Opportunistic Screening for Osteoporosis Using Computed Tomography: State of the Art and Argument for Paradigm Shift
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Purpose of Review
Osteoporosis is disproportionately common in rheumatology patients. For the past three decades, the diagnosis of osteoporosis has benefited from well-established practice guidelines that emphasized the use of dual x-ray absorptiometry (DXA). Despite these guidelines and the wide availability of DXA, approximately two thirds of eligible patients do not undergo testing. One strategy to improve osteoporosis testing is to employ computed tomography (CT) examinations obtained as part of routine patient care to “opportunistically” screen for osteoporosis, without additional cost or radiation exposure to patients. This review examines the role of opportunistic CT in the evaluation of osteoporosis.
Recent evidence suggests that opportunistic measurement of bone attenuation (radiodensity) using CT has sensitivity comparable to DXA. More importantly, such an approach has been shown to predict osteoporotic fractures.
The paradigm shift of using CTs obtained for other reasons to opportunistically screen for osteoporosis promises to substantially improve patient care.
KeywordsComputed tomography Fracture Opportunistic screening Osteoporosis
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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- 6.Balasubramanian A, Wade SW, Adler RA, Saag K, Pannacciulli N, Curtis JR. Glucocorticoid exposure and fracture risk in a cohort of US patients with selected conditions. J Bone Miner Res. 2018. https://doi.org/10.1002/jbmr.3523.
- 9.Buckley L, Guyatt G, Fink HA, Cannon M, Grossman J, Hansen KE, et al. 2017 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Rheum. 2017;69(8):1521–37.Google Scholar
- 10.Expert Panel on Musculoskeletal Imaging, Ward RJ, Roberts CC, Bencardino JT, Arnold E, Baccei SJ, et al. ACR Appropriateness Criteria® osteoporosis and bone mineral density. J Am Coll Radiol. 2017;14(5S):S189–202.Google Scholar
- 14.Camacho PM, Petak SM, Binkley N, Clarke BL, Harris ST, Hurley DL, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis - 2016. Endocr Pract. 2016;22(Suppl 4):1–42.PubMedGoogle Scholar
- 20.Seaman AT, Steffen M, Doo T, Healy HS, Solimeo SL. Metasynthesis of patient attitudes toward bone densitometry. J Gen Intern Med. 2018;27:1–9.Google Scholar
- 21.Ozen G, Kamen DL, Mikuls TR, England BR, Wolfe F, Michaud K. Trends and determinants of osteoporosis treatment and screening in patients with rheumatoid arthritis compared to osteoarthritis. Arthritis Care Res. 2018;70(5):713–23.Google Scholar
- 23.IMV Medical Information Division. 2017 CT market outlook report. IMV website https://imvinfocom/product/2017-ct-market-outlook-report Published November 2017. [Accessed August 24, 2018].
- 28.Lenchik L, Register TC, Hsu F-C, Nicklas BJ, Freedman BI, Langefeld CD, et al. Adiponectin as a novel determinant of bone mineral density and visceral fat. Bone. 2003;33(4):646–51.Google Scholar
- 30.Freedman BI, Bowden DW, Ziegler JT, Langefeld CD, Lehtinen AB, Rudock ME, et al. Bone morphogenetic protein 7 (BMP7) gene polymorphisms are associated with inverse relationships between vascular calcification and BMD: the Diabetes Heart Study. J Bone Miner Res. 2009;24(10):1719–27.PubMedPubMedCentralGoogle Scholar
- 33.Beavers KM, Walkup MP, Weaver AA, Lenchik L, Kritchevsky SB, Nicklas BJ, et al. Effect of exercise modality during weight loss on bone health in older adults with obesity and cardiovascular disease or metabolic syndrome: a randomized controlled trial. J Bone Miner Res. 2018. https://doi.org/10.1002/jbmr.3555.
- 52.Gerety EL, Hopper MA, Bearcroft PW. The reliability of measuring the density of the L1 vertebral body on CT imaging as a predictor of bone mineral density. Clin Radiol. 2017;72(2):177.e9–177.e15.Google Scholar
- 54.Graffy PM, Lee SJ, Ziemlewicz TJ, Pickhardt PJ. Prevalence of vertebral compression fractures on routine CT scans according to L1 trabecular attenuation: determining relevant thresholds for opportunistic osteoporosis screening. AJR Am J Roentgenol. 2017;22:1–6.Google Scholar
- 55.Dillon C, Breeden W, Clements J, et al. ACR computed tomography quality control manual. American College of Radiology. 2017.Google Scholar
- 68.Pickhardt PJ, Lee LJ, del Rio AM, Lauder T, Bruce RJ, Summers RM, et al. Simultaneous screening for osteoporosis at CT colonography: bone mineral density assessment using MDCT attenuation techniques compared with the DXA reference standard. J Bone Miner Res. 2011;26(9):2194–203.PubMedPubMedCentralGoogle Scholar
- 72.Fang J, Franconeri A, Boos J, Nimhuircheartaigh J, Zhang Z, Brook A, Brook OR. Opportunistic bone density measurement on abdomen and pelvis computed tomography to predict fracture risk in women aged 50 to 64 years without osteoporosis risk factors. J Comput Assist Tomogr. 2018;42(5):798–806. https://doi.org/10.1097/RCT.0000000000000744.
- 73.Lee SJ, Anderson PA, Pickhardt PJ. Predicting future hip fractures on routine abdominal CT using opportunistic osteoporosis screening measures: a matched case-control study. AJR Am J Roentgenol. 2017;1:1–8.Google Scholar
- 75.• Lee SJ, Pickhardt PJ. Opportunistic screening for osteoporosis using body CT scans obtained for other indications: the UW experience. Clinical Reviews in Bone and Mineral Metabolism. 2017;15(3):128–37 Provides practical approach for implementing opportunistic CT screening. Google Scholar
- 78.• Adams AL, Fischer H, Kopperdahl DL, Lee DC, Black DM, Bouxsein ML, et al. Osteoporosis and hip fracture risk from routine computed tomography scans: the fracture, osteoporosis, and CT utilization study (FOCUS). J Bone Miner Res. 2018;33(7):1291–301 Largest study comparing clinical CT to DXA for identifying patients at risk for hip fracture. PubMedGoogle Scholar
- 86.Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States, 2015–2016. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2017.Google Scholar
- 91.Foster B, Boutin RD, Lenchik L, Gedeon D, Liu Y, Nittur V, Badawi RD, Li CS, Canter RJ, Chaudhari AJ. Skeletal muscle metrics on clinical (18)F-FDG PET/CT predict health outcomes in patients with sarcoma. J Nat Sci. 2018;4(5).Google Scholar
- 92.Lenchik L, Lenoir KM, Tan J, Boutin RD, Callahan KE, Kritchevsky SB, Wells BJ. Opportunistic measurement of skeletal muscle size and muscle attenuation on computed tomography predicts one-year mortality in medicare patients. J Gerontol A Biol Sci Med Sci. 2018. https://doi.org/10.1093/gerona/gly183.
- 93.Paintin J, Cooper C, Dennison E. Osteosarcopenia. Br J Hosp Med (Lond). 2018;79(5):253–8.Google Scholar
- 94.• Lenchik L, Boutin RD. Sarcopenia: beyond muscle atrophy and into the new frontiers of opportunistic imaging, precision medicine, and machine learning. Semin Musculoskelet Radiol. 2018;22(3):307–22 Provides a perspective on combining opportunistic screening for osteoporosis with screening for sarcopenia. PubMedGoogle Scholar
- 95.Schoell SL, Weaver AA, Beavers DP, Lenchik L, Marsh AP, Rejeski WJ, Stitzel JD, Beavers KM. Development of subject-specific proximal femur finite element models of older adults with obesity to evaluate the effects of weight loss on bone strength. J Osteoporos Phys Act. 2018;6(1). https://doi.org/10.4172/2329-9509.1000213.
- 96.Schoell SL, Beavers KM, Beavers DP, Lenchik L, Rejeski WJ, Stitzel JD, Weaver AA. Prediction of lumbar vertebral body compressive strength of older obese adults using morphed subject-specific finite element models to evaluate the effects of weight loss. Aging Clin Exp Res. 2018. https://doi.org/10.1007/s40520-018-1010-1.