Clinical Reviews in Bone and Mineral Metabolism

, Volume 15, Issue 3, pp 128–137 | Cite as

Opportunistic Screening for Osteoporosis Using Body CT Scans Obtained for Other Indications: the UW Experience

  • Scott J. Lee
  • Perry J. PickhardtEmail author
Review Paper


Low bone mineral density (osteoporosis and osteopenia) leading to fragility fractures is associated with significant morbidity and mortality in our aging population. This condition is grossly underdiagnosed due to both insufficient screening and its silent nature prior to complicating fragility fractures. Body CT scans are commonly obtained among older adults for a wide variety of indications and contain rich data regarding bone health that are often ignored. At the University of Wisconsin, we have sought to harness this CT information for “opportunistic” osteoporosis screening. In this article, we review the various CT-based approaches we have taken to date, including routine assessment of the spine for both vertebral fractures and trabecular density, as well as assessment of the hip, deriving femoral neck T-scores that are essentially equivalent to dual-energy x-ray absorptiometry (DXA). Future directions of research and clinical implementation are also discussed.


CT Computed tomography Opportunistic screening Osteoporosis 


Compliance with Ethical Standards


This study supported in part by the Institute for Clinical and Translation Research (ICTR) at the University of Wisconsin—Madison.

Conflict of Interest

Dr. Pickhardt is co-founder of VirtuoCTC; advisor to Bracco and Check-Cap; and shareholder in SHINE, Elucent, and Cellectar Biosciences. The authors declare no relevant conflicts of interest for this work.

Ethical Approval and Informed Consent

N/A (review article).


  1. 1.
    Kanis JA, Borgstrom F, De Laet C, et al. Assessment of fracture risk. Osteoporos Int. 2005;16:581–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Cauley JA, Thompson DE, Ensrud KC, et al. Risk of mortality following clinical fractures. Osteoporos Int. 2000;11:556–61.CrossRefPubMedGoogle Scholar
  3. 3.
    U.S. Department of Health and Human Services. Bone health and osteoporosis: a report of the Surgeon General. Rockville: U.S. Department of Health and Human Services, Office of the Surgeon General; 2004.Google Scholar
  4. 4.
    Wang Z, Ward MM, Chan L, Bhattacharyya T. Adherence to oral bisphosphonates and the risk of subtrochanteric and femoral shaft fractures among female medicare beneficiaries. Osteoporos Int. 2014;25:2109–16.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Curtis JR, Carbone L, Cheng H, et al. Longitudinal trends in use of bone mass measurement among older americans, 1999-2005. J Bone Miner Res. 2008;23:1061–7.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Cohen K, Maier D. Osteoporosis: evaluation of screening patterns in a primary-care group practice. J Clin Densitom. 2008;11:498–502.CrossRefPubMedGoogle Scholar
  7. 7.
    Mettler FA, Thomadsen BR, Bhargavan M, et al. Medical radiation exposure in the U.S. in 2006: preliminary results. Health Phys. 2008;95:502–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Gillies RJ, Kinahan PE, Hricak H. Radiomics: images are more than pictures, they are data. Radiology. 2016;278:563–77.CrossRefPubMedGoogle Scholar
  9. 9.
    Pickhardt PJ, Pooler BD, Lauder T, et al. Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med. 2013;158:588–95.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Steiger P, Block JE, Steiger S, et al. Spinal bone mineral density measured with quantitiative CT - effect of region of interest, vertebral level, and technique. Radiology. 1990;175:537–43.CrossRefPubMedGoogle Scholar
  11. 11.
    Lee SJ, Binkley N, Lubner MG, et al. Opportunistic screening for osteoporosis using the sagittal reconstruction from routine abdominal CT for combined assessment of vertebral fractures and density. Osteoporos Int. 2016;27:1131–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Carberry GA, Pooler BD, Binkley N, et al. Unreported vertebral body compression fractures at abdominal multidetector CT. Radiology. 2013;268:120–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Pickhardt PJ, Lee SJ, Muñoz Del Rio A, 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;26:2194–203.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Buckens CF, Dijkhuis G, de Keizer B, et al. Opportunistic screening for osteoporosis on routine computed tomography? An external validation study. Eur Radiol. 2015;25:2074–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Alacreu E, Moratal D, Arana E. Opportunistic screening for osteoporosis by routine CT in southern Europe. Osteoporos Int. 2017;28:983–90.CrossRefPubMedGoogle Scholar
  16. 16.
    Burke CJ, Didolkar MM, Barnhart HX, Vinson EN. The use of routine non-density calibrated clinical computed tomography data as a potentially useful screening tool for identifying patients with osteoporosis. Clin Cases Miner Bone Metab. 2016;13(2):135–40.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Majumdar SR, Leslie WD. Conventional computed tomography imaging and bone mineral density: opportunistic screening or “incidentaloporosis”? Ann Intern Med. 2013;158:630–1.CrossRefPubMedGoogle Scholar
  18. 18.
    Graffy PM, Lee SJ, Ziemlewicz TJ, Pickhardt PJ. Prevalence of vertebral compression fractures on routine body CT scans according to L1 trabecular attenuation: determining relevant thresholds for opportunistic osteoporosis screening. Am J Roentgenol. 2017;209:1–6.CrossRefGoogle Scholar
  19. 19.
    Lee SJ, Anderson PA, Pickhardt PJ. Predicting future hip fractures at routine abdominal CT using opportunistic osteoporosis screening measures: a matched case-control study. Am J Roentgenol. 2017;209:1–8.CrossRefGoogle Scholar
  20. 20.
    Pompe E, de Jong PA, de Jong WU, et al. Inter-observer and inter-examination variability of manual vertebral bone attenuation measurements on computed tomography. Eur Radiol. 2016;26:3046–53.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Gerety E-L, Hopper MA, PWP B. The reliability of measuring the density of the L1 vertebral body on CT imaging as a predictor of bone mineral density. Clin Radiol. 2017;72:177.e9–177.e15.CrossRefGoogle Scholar
  22. 22.
    Pompe E, Willemink MJ, Dijkhuis GR, et al. Intravenous contrast injection significantly affects bone mineral density measured on CT. Eur Radiol. 2015;25:283–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Pickhardt PJ, Lauder T, Pooler BD, et al. Effect of IV contrast on lumbar trabecular attenuation at routine abdominal CT: correlation with DXA and implications for opportunistic osteoporosis screening. Osteoporos Int. 2016;27:147–52.CrossRefPubMedGoogle Scholar
  24. 24.
    Garner HW, Paturzo MM, Gaudier G, et al. Variation in attenuation in L1 trabecular bone at different tube voltages: caution is warranted when screening for osteoporosis with the use of opportunistic CT. Am J Roentgenol. 2017;208:165–70.CrossRefGoogle Scholar
  25. 25.
    Lamba R, McGahan JP, Corwin MT, et al. CT Hounsfield numbers of soft tissues on unenhanced abdominal CT scans: variability between two different manufacturers’ MDCT scanners. Am J Roentgenol. 2014;203:1013–20.CrossRefGoogle Scholar
  26. 26.
    Adams JE. Quantitative computed tomography. Eur J Radiol. 2009;71:415–24.CrossRefPubMedGoogle Scholar
  27. 27.
    Riggs BL, Melton LJ, Robb RA, et al. A population-based assessment of rates of bone loss at multiple skeletal sites: evidence for substantial trabecular bone loss in young adult women and men. J Bone Miner Res. 2007;23:205–14.CrossRefPubMedCentralGoogle Scholar
  28. 28.
    Brown JK, Timm W, Bodeen G, et al. Asynchronously calibrated quantitative bone densitometry. J Clin Densitom. 2017;20:216–25.CrossRefGoogle Scholar
  29. 29.
    Summers RM, Baecher N, Yao J, et al. Feasibility of simultaneous computed tomographic colonography and fully automated bone mineral densitometry in a single examination. J Comput Assist Tomogr. 2011;35:212–6.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Pickhardt PJ, Bodeen G, Brett A, et al. Comparison of femoral neck BMD evaluation obtained using lunar DXA and QCT with asynchronous calibration from CT Colonography. J Clin Densitom. 2015;18:5–12.CrossRefPubMedGoogle Scholar
  31. 31.
    Ziemlewicz TJ, Maciejewski A, Binkley N, et al. Opportunistic quantitative CT bone mineral density measurement at the proximal femur using routine contrast-enhanced scans: direct comparison with DXA in 355 adults. J Bone Miner Res. 2016;31:1835–40.CrossRefPubMedGoogle Scholar
  32. 32.
    Ziemlewicz TJ, Maciejewski A, Binkley N, et al. Direct comparison of unenhanced and contrast-enhanced CT for opportunistic proximal femur bone mineral density measurement: implications for osteoporosis screening. Am J Roentgenol. 2016;206:694–8.CrossRefGoogle Scholar
  33. 33.
    Ziemlewicz TJ, Binkley N, Pickhardt PJ. Opportunistic osteoporosis screening: addition of quantitative CT bone mineral density evaluation to CT Colonography. J Am Coll Radiol. 2015;12:1036–41.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Pompe E, Bartstra J, Verhaar HJ, et al. Bone density loss on computed tomography at 3-year follow-up in current compared to former male smokers. Eur J Radiol. 2017;89:177–81.CrossRefPubMedGoogle Scholar
  35. 35.
    Fidler JL, Murthy NS, Khosla S, et al. Comprehensive assessment of osteoporosis and bone fragility with CT Colonography. Radiology. 2016;278:172–80.CrossRefPubMedGoogle Scholar
  36. 36.
    Keaveny TM. Biomechanical computed tomography-noninvasive bone strength analysis using clinical computed tomography scans. Ann N Y Acad Sci. 2010;1192:57–65.CrossRefPubMedGoogle Scholar
  37. 37.
    Weber NK, Fidler JL, Keaveny TM, et al. Validation of a CT-derived method for osteoporosis screening in IBD patients undergoing contrast-enhanced CT enterography. Am J Gastroenterol. 2014;109:401–8.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    McDonald AM, Swain TA, Mayhew DL, et al. CT measures of bone mineral density and muscle mass can be used to predict noncancer death in men with prostate cancer. Radiology. 2017;282:475–83.CrossRefPubMedGoogle Scholar
  39. 39.
    McDonald AM, Jones JA, Cardan RA, et al. Combining computed tomography-based bone density assessment with FRAX screening in men with prostate cancer. J Clin Densitom. 2016;19:430–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Fox CS, Massaro JM, Hoffmann U, et al. Abdominal visceral and subcutaneous adipose tissue compartments: association with metabolic risk factors in the Framingham heart study. Circulation. 2007;116:39–48.CrossRefPubMedGoogle Scholar
  41. 41.
    Pickhardt PJ, Jee Y, O’Connor SD, del Rio AM. Visceral adiposity and hepatic steatosis at abdominal CT: association with the metabolic syndrome. AJR Am J Roentgenol. 2012;198:1100–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Wong ND, Lopez VA, Allison M, et al. Abdominal aortic calcium and multi-site atherosclerosis: the multiethnic study of atherosclerosis. Atherosclerosis. 2011;214:436–41.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Reaven PD, Sacks J. Coronary artery and abdominal aortic calcification are associated with cardiovascular disease in type 2 diabetes. Diabetologia. 2005;48:379–85.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.University of Wisconsin School of Medicine and Public HealthMadisonUSA
  2. 2.Department of RadiologyUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA

Personalised recommendations