CHAPTER 1 INTRODUCTION

Dual Energy X-ray Absorptiometry (DEXA) is an instrumental technique used to measure bone mineral density (BMD) that includes the hip and spine, compared to SXA (Single Energy X-ray Absorptiometry) that measures only the wrist or heel bone. BMD is the widely accepted indicator of bone strength. DEXA (the whole body scanner) uses low dose x-rays to give us information on bone content and density. It is currently the most widely used machine in the clinical setting to diagnose the disease osteoporosis, the thinning of bones. DXA scans are used primarily to evaluate bone mineral density. DXA scans can also be used to measure total body composition and fat content with a high degree of accuracy comparable to hydrostatic weighing with a few important caveats. However, it has been suggested that, while very accurately measuring minerals and lean soft tissue (LST), DXA may provide skewed results as a result of its method of indirectly calculating fat mass by subtracting it from the LST and/or body cell mass (BCM) that DXA actually measures. At present, DXA scanning focuses on two main areas -- the hip and spine. Although osteoporosis involves the whole body, measurements of BMD at one site can be predictive of fractures at other sites. Scanning generally takes 10 to 20 minutes to complete and is painless. DEXA stands for 'dual energy X-ray absorptiometry'. It is a test that measures the density of bones. Density means how much of something there is in a certain amount of space. The denser the tissue, the less X-rays passes through. Air and water are less dense than solid things such as bone. This is because the particles which make air and water are not held closely together. In general, the more dense the bone, the stronger it is, and the less likely it is to break.

There are two different types of DEXA scanning devices: Central DEXA devices are large machines that can measure bone density in the centre of your skeleton, such as your hip and spine. Peripheral DEXA devices are smaller, portable machines that are used to measure bone density on the periphery of your skeleton, such as your wrist, heel or finger.

A DEXA scan uses low-energy X-rays. A machine sends X-rays from two different sources through the bone being tested. Bone blocks a certain amount of the X-rays. The more dense the bone is, the less X-rays get through to the detector. By using two different X-ray sources rather than one it greatly improves the accuracy in measuring the bone density. The amount of X-rays that comes through the bone from each of the two X-ray sources is measured by a detector. This information is sent to a computer which calculates a score of the average density of the bone. A low score indicates that the bone is less dense than it should be, some material of the bone has been lost, and it is more prone to fracture.

CHAPTER 2 PRINCIPLES OF DUAL ENERGY X-RAY ABSORPTIOMETRY

2.1Principal components of a DEXA system
A typical DEXA system is shown in the figure.

Figure 2.1 The DEXA system

The DEXA scanner consists of the following basic components:

1. 2. 3.

Source of X-rays The sample space The detector

Two separate beams of X-rays of known energies (E0,1 and E0,2) produced at the source are passed through a desired absorber material (sample)-usually human body- positioned in the sample space (DEXA table). The sample interacts with the incident beams altering their energies to E1 and E2. The detector determines the energies (E1 and E2) of the emerging beams of X-radiation. A data acquisition and control unit manipulates the data. The operation of this electronic machine is fully controlled by a computer system.

Figure 2.2 The principal components of DEXA system

We will understand the working principle of DEXA by first considering the interaction of a single beam of X-Rays with matter.

2.2 Interaction of X-ray photon with physical matter

When a beam of X-rays is allowed to pass through an absorber material, the X-ray photons interact with the electrons of the material in 2 different ways. a. The photon knocks the weakly bound outer orbit electron giving up some of its energy to the electron and gets deflected (scattered) from its path. The scattered photon has a lower energy and hence a longer wavelength than the incident photon. This is Compton scattering .
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b. The photon collides with more tightly bound orbit electron giving up all its energy to the electron and the photon ceases to exist. This is photoelectric collision.

Figure 2.3Photoelectric effect

Both these interactions result in a reduction or attenuation of the energy of the X-ray beam. In fact, the incident photon energy is exponentially reduced or attenuated as it passes through the absorber .

Figure 2.4. Attenuation of X-Ray energy by the interaction of the absorber.

2.3 Mass attenuation coefficient (U) and mass per unit area (M) of the absorber
The extent to which the photon energy is attenuated is a function of the initial energy of the X-ray photon, the mass per unit area (M) of the absorber material and the mass attenuation coefficient (U) of the absorber. For a given absorber material, U (which is a measure of the degree of attenuation) is a constant at any given photon energy. For instance, at an incident photon energy of 40 keV, A for hydrogen is 0.3458 cm2/g; at an incident photon energy of 70 keV, it is 0.3175 cm2/g. The mass attenuation coefficients of some absorber elements are given below for two photon energies for examination:

Table 1 : Mass attenuation coefficients of some elements. Element Atomic number U (cm /g) 40 keV H C N O Na Mg P S Cl K Ca 1 6 7 8 11 15 15 16 18 19 20 0.3458 0.2047 0.2246 0.2533 0.3851 0.4704 0.7784 0.9509 1.1000 1.4840 1.7920 70 keV 0.3175 0.1678 0.1722 0.1788 0.2022 0.2244 0.2839 0.3258 0.3491 0.4297 0.5059
2

From the table it is clear, that (a) U increases with atomic number of the element. In other words, higher atomic number

elements attenuate the X-ray beam to a greater degree than lower atomic number elements. (b) beam. U can be used to calculate the Mass per unit area (M) of a homogenous absorber irradiated at a specific incident X-ray energy. The lower energy beam is always attenuated to a greater degree than the higher energy

Table 2: Mass attenuation coefficients of some homogeneous absorber materials.

Component

U 40 keV 70 keV 0.5059 0.1942 0.1831 0.1872 0.3159

Ca Water Protein Fat(Oleic acid) Bone mineral

1.7920 0.2636 0.2363 0.2273 0.9039

2.4 Determination of Mass per unit area of a homogeneous absorber

When X-rays scan a 3-dimensional absorber such as a human being, it produces a 2dimensional flat image. Let us consider the X-ray image of a human leg.

Figure 2.5 X-ray image of a human leg. The square mark on the image represents an area of 1 cm

This is a flat 2-dimensional image of a real 3-dimensional leg. The image is made up of many small picture elements or pixels. Each pixel is uniform and represents a snap shot taken during the X-ray scan. Let us now consider a square of area 1cm2 on the image. The mass of
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bone and soft tissue below this square would represent the mass per unit area of the absorber, viz., leg. For instance, if there are 100 grams of bone and soft tissue below this square, the mass per unit area (M) would be 100 g/cm2. Knowledge of M of the human body components, especially of bone, is important in determining the possibility of osteoporosis.

Calculation of M:
From a knowledge of mass attenuation coefficient (U ) of the absorber and the energy of the incident X-ray beam (E0) and of the emerging beam (E), we can calculate M of a homogeneous absorber from the following relationship connecting these properties.

ln ( E0 / E ) = U x M M = ln ( E0 / E ) / U For instance, let us consider that we allow a 40 keV X-ray beam to pass through the absorber bone mineral, whose U value is 0.9039 cm2/g (see Table 2). Some of the energy will be lost due to Compton scattering and photoelectric effect. Let the emerging X-ray beam be attenuated to 10 keV. Then, the mass per unit area of this homogeneous absorber, bone mineral, is given by

M = ln (40/10) / 0.9039

= ( ln 4 ) / 0.9039 = 1.534 g /cm2

Thus using a single X-ray beam we are able to determine the mass of bone mineral in our sample. Unfortunately, a human body is not a homogeneous absorber since there are several different components in the body, such as fat, lean tissue, and bone

CHAPTER3 DEXA ANALYSIS OF HUMAN BODY COMPOSITION

While a mono energetic X-ray source is capable of measuring the areal density of a homogeneous absorber, a dual energy X-ray source is required to determine the areal densities of up to two components of an absorber. Before we discuss the DEXA body composition analysis, let us have a look at the various components of human body.

3.1 Components of a human body

Bone mineral Non-bone mineral Glycogen Proteins Water Fat

The sum of all these make up the body weight. These 6 components can be conveniently grouped into a 2-component system: Soft tissue mass and Bone mineral mass. Here soft tissue mass includes all the non-bone mass (items 2 to 6) made up of lean tissue mass (items 2 to 5) and fat tissue mass (item 6). In areas that contain no bone, the soft tissue component can be divided into its own 2component model consisting of Fat soft tissue and Lean soft tissue. By considering the body to be made up of a series of 2-component systems, DEXA can analyze each 2-component system separately and then combine the results for a complete body composition analysis

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Thus, when the dual energy X-ray beams are over a position of the body that contains no bone, DEXA can analyze the area for the 2 components, fat tissue mass and lean tissue mass. When the dual energy X-ray beams are over a position of the body that does contain bone, DEXA can analyse the area for the 2 components, soft tissue mass (fat and lean combined) and bone mineral mass. The fat and lean components of the bone-containing areas can then be deducted by a method that we shall discuss. This way, the human body can be regarded as consisting of 3 principal components viz., fat mass, lean mass and bone mass (see Figure 6) and these 3 components can be estimated by a 2-component technique using dual energy X-rays.

Figure 3.1 Human body composition

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3.2 A model of DEXA analysis

For convenience, we shall reduce the human example into a block of tissue containg the 3 components we are interested in. The left half of the block represents an area of tissue containg only soft tissue (fat + lean). The right half represents an area of tissue that contains both soft tissue and bone

Figure 3.2. A block of tissue

As the dual energy X-ray beams pass through the soft-tissue only region, the mass of the 2 components, fat tissue and lean tissue, can be determined. Similarly, as the dual energy X-ray beams scan through the bone + soft-tissue region, the mass of its 2 components, bone mineral and soft tissue, can be determined. The composition of the soft tissue over the bone is nearly the same as the composition of the soft tissue in the no-bone area. For instance, if the total soft tissue mass of the soft tissue only area is 10g and it contains 2g fat (known from scan), then we have the following results:

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No-Bone area

% Fat

= 2 x 100 /10 = 20

% Lean = 100 20 = 80 This composition of the soft tissue in the no-bone area is assumed to be the composition of the soft tissue in the bone area also. Thus, Bone area

Fat mass = 2g % Fat = 2 x 100 /10 = 20

% Lean = 100 20 = 80 If the total mass of the soft tissue in the bone area is 5g (known from the scan), then the fat mass of this area can now be calculated as

Bone area

% fat

= 20

soft tissue mass (from scan) = 5g

fat mass = 5 x 20/100 = 1g lean mass = 5 1 = 4g (Bone mass is also known from the scan) We have thus understood how 3 components of the body can be determined using a technique that can only measure 2 components at one time.

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CHAPTER4 ACTUAL DEXA CALCULATION

4.1The R-value
To understand this, we need to define a new term, namely R-value. R-value is simply the ratio of the low-energy attenuation coefficient to the high-energy attenuation coefficient. Let us return to Tables 1 and 2 to calculate the R values of some homogeneous absorbers. We get a column of R-values for these absorbers in relation to the 40 and 70 keV X-rays (see Tables 3 and 4 generated from Tables 1 and 2).
Table 3 : R values of some elements. Element Atomic number U (cm /g) 40 keV H C N O Na Mg P S Cl K Ca 1 6 7 8 11 15 15 16 18 19 20 0.3458 0.2047 0.2246 0.2533 0.3851 0.4704 0.7784 0.9509 1.1000 1.4840 1.7920 70 keV 0.3175 0.1678 0.1722 0.1788 0.2022 0.2244 0.2839 0.3258 0.3491 0.4297 0.5059 1.0891 1.2199 1.3043 1.4167 1.9045 2.0963 2.7418 2.9187 3.1600 3.4536 3.5422
2

R-value

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Table 4: R-values of some homogeneous absorber materials.

Component

U 40 keV 70 keV 0.5059 0.1942 0.1831 0.1872 0.3159

R-value

Ca Water Protein Fat(Oleic acid) Bone mineral

1.7920 0.2636 0.2363 0.2273 0.9039

3.5422 1.3574 1.2906 1.2136 2.8613

For absorbers composed of more than one component, the R-value is a function of mass attenuation coefficient of each component as well as the mass fraction of each component.

4.2Use of R-value
Using R-value, we can determine the mass fraction of each component in a 2-component system, if we also know the mass attenuation coefficients of each component. In fact, the Rvalue for soft tissue (made up of fat and lean) is linearly related to the amount of fat in the tissue. It decreases with increase in the fat content (see Figure ). Let us now consider a DEXA scanning experiment using a low-energy X-ray beam of energy 40 keV and a high-energy X-ray beam of energy 70 keV. The sample used is the block of tissue considered earlier. The DEXA detectors measure the energies of the attenuated X-ray beams emerging from the sample. Let us first scan through the soft tissue (ST) only area. The energy of the 40 keV beam has been attenuated to 0.358 keV and that of 70 keV to 2.291 keV. Now scan the bone (B) area. The energy of the 40 keV beam has been attenuated to 0.080 keV and that of 70 keV to 1.960 keV. The data collected may be represented as shown
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40 40

E0 = 40 keV

70 70

E0 = 70 keV

EST = 0.358 keV EB = 0.080 keV

EST = 2.291 keV EB = 1.960 keV

40

70

We have now collected all the necessary DEXA data to determine the composition of our tissue block. We need to know the mass attenuation coefficients and R-values for fat tissue (F), lean tissue (L) and bone (B). These are known from experiments and are given below.
40 40 40

UF = 0.23 cm /g
2

70 70

UF = 0.19 cm /g UL = 0.19 cm /g UB = 0.32 cm /g

2 2

RF = 1.211 RL = 1.421 RB = 3.125

UL = 0.27 cm /g
2

UB = 1.00 cm /g

70

We also need to know the mass attenuation coefficients and R-value for soft tissue (ST). These values will vary from subject to subject. (Recall the variation of soft tissue R value with the amount of fat in the subject.) So we have to determine them from our experimental results by the following procedure.

Calculation of RST:
We know, ln ( E0 / E ) = U x M Thus for 40 keV X-ray we have ln ( 40E0 / 40E ) = 40U x M Similarly, for 40 keV X-ray we have ln ( 70E0 / 70E ) = 70U x M

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Note that M, the mass per unit area of the tissue will not change with the energy of the radiation. Applying these equations for calculating the R value of the soft tissue, we obtain ln ( 40E0 / 40EST ) ----------------- = ln ( 70E0 / 70EST ) RST.
40

UST x MST UST x MST

40

UST UST

----------------70

------ = = RST
70

Thus, substituting the known values on the LHS, we can cal culate the value of

ln ( 40E0 / 40EST ) RST = ----------------ln ( 70E0 / 70EST ) =

ln ( 40 / 0.358) -----------------ln ( 70 / 2.291)

We can now calculate the % Lean content of the soft tissue from the equation % Lean = [(RST RF) / (RL RF)] x 100 = [(1.379-1.211) / (1.421-1.211)] x 100
= [0.168/ 0.21] x 100 = 80 % Fat = 20

Calculation of 40UST and 70UST :

40

UST = (Lean fraction) x 40UL + (Fat fraction) x 40UF UST = (Lean fraction) x 70UL + (Fat fraction) x 70UF

70

Substituting our experimental data, obtain 40UST = 0.262 cm2/g70UST = 0.19

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The summary of data so far developed

From DEXA scan

40 40

E0 = 40 keV

70 70

E0 = 70 keV

EST = 0.358 keV EB = 0.080 keV

EST = 2.291 keV EB = 1.960 keV

40

70

Experimentally known and calculated values

40 40 40 40

UF = 0.23 cm /g
2

70

UF = 0.19 cm /g UL = 0.19 cm /g UB = 0.32 cm /g

2 2 2

RF = 1.211 RL = 1.421 RB = 3.125 RST = 1.379

UL = 0.27 cm /g
2

70 70 70

UB = 1.00 cm /g
2

UST = 0.262 cm /g

UST = 0.19 cm /g

4.3Calculation of areal densities of the components :

Bone mineral density (MB): It is calculated using the equation, ln ( 40E0/ 40EB ) - RST x ln ( 70E0 / 70EB ) MB = ----------------------------------------------40

UB -

70

UB x RST

On substituting the valures we obtain MB = 2.30 g / cm2 Soft tissue density (MST), Lean tissue density (ML) and Fat tissue density (MF) over the bone: This is calculated using the expression ln ( 40E0/ 40EB ) - RB x ln ( 70E0 / 70EB ) MST = ----------------------------------------------40

UST -

70

UST x RB
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= 14.95 g/ cm2

We now assume that the composition of this soft tissue in the bone area is approximately equal to that of the adjacent soft tissue in the no-bone area:

% Lean of ST (No-bone area) = 80 % Fat of ST (No-bone area) = 20 So, % Lean of ST (Bone area)=808 % Lean of Fat (Bone area) ML (Bone area) = 80 = 20 = 14.95 x = 0.80 11.96 g/ cm2

MF (Bone area) = 14.95 x 0.20 = 2.99 g/ cm2 Soft tissue density (MST), Lean tissue density (ML) and Fat tissue density (MF) in the nobone area: Finally, we calculate the areal densities of the Lean and Fat tissue fractions of the ST only area using the same above formulas.

ML (No-Bone area) = 18 x 0.80 = 14.4 g/ cm2 MF (No-Bone area) = 18 x 0.20 = 3.6 g/ cm2 If we sum all the areal densities that we have calculated, we would obtain an accurate measurement of the total weight of our tissue block: MB ML (Bone area) MF (Bone area) = 2.3 g / cm2 = 11.96 g / cm2 = 2.99 g / cm2

ML (No-Bone area) = 14.4 g / cm2 MF (No-Bone area) = 3.6 g / cm2 -----------------------------------------------Total tissue weight = 35.25 g / cm2

Evidently, these are tedious calculations to do by hand. We have just shown the calculations with respect to one tissue. In reality, a very large number of tissues are to be
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scanned and then the results are to be consolidated. A computer is absolutely necessary to achieve this. In fact the technician operates the DEXA apparatus from a PC. After completing the scan, the data are analysed using the PC as well. It is possible to divide the scanned image into various regions of interest (ROIs) by properly positioning the cut lines. The DEXA software then analyzes each of the ROIs and generates a report of the composition of each of the ROIs , as well as the whole body analysis.

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CHAPTER 5 ADVANTAGES OF DEXA SCANNING

Dual Energy X-ray Absortiometry, or DEXA scanning, is currently the most widely used method to measure bone mineral density. For the test, a patient lies down on an examining table, and the scanner rapidly directs x-ray energy from two different sources towards the bone being examined. The X-ray source and the detector move in a coordinated rectilinear pattern over the patient. The mineral density of the patients bone weakens, or prolongs the transmission of these two sources of x-ray energy through a filter onto a counter in a degree related to the amount of bone mass present. The greater the bone mineral density, the greater the signal picked up by the photon counter. The use of the two different x-ray energy sources rather than more traditional radioisotope studies (such that would be used for a bone scan) greatly improves the precision and accuracy of the measurements. The DEXA images of hip and spine are shown below.

DEXA scanning has become the most widely used method for measuring bone mineral density for several reasons. When compared with radiographic absortiometry or single energy x-ray absortiometry, DEXA scanning more precisely documents small changes in bone mass and is also more flexible since it can be used to examine
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both the spine and the extremities. A scan of the spine, hip or the total body requires only one, two or four minutes respectively. Qualitative computed tomography (QCT) is the only technique that can directly measure bone density and volume but can distinguish trabecular from cortical bone. DEXA scanning is less expensive, exposes the patient to less radiation and is more sensitive and accurate at measuring subtle changes in bone density over time or in response to drug therapy than is QCT

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CONCLUSION
DEXA is the most commonly used modern technique to determine the bone density and hence the bone strength. The DEXA results help to predict the patients risk factors for osteoporosis. It is a fast, accurate, and less expensive technique. It exposes the patient to fewer amounts of Radiations. So the risk is reduced to a great extend. Studies using DEXA scanning have shown that women with osteoporosis have substantially lower bone density measurements than normal, age-matched women. Bone mineral density is widely accepted as a good indicator of bone strength. Thus low values can be compared against standard bone density measurements and help predict a patients risk for fracture based upon the DEXA scan measurements.

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REFERENCES
Blake, G. M. and Fogelman, I. Technical principles of dual energy X ray apsorptiometry. Semin. Nucl. Med. 27, 197209 (1997). Njeh, C. F., Fuerst, T., Hans, D., Blake, G. M. and Genant, H. K. Radiation exposure in bone mineral density assessment. Appl. Radiat. Isot. 50, 215236 (1999). Pludowski, Pawel; Lebiedowski, Michal; Lorenc, Roman S. (2004). "Evaluation of the possibility to assess bone age on the basis of DXA derived hand scans preliminary results".Osteoporosis International 15 (4): 31722 Van Der Sluis, I M; De Ridder, MA; Boot, AM; Krenning, EP; De Muinck Keizer-Schrama, SM (2002). "Reference data for bone density and body composition measured with dual energy x ray absorptiometry in white children and young adults".
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