Download PDF
Semin Musculoskelet Radiol 2024; 28(05): 620-627
DOI: 10.1055/s-0044-1788816
Review Article

Opportunistic Screening of Bone Fragility Using Computed Tomography

Julian B. Herrera Acevedo
1   Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
,
Leon Lenchik
1   Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
,
Ashley A. Weaver
2   Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, North Carolina
,
Robert D. Boutin
3   Department of Radiology, Stanford University School of Medicine, Stanford, California
,
Scott Wuertzer
1   Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Opportunistic screening uses existing imaging studies for additional diagnostic insights without imposing further burden on patients. We explore the potential of opportunistic computed tomography (CT) screening for osteoporosis, a condition affecting 500 million people globally and leading to significant health care costs and fragility fractures. Although dual-energy X-ray absorptiometry (DXA) remains the gold standard for diagnosing osteoporosis, > 50% of fractures occur in individuals not screened previously with DXA. With recent advancements in technology, CT has emerged as the most promising tool for opportunistic screening due to its wide use and the ability to provide quantitative measurements of bone attenuation, a surrogate of bone mineral density.

This article discusses the technical considerations, calibration methods, and potential benefits of CT for osteoporosis screening. It also explores the role of automation, supervised and unsupervised, in streamlining the diagnostic process, improving accuracy, and potentially developing new biomarkers of bone health. The potential addition of radiomics and genomics is also highlighted, showcasing the synergy between genetic and imaging data for a more comprehensive understanding of osteoporosis pathophysiology and with it possible novel osteoporosis therapies. The future of opportunistic CT screening holds significant promise, with automation and advanced image processing ultimately enhancing patient care, reducing rates of osteoporotic fractures, and improving patient outcomes.

Keywords

osteoporosis - computed tomography - dual-energy X-ray absorptiometry


Publication History

Article published online:
15 October 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Kanis JA, McCloskey EV, Johansson H, Oden A, Melton III LJ, Khaltaev N. A reference standard for the description of osteoporosis. Bone 2008; 42 (03) 467-475
    CrossrefPubMedSearch in Google Scholar
  • 2 Wu AM, Bisignano C, James SL. et al; GBD 2019 Fracture Collaborators. Global, regional, and national burden of bone fractures in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet Healthy Longev 2021; 2 (09) e580-e592
    CrossrefPubMedSearch in Google Scholar
  • 3 Clynes MA, Harvey NC, Curtis EM, Fuggle NR, Dennison EM, Cooper C. The epidemiology of osteoporosis. Br Med Bull 2020; 133 (01) 105-117
    PubMedSearch in Google Scholar
  • 4 United Nations. World population ageing 2020 highlights: living arrangements of older persons. . Available at: https://www.un.org/development/desa/pd/news/world-population-ageing-2020-highlights . Accessed July 15, 2024
    PubMed
  • 5 International Osteoporosis Foundation. Treatment. Available at: https://www.osteoporosis.foundation/patients/treatment . Accessed March 19, 2024
    PubMed
  • 6 Lenchik L, Weaver AA, Ward RJ, Boone JM, Boutin RD. Opportunistic screening for osteoporosis using computed tomography: state of the art and argument for paradigm shift. Curr Rheumatol Rep 2018; 20 (12) 74
    CrossrefPubMedSearch in Google Scholar
  • 7 Pickhardt PJ. Value-added opportunistic CT screening: state of the art. Radiology 2022; 303 (02) 241-254
    CrossrefPubMedSearch in Google Scholar
  • 8 des Bordes J, Prasad S, Pratt G, Suarez-Almazor ME, Lopez-Olivo MA. Knowledge, beliefs, and concerns about bone health from a systematic review and metasynthesis of qualitative studies. PLoS One 2020; 15 (01) e0227765
    CrossrefPubMedSearch in Google Scholar
  • 9 Epidemiology of Osteoporosis and Fragility Fractures. Available at: https://www.osteoporosis.foundation/facts-statistics/epidemiology-of-osteoporosis-and-fragility-fractures . Accessed March 21, 2024
    PubMed
  • 10 Organization for Economic Co-operation and Development. Data Explorer. Available at: https://data-explorer.oecd.org . Accessed March 19, 2024
    PubMed
  • 11 Radwan RW, Tang AM, Beasley WD. Computed tomography as a first-line investigation for elderly patients admitted to a surgical assessment unit. Ann R Coll Surg Engl 2018; 100 (04) 285-289
    CrossrefPubMedSearch in Google Scholar
  • 12 Laur O, Weaver MJ, Bridge C. et al. Computed tomography-based body composition profile as a screening tool for geriatric frailty detection. Skeletal Radiol 2022; 51 (07) 1371-1380
    CrossrefPubMedSearch in Google Scholar
  • 13 Boutin RD, Lenchik L. Value-added opportunistic CT: insights into osteoporosis and sarcopenia. AJR Am J Roentgenol 2020; 215 (03) 582-594
    CrossrefPubMedSearch in Google Scholar
  • 14 Lenchik L, Lenoir KM, Tan J. et al. Opportunistic measurement of skeletal muscle size and muscle attenuation on computed tomography predicts 1-Year mortality in Medicare patients. J Gerontol A Biol Sci Med Sci 2019; 74 (07) 1063-1069
    CrossrefPubMedSearch in Google Scholar
  • 15 Boutin RD, Bamrungchart S, Bateni CP. et al. CT of patients with hip fracture: muscle size and attenuation help predict mortality. AJR Am J Roentgenol 2017; 208 (06) W208-W215
    CrossrefPubMedSearch in Google Scholar
  • 16 Yu EW, Bouxsein ML, Roy AE. et al. Bone loss after bariatric surgery: discordant results between DXA and QCT bone density. J Bone Miner Res 2014; 29 (03) 542-550
    CrossrefPubMedSearch in Google Scholar
  • 17 Li N, Li XM, Xu L, Sun WJ, Cheng XG, Tian W. Comparison of QCT and DXA: osteoporosis detection rates in postmenopausal women. Int J Endocrinol 2013; 2013: 895474
    PubMedSearch in Google Scholar
  • 18 Black DM, Greenspan SL, Ensrud KE. et al; PaTH Study Investigators. The effects of parathyroid hormone and alendronate alone or in combination in postmenopausal osteoporosis. N Engl J Med 2003; 349 (13) 1207-1215
    CrossrefPubMedSearch in Google Scholar
  • 19 Löffler MT, Jacob A, Valentinitsch A. et al. Improved prediction of incident vertebral fractures using opportunistic QCT compared to DXA. Eur Radiol 2019; 29 (09) 4980-4989
    CrossrefPubMedSearch in Google Scholar
  • 20 Bergot C, Laval-Jeantet AM, Hutchinson K, Dautraix I, Caulin F, Genant HK. A comparison of spinal quantitative computed tomography with dual energy X-ray absorptiometry in European women with vertebral and nonvertebral fractures. Calcif Tissue Int 2001; 68 (02) 74-82
    CrossrefPubMedSearch in Google Scholar
  • 21 Boutin RD, Yao L, Canter RJ, Lenchik L. Sarcopenia: current concepts and imaging implications. AJR Am J Roentgenol 2015; 205 (03) W255-W266
    CrossrefPubMedSearch in Google Scholar
  • 22 Yu JS, Krishna NG, Fox MG. et al; Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J Am Coll Radiol 2022; 19 (11S): S417-S432
    CrossrefPubMedSearch in Google Scholar
  • 23 Wáng YXJ, Blake GM, Tang SN, Guermazi A, Griffith JF. Quantitative CT lumbar spine BMD cutpoint value for classifying osteoporosis among older East Asian women should be lower than the value for Caucasians. Skeletal Radiol 2024; 53 (08) 1473-1480
    CrossrefPubMedSearch in Google Scholar
  • 24 Bartenschlager S, Cavallaro A, Pogarell T. et al. Opportunistic screening with CT: comparison of phantomless BMD calibration methods. J Bone Miner Res 2023; 38 (11) 1689-1699
    CrossrefPubMedSearch in Google Scholar
  • 25 Engelke K, Chaudry O, Bartenschlager S. Opportunistic screening techniques for analysis of CT scans. Curr Osteoporos Rep 2023; 21 (01) 65-76
    CrossrefPubMedSearch in Google Scholar
  • 26 van Vugt JLA, Levolger S, Gharbharan A. et al. A comparative study of software programmes for cross-sectional skeletal muscle and adipose tissue measurements on abdominal computed tomography scans of rectal cancer patients. J Cachexia Sarcopenia Muscle 2017; 8 (02) 285-297
    CrossrefPubMedSearch in Google Scholar
  • 27 Barbalho ER, Rocha IMGD, Medeiros GOC, Friedman R, Fayh APT. Agreement between software programmes of body composition analyses on abdominal computed tomography scans of obese adults. Arch Endocrinol Metab 2020; 64 (01) 24-29
    PubMedSearch in Google Scholar
  • 28 Dillon C, Breeden W, Clements J. et al. American College of Radiology Computed Tomography Quality Control Manual. Available at: https://www.acr.org/-/media/ACR/Files/Clinical-Resources/QC-Manuals/CT_QCManual.pdf . Accessed July 15, 2024
    PubMed
  • 29 Lee SJ, Binkley N, Lubner MG, Bruce RJ, Ziemlewicz TJ, Pickhardt PJ. Opportunistic screening for osteoporosis using the sagittal reconstruction from routine abdominal CT for combined assessment of vertebral fractures and density. Osteoporos Int 2016; 27 (03) 1131-1136
    CrossrefPubMedSearch in Google Scholar
  • 30 Lee SJ, Pickhardt PJ. Opportunistic screening for osteoporosis using body CT scans obtained for other indications: the UW experience. Clin Rev Bone Miner Metab 2017; 15 (03) 128-137
    CrossrefPubMedSearch in Google Scholar
  • 31 Pickhardt PJ, Graffy PM, Perez AA, Lubner MG, Elton DC, Summers RM. Opportunistic screening at abdominal CT: use of automated body composition biomarkers for added cardiometabolic value. Radiographics 2021; 41 (02) 524-542
    CrossrefPubMedSearch in Google Scholar
  • 32 Carey JJ, Chih-Hsing Wu P, Bergin D. Risk assessment tools for osteoporosis and fractures in 2022. Best Pract Res Clin Rheumatol 2022; 36 (03) 101775
    CrossrefPubMedSearch in Google Scholar
  • 33 International Society for Clinical Densitometry. Official Positions. Available at: https://iscd.org/official-positions-2023 . Accessed March 19, 2024
    PubMed
  • 34 Gausden EB, Nwachukwu BU, Schreiber JJ, Lorich DG, Lane JM. Opportunistic use of CT imaging for osteoporosis screening and bone density assessment: a qualitative systematic review. J Bone Joint Surg Am 2017; 99 (18) 1580-1590
    CrossrefPubMedSearch in Google Scholar
  • 35 Boutin RD. et al. Understanding the role of muscle and body composition. Paper presented at the National Cancer Institute workshop; September 25–26, 2017; Bethesda, MD
    PubMed
  • 36 Szczykutowicz TP, DuPlissis A, Pickhardt PJ. Variation in CT number and image noise uniformity according to patient positioning in MDCT. AJR Am J Roentgenol 2017; 208 (05) 1064-1072
    CrossrefPubMedSearch in Google Scholar
  • 37 Lee MH, Liu D, Garrett JW. et al. Comparing fully automated AI body composition measures derived from thin and thick slice CT image data. Abdom Radiol (NY) 2024; 49 (03) 985-996
    CrossrefPubMedSearch in Google Scholar
  • 38 Morsbach F, Zhang YH, Martin L, Lindqvist C, Brismar T. Body composition evaluation with computed tomography: contrast media and slice thickness cause methodological errors. Nutrition 2019; 59: 50-55
    CrossrefPubMedSearch in Google Scholar
  • 39 Bae KT. Intravenous contrast medium administration and scan timing at CT: considerations and approaches. Radiology 2010; 256 (01) 32-61
    CrossrefPubMedSearch in Google Scholar
  • 40 Boutin RD, Kaptuch JM, Bateni CP, Chalfant JS, Yao L. Influence of IV contrast administration on CT measures of muscle and bone attenuation: implications for sarcopenia and osteoporosis evaluation. AJR Am J Roentgenol 2016; 207 (05) 1046-1054
    CrossrefPubMedSearch in Google Scholar
  • 41 Pompe E, Willemink MJ, Dijkhuis GR, Verhaar HJJ, Mohamed Hoesein FA, de Jong PA. Intravenous contrast injection significantly affects bone mineral density measured on CT. Eur Radiol 2015; 25 (02) 283-289
    CrossrefPubMedSearch in Google Scholar
  • 42 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 (01) 147-152
    CrossrefPubMedSearch in Google Scholar
  • 43 Link TM, Koppers BB, Licht T, Bauer J, Lu Y, Rummeny EJ. In vitro and in vivo spiral CT to determine bone mineral density: initial experience in patients at risk for osteoporosis. Radiology 2004; 231 (03) 805-811
    CrossrefPubMedSearch in Google Scholar
  • 44 Bauer JS, Henning TD, Müeller D, Lu Y, Majumdar S, Link TM. Volumetric quantitative CT of the spine and hip derived from contrast-enhanced MDCT: conversion factors. AJR Am J Roentgenol 2007; 188 (05) 1294-1301
    CrossrefPubMedSearch in Google Scholar
  • 45 Jang S, Graffy PM, Ziemlewicz TJ, Lee SJ, Summers RM, Pickhardt PJ. Opportunistic osteoporosis screening at routine abdominal and thoracic CT: normative L1 trabecular attenuation values in more than 20 000 adults. Radiology 2019; 291 (02) 360-367
    CrossrefPubMedSearch in Google Scholar
  • 46 Perez AA, Pickhardt PJ, Elton DC, Sandfort V, Summers RM. Fully automated CT imaging biomarkers of bone, muscle, and fat: correcting for the effect of intravenous contrast. Abdom Radiol (NY) 2021; 46 (03) 1229-1235
    CrossrefPubMedSearch in Google Scholar
  • 47 Schröder G, Andresen JR, Hiepe L. et al. Interobserver variability in the determination of bone mineral density in Hounsfield units from differently configured fields of measurement in the cancellous bone of vertebral bodies from elderly body donors. J Orthop 2023; 49: 48-55
    CrossrefPubMedSearch in Google Scholar
  • 48 Buenger F, Sakr Y, Eckardt N, Senft C, Schwarz F. Correlation of quantitative computed tomography derived bone density values with Hounsfield units of a contrast medium computed tomography in 98 thoraco-lumbar vertebral bodies. Arch Orthop Trauma Surg 2022; 142 (11) 3335-3340
    CrossrefPubMedSearch in Google Scholar
  • 49 Simion G, Eckardt N, Ullrich BW, Senft C, Schwarz F. Bone density of the cervical, thoracic and lumbar spine measured using Hounsfield units of computed tomography—results of 4350 vertebras. BMC Musculoskelet Disord 2024; 25 (01) 200
    CrossrefPubMedSearch in Google Scholar
  • 50 Buenger F, Eckardt N, Sakr Y, Senft C, Schwarz F. Correlation of bone density values of quantitative computed tomography and Hounsfield units measured in native computed tomography in 902 vertebral bodies. World Neurosurg 2021; 151: e599-e606
    CrossrefPubMedSearch in Google Scholar
  • 51 Baum T, Müller D, Dobritz M. et al. Converted lumbar BMD values derived from sagittal reformations of contrast-enhanced MDCT predict incidental osteoporotic vertebral fractures. Calcif Tissue Int 2012; 90 (06) 481-487
    CrossrefPubMedSearch in Google Scholar
  • 52 Papadakis AE, Karantanas AH, Papadokostakis G, Petinellis E, Damilakis J. Can abdominal multi-detector CT diagnose spinal osteoporosis?. Eur Radiol 2009; 19 (01) 172-176
    CrossrefPubMedSearch in Google Scholar
  • 53 Garner HW, Paturzo MM, Gaudier G, Pickhardt PJ, Wessell DE. Variation in attenuation in L1 trabecular bone at different tube voltages: caution is warranted when screening for osteoporosis with the use of opportunistic CT. AJR Am J Roentgenol 2017; 208 (01) 165-170
    CrossrefPubMedSearch in Google Scholar
  • 54 Lin M, Ridley L, Seibel MJ. Prediction of low DEXA T-scores by routine computed tomography body scans at different kilovoltage peaks. J Med Imaging Radiat Oncol 2023; 67 (06) 602-608
    CrossrefPubMedSearch in Google Scholar
  • 55 Merlijn T, Swart KMA, van der Horst HE, Netelenbos JC, Elders PJM. Fracture prevention by screening for high fracture risk: a systematic review and meta-analysis. Osteoporos Int 2020; 31 (02) 251-257
    CrossrefPubMedSearch in Google Scholar
  • 56 Barton DW, Behrend CJ, Carmouche JJ. Rates of osteoporosis screening and treatment following vertebral fracture. Spine J 2019; 19 (03) 411-417
    CrossrefPubMedSearch in Google Scholar
  • 57 Malik AT, Retchin S, Phillips FM. et al. Declining trend in osteoporosis management and screening following vertebral compression fractures—a national analysis of commercial insurance and Medicare Advantage beneficiaries. Spine J 2020; 20 (04) 538-546
    CrossrefPubMedSearch in Google Scholar
  • 58 Sabri SA, Chavarria JC, Ackert-Bicknell C, Swanson C, Burger E. Osteoporosis: an update on screening, diagnosis, evaluation, and treatment. Orthopedics 2023; 46 (01) e20-e26
    CrossrefPubMedSearch in Google Scholar
  • 59 Gyftopoulos S, Pelzl CE, Da Silva Cardoso M, Xie J, Kwon SC, Chang CY. Bone density screening rates among medicare beneficiaries: an analysis with a focus on Asian Americans. . Skeletal Radiol 2024
    PubMed
  • 60 Aggarwal V, Maslen C, Abel RL. et al. Opportunistic diagnosis of osteoporosis, fragile bone strength and vertebral fractures from routine CT scans; a review of approved technology systems and pathways to implementation. Ther Adv Musculoskelet Dis 2021; 13: 17 59720X211024029
    CrossrefPubMedSearch in Google Scholar
  • 61 Boutin RD, Hernandez AM, Lenchik L, Seibert JA, Gress DA, Boone JM. CT Phantom evaluation of 67,392 American College of Radiology accreditation examinations: implications for opportunistic screening of osteoporosis using CT. AJR Am J Roentgenol 2021; 216 (02) 447-452
    CrossrefPubMedSearch in Google Scholar
  • 62 Zhu Y, Triphuridet N, Yip R. et al. Opportunistic CT screening of osteoporosis on thoracic and lumbar spine: a meta-analysis. Clin Imaging 2021; 80: 382-390
    CrossrefPubMedSearch in Google Scholar
  • 63 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; 209 (02) 395-402
    CrossrefPubMedSearch in Google Scholar
  • 64 Pickhardt PJ, Graffy PM, Zea R. et al. Automated abdominal CT imaging biomarkers for opportunistic prediction of future major osteoporotic fractures in asymptomatic adults. Radiology 2020; 297 (01) 64-72
    CrossrefPubMedSearch in Google Scholar
  • 65 Lenchik L, Heacock L, Weaver AA. et al. Automated segmentation of tissues using CT and MRI: a systematic review. Acad Radiol 2019; 26 (12) 1695-1706
    CrossrefPubMedSearch in Google Scholar
  • 66 Blankemeier L, Desai A, Chaves JMZ. et al. Comp2Comp: Open-source body composition assessment on computed tomography. Available at: https://arxiv.org/abs/2302.06568 . Accessed July 15, 2024
    PubMed
  • 67 Reis EP, Blankemeier L, Chaves JMZ. et al. Automatic contrast phase detection on abdominal computed tomography using clinically-inspired techniques. Available at: https://openreview.net/forum?id=B8e-iS9j43 . Accessed August 9, 2024
    PubMed
  • 68 Löffler MT, Jacob A, Scharr A. et al. Automatic opportunistic osteoporosis screening in routine CT: improved prediction of patients with prevalent vertebral fractures compared to DXA. Eur Radiol 2021; 31 (08) 6069-6077
    CrossrefPubMedSearch in Google Scholar
  • 69 Dieckmeyer M, Löffler MT, El Husseini M. et al. Level-specific volumetric BMD threshold values for the prediction of incident vertebral fractures using opportunistic QCT: a case-control study. Front Endocrinol (Lausanne) 2022; 13: 882163
    CrossrefPubMedSearch in Google Scholar
  • 70 Sollmann N, Löffler MT, El Husseini M. et al. Automated opportunistic osteoporosis screening in routine computed tomography of the spine: comparison with dedicated quantitative CT. J Bone Miner Res 2022; 37 (07) 1287-1296
    CrossrefPubMedSearch in Google Scholar
  • 71 Rühling S, Schwarting J, Froelich MF. et al. Cost-effectiveness of opportunistic QCT-based osteoporosis screening for the prediction of incident vertebral fractures. Front Endocrinol (Lausanne) 2023; 14: 1222041
    CrossrefPubMedSearch in Google Scholar
  • 72 Keaveny TM, Clarke BL, Cosman F. et al. Biomechanical computed tomography analysis (BCT) for clinical assessment of osteoporosis. Osteoporos Int 2020; 31 (06) 1025-1048
    CrossrefPubMedSearch in Google Scholar
  • 73 Dailey HL, Kersh ME, Collins CJ, Troy KL. Mechanical biomarkers in bone using image-based finite element analysis. Curr Osteoporos Rep 2023; 21 (03) 266-277
    CrossrefPubMedSearch in Google Scholar
  • 74 Johannesdottir F, Allaire B, Bouxsein ML. Fracture prediction by computed tomography and finite element analysis: current and future perspectives. Curr Osteoporos Rep 2018; 16 (04) 411-422
    CrossrefPubMedSearch in Google Scholar
  • 75 Mühlberg A, Museyko O, Bousson V, Pottecher P, Laredo JD, Engelke K. Three-dimensional distribution of muscle and adipose tissue of the thigh at CT: association with acute hip fracture. Radiology 2019; 290 (02) 426-434
    CrossrefPubMedSearch in Google Scholar
  • 76 Wang L, Yin L, Yang M. et al. Muscle density is an independent risk factor of second hip fracture: a prospective cohort study. J Cachexia Sarcopenia Muscle 2022; 13 (03) 1927-1937
    CrossrefPubMedSearch in Google Scholar
  • 77 Ong W, Liu RW, Makmur A. et al. Artificial intelligence applications for osteoporosis classification using computed tomography. Bioengineering (Basel) 2023; 10 (12) 1364
    CrossrefPubMedSearch in Google Scholar