N u c l e a r M e d i c i n e a n d M o l e c u l a r I m a g i n g P i c t o r i a l E s s ay

Lorente-Ramos et al.
DEXA of Osteoporosis

Nuclear Medicine and Molecular Imaging

Pictorial Essay

Dual-Energy X-Ray Absorptiometry

in the Diagnosis of Osteoporosis:
A Practical Guide
Rosa Lorente-Ramos1 OBJECTIVE. The purpose of this essay is a quick and comprehensive review of dual-
Javier Azpeitia-Armn energy x-ray absorptiometry in the diagnosis of osteoporosis that shows how to achieve the
Araceli Muoz-Hernndez best performance in three steps.
Jos Manuel Garca-Gmez CONCLUSION. The three-step procedure for dual-energy x-ray absorptiometry in-
Patricia Dez-Martnez cludes image acquisition emphasizing proper patient positioning and regions of interest; anal-
ysis, including areas to scan and detection of artifacts that should be excluded from the analy-
Miguel Grande-Brez
sis and noted in the report because they can necessitate additional imaging; and interpretation
American Journal of Roentgenology 2011.196:897-904.

Lorente-Ramos R, Azpeitia-Armn J, Muoz- of results.

Hernndez A, Garca-Gmez JM, Dez-Martnez P,
Grande-Brez M

Keywords: bone mineral density, DEXA, dual-energy
x-ray absorptiometry, osteoporosis
DOI:10.2214/AJR.10.5416
Received July 30, 2010; accepted after revision
October 14, 2010.
1
All authors: Unidad Central de Radiodiagnstico de la
CAM, Hospital Infanta Leonor, Av gran Va del Este 80,
28031 Madrid, Spain. Address correspondence to
R. Lorente-Ramos (rosa.lorenteramos@salud.madrid.org).
AJR 2011; 196:897904
0361803X/11/1964897
American Roentgen Ray Society
D
ual-energy x-ray absorptiometry
(DEXA) is the technique of choice
in the assessment of bone mineral
density (BMD) [1], the average
concentration of mineral in a defined section of
bone [2]. DEXA is a quick method that is accu-
rate (exact measurement of BMD), precise (re-
producible), and flexible (different regions can
be scanned) and is performed with a low radia-
tion dose [3, 4]. Although other factors, such as
trabecular bone structure, are important, cen-
tral BMD measurements are helpful in the diag-
nosis of osteoporosis for estimating the risk of
nontraumatic fracture and in choosing and
monitoring treatments. Understanding every
step of the procedure is important for maximiz-
ing the usefulness of the imaging evaluation to
patients and referring clinicians.
A DEXA scanner consists of a low-dose
x-ray tube with two energies for separating
mineral and soft-tissue components and a
high-resolution multidetector array. The de-
vices have one of two different systems: a fan-
beam device that emits alternating high (140
kVp) and low (70100 kVp) x-rays and sweeps
across a scan area or a constant x-ray beam
with a rare-earth filter and energy-specific ab-
sorption, which separates photons of higher
(70 keV) and lower (40 keV) energy [5].
Image Acquisition
Areas Scanned
In adult patients, central DEXA measure-
ments of the lumbar spine and proximal femur
are recommended [6]. Two regions should be
measured so that if one is unevaluable, the
forearm can be imaged. For children (younger
than 20 years) only the lumbar spine is stud-
ied [7] because variability in femoral matura-
tion results in lack of reproducibility in the hip
region, so the reference database is available
only for the spine.
Lumbar spinePosteroanterior images
of the lumbar spine include vertebral bodies
L1L4 (Fig. 1A).
Proximal femurEither hip may be used for
DEXA of the proximal femur. The lowest-level
data on the femoral neck and total hip are used
for diagnosis (Fig. 1B). Total hip is the most
reproducible measurement of the hip.
ForearmThe forearm is used in three con-
ditions when the hip and spine cannot be mea-
sured or the data interpreted, in examinations
of patients with hyperparathyroidism and those
whose weight exceeds the limit for the table.
Primary hyperparathyroidism decreases
BMD, which is greater in structures with pre-
dominantly cortical bone as opposed to trabec-
ular bone. Recommendations include measure-
ment at the three sites (hip, spine, and radius)
for diagnosis and for follow-up after surgical
and medical treatment. The areas imaged are
total bone, one third of the radius, the ultra-
distal radius, and the ulna. The most useful
measurements are the ultradistal portion of
the radius as an indicator of trabecular bone
loss and the distal one third of the radius (distal
radial diaphysis, excluding the ultradistal por-
tion) as an indicator of cortical bone mineral
loss. According to the International Society

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for Clinical Densitometry [6], the distal one
third (33% radius) of the nondominant forearm
is the region of choice in the assessment of os-
teoporosis (Fig. 1C).
Appropriate Patient Positioning
Appropriate patient positioning is essential
for optimizing BMD measurement. The patients
are placed in the supine position for posteroan-
terior imaging of the lumbar spine (Fig. 2A) and
femoral neck (Fig. 2B) and sitting next to the ta-
ble for imaging of the forearm (Fig. 2C).
Image Assessment
Images are assessed for patient movement.
The area of interest exceeding 12 cm and su-
perior and inferior limits should be included
to verify that the complete anatomic region
is scanned. The bone axis should be straight
and centered (Fig. 1), and the lesser trochanter
should not be seen on images of the proximal
American Journal of Roentgenology 2011.196:897-904.
femur (Fig. 1B).
Analysis
Placement of Region of Interest
Equipment from various manufacturers gen-
erates automatic ROIs, which should be re-
viewed. Correct numbering of vertebral bodies
is the main goal in DEXA of the lumbar spine.
The indicators of correct positioning are as fol-
lows: the ribs appear at T12, the largest trans-
verse processes are L3, the vertebral area values
increase from L1 to L4, BMD increases from
L1 to L3, and the BMD of L4 is similar to or
slightly less than that of L3. Sometimes radio-
graphs are necessary for correlation. Altered
vertebrae (deformed or with lesions or artifacts
in them) should be excluded from the analysis.
If only one vertebral body is left, the region is
not useful for diagnosis. In hip scanning, it is
important to avoid undesired bone. The ana-
tomic landmark selected for femoral neck ROI
placement is the greater trochanteric notch
(Figs. 3A and 3B).
Pitfalls
Inappropriate patient positioningThe
most important source of false BMD mea-
surements is inappropriate patient positioning
(Figs. 4A and 4B). Longitudinal in vivo pre-
cision reflects variability due to positioning:
spine, 1.1%; femoral neck, 1.2%; trochanter
1.3% [8].
ArtifactsImages should be assessed for
artifacts, which should be excluded from the
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Lorente-Ramos et al.
ROI [9]. Artifacts include dense objects such
as piercings (Fig. 5A), catheters (Fig. 5B), and
surgical material (Fig. 5C); retained contrast
medium, such as barium (Fig. 6A) and myel-
ographic agents (Fig. 6B);and vertebroplasty
cement (Fig. 6C). Calcifications that do not
affect the analysis, such as calcified kidneys
(Fig. 7A), hydatid cysts (Fig. 7B), myomas,
and lithiasis, should be noted in the report
as incidental findings. Calcifications super-
imposed on the ROI, such as dermatomyosi-
tis (Fig. 8) and bone grafts (Fig. 9), should be
noted as causes of increased BMD.
DisordersMany diseases spuriously al-
ter BMD measurement. In analysis of the
lumbar spine, a greater than 1 point differ-
ence in T-score between two adjacent ver-
tebrae indicates a vertebra is abnormal, and
radiography is mandatory for diagnosis. De-
generation due to osteoarthrosis artifactually
increases spinal BMD in elderly patients and
causes several morphologic changes, such
as osteophytes (bone growths) and verte-
bral endplate reactions to degenerative disks
(Fig. 10). In the presence of fractures, BMD
is altered owing to higher bone density with a
smaller surface (Fig. 11). Lytic and sclerotic
bone lesions, such as metastatic lesions, lym-
phoma, bone islands (Fig. 12), lesions due to
Paget disease, hemangiomas, and dense pedi-
cles (Fig. 13), also are impediments to BMD
measurement. Diffuse diseases, such as an-
kylosing spondylitis and osteopetrosis, alter
osseous structure and bone density (Fig. 14).
Interpretation
The scanner calculates BMD in grams
per square centimeter. A reference database
is consulted, and values and curves are ob-
tained. The main parameters are T-score,
which represents the SD by which the BMD
differs from the mean BMD of a young adult
reference population of the same ethnicity and
sex, and Z-score, which is the SD by which
the BMD differs from the mean BMD of a
healthy population of the same ethnicity, sex,
and age as the person undergoing DEXA.
For estimation of fracture risk, it is gener-
ally accepted that each SD in T-score increas-
es risk by a factor of 2 [10]. According to the
World Health Organization, among postmeno-
pausal women and men 50 years old and old-
er, diagnosis is based on T-score, normal being
greater than 1.0; osteopenia, 1 to 2.5; and
osteoporosis, less than 2.5. Z-scores are used
in evaluations of premenopausal women, men
younger than 50 years, and children and teen-
agers (younger than 20 years) [6]. Osteoporosis
should not be diagnosed on the basis of densi-
tometric criteria alone [5]. A Z-score less than
2 indicates the diagnosis is below the expect-
ed range for age (adults) or low bone density for
chronologic age (children).
Conclusion
DEXA is a quick, accurate, low-cost imag-
ing method for the diagnosis of osteoporosis.
It comprises adequate performance (symme-
try, morphology, positioning), ROI placement,
detection of artifacts, pathologic evaluation
(incidental findings and those affecting analy-
sis), and evaluation of bone mineral density.
References
1. Lewiecki EM, Watts NB, McLung MR, et al. Of-
ficial positions of the International Society for
Clinical Densitometry. J Clin Endocrinol Metab
2004; 89:36513655
2. Wahner H. Technical aspects and clinical inter-
pretation of bone mineral measurements. Public
Health Rep 1989; 104[suppl]:2730
3. Cummings SR, Bates D, Black DM. Clinical use
of bone densitometry. JAMA 2002; 288:1889
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4. Lentle BC, Prior JC. Osteoporosis: what a clini-
cian expects to learn from a patients bone density
examination. Radiology 2003; 228:620628
5. Adams JE. Single and dual energy X-ray absorpti-
ometry. Eur Radiol 1997; 7:S20S31
6. Baim S, Binkley N, Bilezikian JP, et al. Official
position of the International Society for Clinical
Densitometry and executive summary of the 2007
ISCD position development conference. J Clin
Densitom 2008; 11:7591
7. Baim S, Leonard MB, Bianchi ML, et al. Official
positions of the International Society for Clinical
Densitometry and executive summary of the 2007
ISCD pediatric position development conference.
J Clin Densitom 2008; 11:621
8. Orwoll ES, Oviatt SK. Longitudinal precision of
dual-energy x-ray absorptiometry in a multicenter
study. The Nafarelin/Bone Study Group. J Bone
Miner Res 1991; 6:191197
9. Jacobson JA, Jamadar DA, Hayes CW. Dual X-ray
absorptiometry: recognizing image artifacts and
pathology. AJR 2000; 174:16991705
10. [No authors listed]. Assessment of fracture risk and
its application to screening for postmenopausal os-
teoporosis: report of a WHO study group. World
Health Organ Tech Rep Ser 1994;843:1129
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A B
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C
Fig. 152-year-old woman with hyperparathyroidism. Region of interest (ROI) and image assessment.
A, Posteroanterior dual-energy x-ray absorptiometric (DEXA) image of lumbar spine includes T12 and ribs, L5
and iliac bone, and straight and centered spine.
B, DEXA image of left proximal femur shows four ROIs are femoral neck, trochanter, intertrochanteric region,
and Ward triangle. Total hip image comprises four ROIs. Image includes all of femoral head and at least 1 cm
under region of lesser trochanter, which should not be seen owing to rotation. Femoral axis is straight.
C, DEXA image of left forearm. Most important ROI is one-third (1/3) radius (arrow). Image should include 2
cm of diaphysis over one third of forearm and part of carpal bones. Axis is straight and centered. BMD = bone
mineral density, UD = ultradistal.

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 Lorente-Ramos et al.

A B
Fig. 2Patient positioning.
A, Photograph shows position for posteroanterior imaging of lumbar spine: supine
with hips and knees flexed over support to reduce lordosis.
B, Photograph shows position for imaging of proximal femur: supine with lower
extremity internally rotated 1530 and slightly abducted to keep femoral axis
straight.
C, Photograph shows position for imaging of forearm: sitting beside table with
American Journal of Roentgenology 2011.196:897-904.

forearm resting on table, hand pronated and held by straps.

A B
Fig. 358-year-old menopausal woman with osteopenia. Green = normal, yellow = osteopenia; red = osteoporosis, BMD = bone mineral density, BMC = bone mineral
content, Sup = superior, Inf = inferior, Ward = Ward triangle.
A, Dual-energy x-ray absorptiometric (DEXA) image shows incorrect placement of region of interest (ROI) in which boundary includes bone other than area of interest
(femoral neck T-score, 2,6; total femur, 2).
B, DEXA image shows correct ROI placement. Equipment allows operator to reduce ROI size and change angulation according to morphologic features of femoral neck or
exclude area from analysis. T-score decreases with correct ROI placement (femoral neck T-score, 2.1; total femur, 1.8).

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 DEXA of Osteoporosis

A B
Fig. 473-year-old woman with osteopenia. Green = normal, yellow = osteopenia; red = osteoporosis, BMD = bone mineral density, BMC = bone mineral content, Sup =
superior, Inf = inferior, Ward = Ward triangle.
A, Dual-energy x-ray absorptiometric (DEXA) image of proximal femur shows inappropriate positioning of femoral head resulting in depiction of lesser trochanter (arrow)
and normal femoral neck T-score of 0.9.
B, DEXA image shows appropriate rotation in that lesser trochanter is not depicted (arrow). Modification of hip rotation to proper position results in femoral neck T-score
of 1.3, indicating presence of osteopenia.
American Journal of Roentgenology 2011.196:897-904.

Fig. 5Artifacts caused by dense objects.

A, 18-year-old girl with anorexia nervosa. Dual-
energy x-ray absorptiometric (DEXA) image
shows density superimposed on L4 (arrow) found
to be metallic removable piercing not noticed by
technologist. Examination was repeated after
removal of object, and L4 Z-score decreased from 1.6
to 3 and L1L4 Z-score from 1.7 to 3.
B, 65-year-old woman with enteric tube. DEXA image
shows dense structure (arrow) superimposed over L1
vertebral body. Exclusion of L1 from analysis changed
T-score from 1 for L1L4 to 1.2 for L2L4.
C, 68-year-old woman with spinal fixation. DEXA
image shows presence of surgical material over L4
L5 increases bone mineral density values (L3 T-score,
2.8; L4, 1.2). Exclusion of L4 changes T-score from
1.8 for L1L4 to 2.7 for L1L3. Green = normal,
yellow = osteopenia; red = osteoporosis, BMD = bone
mineral density, BMC = bone mineral content, D11
and D12 = T11 and T12.

A B

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A B

C
Fig. 6Artifacts caused by contrast material.
Green = normal, yellow = osteopenia; red = osteoporosis, BMD = bone mineral density.
A, 65-year-old woman who underwent barium examination of upper gastrointestinal tract day before dual-energy x-ray absorptiometric (DEXA). DEXA image shows
higher of T-score in L3 (1.6) than in adjacent vertebrae (L2, 3.3; L4, 1.1). Exclusion of L3 changes L1L4 T-score from 1.4 to 2.3. Because artifacts can be caused by
retained contrast material from previous examinations, every patient should be asked whether barium examination has been performed within past few days, and DEXA
should be postponed if it has.
B, 72-year-old woman with remote history of myelography. DEXA image shows densities overlying L3 and L5 caused by retained myelographic contrast medium from
examination performed 25 years ago. Area should be excluded from analysis. With exclusion of L3, L1L4 T-score changes from 2.1 to 2.5.
C, 75-year-old woman with osteoporotic L1 and L3 fractures sustained 1 year ago and managed with vertebroplasty. DEXA image shows T-scores are higher than for
adjacent vertebrae (L1, 0.2; L2, 3.5; L3, 1.2; L4, 4). Excluding L1 and L3 from analysis changes L1L4 T-score from 2.1 to 3.8.

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A B
Fig. 7Calcifications not affecting analysis.
A, 67-year-old-woman with calcified kidney. Dual-energy x-ray absorptiometric (DEXA) image shows previously unknown calcified nonfunctioning kidney. Radiograph
confirms finding.
B, 54-year-old woman with calcified hydatid cyst. DEXA image and radiograph show calcification that proved to be hepatic hydatid cyst.
American Journal of Roentgenology 2011.196:897-904.

Fig. 870-year-old woman with dermatomyositis. Dual-energy x-ray Fig. 967-year-old woman with bone graft. Dual-energy x-ray absorptiometric
absorptiometric image and radiograph show multiple seeming calcifications image and radiograph show area of laminectomy and calcified bone graft over
superimposed on left hip. Erroneous increase in bone mineral density (arrow) L4L5 vertebral bodies. Exclusion of L3 and L4 changes L1L4 T-score of 1.8 to
precludes analysis. L1L2 T-score of 1.6.

Fig. 1072-year-old woman with osteoarthrosis. Dual-energy x-ray absorptiometric
image shows artifactual increase in bone mineral density (arrow) in affected
vertebrae due to osteophytes and vertebral endplate reaction to degenerative disk.
Affected vertebrae have higher bone mineral density and T-score (L2, 1.0; L3, 0.8)
than adjacent vertebral bodies (L1, 1.7; L4, 2.4). BMD = bone mineral density,
green = normal, yellow = osteopenia; red = osteoporosis.
Fig. 1166-year-old woman with vertebral fracture. Dual-energy x-ray
absorptiometric image shows high-density L1 vertebral body of reduced size
consistent with vertebral fracture (arrow). Lateral radiograph of lumbar spine
confirms presence of fracture (arrow). Top = normal, center = osteopenia;
bottom = osteoporosis, BMD = bone mineral density.

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Fig. 1256-year-old woman with sclerotic bone island. Dual-energy x-ray

absorptiometric image and radiograph depict dense round area in trochanteric
region
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Fig. 1379-year-old woman with sclerotic vertebral pedicle. Dual-energy
x-ray absorptiometric image and radiograph show dense round area overlying
L4 vertebral body (solid arrows) that turned out to be left L4 sclerotic pedicle.
Cholecystectomy clips (open arrows) are evident. Green = normal, yellow =
osteopenia; red = osteoporosis, BMD = bone mineral density.
Fig. 1450-year-old woman with osteopetrosis. Posteroanterior dual-energy
x-ray absorptiometric (DXA) image of lumbar spine shows dense vertebrae with
high T-score at all levels. BMC = bone mineral content, BMD = bone mineral
density, CV = coefficient of variation, ACF = autocorrelation function, BCF = bias
correction factor, TH = total hip.

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