Bone density

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From Wikipedia, the free encyclopedia

A scanner used to measure bone density using dual energy X-

Bone density, or bone mineral density, is the amount of bone mineral in bone tissue. The concept is
of mass of mineral per volume of bone (relating to density in the physics sense), although clinically it
is measured by proxy according to optical density per square centimetre of bone surface
upon imaging.[1] Bone density measurement is used in clinical medicine as an indirect indicator
of osteoporosis and fracture risk. It is measured by a procedure called densitometry, often performed
in the radiology or nuclear medicine departments of hospitals or clinics. The measurement is
painless and non-invasive and involves low radiation exposure. Measurements are most commonly
made over the lumbar spine and over the upper part of the hip.[2] The forearm may be scanned if the
hip and lumbar spine are not accessible.

There is a statistical association between poor bone density and higher probability of fracture.
Fractures of the legs and pelvis due to falls are a significant public health problem, especially in
elderly women, leading to substantial medical costs, inability to live independently and even risk of
death.[3] Bone density measurements are used to screen people for osteoporosis risk and to identify
those who might benefit from measures to improve bone strength.
Testing

[edit]

A bone density test may detect osteoporosis or osteopenia.[4] The usual response to either of these
indications is consultation with a physician.[4] Bone density tests are not recommended for people
without risk factors for weak bones,[5][4] which is more likely to result in unnecessary treatment rather
than discovery of a weakness.[4]

Indications for testing

[edit]

The risk factors for low bone density and primary considerations for a bone density test include:

• females age 65 or older.[4]

• males age 70 or older.[4]

• people over age 50 with:

• previous bone fracture from minor trauma.[4]

• rheumatoid arthritis.[4]

• low body weight.[4]

• a parent with a hip fracture.[4]

• individuals with vertebral abnormalities.[6]

• individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy.[6]

• individuals with primary hyperparathyroidism.[6]

• individuals being monitored to assess the response or efficacy of an approved osteoporosis

• when androgen deprivation therapy is being planned for prostate cancer.

• individuals with a history of eating disorders.[6]

Other considerations that are related to risk of low bone density and the need for a test include
smoking habits, drinking habits, the long-term use of corticosteroid drugs, and a vitamin D
deficiency.[4]

Test result terms

[edit]

Results of the test are reported in three forms:

• Measured areal density in g cm−2.

• Z-score: the number of standard deviations above or below the mean for the patient's age, sex
and ethnicity.
 • T-score: the number of standard deviations above or below the mean for a healthy 30-year-old
adult of the same sex and ethnicity as the patient.

Types of tests

[edit]

Illustration of Bone Densitometry Scan

While there are many types of bone mineral density tests, all are non-invasive. The tests differ
according to which bones are measured to determine the test result.

These tests include:

• Dual-energy X-ray absorptiometry (DXA or DEXA)

• Trabecular bone score

• Dual X-ray Absorptiometry and Laser (DXL)

• Quantitative computed tomography (QCT)

• Quantitative ultrasound (QUS)

• Single photon absorptiometry (SPA)

• Dual photon absorptiometry (DPA)

• Digital X-ray radiogrammetry (DXR)

• Single energy X-ray absorptiometry (SEXA)

DXA is the most commonly used testing method as of 2016.[7] The DXA test works by measuring a
specific bone or bones, usually the spine, hip, and wrist. The density of these bones is then compared
with an average index based on age, sex, and size. The resulting comparison is used to determine the
risk for fractures and the stage of osteoporosis (if any) in an individual.

Quantitative ultrasound (QUS) has been described as a more cost-effective approach for measuring
bone density, as compared to DXA.[8]

Average bone mineral density = BMC / W [g/cm2]

• W = width at the scanned line

Interpretation

[edit]

Results are generally scored by two measures, the T-score and the Z-score. Scores indicate the
amount one's bone mineral density varies from the mean. Negative scores indicate lower bone
density, and positive scores indicate higher.

Less than 0.5% of patients who underwent DXA-scanning were found to have a T- or Z-score of more
than +4.0, often the cause of an unusually high bone mass (HBM) and associated with mild
skeletal dysplasia and the inability to float in water.[9]

T-score

[edit]

The T-score is the relevant measure when screening for osteoporosis. It is the bone mineral density at
the site when compared to the "young normal reference mean". It is a comparison of a patient's bone
mineral density to that of a healthy 30-year-old.[10] The US standard is to use data for a 30-year-old of
the same sex and ethnicity, but the WHO recommends using data for a 30-year-old white female for
everyone.[11] Values for 30-year-olds are used in post-menopausal women and men over age 50
because they better predict risk of future fracture.[12] The criteria of the World Health
Organization are:[13]

• Normal is a T-score of −1.0 or higher[14]

• Osteopenia is defined as between −1.0 and −2.5

• Osteoporosis is defined as −2.5 or lower, meaning a bone density that is two and a half
standard deviations below the mean of a 30-year-old man/woman.

Hip fractures per 1000 patient-years[15]

WHO category Age 50–64 Age > 64 Overall

Normal 5.3 9.4 6.6

Osteopenia 11.4 19.6 15.7

Osteoporosis 22.4 46.6 40.6

Z-score

[edit]

The Z-score for bone density is the comparison to the "age-matched normal" and is usually used in
cases of severe osteoporosis. This is the standard score or number of standard deviations a patient's
bone mineral density differs from the average for their age, sex, and ethnicity. This value is used in
premenopausal women, men under the age of 50, and in children and adolescents.[12][16] It is most
useful when the score is less than 2 standard deviations below this normal. In this setting, it is helpful
to scrutinize for coexisting illnesses or treatments that may contribute to osteoporosis such
as glucocorticoid therapy, hyperparathyroidism, or alcoholism.

Prevention

[edit]

To prevent low bone density it is recommended to have sufficient calcium and vitamin
D.[17][18] Sufficient calcium is defined as 1,000 mg per day, increasing to 1,200 mg for women above 50
and men above 70.[18] Sufficient vitamin D is defined as 600 IUs per day for adults 19 to 70, increasing
to 800 IUs per day for those over 71.[18] Exercise, especially weight-bearing and resistance exercises
are most effective for building bone. Weight-bearing exercise includes walking, jogging, dancing, and
hiking. Resistance exercise is often accomplished through lifting weights.[19] Other therapies, such
as estrogens (e.g., estradiol, conjugated estrogens), selective estrogen receptor
modulators (e.g., raloxifene, bazedoxifene), and bisphosphonates (e.g., alendronic acid, risedronic
acid), can also be used to improve or maintain bone density. Tobacco use and excessive alcohol
consumption have detrimental effects on bone density.[20][18] Excessive alcohol consumption is
defined as more than one standard-sized alcoholic beverage per day for women, and drinking two or
more alcoholic beverages per day for men.[18]

Genetics

[edit]

Bone mineral density is highly variable between individuals. While there are many environmental
factors that affect bone mineral density, genetic factors play the largest role.[7][21] Bone mineral density
variation has been estimated to have 0.6–0.8 heritability factor, meaning that 60–80% of its variation
is inherited from parents.[22] Because of the heritability of bone mineral density, family history of
fractures is considered as a risk factor for osteoporosis.[23] Bone mineral density is polygenic and
many of the genetic mechanisms remain poorly understood.[21]