Osteoporosis X-ray

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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

An X-ray may be helpful in the diagnosis of osteoporosis. The main X-ray finding suggestive of osteoporosis is the bone mass loss. Primarily, the loss is mainly in bony trabecula, than the bone loss involves cortical thickness. The most common bones monitored for osteoporosis are the femoral neck, lumbar vertebrae, and calcaneus. Plain radiography needs at least 30-50% of the bone loss to demonstrate decreased bone density; therefore, it is not a very sensitive modality.

An X-ray may be helpful in the diagnosis of osteoporosis. The main finding on x-ray suggestive of osteoporosis is the bone mass loss, identified with decreased bony trabecula in primary stages and then decreased cortical thickness. The most common bones monitored for osteoporosis are the femoral neck, lumbar vertebrae, and calcaneus. Plain radiography needs at least 30-50% of the bone loss to demonstrate decreased bone density; therefore, it is not a very sensitive modality.

Consider vertebral imaging tests for the following individuals:

All women age 70 and older and all men age 80 and older if BMD T-score at the spine, total hip, or femoral neck is ≤−1.0
Women age 65 to 69 and men age 70 to 79 if BMD T-score at the spine, total hip, or femoral neck is ≤−1.5
Postmenopausal women and men age 50 and older with specific risk factors include:
- Low-trauma fractures during adulthood (age 50 and older)
- Historical height loss of 1.5 in or more (4 cm)
- Prospective height loss of 0.8 in or more (2 cm)
- Recent or ongoing long-term glucocorticoid treatment^[2]
X-rays of children with idiopathic juvenile osteoporosis (IJO) often show low bone density, fractures of weight-bearing bones, and collapsed or misshapen vertebrae. However, conventional X-rays may not be able to detect osteoporosis until significant bone mass already has been lost. Newer methods such as dual energy x-ray absorptiometry (DXA), and quantitative computed tomography (QCT) allow for earlier and more accurate diagnosis of low bone mass.^[3]

The major findings correlated to osteoporosis in lumbar vertebrae include:
- Wedge shape of vertebrae (decreasing anterior aspect of the body)
- Picture frame vertebrae (decreased cortical bone in periphery)
- Ghost vertebrae (decreased trabecular bone in the body)
- Vertebra plana (severe compression fracture)^[4]

Singh's index: Categorization of femoral neck bone mineral density upon the visual scale of the trabecular bone existence on x-ray.
The Singh's categories include:
- Grade 1: Thin principle compression trabeculae
- Grade 2: Principle compression trabeculae
- Grade 3: Thin principle tensile trabeculae, with discontinuity
- Grade 4: Thin principle tensile trabeculae, with continuity
- Grade 5: Thin principle tensile and compression trabeculae
- Grade 6: Normal appearance
Reduced density of trabecular bone in the area, which is described by means of Singh's index (grades 3, 2, and 1), could reflect the diagnosis of osteoporosis^[5]

Osteoporosis in these bones, especially metacarpals and metatarsals, appeared as loss of cortical thickness. However, cortical thickness of less than 25% of entire bone demonstrates osteoporosis.^[4]

$Pathological fracture in T12 and L1 (saggital view) - Case courtesy of Dr Roberto Schubert, Via: Radiopaedia.org[6]$

Pathological fracture in T12 and L1 (saggital view) - Case courtesy of Dr Roberto Schubert, Via: Radiopaedia.org^[6]
$Pathological fracture in T12 and L1 (axial view) - Case courtesy of Dr Roberto Schubert, Via: Radiopaedia.org[7]$

Pathological fracture in T12 and L1 (axial view) - Case courtesy of Dr Roberto Schubert, Via: Radiopaedia.org^[7]
Dowager's hump - Case courtesy of Dr Roberto Schubert, Via: Radiopaedia.org^[8]
Idiopathic transient osteoporosis of the hip- Case courtesy of Dr Ahmed Abd Rabou, Via: Radiopaedia.org^[9]
Juvenile osteoporosis in osteogenesis imperfecta, Via: Radiopaedia.org^[10]