The Role of the

Radiologi When
encountering
Osteoporosis in Women
Disusun oleh : Agy Faqih D
NRP : 1610221099
Pembimbing : dr Novita Elyana, Sp. Rad
 OBJECTIVE. This article describes the extent and
potentially devastating consequences of osteoporosis in
adult women. There is discussion of the importance of
radiologists in the correct diagnosis and reporting of
probable osteoporotic vertebral fractures on medical
imaging studies.

 CONCLUSION. The Genant semiquantitative method for

diagnosing osteoporotic vertebral fractures is presented.
The importance of dual-energy x-ray absorptiometry
reproducibility is also briefly discussed.
Definition
 In women, primary osteoporosis is defined as a bone
mineral density (BMD) of 2.5 SD below that of a young
healthy adult (i.e., a Tscore at or below −2.5).
 Restrictions of this definition are that it must be based on
a BMD measurement optimally obtained with two sites at
the spine, hip, or forearm by use of a dual-energy x-ray
absorptiometry (DXA) device, with forearm DXA
measurements limited to patients without an alternate
second site
 (e.g., spine or either hip);
 the patient should be postmenopausal;
 and a cause for secondary osteoporosis should not be
present [1–3
Important Considerations for Radiologists
Performing DXA Scans
 Lack of reproducibility of BMD measurements using
DXA can be a problem. This lack of reproducibility
can be due to variation in patient positioning, lack of
consistency in data analysis, and the inherent
precision error of the technique. Some common
 operator errors include poor patient positioning,
inconsistent selection of vertebral levels, poor
placement of disk markers for the lumbar spine,
improper hip rotation, and the inconsistent
determination of regions of interest for the hip [26].
epidemiology
 According to estimated figures, osteoporosis was responsible for
more than 2 million fractures in 2005, including approximately
297,000 hip fractures, 547,000 vertebral body fractures,
397,000 wrist fractures, 135,000 pelvic fractures, and 675,000
fractures at other sites. The number of fractures due to
osteoporosis is expected to increase to more than 3 million by
2025 [3].
 Vertebral fractures are a frequent consequence of osteoporosis.
As one of the more common kinds of fractures in the United
States, with an occurrence rate of approximately 700,000 cases
per year [5], an estimated 547,000 vertebral fractures are
secondary to osteoporosis [2]. Vertebral fractures cause back
pain and lead to loss of mobility and pulmonary difficulties [6].
epidemiology

 With regard to hip fractures, on average, 24% of

patients with hip fractures who are 50 years old
and older die during the year following their
fracture. One (20%) of five patients who were
ambulatory before their hip fracture requires
long-term care afterward. At 6 months after a hip
fracture, only 15% of patients can ambulate
across a room without help [2].
Diagnosis and Treatment
 Osteoporotic fractures and their concomitant association
with mortality and morbidity are potentially preventable.
Bisphosphonates are one of the advancements in the
treatment of osteoporosis in the past decade, with results
of clinical trials showing risk reductions of 40–50% for
osteoporosis-associated vertebral fractures and 20–40% for
nonvertebral fractures, including hip fractures [7– 10].
Because there is increased morbidity and mortality with
osteoporosis-associated fractures, decreasing their
incidence (such as with bisphosphonates) will decrease
the ageadjusted morbidity and mortality rates in patients
with osteoporosis. Therefore, it is desirable to diagnose
osteoporosis as early as reasonably possible so that
treatment can be instituted before the first osteoporosis-
associated fracture occurs or before additional fractures
occur.
Diagnosis and treatment
 An association between long-term bisphosphonate
therapy and low-energy insufficiency subtrochanteric
femoral fractures has been recently reported [22–24].
Data from three large placebo-controlled randomized
trials indicate that the risk of fracture of the
subtrochanteric or diaphyseal femur associated with
the use of bisphosphonates was low. There were 12
subtrochanteric femoral insufficiency fractures during
51,287 patient-years in the three studies; the
combined rate was 2.3 fractures per 10,000 patient-
years [25].
Diagnosis and treatment
 Even among women with up to 10 years of bisphosphonate
treatment, the risk of fracture of the subtrochanteric or
diaphyseal femur ranged from one to six cases per 10,000
patient-years. However, the radiologist should be aware
that results from case series suggest that, in patients
taking bisphosphonates who have persistent thigh pain,
evidence of an incomplete insufficiency fracture or a
contralateral femur fracture should prompt consideration
of further testing and possible interventions [22–25]. From
case studies, factors for increased likelihood of having a
subtrochanteric insufficiency fracture of the femur in
patients receiving bisphosphonates are corticosteroid use,
proton-pump inhibitor use, and markedly suppressed bone
turnover (perhaps owing to the use of multiple
antiresorptive medications).
Fig. 8—89-year-old woman with osteoporosis and long-term treatment with
bisphosphonate. A, First anteroposterior radiograph of left hip shows lateral cortical
thickening and uninterrupted periostitis (arrow) in left femur (also described as
cortical beaking). This represents incomplete insufficiency fracture secondary to long-
term bisphosphonate treatment. B, Patient later went on to complete fracture at this
level.
Screening
 Screening for osteoporosis is indicated in women [2]
 65 years old and older;
 who are postmenopausal or perimenopausal and have risk
factors for fracture;
 who have a fragility fracture, regardless of age or
menopausal status;
 or who have a disease or condition or take a medication
associated with low bone mass or bone loss.
 It should be noted that radiologists can play a role in the
diagnosis of fragility or insufficiency fractures even if they
are not involved in interpreting screening DXA studies.
Screening
 Retrospective studies of standard upright
posteroanterior and lateral chest radiographs
obtained in emergency treatment centers
revealed a 55–65% diagnosis rate for osteoporotic
vertebral fractures [12, 13]. Even more
concerning is that one of these studies found that
only about one-fourth (25%) of patients with
osteoporotic vertebral fractures already had a
diagnosis of osteoporosis. Therefore, three-
fourths (75%) of the patients in this study with an
osteoporotic vertebral fracture needed screening.
Identifying and Reporting Fragility and
Insufficiency Fractures

 How can the radiologist help patients with undiagnosed

osteoporosis? One immediate response would be to say that
radiologists can report fragility and insufficiency fractures
(even when they are incidental and asymptomatic) and make
recommendations or suggestions for BMD testing if clinically
warranted. Radiologists also play a role in notifying the
referring physician that the fracture identified is not an
osteoporotic fracture but is due to some other cause (e.g., a
pathologic fracture due to metastatic disease or an
insufficiency fracture due to Paget disease), thereby preventing
unnecessary BMD testing in women younger than 65 years.
The Difficulty in Reporting Osteoporotic
Vertebral Fractures: Is It Really an
Osteoporotic Vertebral Fracture?
 The standard imaging approach for assessment of
vertebral fracture is radiography of the thoracolumbar
spine; however, there is no universal reference standard
for the definition of osteoporotic vertebral fracture [15],
because the normal radiographic appearance of the
vertebrae can vary, parallax effect can cause normal
vertebrae to appear compressed (Fig. 1), and strict
morphometric measurements on radiographs can overor
underestimate osteoporotic fractures [16, 17]. The
Genant semiquantitative method is and has been used as a
surrogate reference standard in several studies of
osteoporosis [16–18]. The reported inter- and
intraobserver agreement is substantial [16].
65-year-old woman with facet arthropathy in lumbar spine. Radiograph shows
potential pitfall of overdiagnosing osteoporotic fracture that parallax can cause.
One might mistakenly measure vertebral body height from closest projecting
vertebral body endplates (black line) and overdiagnose vertebral fracture.
However, correctly corresponding vertebral endplate lines are shown by white line.
Genant Semiquantitative Method

 The method for evaluating vertebrae for an

osteoporotic fracture is shown in Figure 2. Twenty
percent or more loss of height in the anterior
aspect (wedge fracture), middle aspect
(biconcave fracture), or posterior aspect (crush
fracture) is diagnosed as an osteoporotic fracture
[19] (Fig. 2). Radiographic examples of wedge,
biconcave, and crush fractures are shown in
Figures 3, 4, and 5.
Fig. 2—Diagram of Genant semiquantitative method for diagnosing osteoporotic vertebral fractures. Vertebra that is
suspicious for being fractured should be carefully compared with adjacent vertebrae to rule out normal variants or
Scheuermann disease. Fractured vertebra also needs to be carefully inspected for any evidence of nonosteoporotic
vertebral fracture (e.g., metastasis or multiple myeloma). Osteoporotic vertebral fracture is diagnosed if there is more
than 20% loss of height at site of maximum compression and there are no nonosteoporotic causes of fracture. Type of
fracture should also be described in report as wedge, biconcave, or crush (predominantly anterior, midportion, or
posterior compression, respectively). Reprinted from [32].
Fig. 3—70-yearold woman with osteoporotic
fracture. L1 vertebra (asterisk) shows severe
(grade 3, > 40% loss of height) wedge
osteoporotic fracture.
Fig. 4—90-year-old woman with multiple osteoporotic
fractures. Diffuse demineralization of bones is present.
There is moderate (grade 2, 26–40% loss of height) biconcave
fracture (black asterisk) of T5 vertebra. T6 vertebra (white
asterisk) does not have probable osteoporotic fracture
because any height loss is less than 20%.
Fig. 5—95-year-old woman with multiple osteoporotic fractures. A, Radiograph
shows mild (grade 1, 20–25% loss of height posteriorly) crush fracture (black
asterisk) of L5 vertebra. L4 vertebral body moderate biconcave fracture (white
asterisk) (26–40% loss of height centrally) is also seen. B, T1-weighted MRI scan
shows fractures to better advantage. Biconcave fracture (white asterisk) is
more acute as evidenced by horizontally oriented bandlike edema at superior
endplate (low signal). L5 crush fracture (black asterisk) is old because vertebra
contains all fatlike signal.
Genant Semiquantitative Method

 The Genant semiquantitative method is the

current technique of choice in identifying
osteoporotic vertebral fractures with DXA (as well
as radiographs). Vertebral fracture assessment
reports should comment on unevaluable
vertebrae, deformed vertebrae not consistent
with a fracture, and any unexplained vertebral or
extravertebral pathologic abnormality.
Fig. 6—55-year-old woman with Cupid’s bow normal variant. Lumbar spine radiographs show Cupid’s bow normal variant in lower
lumbar spine. A, On lateral view, inferior endplates at L4 and L5 show unusual indentation of posterior aspect of inferior endplates
(arrows). B, Anteroposterior view shows classic biconcave Cupid’s bow facing cephalad at L4 (superimposed black outline) and L5
(arrows). This is normal variant and should not be confused with osteoporotic compression fracture or other abnormality [33].
Fig. 7—50-year-old woman with Scheuermann disease.
Lateral radiograph of spine shows anterior wedging of
multiple vertebrae with accompanying endplate
irregularities (arrows) and kyphosis. These are imaging
hallmarks of Scheuermann disease [34] and should not be
Summary
 The correct diagnosis and reporting of a probable osteoporotic vertebral fracture by
radiologists affects patient treatment by enabling the diagnosis of osteoporosis, helping
select patients for effective pharmacologic therapy, improving the physician’s ability to
correctly assess the risk of future fracture, and providing a documented rationale for BMD
testing. Given improved treatments and better diagnostic tests for low BMD, now is the
time for some of us to renew our efforts in reporting these fractures [19, 32]. The Genant
semiquantitative method is the current technique of choice in identifying osteoporotic
vertebral fractures with DXA and radiographs. The diagnosis of primary osteoporosis is
based on a BMD measurement optimally obtained using two sites at the spine, hip, or
forearm by a DXA device, with forearm DXA measurements limited to patients without an
alternative second site (e.g., spine or either hip). Finally, for a facility to have the best
DXA reproducibility, calibration assessment and precision assessment must be done
correctly for each individual technologist.