimensional image of a 3-dimensional subject, mainly depends on the size of the [[bone]] which is studied. [[Dual energy X-ray absorptiometry|DEXA]] is the gold standard for the diagnosis of [[osteoporosis]] and [[fracture]] risk assessment. Finite element modeling (FEM) is an [[engineering]] computer-based simulation software that typically simulates the physical loading effects on materials. The effects may be strain or compression, while the subject is determined as net-like elements connected to each other. [[Bone mineral density|BMD]] is focused on density and does not imply for microstructure or architecture of [[bones]]. One of the most powerful methods to determine the microstructure is [[trabecular bone]] score (TBS) as a complementary method for [[Dual energy X-ray absorptiometry|DEXA]].


==Other Imaging Findings==
==Other imaging findings==
* According to [[WHO|world health organization (WHO)]], two [[diagnostic]] measures for osteoporosis are bone marrow density (BMD), and bone marrow content (BMC). Both of these measures concluded through dual X-ray absorbtiometry (DXA) method. The cut off point for both BMD and BMC is -2.5 T-score, compared to the normal population.  
{| align="right"
| [[image:Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID 45996.jpg|thumb|300px|Osteopenia with forearm measurement - Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID 45996]]
|- |
| [[image:Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID 45997.jpg|thumb|300px|Osteoporosis - Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID 45997]]
|}
 
=== Dual energy X-ray absorptiometery (DEXA, DXA) ===
 
* The most important [[modality]] for measuring [[Bone mineral density|bone mineral density (BMD)]], on which every [[osteoporosis]] diagnostic and [[therapeutic]] decision is based on, is [[Dual energy X-ray absorptiometry|dual energy X-ray absorptiometry (DEXA)]].<ref name="pmid27048946">{{cite journal |vauthors=Messina C, Monaco CG, Ulivieri FM, Sardanelli F, Sconfienza LM |title=Dual-energy X-ray absorptiometry body composition in patients with secondary osteoporosis |journal=Eur J Radiol |volume=85 |issue=8 |pages=1493–8 |year=2016 |pmid=27048946 |doi=10.1016/j.ejrad.2016.03.018 |url=}}</ref> [[Dual energy X-ray absorptiometry|DEXA]] is a 2-dimensional image of a 3-dimensional subject, mainly dependent on the size of the [[bone]] which is studied; therefore, explaining the variety of [[Bone mineral density|BMD]] seen among different sexes, [[body weight]]s, and also [[Ethnicity and health|ethnicity]].<ref name="pmid9589631">{{cite journal |vauthors=Seeman E |title=Growth in bone mass and size--are racial and gender differences in bone mineral density more apparent than real? |journal=J. Clin. Endocrinol. Metab. |volume=83 |issue=5 |pages=1414–9 |year=1998 |pmid=9589631 |doi=10.1210/jcem.83.5.4844 |url=}}</ref>
* Considering the effect of [[bone]] size on the 2-dimensional image of [[Dual energy X-ray absorptiometry|DEXA]], the measured [[Bone mineral density|BMD]] is not reflecting the exact [[Bone mineral density|BMD]]; however, the [[Dual energy X-ray absorptiometry|DEXA]] [[fracture]] prediction would be better than 3-dimensional images, because small [[bones]] [[Fracture|fracture]] easily than large [[bones]].<ref name="pmid18348697">{{cite journal |vauthors=Black DM, Bouxsein ML, Marshall LM, Cummings SR, Lang TF, Cauley JA, Ensrud KE, Nielson CM, Orwoll ES |title=Proximal femoral structure and the prediction of hip fracture in men: a large prospective study using QCT |journal=J. Bone Miner. Res. |volume=23 |issue=8 |pages=1326–33 |year=2008 |pmid=18348697 |pmc=2680175 |doi=10.1359/jbmr.080316 |url=}}</ref>
* [[Dual energy X-ray absorptiometry|DEXA]] is the choice [[modality]] because of the following factors:
** Short duration of procedure
** High [[validity]] in [[Bone mineral density|BMD]] measurement (accuracy)
** High [[reliability]] in [[Bone mineral density|BMD]] measurement (reproducible)
** High range of application (different [[bone]] sites)<ref name="pmid12377088">{{cite journal |vauthors=Cummings SR, Bates D, Black DM |title=Clinical use of bone densitometry: scientific review |journal=JAMA |volume=288 |issue=15 |pages=1889–97 |year=2002 |pmid=12377088 |doi= |url=}}</ref>
 
* [[Dual energy X-ray absorptiometry|DEXA]] is the best predictor of [[osteoporosis]] and osteoporotic [[fractures]] by means of central [[Bone mineral density|BMD]] surveys.<ref name="pmid21427343">{{cite journal |vauthors=Lorente-Ramos R, Azpeitia-Armán J, Muñoz-Hernández A, García-Gómez JM, Díez-Martínez P, Grande-Bárez M |title=Dual-energy x-ray absorptiometry in the diagnosis of osteoporosis: a practical guide |journal=AJR Am J Roentgenol |volume=196 |issue=4 |pages=897–904 |year=2011 |pmid=21427343 |doi=10.2214/AJR.10.5416 |url=}}</ref>
* For adults, it has to be always two sites of [[Bone mineral density|BMD]] measurement; [[lumbar spine]], and [[Femur neck|femoral neck]]. In case, if both are unavailable for evaluation, [[forearm]] can also be used.<ref name="pmid18442754">{{cite journal |vauthors=Baim S, Binkley N, Bilezikian JP, Kendler DL, Hans DB, Lewiecki EM, Silverman S |title=Official Positions of the International Society for Clinical Densitometry and executive summary of the 2007 ISCD Position Development Conference |journal=J Clin Densitom |volume=11 |issue=1 |pages=75–91 |year=2008 |pmid=18442754 |doi=10.1016/j.jocd.2007.12.007 |url=}}</ref>
* For children (less than 20 years old), [[femoral]] [[Maturity (psychological)|maturity]] level may be different among the population, leading to lack of unique reference measure; thus, just one site of measurement (i.e., [[lumbar spine]]) is considered.<ref name="pmid18442749">{{cite journal |vauthors=Baim S, Leonard MB, Bianchi ML, Hans DB, Kalkwarf HJ, Langman CB, Rauch F |title=Official Positions of the International Society for Clinical Densitometry and executive summary of the 2007 ISCD Pediatric Position Development Conference |journal=J Clin Densitom |volume=11 |issue=1 |pages=6–21 |year=2008 |pmid=18442749 |doi=10.1016/j.jocd.2007.12.002 |url=}}</ref>
* Upon the [[World Health Organization|world health organization (WHO)]] report in 1994, using the T-score ([[Standard deviation|standard deviations (SD)]] below or above the average of young Caucasian women), [[Bone mineral density|BMD]] measures are divided into three groups:
** T-score greater than -1.0 [[Standard deviation|SD]] assumed as normal [[Bone mineral density|BMD]]
** T-score between -1.0 and -2.5 [[Standard deviation|SD]] assumed as [[osteopenia]]
** T-score less than -2.5 [[Standard deviation|SD]] assumed as [[osteoporosis]]<ref name="urlWHO IRIS: Assessment of fracture risk and its application to screening for postmenopausal osteoporosis : report of a WHO study group [meeting held in Rome from 22 to 25 June 1992]">{{cite web |url=http://apps.who.int/iris/handle/10665/39142 |title=WHO IRIS: Assessment of fracture risk and its application to screening for postmenopausal osteoporosis : report of a WHO study group [meeting held in Rome from 22 to 25 June 1992] |format= |work= |accessdate=}}</ref>
 
* [[Z-score]] is the same as the T-score, but the target population is matched for [[age]], sex, [[race]], and also in some studies, for [[weight]].
* [[Dual energy X-ray absorptiometry|DEXA]] in men, almost always show higher [[Bone mineral density|BMD]] levels. But regarding the effect of [[bone]] size on [[Dual energy X-ray absorptiometry|DEXA]] measured [[Bone mineral density|BMD]] levels, it seems that higher [[Bone mineral density|BMD]] levels may be due to larger [[bones]] in men. Surprisingly, after matching the [[Bone mineral density|BMD]] levels, it is concluded that volumetric [[Bone mineral density|BMD]] is even lower in men. However, their [[fracture]] risk is same as women's risk; thus, the women's reference range of [[Bone mineral density|BMD]] is assumed for men, too.<ref name="pmid22057550">{{cite journal |vauthors=Srinivasan B, Kopperdahl DL, Amin S, Atkinson EJ, Camp J, Robb RA, Riggs BL, Orwoll ES, Melton LJ, Keaveny TM, Khosla S |title=Relationship of femoral neck areal bone mineral density to volumetric bone mineral density, bone size, and femoral strength in men and women |journal=Osteoporos Int |volume=23 |issue=1 |pages=155–62 |year=2012 |pmid=22057550 |pmc=3640410 |doi=10.1007/s00198-011-1822-8 |url=}}</ref>
* Regarding the vast advantages of [[Dual energy X-ray absorptiometry|DEXA]] (low [[radiation exposure]], high availability, and tremendous information related to [[fracture]] risk), it seems that [[Dual energy X-ray absorptiometry|DEXA]] will remain the masterpiece of [[fracture]] risk assessment and also [[osteoporosis]] diagnosis.<ref name="pmid28716497">{{cite journal |vauthors=Jain RK, Vokes T |title=Dual-energy X-ray Absorptiometry |journal=J Clin Densitom |volume= |issue= |pages= |year=2017 |pmid=28716497 |doi=10.1016/j.jocd.2017.06.014 |url=}}</ref>
 
=== Indications for BMD testing ===
* Women of age 65 and older and men of age 70 and older, regardless of clinical risk factors.
* Younger [[postmenopausal]] women, women in the [[menopausal]] transition, and men of age 50 to 69 with clinical risk factors for [[fracture]].
* Adults who have a [[fracture]] at or after age 50.
* Adults with any condition that can increase the risk for osteoporosis (e.g., [[rheumatoid arthritis]]) or taking a [[medication]] (e.g., [[glucocorticoids]] in a daily dose ≥5 mg [[prednisone]] or equivalent for ≥3 months) associated with low [[bone mass]] or [[bone loss]]<ref name="pmid25182228">{{cite journal| author=Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S et al.| title=Clinician's Guide to Prevention and Treatment of Osteoporosis. | journal=Osteoporos Int | year= 2014 | volume= 25 | issue= 10 | pages= 2359-81 | pmid=25182228 | doi=10.1007/s00198-014-2794-2 | pmc=4176573 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25182228  }}</ref>
 
=== BMD in children and adolescent ===
* The preferred skeletal sites for [[DXA]] measurements in children are [[lumbar spine]] (L1–4) and total body, excluding the [[head]]. The [[cranium]] should be excluded from the total body scan analysis because the head constitutes a large portion of the total body bone mass but changes little with growth, activity, or disease; thus, the inclusion of the [[skull]] may potentially mask gains or losses at other skeletal sites.
 
* For children younger than 5 years old, the [[spine]] bone mineral content (BMC) and [[Bone mineral density|BMD]] can be measured; whole-body measurements are feasible only for those aged 3 years or older. [[DXA]] measurements of the [[hip]] region (total [[hip]] or [[femoral neck]]) are not as reliable in younger patients (<13 years) because of difficulties in identifying the bony landmarks for this region of interest.
* Scans of alternative regions of interest are recommended in special cases. [[DXA]] assessments of the lateral distal [[femur]] can be valuable in children with immobilization disorders and in those with [[contractures]] who cannot be positioned properly for [[spine]] or whole-body studies. The distal [[radius]] can be measured in patients who exceed the weight limit for the [[DXA]] table or those who cannot transfer onto the table because of a mobilization disorder. Scanning of these alternate skeletal sites also may be necessary for patients with metal hardware (eg, rodding for [[scoliosis]]) in the standard regions of interest.
* A [[vertebral fracture]] that occurs without major trauma is an important indication of abnormal bone fragility. Because these fractures can be asymptomatic, some type of imaging is needed to rule out [[vertebral fractures]] in patients with high risks, such as those receiving long-term [[glucocorticoid]] therapy. In the past, a lateral thoracolumbar radiograph has been used to assess for loss of [[vertebral]] height. Alternatively, [[vertebral fracture]] analysis (VFA) by [[DXA]] has been used with far less radiation than conventional radiography.<ref name="BachrachGordon2016">{{cite journal|last1=Bachrach|first1=L. K.|last2=Gordon|first2=C. M.|title=Bone Densitometry in Children and Adolescents|journal=PEDIATRICS|volume=138|issue=4|year=2016|pages=e20162398–e20162398|issn=0031-4005|doi=10.1542/peds.2016-2398}}</ref>
 
=== Finite element modeling (FEM) ===
* Finite element modeling (FEM) is basically an [[engineering]] computer-based simulation software. FEM typically simulates the physical loading effects on materials. The effects may be strain or compression, while the subject determined as net-like elements connected to each other.
* Currently, basic models for FEM is provided by vQCT scanners. Then, [[Elastic properties of the elements (data page)|elastic properties]] of [[bone]] can be measured with [[Bone mineral density|bone mineral density (BMD)]]. Finally, all of the [[anisotropic]], non-homogeneous, and complex [[geometry]] of the [[bone]] is presented to determine the risk of [[fracture]].
* Studies have shown that however [[Osteoporosis|osteoporotic]] [[vertebrae]] are capable of bearing daily stresses as same as normal [[bones]], but the stress that is encountered by the [[Osteoporosis|osteoporotic]] [[bone]] during forward bending may be more severe.<ref name="pmid18556648">{{cite journal |vauthors=Genant HK, Engelke K, Prevrhal S |title=Advanced CT bone imaging in osteoporosis |journal=Rheumatology (Oxford) |volume=47 Suppl 4 |issue= |pages=iv9–16 |year=2008 |pmid=18556648 |pmc=2427166 |doi=10.1093/rheumatology/ken180 |url=}}</ref>
 
=== Trabecular bone score (TBS) ===
* [[Bone fracture|Fracture]] risk assessment is very important in [[osteoporosis]]. It is based on a couple of factors, including [[age]], [[body weight]], and some past medical histories (e.g., [[smoking]] or [[Alcohol abuse|alcohol use]]); and is measured by means of [[Bone mineral density|BMD]] assessment through [[Dual energy X-ray absorptiometry|DEXA]] scans. 
* The main limitation of using [[Bone mineral density|BMD]] as the identifier of [[osteoporosis]] is that the [[Bone mineral density|BMD]] is focused on density and does not imply for microstructure or architecture of [[bones]], at all. One of the most powerful methods to determine the microstructure is the [[trabecular bone]] score (TBS) as a complementary method for [[Dual energy X-ray absorptiometry|DEXA]].
* TBS is a texture identifier of [[bones]], measured and extracted from [[Dual energy X-ray absorptiometry|DEXA]] scan findings. TBS findings are including:
** Elevated levels of TBS reflect the better microstructure of [[bones]].
** Reduced levels of TBS is associated with higher risk of [[Bone fracture|fracture]]. 
* The literature supports the use of TBS along with [[Bone mineral density|BMD]] to predict the [[fracture]] risk more precisely.<ref name="pmid28734710">{{cite journal |vauthors=Shevroja E, Lamy O, Kohlmeier L, Koromani F, Rivadeneira F, Hans D |title=Use of Trabecular Bone Score (TBS) as a Complementary Approach to Dual-energy X-ray Absorptiometry (DXA) for Fracture Risk Assessment in Clinical Practice |journal=J Clin Densitom |volume= |issue= |pages= |year=2017 |pmid=28734710 |doi=10.1016/j.jocd.2017.06.019 |url=}}</ref>
* The major characteristics of TBS are as follow:
** TBS is reduced in [[postmenopausal]] women
** TBS is reduced in men with previous [[Osteoporosis|osteoporotic]] [[Bone fracture|fractures]]
** TBS is complimentary for [[lumbar spine]] [[Dual energy X-ray absorptiometry|DEXA]]
** TBS is reduced in women who experienced [[Osteoporosis|osteoporotic]] [[Bone fracture|fractures]] (in whom [[Dual energy X-ray absorptiometry|DEXA]] was normal)
** TBS is the same as [[lumbar spine]] [[Bone mineral density|BMD]] in predicting [[fracture]] risk in [[postmenopausal]] women
** TBS is associated with [[fractures]] induced by [[bone]] mass loss<ref name="pmid24443324">{{cite journal |vauthors=Silva BC, Leslie WD, Resch H, Lamy O, Lesnyak O, Binkley N, McCloskey EV, Kanis JA, Bilezikian JP |title=Trabecular bone score: a noninvasive analytical method based upon the DXA image |journal=J. Bone Miner. Res. |volume=29 |issue=3 |pages=518–30 |year=2014 |pmid=24443324 |doi=10.1002/jbmr.2176 |url=}}</ref>


==References==
==References==
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

The most important modality for measuring bone mineral density (BMD), on which every osteoporosis diagnostic and therapeutic decision is based on, is dual energy X-ray absorptiometry (DEXA). DEXA is a 2-dimensional image of a 3-dimensional subject, mainly depends on the size of the bone which is studied. DEXA is the gold standard for the diagnosis of osteoporosis and fracture risk assessment. Finite element modeling (FEM) is an engineering computer-based simulation software that typically simulates the physical loading effects on materials. The effects may be strain or compression, while the subject is determined as net-like elements connected to each other. BMD is focused on density and does not imply for microstructure or architecture of bones. One of the most powerful methods to determine the microstructure is trabecular bone score (TBS) as a complementary method for DEXA.

Other imaging findings

Osteopenia with forearm measurement - Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID 45996
Osteoporosis - Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID 45997

Dual energy X-ray absorptiometery (DEXA, DXA)

  • Z-score is the same as the T-score, but the target population is matched for age, sex, race, and also in some studies, for weight.
  • DEXA in men, almost always show higher BMD levels. But regarding the effect of bone size on DEXA measured BMD levels, it seems that higher BMD levels may be due to larger bones in men. Surprisingly, after matching the BMD levels, it is concluded that volumetric BMD is even lower in men. However, their fracture risk is same as women's risk; thus, the women's reference range of BMD is assumed for men, too.[9]
  • Regarding the vast advantages of DEXA (low radiation exposure, high availability, and tremendous information related to fracture risk), it seems that DEXA will remain the masterpiece of fracture risk assessment and also osteoporosis diagnosis.[10]

Indications for BMD testing

BMD in children and adolescent

  • The preferred skeletal sites for DXA measurements in children are lumbar spine (L1–4) and total body, excluding the head. The cranium should be excluded from the total body scan analysis because the head constitutes a large portion of the total body bone mass but changes little with growth, activity, or disease; thus, the inclusion of the skull may potentially mask gains or losses at other skeletal sites.
  • For children younger than 5 years old, the spine bone mineral content (BMC) and BMD can be measured; whole-body measurements are feasible only for those aged 3 years or older. DXA measurements of the hip region (total hip or femoral neck) are not as reliable in younger patients (<13 years) because of difficulties in identifying the bony landmarks for this region of interest.
  • Scans of alternative regions of interest are recommended in special cases. DXA assessments of the lateral distal femur can be valuable in children with immobilization disorders and in those with contractures who cannot be positioned properly for spine or whole-body studies. The distal radius can be measured in patients who exceed the weight limit for the DXA table or those who cannot transfer onto the table because of a mobilization disorder. Scanning of these alternate skeletal sites also may be necessary for patients with metal hardware (eg, rodding for scoliosis) in the standard regions of interest.
  • A vertebral fracture that occurs without major trauma is an important indication of abnormal bone fragility. Because these fractures can be asymptomatic, some type of imaging is needed to rule out vertebral fractures in patients with high risks, such as those receiving long-term glucocorticoid therapy. In the past, a lateral thoracolumbar radiograph has been used to assess for loss of vertebral height. Alternatively, vertebral fracture analysis (VFA) by DXA has been used with far less radiation than conventional radiography.[12]

Finite element modeling (FEM)

  • Finite element modeling (FEM) is basically an engineering computer-based simulation software. FEM typically simulates the physical loading effects on materials. The effects may be strain or compression, while the subject determined as net-like elements connected to each other.
  • Currently, basic models for FEM is provided by vQCT scanners. Then, elastic properties of bone can be measured with bone mineral density (BMD). Finally, all of the anisotropic, non-homogeneous, and complex geometry of the bone is presented to determine the risk of fracture.
  • Studies have shown that however osteoporotic vertebrae are capable of bearing daily stresses as same as normal bones, but the stress that is encountered by the osteoporotic bone during forward bending may be more severe.[13]

Trabecular bone score (TBS)

  • Fracture risk assessment is very important in osteoporosis. It is based on a couple of factors, including age, body weight, and some past medical histories (e.g., smoking or alcohol use); and is measured by means of BMD assessment through DEXA scans.
  • The main limitation of using BMD as the identifier of osteoporosis is that the BMD is focused on density and does not imply for microstructure or architecture of bones, at all. One of the most powerful methods to determine the microstructure is the trabecular bone score (TBS) as a complementary method for DEXA.
  • TBS is a texture identifier of bones, measured and extracted from DEXA scan findings. TBS findings are including:
    • Elevated levels of TBS reflect the better microstructure of bones.
    • Reduced levels of TBS is associated with higher risk of fracture.
  • The literature supports the use of TBS along with BMD to predict the fracture risk more precisely.[14]
  • The major characteristics of TBS are as follow:

References

  1. ↑ Messina C, Monaco CG, Ulivieri FM, Sardanelli F, Sconfienza LM (2016). "Dual-energy X-ray absorptiometry body composition in patients with secondary osteoporosis". Eur J Radiol. 85 (8): 1493–8. doi:10.1016/j.ejrad.2016.03.018. PMID 27048946.
  2. ↑ Seeman E (1998). "Growth in bone mass and size--are racial and gender differences in bone mineral density more apparent than real?". J. Clin. Endocrinol. Metab. 83 (5): 1414–9. doi:10.1210/jcem.83.5.4844. PMID 9589631.
  3. ↑ Black DM, Bouxsein ML, Marshall LM, Cummings SR, Lang TF, Cauley JA, Ensrud KE, Nielson CM, Orwoll ES (2008). "Proximal femoral structure and the prediction of hip fracture in men: a large prospective study using QCT". J. Bone Miner. Res. 23 (8): 1326–33. doi:10.1359/jbmr.080316. PMC 2680175. PMID 18348697.
  4. ↑ Cummings SR, Bates D, Black DM (2002). "Clinical use of bone densitometry: scientific review". JAMA. 288 (15): 1889–97. PMID 12377088.
  5. ↑ Lorente-Ramos R, Azpeitia-Armán J, Muñoz-Hernández A, García-Gómez JM, Díez-Martínez P, Grande-Bárez M (2011). "Dual-energy x-ray absorptiometry in the diagnosis of osteoporosis: a practical guide". AJR Am J Roentgenol. 196 (4): 897–904. doi:10.2214/AJR.10.5416. PMID 21427343.
  6. ↑ Baim S, Binkley N, Bilezikian JP, Kendler DL, Hans DB, Lewiecki EM, Silverman S (2008). "Official Positions of the International Society for Clinical Densitometry and executive summary of the 2007 ISCD Position Development Conference". J Clin Densitom. 11 (1): 75–91. doi:10.1016/j.jocd.2007.12.007. PMID 18442754.
  7. ↑ Baim S, Leonard MB, Bianchi ML, Hans DB, Kalkwarf HJ, Langman CB, Rauch F (2008). "Official Positions of the International Society for Clinical Densitometry and executive summary of the 2007 ISCD Pediatric Position Development Conference". J Clin Densitom. 11 (1): 6–21. doi:10.1016/j.jocd.2007.12.002. PMID 18442749.
  8. ↑ "WHO IRIS: Assessment of fracture risk and its application to screening for postmenopausal osteoporosis : report of a WHO study group [meeting held in Rome from 22 to 25 June 1992]".
  9. ↑ Srinivasan B, Kopperdahl DL, Amin S, Atkinson EJ, Camp J, Robb RA, Riggs BL, Orwoll ES, Melton LJ, Keaveny TM, Khosla S (2012). "Relationship of femoral neck areal bone mineral density to volumetric bone mineral density, bone size, and femoral strength in men and women". Osteoporos Int. 23 (1): 155–62. doi:10.1007/s00198-011-1822-8. PMC 3640410. PMID 22057550.
  10. ↑ Jain RK, Vokes T (2017). "Dual-energy X-ray Absorptiometry". J Clin Densitom. doi:10.1016/j.jocd.2017.06.014. PMID 28716497.
  11. ↑ Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S; et al. (2014). "Clinician's Guide to Prevention and Treatment of Osteoporosis". Osteoporos Int. 25 (10): 2359–81. doi:10.1007/s00198-014-2794-2. PMC 4176573. PMID 25182228.
  12. ↑ Bachrach, L. K.; Gordon, C. M. (2016). "Bone Densitometry in Children and Adolescents". PEDIATRICS. 138 (4): e20162398–e20162398. doi:10.1542/peds.2016-2398. ISSN 0031-4005.
  13. ↑ Genant HK, Engelke K, Prevrhal S (2008). "Advanced CT bone imaging in osteoporosis". Rheumatology (Oxford). 47 Suppl 4: iv9–16. doi:10.1093/rheumatology/ken180. PMC 2427166. PMID 18556648.
  14. ↑ Shevroja E, Lamy O, Kohlmeier L, Koromani F, Rivadeneira F, Hans D (2017). "Use of Trabecular Bone Score (TBS) as a Complementary Approach to Dual-energy X-ray Absorptiometry (DXA) for Fracture Risk Assessment in Clinical Practice". J Clin Densitom. doi:10.1016/j.jocd.2017.06.019. PMID 28734710.
  15. ↑ Silva BC, Leslie WD, Resch H, Lamy O, Lesnyak O, Binkley N, McCloskey EV, Kanis JA, Bilezikian JP (2014). "Trabecular bone score: a noninvasive analytical method based upon the DXA image". J. Bone Miner. Res. 29 (3): 518–30. doi:10.1002/jbmr.2176. PMID 24443324.

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