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(A) An 88-year-old woman with fracture of the L2 vertebral body (arrow) demonstrates diffusely decreased BMD with exception of the level of the compression fracture. (B) A patient with avascular necrosis of the left femoral head (arrow). The femoral head appears dense and is associated with flattening and deformity. (C) DEXA image in a patient status post vertebroplasty of L2 and L3 with introduction of radiopaque cement preparation (arrows).
Source publication
Bone mineral densitometry (BMD) using dual-energy x-ray absorptiometry (DEXA) has been widely adopted as the standard method of assessing bone density. Although not intended to be a primary imaging modality, the technique generates attenuation map images that are used to guide region-of-interest placement. Artifacts and incidental findings are freq...
Contexts in source publication
Context 1
... 43 Fractures do not change the amount of calcification present within vertebrae; however, loss of height leads to a relative concentration of bone resulting in an absolute increase in the areal bone density. Vertebral fractures are easily recognized on DEXA images owing to the loss of vertebral body height coupled with a sclerotic appearance 2 ( Fig. 2A). In a similar manner, condensation of the bone in avascular necrosis results in deformity and increased density (Fig. 2B). Treatment of vertebral fractures by vertebroplasty will also increase the measured BMD, owing to density of the polymethylmethacry- late cement preparation, which has purposefully been rendered radiopaque 44,45 ...
Context 2
... concentration of bone resulting in an absolute increase in the areal bone density. Vertebral fractures are easily recognized on DEXA images owing to the loss of vertebral body height coupled with a sclerotic appearance 2 ( Fig. 2A). In a similar manner, condensation of the bone in avascular necrosis results in deformity and increased density (Fig. 2B). Treatment of vertebral fractures by vertebroplasty will also increase the measured BMD, owing to density of the polymethylmethacry- late cement preparation, which has purposefully been rendered radiopaque 44,45 (Fig. 2C). A study using single photon absorptiometry demonstrated that following wrist fracture, BMD of the forearm is ...
Context 3
... 2 ( Fig. 2A). In a similar manner, condensation of the bone in avascular necrosis results in deformity and increased density (Fig. 2B). Treatment of vertebral fractures by vertebroplasty will also increase the measured BMD, owing to density of the polymethylmethacry- late cement preparation, which has purposefully been rendered radiopaque 44,45 (Fig. 2C). A study using single photon absorptiometry demonstrated that following wrist fracture, BMD of the forearm is initially decreased but ultimately becomes persistently increased by 10 years after fracture. 46 Sclerotic osseous metastases, not uncommon in the age group being studied by DEXA, can cause increased BMD; prostate cancer in men ...
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Uremic leontiasis ossea is a very rare manifestation of renal osteodystrophy with associated secondary or tertiary hyperparathyroidism, resulting in a diffuse and symmetrical enlargement of the craniofacial bones. Although its pathophysiology remains uncertain, it seems that hyperphosphatemia and hypocalcemia secondary to chronic renal failure are...
Background: Hemodialysis patients with chronic kidney disease have low glomerular filtration rates, and hyperphosphatemia develops due to difficulty reducing the phosphate load. Hyperphosphatemia can cause renal osteodystrophy, cardiovascular calcification, and secondary hyperparathyroidism.
Methods: This is a descriptive research study designed to...
Bone and mineral metabolism
disorders are common in patients with chronic kidney disease (CKD).
These patients are susceptible to fractures. Bilateral femoral neck
fracture secondary to renal osteodystrophy is a rare complication. We
report a case of CKD with bilateral spontaneous femoral neck fracture
associated with secondary hyperparathyroidism...
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Citations
... In cases where spine imaging is not assessable, the ultradistal radius may be useful to evaluate trabecular bone, and BMD at the distal onethird radius may be particularly interesting in CKD, as it informs on cortical bone. For the lumbar spine, well-known sources of bias include deformities in the form of vertebral fractures, scoliosis, or degenerative and sclerotic bone disease [97 ]. Specifically to CKD, peritoneal dialysate [98 ] and mineral-containing phosphate binders within the gastrointestinal tract [99 ] may interfere with imaging. ...
Patients with chronic kidney disease (CKD) experience a several-fold increased risk of fracture. Despite the high incidence and the associated excess morbidity and premature mortality, bone fragility in CKD, or CKD-associated osteoporosis, remains a blind spot in nephrology with an immense treatment gap. Defining the bone phenotype is a prerequisite for the appropriate therapy of CKD-associated osteoporosis at the patient level. In the present review, we suggest ten practical ‘tips and tricks’ for the assessment of bone health in patients with CKD. We describe the clinical, biochemical, and radiological evaluation of bone health, alongside the benefits and limitations of the available diagnostics. A bone biopsy, although the gold standard for diagnosing renal bone disease, is invasive and not widely available; though useful in complex cases, we do not consider it an essential component of bone assessment in patients with CKD-associated osteoporosis. Furthermore, we advocate for the deployment of multi-disciplinary expert teams at local, national, and potentially international level. Finally, we address the knowledge gap in the diagnosis, particularly early detection, appropriate ‘real-time’ monitoring of bone health in this highly vulnerable population, and emerging diagnostic tools, currently primarily used in research, that may be on the horizon of clinical practice.
... DXA is the established standard for assessing BMD [91]. However, its diagnostic sensitivity can be compromised by internal artifacts [92,93]. DXA provides a two-dimensional anteroposterior projection of the lumbar spine; hence, areal BMD measurements may be affected by structural irregularities, such as osteophytes and compression fracture-associated vertebral deformities [94]. ...
The increased incidence of osteoarthritis (OA), particularly knee and hip OA, and osteoporosis (OP), owing to population aging, have escalated the medical expense burden. Osteoarthritis is more prevalent in older women, and the involvement of subchondral bone fragility spotlights its association with OP. Notably, subchondral insufficiency fracture (SIF) may represent a more pronounced condition of OA pathophysiology. This review summarizes the relationship between OA and OP, incorporating recent insights into SIF. Progressive SIF leads to joint collapse and secondary OA and is associated with OP. Furthermore, the thinning and fragility of subchondral bone in early-stage OA suggest that SIF may be a subtype of OA (osteoporosis-related OA, OPOA) characterized by significant subchondral bone damage. The high bone mineral density observed in OA may be overestimated due to osteophytes and sclerosis and can potentially contribute to OPOA. The incidence of OPOA is expected to increase along with population aging. Therefore, prioritizing OP screening, early interventions for patients with early-stage OA, and fracture prevention measures such as rehabilitation, fracture liaison services, nutritional management, and medication guidance are essential.
... In particular, Masud et al. reported that the presence of even mild osteophytosis produced an average 24% increase in lumbar spine bone mineral density [6]. In fact, in the context of the spine, osteoarthritis manifestations include disc space narrowing, facet joint arthropathy, end-plate osteophytosis, and vertebral plate sclerosis that can create challenges for accurate BMD measurements by DXA [8][9][10]. To address this issue, there has been a suggestion to measure lumbar spine BMD from the lateral view of DXA, thereby avoiding the projection of inter-apophyseal joints. ...
Background: Osteoarthritis (OA) in the lumbar spine can potentially lead to an overestimation of bone mineral density (BMD), and this can be a challenge in accurately diagnosing conditions like osteoporosis, where precise measurement of BMD is crucial. Radiofrequency Echographic Multi Spectrometry (REMS) is being recognized as an innovative diagnostic tool for assessing bone status. The purpose of this study was to evaluate whether the use of REMS may enhance the identification of osteoporosis in patients with osteoarthritis. Methods: A cohort of 500 patients (mean age: 63.9 ± 11.2 years) diagnosed with osteoarthritis and having a medical prescription for dual-energy X-ray absorptiometry (DXA) were recruited for the study. All patients underwent BMD measurements at lumbar spine and femoral sites by both DXA and REMS techniques. Results: The T-score values for BMD at the lumbar spine (BMD-LS) by DXA were significantly higher with respect to BMD-LS by REMS across all OA severity scores, and the differences were more pronounced in patients with a higher degree of OA severity (p < 0.001). Furthermore, the percentage of subjects classified as “osteoporotic”, on the basis of BMD by REMS was markedly higher than those classified by DXA, both when considering all skeletal sites (39.4% vs. 15.1%, respectively) and the lumbar spine alone (30.5% vs. 6.0%, respectively). A similar pattern was observed when OA patients were grouped according to the Kellgren–Lawrence grading score. Conclusions: The findings from our study indicate that, in a population with varying severity levels of osteoarthritis, REMS demonstrated a higher capability to diagnose osteoporosis compared to DXA, and this could lead to earlier intervention and improved outcomes for patients with bone fragility, reducing the likelihood of fractures and associated complications.
... The established gold standard for determining the risk of fragility fractures is the assessment of BMD through dual-energy X-ray absorptiometry (DXA) [7]. However, it has been shown that the diagnostic sensitivity of DXA can be undermined by internal artifacts [8,9]. Given that DXA provides a two-dimensional anteroposterior projection of the lumbar spine, the areal BMD measurements may be influenced by structural abnormalities, such as osteophytes and vertebral deformities, often resulting from vertebral compression fractures [10]. ...
Purpose
This study measured bone mineral density (BMD) in a Japanese population using the novel non-ionizing system using radiofrequency echographic multispectrometry (REMS) and compared the results with those obtained using traditional dual-energy X-ray absorptiometry (DXA). We aimed to identify any discrepancies between measurements obtained using these instruments and identify the influencing factors.
Methods
This cross-sectional study examined patients with osteoporosis treated at a single center from April to August 2023. We examined BMD assessment by DXA and REMS in lumbar spine and proximal femur. Patients were categorized into two groups: those with discrepancies between lumbar spine BMD measured by DXA and REMS, and those without. Semiquantitative evaluation of vertebral fractures and abdominal aortic calcification scoring were also performed and compared between the two groups, along with various patient characteristics.
Results
A total of 70 patients (88.6% female; mean age 78.39 ± 9.50 years) undergoing osteoporosis treatment were included in the study. A significant difference was noted between DXA and REMS measurement of BMD and T-scores, with REMS recording consistently lower values. The discrepancy group exhibited a higher incidence of multiple vertebral fractures and increased vascular calcification than the non-discrepancy group. Multivariate analysis indicated that diabetes mellitus, severe vertebral fractures, and increased abdominal aortic calcification scores were significantly associated with discrepancies in lumbar spine T-scores.
Conclusion
This study suggests that REMS may offer a more accurate measurement of BMD, overcoming the overestimation of BMD by DXA owing to factors such as vertebral deformities, abdominal aortic calcification, and diabetes mellitus.
... flipping of the image, random rotation, zooming, warping, light, and contrast change. This data augmentation was performed to improve the model's ability to generalize in its predictions relative to variation in contrast and other image artifacts common to DXA scanning 39 . ...
Electronic health records are often incomplete, reducing the power of genetic association studies. For some diseases, such as knee osteoarthritis where the routine course of diagnosis involves an X-ray, image-based phenotyping offers an alternate and unbiased way to ascertain disease cases. We investigated this by training a deep-learning model to ascertain knee osteoarthritis cases from knee DXA scans that achieved clinician-level performance. Using our model, we identified 1931 (178%) more cases than currently diagnosed in the health record. Individuals diagnosed as cases by our model had higher rates of self-reported knee pain, for longer durations and with increased severity compared to control individuals. We trained another deep-learning model to measure the knee joint space width, a quantitative phenotype linked to knee osteoarthritis severity. In performing genetic association analysis, we found that use of a quantitative measure improved the number of genome-wide significant loci we discovered by an order of magnitude compared with our binary model of cases and controls despite the two phenotypes being highly genetically correlated. In addition we discovered associations between our quantitative measure of knee osteoarthritis and increased risk of adult fractures- a leading cause of injury-related death in older individuals-, illustrating the capability of image-based phenotyping to reveal epidemiological associations not captured in the electronic health record. For diseases with radiographic diagnosis, our results demonstrate the potential for using deep learning to phenotype at biobank scale, improving power for both genetic and epidemiological association analysis.
... Unfortunately, DXA has certain limitations; a 2015 study determined that 90% of DXA exams experienced errors (including errors while setting the location information for the patient, during patient positioning, and errors occurring during the analysis) [3]. Moreover, some artifacts can alter DXA results; for example, aortic calcification can lead to an overestimation of bone mineral density [4]; vertebroplasty, especially when involving two or more lumbar vertebrae, limits the ability to obtain an adequate assessment of BMD using DXA [5]; and osteoarthritis (OA), which represents the most common cause of artifacts when using DXA, especially in older patients [6]. In fact, the presence of structural abnormalities caused by OA (sclerosis, osteophytosis) artificially increases BMD measurements for the lumbar spine when using DXA [6]. ...
Osteoporosis is a frequently occurring skeletal disease, and osteoporosis-related fractures represent a significant burden for healthcare systems. Dual-Energy X-ray Absorptiometry (DXA) is the most commonly used method for assessing bone mineral density (BMD). Today, particular attention is being directed towards new technologies, especially those that do not use radiation, for the early diagnosis of altered bone status. Radiofrequency Echographic Multi Spectrometry (REMS) is a non-ionizing technology that evaluates the bone status at axial skeletal sites by analyzing raw ultrasound signals. In this review, we evaluated the data on the REMS technique present in the literature. The literature data confirmed diagnostic concordance between BMD values obtained using DXA and REMS. Furthermore, REMS has adequate precision and repeatability characteristics, is able to predict the risk of fragility fractures, and may be able to overcome some of the limitations of DXA. In conclusion, REMS could become the method of choice for the assessment of bone status in children, in women of childbearing age or who are pregnant, and in several secondary osteoporosis conditions due to its good precision and replicability, its transportability, and the absence of ionizing radiation. Finally, REMS may allow qualitative and not just quantitative assessments of bone status.
... It should not be performed in pregnant women due to radiation exposure. Poor patient positioning or the presence of artifacts (e.g., surgical hardware, laminectomy, vertebral augmentation, degenerative changes) may falsely increase or decrease the BMD [56][57][58][59][60]. The hip BMD can be altered by improper hip positioning, extrinsic artifacts, avascular necrosis, metastases, and primary bone lesions. ...
Osteoporosis (OP) is a major global health concern, with aging being one of the most important risk factors. Osteoarthritis (OA) is also an age-related disorder. Patients with OP and/or OA may be treated surgically for fractures or when their quality of life is impaired. Poor bone quality due to OP can seriously complicate the stability of a bone fixation construct and/or surgical fracture treatment. This review summarizes the current knowledge on the pathophysiology of normal and osteoporotic bone healing, the effect of a bone fracture on bone turnover markers, the diagnosis of a low bone mineral density (BMD) before surgical intervention, and the effect of available anti-osteoporosis treatment. Interventions that improve bone health may enhance the probability of favorable surgical outcomes. Fracture healing and the treatment of atypical femoral fractures are also discussed.
... Any calcifications in the path of the x-ray beam can lead to falsely elevated BMD. 6 The most common example is degenerative changes of the spine, which can increase the BMD-estimate by as much as 25%. 7 A particular issue in patients with CKD is the potential capture of calcifications of the abdominal aorta in the anteriorposterior (AP) projection of the spine. ...
Background
Dual-energy X-ray absorptiometry (DXA) measurements are sensitive to artifacts from surrounding tissues. This study investigates the impact of abdominal aortic calcification (AAC) on bone mineral density (BMD) in patients with chronic kidney disease (CKD).
Methods
In 88 patients with CKD stage G5D, lumbar spine BMD was measured in both anterior-posterior (AP) and lateral DXA projections. AAC was determined from lateral lumbar radiographs.
Results
Median age was 51 ± 14 years, and 61 % were men. AAC was present in 59 %. There was no difference in lumbar spine BMD between patients with and without AAC (AP: 0.823 vs. 0.806 g/cm², p = 0.66). The ΔBMD between AP and lateral projections was similar in patients with and without AAC (13.4 ± 6.7 % vs. 11.5 ± 6.3 %; difference 1.9 %, 95 % CI −0.9 to 4.7 %, p = 0.18). When comparing single vertebrae at levels with high vs. low degree of AAC within the same individual, there was no difference in BMD (AP: 0.827 ± 0.202 vs. 0.818 ± 0.291 g/cm², p = 0.78), nor in the ΔBMD between AP and lateral projections (12.9 ± 8.1 % vs. 14.3 ± 8.3 %, p = 0.12).
Conclusion
We could not detect an impact of AAC on lumbar spine BMD. These findings challenge the dogma that lumbar spine BMD by DXA is unreliable due to widespread AAC in patients with CKD.
... and incidental findings may be observed that warrant recognition by the interpreting physician [2]. ...
... Even though very severe calcifications of the aorta can lead to an overestimation of BMD, aortic calcifications have a minimal influence on BMD in the majority of cases [4]. Moreover, the treatment of vertebral fractures by vertebroplasty, especially when it involves two or more lumbar vertebrae, limits the possibility of obtaining an adequate evaluation of BMD by DXA [2]. ...
Background
Osteoarthritis (OA) and vertebral fractures at the lumbar spine lead to an overestimation of bone mineral density (BMD). Recently, a new approach for osteoporosis diagnosis, defined as radiofrequency echographic multi-spectrometry (REMS), represents an innovative diagnostic tool that seems to be able to investigate bone quality and provide an estimation of fracture risk independent of BMD.
The aim of this paper was to evaluate whether the use of REMS technology can favor the diagnosis of osteoporosis in subjects with an apparent increase in BMD.
Methods
In a cohort of 159 postmenopausal (66.2 ± 11.6 yrs) women with overestimated BMD by DXA at the lumbar spine, we performed an echographic scan with the REMS technique.
Results
The mean values of BMD at different skeletal sites obtained by the DXA and REMS techniques showed that the BMD T-scores by REMS were significantly lower than those obtained by the DXA technique both at the lumbar spine ( p < 0.01) and at all femoral subregions ( p < 0.05). In OA subjects, the percentage of women classified as “osteoporotic” on the basis of BMD by REMS was markedly higher with respect to those classified by DXA (35.1% vs 9.3%, respectively). Similarly, the REMS allows a greater number of fractured patients to be classified as osteoporotic than DXA (58.7% vs 23.3%, respectively).
Conclusions
REMS technology by the analysis of native raw unfiltered ultrasound signals appears to be able to overcome the most common artifacts, such as OA and vertebral fracture of the lumbar spine, which affect the value of BMD by DXA.
... BMD is a major determinant of bone strength and is the most reliable measure for assessing fracture risk. However, BMD has limited accuracy for assessing bone strength in certain conditions, such as the presence of vertebral compression fractures, aortic calcification, or osteophytes, all of which increase with age [21,22]. Moreover, in other pathological conditions including lytic bone disease, chronic inflammatory disease, laminectomy, metallic materials, or obesity, BMD has limited ability in predicting fracture risk [22]. ...
... However, BMD has limited accuracy for assessing bone strength in certain conditions, such as the presence of vertebral compression fractures, aortic calcification, or osteophytes, all of which increase with age [21,22]. Moreover, in other pathological conditions including lytic bone disease, chronic inflammatory disease, laminectomy, metallic materials, or obesity, BMD has limited ability in predicting fracture risk [22]. For these reasons, BMD by itself may not be the best measure for assessing bone strength. ...
Bone quality is a critical factor that, along with bone quantity, determines bone strength. Image-based parameters are used for assessing bone quality non-invasively. The trabecular bone score (TBS) is used to assess quality of trabecular bone and femur geometry for cortical bone. Little is known about the associations between these two bone quality parameters and whether they show differences in the relationships with age and body mass index (BMI). We investigated the associations between the trabecular bone score (TBS) and femur cortical geometry. Areal bone mineral density (BMD) was assessed using dual energy X-ray absorptiometry (DXA) and the TBS was assessed using iNsight software and, femur geometry using APEX (Hologic). A total of 452 men and 517 women aged 50 years and older with no medical history of a condition affecting bone metabolism were included. Z-scores for TBS and cortical thickness were calculated using the age-specific mean and SD for each parameter. A ‘discrepancy group’ was defined as patients whose absolute Z-score difference between TBS and cortical thickness was > 1 point. TBS and cortical thickness correlated negatively with age both in men and women, but the associations were stronger in women. Regarding the associations with BMI, TBS provided significant negative correlation with BMI in the range of BMI > 25 kg/m ² . By contrast, cortical thickness correlated positively with BMI for all BMI ranges. These bone quality-related parameters, TBS and cortical thickness, significantly correlated, but discordance between these two parameters was observed in about one-third of the men and women (32.7% and 33.4%, respectively). Conclusively, image-based bone quality parameters for trabecular and cortical bone exhibit both similarities and differences in terms of their associations with age and BMI. These different profiles in TBS and FN cortical thickness might results in different risk profiles for the vertebral fractures or hip fractures in a certain percentage of people.
