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## Complete Summary

#### GUIDELINE TITLE

Osteoporosis and bone mineral density.

#### BIBLIOGRAPHIC SOURCE(S)

Richmond BJ, Dalinka MK, Daffner RH, Bennett DL, JA Jacobson, Resnik CS,
Roberts CC, Rubin DA, Schweitzer ME, Seeger LL, Taljanovik M, Weissman
BN, Haralson RH, Expert Panel on Musculoskeletal Imaging. Osteoporosis
and bone mineral density. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2007. 12 p. \[62 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previous version: American College of Radiology (ACR),
Expert Panel on Musculoskeletal Imaging. Osteoporosis and bone mineral
density. Reston (VA): American College of Radiology (ACR); 2001. 17 p.
(ACR appropriateness criteria). \[49 references\]

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Osteoporosis

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Risk Assessment\
Screening

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Obstetrics and Gynecology\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of bone mineral density (BMD)
measurement procedures for osteoporosis

#### TARGET POPULATION

Patients at risk of developing osteoporosis

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Dual X-ray absorptiometry (DXA)

    -   Posteroanterior (PA) spine

    -   Proximal femur

    -   Femoral neck

    -   Total hip

    -   Forearm

    -   Lateral spine

    -   Total body calcium

    -   Vertebral fracture assessment (VFA)

2.  Quantitative computed tomography (QCT)

    -   Spine

    -   Proximal femur

3.  Peripheral quantitative computed tomography (pQCT)

4.  Single x-ray absorptiometry/dual energy x-ray absorptiometry
    (SXA/DXA)

    -   Heel

    -   Wrist

5.  Quantitative ultrasound (QUS)

    -   Heel

6.  X-ray

    -   Thoracic and lumbar spine

7.  Radiographic absorptiometry

8.  Height by stadiometer

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Osteoporosis and Bone Mineral Density**

**Variant 1: Identification of low bone density and fracture risk.
Females, postmenopausal, greater than 50 years old. Males greater than
50 years old with risk factors. All races.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  DXA PA spine          9                                              Min

  DXA proximal femur    9                                              Min
  and femoral neck and                                                 
  total hip                                                            

  QCT spine             8            Preferred method of evaluation if Min
                                     DXA not available or cannot be    
                                     performed.                        

  QUS heel              4            Can be used for preliminary       None
                                     evaluation of patients at risk    
                                     for fracture. If abnormal, DXA    
                                     may follow.                       

  DXA forearm           3            Only if hip/spine or hip/hip      Min
                                     can\'t be done or patient over    
                                     the table limit for weight.       
                                     Primary site for patients with    
                                     hyperparathyroidism.              

  SXA/DXA heel          3                                              Min

  QCT proximal femur    3            Limited clinical experience.      Min
                                     Currently, primarily a research   
                                     tool.                             

  pQCT                  2                                              Min

  X-ray thoracic or     2            Useful for diagnosing stress      Low
  lumbar spine                       fractures, not osteoporosis.      

  Radiographic          1                                              Min
  absorptiometry                                                       

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

-   World Health Organization (WHO) diagnostic criteria was originally
    made for 65-year-old postmenopausal women using DXA of the spine,
    femoral neck, and forearm, T-score.

-   ISCD position statements changed indications to 50-year-old males
    and postmenopausal females using the WHO diagnostic criteria.
    T-score and Z-score are used to further evaluate non-caucasian
    individuals with an age-matched reference data base.

-   Forearm scans are used for hyperparathyroidism primary site, obesity
    (over table limit), and as a second site if only one other is
    available. Preference is for two sites beginning with hip/AP spine;
    if spine cannot be scanned then use hip/hip; if only one hip is
    available then use hip/forearm or alternatively hip/total body.
    Total body is rarely used in adults, especially for follow-up unless
    total body composition is measured.

-   Fracture risk assessment is part of reporting BMD and should be a
    combination of clinical risk factors and BMD. Relative fracture risk
    should be defined as to what group the patient is being compared to
    -- young adult or age matched.

-   Any device above can predict fracture risk, but if the patient has
    had a DXA or QCT, the fracture risk should be based on that study.
    Once DXA or QCT is begun, a peripheral device should not be used.
    Conversely, if a patient is at risk with a peripheral device then
    DXA (preferably for diagnosis) or QCT should be performed and
    followed on that specific device. Once treatment has started then
    fracture risk is more difficult to estimate.

**Variant 2: Follow-up. Patients demonstrated to have risk for fracture
or low density.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  DXA PA spine          9                                              Min

  DXA proximal femur    9                                              Min
  and femoral neck and                                                 
  total hip                                                            

  QCT spine             8                                              Min

  DXA forearm           3            Response to treatment             Min
                                     significantly slower. Primary     
                                     site for patients with            
                                     hyperparathyroidism.              

  QCT proximal femur    3                                              Min

  DXA lateral spine     1            Low precision and inadequate      Min
                                     reference database                

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

-   Follow-up scans are after the diagnostic scan. BMD is compared in
    gm/cm^2^ -- NOT T-score or Z-score.

-   QCT reported in g/cm^3^.

-   Follow-up scans are used to determine bone loss or gain in patients
    at risk for loss and not taking treatment to help make a decision
    about treatment, or in patients undergoing treatment to determine
    compliance, efficacy.

-   An example of a patient who should have follow-up is one being
    treated with steroids.

-   The patient is followed every 2 years (postmenopausal women) until
    BMD stabilizes. Then follow-up can be lengthened unless risk factors
    or treatment changes.

**Variant 3: Identify low BMD. Premenopausal females with risk factors.
Males 20 to 50 years old with risk factors. All races.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  DXA PA spine          9                                              Min

  DXA proximal femur    9                                              Min
  and femoral neck and                                                 
  total hip                                                            

  QCT spine             8                                              Min

  QCT proximal femur    3                                              Min

  SXA/DXA heel          3                                              Min

  DXA forearm           2            Only if hip/spine or hip/hip      Min
                                     cannot be done or patient over    
                                     the table limit for weight.       
                                     Primary site for patients with    
                                     hyperparathyroidism.              

  QUS heel              2                                              None

  pQCT                  2            Limited usage in United States.   Min

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

-   WHO diagnostic criteria does not apply to this group, Z-score ONLY
    is used (2 standard deviation or more below age matched reference
    database) to determine whether BMD is below expected for age.

-   There are no fracture risk data for BMD in this age group.

-   Peripheral devices above determine fracture risk and suggest low
    BMD.

**Variant 4: Follow-up to low BMD. Premenopausal females with risk
factors. Males 20 to 50 years old with risk factors. All races.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  DXA PA spine          9                                              Min

  DXA proximal femur    9                                              Min
  and femoral neck and                                                 
  total hip                                                            

  QCT spine             8                                              Min

  QCT proximal femur    3                                              Min

  DXA lateral spine     2            Precision less than for PA spine. Min
                                     Technically demanding.            

  DXA forearm           1            Primary site for patients with    Min
                                     hyperparathyroidism.              

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

-   BMD in gm/cm^2^, NOT Z-score, is used for follow-up comparison.

-   QCT reported in g/cm^3^.

**Variant 5: Diagnosis. Males and females greater than 50 years old with
advanced degenerative changes of the spine +/- scoliosis.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  DXA proximal femur    9            When PA spine cannot be assessed, Min
  and femoral neck and               hip/hip (bilateral) scans should  
  total hip                          be performed. If only one hip is  
                                     available for assessment, hip and 
                                     forearm can be used.              

  QCT spine             8                                              Min

  DXA forearm           3            Appropriate site for patients     Min
                                     with hyperparathyroidism.         

  QTC proximal femur    3                                              Min

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

-   Spine cannot be used with more than 2 compression fractures. A
    minimum of 2 vertebral bodies is required for adequate assessment of
    BMD.

-   Follow-up and fracture risk assessment are the same as they are for
    previous variants for 50 year olds.

**Variant 6: Identify low BMD. Pediatric patients (less than 20 years
old) with risk factors.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  DXA total body        9                                              Min
  calcium                                                              

  DXA PA spine          6            Incomplete database information.  Min
                                     More useful in teens after fusion 
                                     of epiphyses.                     

  QCT spine             6            Should be performed in            Min
                                     experienced setting. Higher       
                                     radiation dose than DXA.          

  DXA total hip         3            Not useful before skeletal        Min
                                     maturity.                         

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

-   WHO diagnostic criteria does not apply. Z-score only is used (2
    standard deviations or lower than age-matched reference database) is
    to determine if BMD lower than expected for age.

-   Limited hip DXA database.

-   Reporting method for pediatric BMD is controversial at present.

**Variant 7: Follow-up. Pediatric patients (less than 20 years old) with
risk factors.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  DXA total body        9            BMD Z-score is used for diagnosis Min
  calcium                            on first scan. Bone mineral       
                                     content can be used for           
                                     follow-up.                        

  QCT spine             7                                              Min

  DXA PA spine          5            Most accurate in patients that    Min
                                     are skeletally mature.            

  DXA total hip         2            Most accurate in patients that    Min
                                     are skeletally mature.            

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

-   Follow-up in pediatrics is not defined. Clinical decisions determine
    follow-up except for steroid treated patients who are scanned at the
    same interval at any age.

-   Confounding factors in follow-up of these patients are a changing
    area because of increasing size of bone and how to determine if BMD
    change is real, QCT avoids this pitfall because of volumetric
    measurement.

-   Very little data are available for hip DXA.

**Variant 8: Suspected fracture, incident or prevalent, of a vertebral
body based on clinical history, height loss, or patient treated with
steroids.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  DXA VFA               9            Point of service, generally       Min
                                     limited to T7-L4.                 
                                     Semi-quantitative and morphology. 
                                     Learning curve.                   

  X-ray thoracic and    8            High radiation dose, high cost.   Low
  lumbar spine                                                         

  Height by stadiometer 4            Indicated height loss that may be None
                                     related to vertebral fractures.   

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

-   Identification of incident or prevalent vertebral fracture indicates
    increased risk for additional vertebral or other fragility fractures
    in the following year and should influence therapy.

-   VFAs reduced radiation, lower cost, and point of service, make it
    preferable over spine radiographs as an initial evaluation unless it
    is contraindicated.

**Summary of Literature Review**

Noninvasive measurement of bone mineral density (BMD) is a technology
that benefits both the patient (as are mammography, blood pressure
testing, and cholesterol measurement) and society through its potential
to decrease the morbidity, mortality, and cost of fractures associated
with osteoporosis through early detection and treatment.

Bone densitometry is the only technology available for accurately
measuring of bone mass or predicting fracture risk. Bone measurements
have been shown to predict fracture risk as well as or better than
cholesterol measurements predict the risk of heart disease or blood
pressure measurements predict the risk of stroke. This unique ability of
bone densitometry to predict fracture risk makes it an important tool
for disease prevention. Before its advent, the diagnosis of osteoporosis
depended on the presence of a fragility fracture. With the ability to
measure bone mass and the recognition of the relation between reductions
in bone mass and increases in fracture risk, the diagnosis of
osteoporosis, using World Health Organization (WHO) criteria modified by
International Society for Clinical Densitometry (ISCD) to apply to males
and females of all races over 50 years of age, can and should be made
according to the level of bone mass as determined by BMD before
fractures occur. Osteoporosis cannot be diagnosed by BMD in individuals
less than 50 years of age using the modified WHO criteria. The only
statement that can be made is that if the Z-score (the age-matched
database recommended by ISCD for evaluating patients younger than age
50, including pediatric patients) is more than 2 standard deviations
below the mean, the BMD is below the expected range for age.
Osteoporosis is a clinical diagnosis in patients under age 50.
Appropriate etiologies should be investigated (secondary causes for low
BMD are numerous), appropriate interventions applied, and appropriate
longitudinal monitoring initiated.

Complete assessment of fracture risk and an estimation of benefit from
interventions designed to reduce fracture risk should be based on a
patient\'s current relative fracture risk, as determined by measured
BMD. Relative fracture risk has been determined using T-score and
Z-score. When reporting relative fracture risk, the reference group used
must be identified. Ten year fracture probability is the most current
proposal for reporting fracture risk and in part depends upon clinical
risk factors and BMD. Assessment of appropriate treatment can be made
using fracture risk as long as the parameters of the fracture risk are
defined.

In specific clinical circumstances, BMD can provide otherwise
unobtainable information that is necessary to the clinical
decision-making process. In 1989, a subcommittee of the Scientific
Advisory Board of the National Osteoporosis Foundation (NOF) described
four clinical situations in which knowledge of the patient\'s bone mass
or fracture risk could affect clinical management decisions. These risks
included estrogen deficiency, vertebral abnormalities or suspected
osteopenia on plain radiography, asymptomatic primary
hyperparathyroidism, and long-term corticosteroid therapy if dosage
adjustments could be made or other treatment could be initiated to
prevent bone loss. Numerous other potential causative factors for low
bone mass can be found in the NOF Physicians Guide to Osteoporosis.

Since the NOF originally published its recommendations, clinical
experience in establishing the precision of newer BMD measurement
techniques has grown so that serial measurements to determine the
efficacy of treatments for osteoporosis are also feasible. Also,
knowledge of a patient\'s bone mass may affect clinical management after
organ transplantation.

Estrogen-deficient women constitute one of the largest patient
populations potentially affected by these recommendations. Women are
more likely to initiate preventive measures for osteoporosis if they are
aware of the presence of low bone mass. BMD measurement may help an
individual decide whether to begin therapy with selective estrogen
receptor modulators (SERMS), or in the appropriate setting of
postmenopausal symptoms, with hormone replacement therapy. Other
therapies may be offered depending upon the density and clinical
factors. In general, a single bone density test can be an extremely
powerful tool for patient education and compliance with lifestyle
modification and drug therapy. Hence, bone density testing is currently
recommended to determine whether pharmacologic intervention is indicated
and to establish individual compliance and response in treated patients.
The testing, if done in the immediate postmenopausal period, should be
performed every 2 years until the possibility of rapid bone loss has
been determined or BMD stabilizes on treatment, or, if necessary, to
demonstrate continued bone loss (if it occurs) so a patient can
determine whether or not to begin therapy.

**Guidelines for the Clinical Utilization of BMD Measurement in the
Adult Population**

An international panel of authorities on BMD headed by Paul D. Miller,
MD, Sydney Bonnick, MD, and Clifford Rosen, MD, of the ISCD (see
Appendix I for panel members) reached a consensus on the important
issues that face physicians who will be ordering, performing, or
interpreting BMD measurement for the diagnosis of low bone mass in the
adult population. These authors developed guidelines to help physicians
use BMD measurement in clinical decision-making. Official positions of
the ISCD for BMD practice can be found on the ISCD.org website. The most
recent position statements were developed in 2005. Many aspects of BMD
measurement and reporting are covered.

The WHO guidelines formed the basis for defining osteoporosis based on
levels of low bone mass in patients who have not yet suffered fracture
based on dual energy x-ray absorptiometry (DXA) of the spine and femoral
neck, and single photon absorptiometry (SPA) of the forearm. These
guidelines on BMD measurement are best defined for Caucasian
postmenopausal women in whom the risk of osteoporosis is greatest. In
addition, the ISCD provided practical guidelines for clinicians to use
in assessing which patients should be tested, what changes in bone mass
are relevant to define response, what skeletal site(s) should be
measured, what techniques should be used, and how clinical reports can
enhance the value of BMD. These diagnostic and utilization guidelines
will be followed soon by treatment and intervention guidelines. This
complete compendium of information will form the basis of clinical
decision-making in caring for patients with low bone mass.

Individual scanner protocols for sites to be scanned are encouraged. The
protocols should be agreed upon with referring physicians and/or
hospitals so that a predictable study outcome will occur. In general,
two sites are measured, spine and a hip. If one of these sites cannot be
measured, the protocol should outline the next site to be used. Having a
protocol should not preclude specific requests by referring physicians
who know the patient clinically and manage the care. For instance, a
forearm may be ordered in a patient with hyperparathyroidism. If an
order is not consistent with protocol without a reasonable clinical
indication, an action plan should be developed in the protocol to ensure
the scan is warranted clinically. Communication with the referring
physician should be part of the protocol.

Scans of the anteroposterior (AP) spine and hip are generally performed.
In the event of vertebral fracture, 2 or 3 vertebral fractures can be
used to assess BMD. If degenerative change or multiple fractures exclude
use of AP spine scan, then both hips can be scanned. If only one hip is
available, then a hip and forearm scan can be used. The forearm is best
for evaluating hyperparathyroidism. In general, the bone loss in senile
or hormonal related osteoporosis is less and slower in the forearm
unless the loss is rapid or aggressive and the response to therapy is
slower.

BMD predicts a patient\'s future risk of fracture**.** The ability of
bone mass to predict future fracture risk is as valuable as cholesterol
testing or blood pressure measurements are for predicting heart attack
or stroke and they should be used more widely to identify at-risk
patients. Osteoporosis can be diagnosed on the basis of BMD even in the
absence of prevalent fractures. Diagnosing osteoporosis before a
fracture occurs is important concept advancement. It is justified by the
recognized inverse and exponential relationship between low bone mass
and future fracture risk and the exceedingly high risk observed for a
second fracture once the first fracture has occurred.

The identification of individuals with high risk of fracture is
performed on many types of scanners. The diagnosis of osteoporosis can
only be made using WHO criteria with DXA scans. Quantitative computed
tomography (QCT) can identify patients with low BMD compared to the QCT
reference database and can identify patients at risk for fracture. QCT
cannot be used to diagnose osteoporosis based on the quantitative BMD
value obtained, since it has never been validated for WHO criteria. It
is, however, the only other technology besides DXA that is approved for
following treatment.

If a patient is originally scanned on DXA but cannot be followed on that
scanner and QCT is available, it can be used with the understanding that
the first scan becomes the new baseline for the QCT and follow-up is
based on this baseline.

BMD measurement provides information that can affect the management of
patients. It should be performed in any patient of any age or sex when
the result will influence clinical decisions. The clinical decisions
that may follow the results are diverse but include whether to initiate
hormonal replacement therapy, to diagnose osteoporosis in a young
fracturing amenorrheic athlete, or to monitor longitudinal changes in a
patient receiving pharmacological therapy to prevent or treat
osteoporosis. There are, therefore, a wide variety of clinical decisions
that can be made more objectively with knowledge of BMD measurement
results.

Choice of the appropriate site(s) for assessing bone mass or fracture
risk may vary, depending on the specific circumstances of the patient.
Because bone mass is discordant in the younger, perimenopausal
population, if the first skeletal site measured is normal, it may be
necessary to measure a second skeletal site to make an accurate
diagnosis. Measuring more than one skeletal site may also be necessary
if artifacts invalidate a particular site. Decisions about which site to
measure and how many sites to measure should be the clinician\'s choice.
In general, because cancellous bone changes more rapidly than cortical
bone over time or with therapeutic intervention, cancellous bone sites
(axial skeleton) may be the preferred sites to measure, though cortical
bone sites (mid radius, femoral neck) may also prove valuable and
independent data. Also, when performing serial measurements in patients
to monitor the natural course of bone loss (or gain) or the response to
pharmacological intervention, clinicians must know if the changes are
real or within the precision error of a particular measurement and a
particular technique. Total body calcium measurement by DXA has the best
precision of any site measured by this technology. It is not reimbursed
and best performs in the pediatric population. Generally trabecular bone
densitometry (TBD) is used for research. No good standard calibration
phantom exists for TBD. This is a workable alternative if the proximal
femur, spine, or both cannot be evaluated owing to degenerative disease,
orthopedic hardware, or both, providing the best estimate of global
fracture risk***.*** Body composition data can also be derived from
these scans.

Choice of the appropriate technique for BMD measurement in any given
clinical circumstance should be based on an understanding of the
strengths and limitations of the different techniques. All BMD
techniques are good for identifying patients at risk for fracture. The
choice of which treatment(s) to use for any patient should also be at
the discretion of the physician. In most countries, DXA is the most
widely used technique because of its low precision error, low radiation
exposure, large clinical experience, and capacity to measure multiple
skeletal sites. However, other techniques such as QCT, ultrasound,
single x-ray absorptiometry (SXA) of the wrist or calcaneus, peripheral
quantitative computed tomography (pQCT), or hand radiogrametry are
valuable and may offer information not assessed by DXA. Some of these
lower-cost techniques may be used to identify a larger percentage of the
population at risk for fracture and low bone mass. Whatever technique is
used, quality control and quality assurance are paramount for providing
competent patient assessment, including appropriate physician and
technologist training. In situations where DXA is not readily accessible
to the target population, such as in small rural practices, QCT is the
best alternative test, because body CT scanners are widely available.
Although QCT (unlike DXA) can selectively evaluate high-turnover
cancellous bone and is the best predictor of vertebral fracture risk,
its relative disadvantages include higher radiation dose, lower
precision, accuracy, and speed, and lower patient throughput because it
is not performed on dedicated densitometric equipment. It should be
noted that DXA scanners can be successfully mobilized to facilitate
patient access.

BMD technologies are not interchangeable. A patient cannot be scanned on
DXA and then followed by QCT without establishing a baseline on QCT. The
ISCD recommendation is to scan the patient on the same scanner as the
original baseline for all follow-up scans.

**Quantitative Computed Tomography**

QCT was developed in the late 1970s by comparing bone to a series of
standard liquids in a phantom for which bone density equivalence had
been established. Most systems today use liquid or solid phantoms,
although there is a phantomless system using muscle and fat in the
patient as a comparative standard. In comparison to DXA, QCT provides a
true volumetric measurement of bone milligrams per cubic centimeter
(mg/cm^3^). It measures trabecular bone density separately from cortical
bone. In a two-dimensional QCT scan, the calibration phantom is placed
under the patient\'s back while the body is scanned. A computed
radiographic localizer view is obtained to determine the levels of L1 to
L3, and each vertebral body is imaged with 1.0-cm section thickness. BMD
is then calculated by comparing the spine scan results to the calibrated
standards. While this technique is accurate, the reproducibility
(precision) can be diminished by variability of slice sampling. The
advent of spiral CT scanners and 3-D software that acquire true
volumetric images has improved reproducibility. There is also software
for measuring the hip that can evaluate cortical, trabecular, and total
bone density. The addition of hip measurement by CT greatly expands the
diagnostic utility of QCT. The diagnostic utility of QCT is to identify
trabecular loss early, but the WHO criteria cannot be applied, and
osteoporosis cannot be diagnosed on the BMD value alone. Patients can be
identified as having low BMD and followed for treatment or bone loss.

Trabecular bone is metabolically more active than cortical bone, and is
the most sensitive indicator of early bone loss and vertebral fracture
risk. There is a strong association between vertebral fracture and
spinal trabecular BMD as measured by QCT. QCT has been shown to have the
strongest ability to discriminate between healthy postmenopausal women
and those with vertebral fractures. Spinal trabecular BMD also
correlates with trochanteric fracture risk. QCT may be useful in
patients with severe scoliosis, facet disease, or hypertropic
arthropathy, in whom DXA scans of the spine will yield spuriously
elevated density. It may also be more accurate for obese or exceedingly
small individuals for whom the assumptions made in DXA calculations
regarding soft tissue may be inaccurate.

Areal measurement of BMD versus true volumetric measurement may also
affect the accuracy of areal BMD calculations due to their dependence on
body size. Increased bone marrow fat content in the very elderly may
exaggerate diminished bone density on QCT, as a single energy
measurement (SEQCT). This uncertainty related to fat is far lower than
the expected biological variation in the normal population. Also the
normal database of SEQCT accounts for most variability of marrow fat
with age. Radiation dosage from QCT, although higher than the dosage
from pencil-beam DXA, is still quite modest when the scan is performed
correctly.

**Peripheral BMD Measurements**

Peripheral BMD measurements, including radiographic absorptiometry (RA)
and peripheral DXA and QCT (pDXA and pQCT), are becoming more readily
available as techniques to identify people at risk from fracture and low
bone mass. Peripheral quantitative ultrasound (QUS), in particular, has
been adopted in primary care due to its low cost, portability, ease of
use, and lack of ionizing radiation. An international consensus group
has reviewed the technology, and standards have been established to
define patients at risk based on standard or modified T scores obtained
with this technology.

Peripheral QUS can assess fracture risk in a manner similar to other
peripheral BMD measures. Its capacity for assessing rates of change or
for monitoring response to therapy has not yet been established. Because
it does not measure BMD but rather speed of sound, which may be a
parameter of a different quality of bone strength, it may yield
additional information regarding fracture risk. However, without
specific guidelines to determine whether central testing is necessary,
some patients with low bone mass may be missed because their peripheral
scans are \"normal\". QUS should be used only in screening appropriate
patients--postmenopausal and elderly who have not had a DXA and are
unable to reach a DXA scanner easily because of rural location. This
technology is used most frequently in health fairs or other screening
events, and if a patient is identified as having an increased risk of
fracture he or she should be referred for DXA to confirm the risk of
fracture and provide a diagnosis. The DXA then establishes a baseline
and follow-up can be performed. QUS can have false negatives and
positives depending on the technology and its age. If a patient has
multiple risk factors for fracture or low BMD he or she should be
referred for DXA evaluation even if QUS is within normal limits. The use
of QUS should be extremely limited with the number of DXA scanners
available.

Peripheral QCT measures cortical and/or trabecular bone in the
ultradistal radius and tibia. It may provide information regarding bone
strength and may be particularly beneficial in the pediatric population
because it measures BMD independently of bone size and with low
radiation exposure. Patients at high risk with intermediate levels of
peripheral BMD should probably have axial measurements in addition.
However, more research is necessary to define the optimal algorithms for
selecting peripheral versus central BMD measures as well as for
selecting appropriate diagnostic and treatment thresholds for all types
of densitometry methods and for all manner of patients.

BMD testing should be accompanied by a clinical interpretation. The
computer printout data provided by BMD equipment manufacturers do not
fully provide the type of clinical information that the primary care
physician needs in order to direct patient care. BMD results have wide
implications for clinical decisions in the care of patients with low
bone mass and may lead to broader diagnostic and therapeutic
interventions than can be provided by blood pressure measurements or
blood chemistry results. A brief narrative report that correlates the
bone-mass measurement to a technician-obtained patient questionnaire
database can allow the clinician interpreting the BMD results to suggest
wider diagnostic and intervention possibilities to the primary care
physician. In pediatric patients with risk factors for low bone mass, it
is mandatory that DXA scans be performed using specialized pediatric
software provided by the equipment manufacturer.

**BMD in Men**

Recent recognition of osteoporosis as a significant health problem in
men, usually related to secondary causes and worsening with age, has
raised awareness for the need to assess this population for BMD in the
appropriate setting. Prior to age 50, only the Z-score should be used.
After age 50, the T-score is used with WHO criteria for diagnosis.
Reference databases should be male.

**BMD in Premenopausal Women and Children**

Specific reasons for evaluating premenopausal women and children should
exist before performing the density measurement. Potential for
misdiagnosis exists. Steroid treatment, eating disorders, amenorrhea and
genetic disorders are among the reasons to evaluate this group.
Reporting of pediatric BMD is controversial. Debate as to the utility of
DXA and QCT is ongoing. Appropriate age-matched and pediatric databases
are required, but have limited data at this time.

**Vertebral Fracture Assessment**

Vertebral fracture assessment (VFA) is a relatively new application for
DXA scanners that allows evaluation for occult fractures of the spine at
the time the patient is being evaluated for BMD. The term VFA is used to
identify the assessment for billing, approved by Medicare, since
manufacturers have used several other proprietary names for the same
technique. Vertebral fractures are the most common osteoporotic
fracture. Traditionally x-rays of the thoracic and lumbar spine are used
to identify compression fracture if fracture is suspected. The radiation
dose and cost of x-rays are significantly higher than those of VFA. The
problem is that up to 70% of osteoporotic compression fractures are
asymptomatic. The importance of identifying these fractures is that they
are predictors for future fracture, that increase with the severity and
number of fractures identified. The identification of fracture also
changes the acuity of treatment for osteoporosis. Many patients with
fractures have an osteopenic BMD, but the presence of a fracture then
changes the diagnosis to osteoporosis. Prevention of further fracture is
cost effective.

Less severe grade 1 fractures may be difficult to identify, and if there
is only one present, there is much less risk of subsequent fracture.
Grades 2 and 3 fractures are readily identified. The technique is
usually limited to T7-L4, however the overwhelming majority of the
osteoporotic fractures occur at these levels.

Criteria for use of VFA include: documented height loss of greater than
2 cm or reported height loss of 4 cm since age 21; history of a fracture
after age 50; treatment with long term steroids; undocumented history of
back pain suspicious for vertebral fracture. (For ISCD position
statements see [www.iscd.org](http://www.iscd.org/).)

The evaluation for VFA uses the Genant semiquantitative analysis
technique with morphometry, semi-automated, as an adjunct in difficult
cases.

**Summary of Key Recommendations**

BMD measurement is used to identify patients with low bone density and
increased fracture risk. DXA is the gold standard and the only BMD
technology for which WHO criteria for diagnosis of osteoporosis,
originally for postmenopausal Caucasian women over age 65, can be used.
ISCD has expanded the diagnostic category to include patients over age
50 of any race or gender (ISCD position statement). The sites that are
used for diagnosis are the AP spine, femoral neck (ISCD includes total
hip, and forearm \[distal one-third radius\]). Follow-up for treatment
can be performed using DXA and QCT only. All other measurements are
peripheral and for identifying individuals at risk for fracture and low
BMD (pDXA, pQCT, SXA, QUS). Hyperparathyroidism is an exception to
routine BMD testing where the forearm is essential for diagnosis.
Another exception is pediatric patients where DXA can measure spine, but
total body calcium is preferred because it helps reduce the issue of
following patients with growing bones.

T-scores are used for men and women after age 50 or menopause to make a
diagnosis and assess fracture risk. Z-scores are used for all
individuals under age 50 to determine low bone density. Fracture risk is
not assessed based on BMD in individuals under age 50. No agreed upon
fracture risk assessment exists. Multiple ways of expressing fracture
risk do exist and each needs to be used defining the reference data. WHO
and NOF will, in the near future, provide a 10-year absolute fracture
risk model that will be available for DXA software. Other modalities
have variable fracture risk based on the study in which the relative
risk of fracture was developed. Vertebral fracture assessment can be
performed with DXA at the point of service at a lower cost and with less
radiation than x-rays. Identification of a prevalent vertebral fracture
has an independent risk for future fracture in the following year. Each
additional fracture significantly raises the risk of another
osteoporotic fracture.

**Abbreviations**

-   BMD, bone mineral density

-   DXA, dual x-ray absorptiometry

-   Min, minimal

-   QCT, quantitative computed tomography

-   PA, posterior-anterior

-   pQCT, peripheral quantitative computed tomography

-   SXA, single x-ray absorptiometry

-   QUS, quantitative ultrasound

-   VFA, vertebral fracture assessment

-   WHO, World Health Organization

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate selection of bone mineral density (BMD) measurement
procedures to evaluate patients at risk for osteoporosis or to diagnose
osteoporosis

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Richmond BJ, Dalinka MK, Daffner RH, Bennett DL, JA Jacobson, Resnik CS,
Roberts CC, Rubin DA, Schweitzer ME, Seeger LL, Taljanovik M, Weissman
BN, Haralson RH, Expert Panel on Musculoskeletal Imaging. Osteoporosis
and bone mineral density. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2007. 12 p. \[62 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1998 (revised 2007)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Musculoskeletal
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Bradford J. Richmond, MD; Murray K. Dalinka, MD;
Richard H. Daffner, MD; D. Lee Bennett, MD; Jon A. Jacobson, MD; Charles
S. Resnik, MD; Catherine C. Roberts, MD; David A. Rubin, MD; Mark E.
Schweitzer, MD; Leanne L. Seeger, MD; Mihra Taljanovic, MD; Barbara N.
Weissman, MD; Robert H. Haralson III, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previous version: American College of Radiology (ACR),
Expert Panel on Musculoskeletal Imaging. Osteoporosis and bone mineral
density. Reston (VA): American College of Radiology (ACR); 2001. 17 p.
(ACR appropriateness criteria). \[49 references\]

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/OsteoporosisandBoneMineralDensityUpdateinProgressDoc17.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx).

-   ACR Appropriateness Criteria®. Relative radiation level information.
    Reston (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/RRLInformation.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on May 6, 2001. The information was
verified by the guideline developer as of June 29, 2001. This summary
was updated by ECRI on July 31, 2002. The updated information was
verified by the guideline developer on October 1, 2002. This NGC summary
was updated by ECRI Institute on November 13, 2007.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx).

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008