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Dr Barry Chatterton, Mr Chris Schultz
Dept Nuclear Medicine &amp; Bone Densitometry
Royal Adelaide Hospital

Dr Tony Roberts
Dept of Endocrinology
Royal Adelaide Hospital

Assoc Professor Allan Need
Division of Clinical Biochemistry
Institute of Medical and Veterinary Science

BoneBone
DensitometryDensitometryDensitometry

A user s guideA user s guideA user s guide

with notes onwith notes onwith notes on

Investigation and Investigation and Investigation and Investigation and Investigation and 
Management of Management of Management of 
OsteoporosisOsteoporosisOsteoporosis



 1995-2002 Nuclear Medicine &amp; Bone Densitometry - Royal Adelaide Hospital

2 Bone Densitometry - Investigation and Management of Osteoporosis

 1995-2002 Nuclear Medicine &amp; Bone Densitometry - Royal Adelaide Hospital

Bone Densitometry - Investigation and Management of Osteoporosis  3

Contents
Bone Densitometry Investigations 3
Introduction 3
Who should be studied ? 3
Available techniques 3
Interpretation of results 4
How do Z and T scores relate to percentile scores? 6
Is there a normal range for children? 6
A note on units 6
What level of BMD should be treated? 6
Which regions are measured, and what do they mean? 7
How much of a change on follow up study is signifi cant
and how often should the examination be repeated? 7
How do I interpret different densities in different areas? 8
Are results obtained on different brands of densitometer comparable? 8
Data overload!! How do I cope? 8
Consistency of reports 8
What about laterals? 9
Quantitative Ultrasound estimates 9
Morphometry 9
Biochemistry 10

Synopsis of Management 11
When should a patient be treated? 11
What treatments are available? 11
Monitoring 13
Referral
Injury reduction 13

Medicare rebate for bone densitometry 14
Sample report 15
Further information 16

Dear Doctor,

The Department of Nuclear Medicine &amp; Bone Densitometry has been involved in bone 
densitometry as part of a multi-disciplinary team involved with osteoporosis research since 
1982. It continues to provide state of the art bone densitometry and general nuclear medicine 
services, which are available on direct referral to all medical practitioners.

This booklet was prepared in response to frequent requests from referring practitioners for 
information to allow the best use of results. It is meant to be a brief, general guide. If you have 
any further questions or comments to help us improve this guide or our service, please contact 
the department.

The department funds a large proportion of its clinical and educational activity from fees paid by 
private patients. Referrals are welcomed.

Dr Barry ChattertonDr Barry Chatterton, Director, Dept Nuclear Medicine &amp; Bone Densitometry

Bone Densitometry Investigations
Introduction
The use of bone densitometry as a clinical tool in the diagnosis and management of 
osteoporosis is now established, but the choice of technique, interpretation of results, 
decision to institute therapy and time to repeat the examination are all subject to debate. 
The following may help in making an informed decision.

Who should be studied ?
Increasing age &amp; menopause are two major factors likely to be associated with 
increasing risk of osteoporosis and therapeutic intervention at this time is also most 
likely to be effective. Some authorities recommend a study in all women about the 
time of the menopause. In addition, 25% of hip fractures occur in men, and should be 
considered for testing where appropriate.

Most other risk factors are either uncommon or not discriminating and no combination of 
these allows good prediction of bone density (which therefore should be measured). 
The risk factors recognised by the Medicare rebate schedule are (in both sexes) : 

  hypogonadism
  chronic glucocorticosteroid use
  chronic liver &amp; renal disease
  hyperparathyroidism &amp; hyperthyroidism
  rheumatoid arthritis
  malabsorption

At present, universal screening is not recommended, and individualised assessment 
should be performed.

Available techniques
The presently widely used techniques use ionising radiation, and have high levels of 
precision. 

  Dual Energy X-ray Absorptiometry (DEXA)
  DEXA measurements include lumbar spine, hip, forearm and whole body. 
  Each has advantages :
    the lumbar spine site is highly reproducible, but may be infl uenced by
   degenerative disease (eg osteophytes or aortic calcifi cation)
    the hip may be the best (by a narrow margin) single investigation to predict 
   future hip fracture.
    the forearm site is both highly reproducible and sensitive to change. 
   SPA (using a radioactive source) forearm densitometry established the
   technique in South Australia in the early 1980 s. Its use is now discontinued,
   and has been replaced by forearm DEXA.
    the whole body is highly reproducible, but not very sensitive to changes. The
   measurement averages data from many areas, possibly giving an integrated
   index of risk 
   DEXA has a very low radiation dose (a few days of background).



 1995-2002 Nuclear Medicine &amp; Bone Densitometry - Royal Adelaide Hospital

4 Bone Densitometry - Investigation and Management of Osteoporosis

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Bone Densitometry - Investigation and Management of Osteoporosis  5

  Quantitative C.T. densitometry (QCT)
  QCT is little used outside the research environment as it gives a much 
  larger radiation dose and has lower precision than DEXA (precluding its use 
  for serial measurements). It is the best non-invasive measure of trabecular 
  volumetric density. 

  Quantitative Ultrasound  Densitometry 
  Ultrasound estimates of bone quality are available, and have the advantage 
  of a total lack of ionising radiation. They will stratify patients into risk groups, 
  perhaps as well as the above mentioned techniques. They have the 
  disadvantage of relatively poor precision, which markedly reduces the value 
  of follow up ultrasound in the short term. Correlation with DEXA is poor, 
  and therefore screening, using ultrasound, is not regarded as appropriate by 
  most authorities in osteoporosis.

The existence of a Medicare rebate only for DEXA and QCT of the axial skeleton has 
infl uenced the choice of technique.

The NIH Consensus Development Conference of 2000 stated   BMD measurements 
have been shown to correlate strongly with load-bearing capacity of the hip and spine 
and with the risk of fracture . Furthermore, measurement of BMD for each scan site is 
the best predictor of fracture at that site. A more detailed discussion of some of these 
techniques appears later in this guide.

Interpretation of results
 or Statistics! Statistics! The                   score!
Unfortunately, the interpretation of bone densitometry depends on a statistical 
understanding, which is sometimes a little different from the accepted way of interpreting 
other laboratory tests eg. a haemoglobin where the result is usually expressed as a 
range which encompasses 95% of normals (ie. 2 Standard Deviations, SD) with each 
range neatly defi ned according to age and sex-matched controls (see between arrows).

This diagram represents the usual (normal) 
distribution of biological variables - bone 
density included. 66% of normal values will 
fall between -1 and +1 SD (and therefore 
34% outside, 17% above and 17% below). 
Commonly, bone density reports plot the 
age matched mean  1 SD. This serves to 
make a larger proportion of the population 
seem abnormal (osteoporotic) than is usual 
for most diagnostic tests. The reason for 
this is somewhat arbitrary, but it is generally 
regarded as appropriate to treat more than 
the lowest 2.5% of densities.

For bone density at any age, the shape of the distribution is normal, but the absolute 
values fall after the peak bone density is reached in early adulthood.

The number of standard deviations away from the mean is represented in most reports 
as a Z score. A Z score of  -1 means that the subject is 1 SD below the mean, and 
+2, 2 SD above the mean. The Z score may be expressed relative to normal people of 
the same age, or compared with young normals. It is the latter comparison (frequently 
designated the T score) which relates more closely to fracture risk. Medicare rebate 
eligibility is related to both T &amp; Z score (see Rebates on page 14).

Although there is no true  fracture threshold  (a value of bone density above which 
fractures do not occur - suffi cient trauma will break any bone), the risk increases 
considerably at bone densities which are less than 2 SD below the young normal mean. 
However, Medicare has decided that osteoporosis occurs at -2.5 SD or lower for the 
purpose of generating a rebate for repeat studies. 

The adjacent graph is a schematic of 
a typical normal bone density curve 
from virtually any bone in women 
(menopause at 50). The horizontal 
lines are 1 SD (ie 1  T  unit) apart,  T  unit) apart,  T 
and the curve shows the mean value 
for age with heavier bars which are 
 1 SD, which is the range usually 
quoted in bone density reports, but for 
reasons mentioned above, excludes 
29% of  normals . The thick horizontal 
line is 2.5 SD below the young normal 
mean, and therefore represents, 
by some defi nitions, the  Fracture 

Threshold , or the upper limit of the osteoporotic range. Note also the increased loss rate 
immediately after the menopause.

It can be seen that many elderly women may have a bone density that is 2.5 or more 
standard deviations below the young normal mean. This makes it  osteoporotic  by the 
above defi nition, despite being average for age. This corresponds with the increased 
fracture risk in the elderly. For comparative purposes, fracture risk approximately doubles 
for every SD reduction in bone density, so the fracture risk at -3 SD (ie T score = -3) is 
about 8 times greater (2x2x2) than the young normal, eg. O on the graph.

The elderly patient O marked above would therefore have a Z score of 0, but a T score 
(or young normal Z score) of -3. If osteoporosis is diagnosed on the basis of the young 
normal distribution, then about 45% of 50 year olds will have at least one site (hip, 
spine or forearm) affected, and virtually 100% of the very elderly will be osteoporotic.  
Bone density is normally higher in the heavier and taller patient. Many instruments will 
correct not only for age but also these factors, so occasionally one may see a heavy post 
menopausal patient with a greater bone density than a young normal, but nevertheless 
a corrected  Z  score of less than age matched!

ZZZZZ
ZZZZZ



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6 Bone Densitometry - Investigation and Management of Osteoporosis

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Bone Densitometry - Investigation and Management of Osteoporosis  7

How do Z and T scores relate to percentile scores?
It is possible to compare Z or T scores with 
percentiles. A Z or T score of  +2 means that 
97.5% of the reference population have less 
density.

Some authorities recommend more intensive 
monitoring and preventative treatment of the 
patients with bone densities in the lowest 
quartile (25%) which correspond to a T score 
of &lt;-0.7, particularly in peri-menopausal 
women. A more conservative approach is to 
use a T score of  &lt;-1.

Is there a normal range for children?
Where a child s bone density needs to be assessed, most densitometer manufacturers 
provide a normal range for children in the lumbar spine and the total body. However, the 
paediatric normal range shows relatively high variability due to differential growth rates 
and puberty. Bone Mineral Content should increase until maturity and may be a better 
prospective parameter than BMD. 

It is recommended that children be assessed and monitored using total body bone 
densitometry and bone mineral content until physical maturity. At physical maturity, 
an additional lumbar spine and femur scan may be acquired and used to continue 
monitoring.

A note on units
Different densitometers express the results using different units of the amount of bone 
present. The BMD (from which the Z and T score are usually derived) is used almost 
exclusively (in hip and spine densitometry) for both diagnosis and follow-up. In some 
forearm machines and the total body, the bone mineral content (BMC) may be used for 
follow up. Bone mineral density (BMD) is more commonly used to compare a patient 
with others of the same age by taking into account the patients size and the size of the 
measured region.

What level of BMD should be treated?
The bone density estimate gives a rough guide to the risk of future fractures, with a 
similar predictive value to that of blood pressure or cholesterol levels on stroke or 
myocardial infarction as an example. As well as the level of bone density estimated on 
an initial study, it maybe prudent to check for rapid bone loss using biochemical tests 
or even follow-up bone density measurements. Treatment with hormones in particular 
will need a full understanding of the patient s wishes and her gynaecological status. As 
in any other fi eld of medicine, the patient rather than a laboratory test is the subject of 
treatment.

A synopsis of management is included in the second half of this guide.

The 1996 Consensus 
Conference on 
Osteoporosis
recommended the 
following :

Which regions are measured, and what do they mean?
With DEXA technology, the usual projection for spine measurement 
is A-P and limited to the lumbar spine to eliminate confounding 
structures. The scan image will contain posterior elements 
(laminae, spinous processes), as well as the vertebral body in the 
measurement. Osteophytes and more anterior calcifi cation (eg 
aorta) will also be included.

In the proximal femur ( hip ), the computer 
produces semi-automated regions of interest. The femoral neck and 
trochanteric regions are self-explanatory, Ward s triangle is shown 
on the scan as a rectangular region! It represents the region in the 
femoral neck with the fewest trabeculae, and therefore the least 
density. For this reason, it is a sensitive indicator of risk, but exact 
placement (&amp; re-positioning) of regions of interest is diffi cult and 
therefore it is the least reproducible of these measurements. More 
recently, the sum of these areas   the total hip 
- has been shown to have the best precision for 
follow-up purposes.

Total body measurements divide the skeleton 
into arbitrary regions, which have some 
diagnostic value, and may also report other 

parameters of body composition such as lean body mass, and total 
body fat. The total body BMD is the value most commonly used.

How much of a change on follow up study is signifi cant and how often 
should the examination be repeated?
Typical reproducibility of bone density estimations is 1% (one of the most precise 
measurements in medicine)!  This means that (statistics again!) 67% of measurements 
repeated on the same day will fall within   1%. To be 99% sure that a change has 
really occurred, a change of three times this magnitude should occur for single serial 
measurements. Real annual changes of this degree occur at the time of the menopause 
or in patients on corticosteroids. Therefore in the individual, there is little point in repeating 
the study in less than 12 months and often 2 years. This limitation of course may not 
apply in research studies, where averaging from many patients allows meaningful results 
from shorter follow up periods. 

Z (or T) scoreZ (or T) score Percentile
 1.5 93%
 1.0 84%
 0.5 69%
 0.0 50%
-0.5 31%
-0.7 25%
-1.0 16%
-1.5 7%
-2.0  2.5%

T score
(Young Normal BMD)(Young Normal BMD)

Recommendation

&gt; + 1 No further measurements
0 to 1 Repeat measure 5 to10 years
-1 to 0 Repeat measure 2 to 5 years

-2.5 to  1 Prophylaxis
&lt; -2.5 Treatment



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8 Bone Densitometry - Investigation and Management of Osteoporosis

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Bone Densitometry - Investigation and Management of Osteoporosis  9

How do I interpret different densities in different areas?
There is incomplete agreement between measurements at different sites, partly due 
to machine errors in measurements, and selection of the normal ranges, but also due 
to real biological variation. (One may have a  thick  waist and thin wrists, and similar 
variation in bone density is also explicable.) Measurements at each site may predict 
fracture to a similar extent. It is probably prudent to use only a predetermined site or sites 
for measurements.

Are results obtained on different brands of densitometer comparable ?
There are 3 major brands of densitometer currently operated in Australia (Hologic, 
LUNAR &amp; Norland). Unfortunately, the calibration of these 3 instruments differ, resulting 
in different BMD and BMC values, and therefore preventing direct numerical comparison 
of results. The normal ranges on these instruments has also been defi ned from different 
populations.

Studies have been performed which allow for cross calibration of the different instruments, 
but this is of limited value, as there will be some discrepancy (due to statistics again!). 
We can provide some of the cross calibration equations on request, but as new models 
are introduced, the number of conversion factors increases.

When performing follow up studies on a patient, it is strongly recommended that the 
same brand of densitometer (and for preference, the same machine) be used to ensure 
the most valid comparisons.

Data overload!! How do I cope?
The highly computed modern densitometers 
produce an excess of data for clinical use, 
and the raw report is often diffi cult to quickly 
assess. Values are often given for BMC, BMD, 
Z scores &amp; percentiles (relating both to young 
normals and age matched controls), for each 
of the lumbar vertebrae and permutations and 
combinations of these, and in the hip, neck, 
Ward s triangle and trochanteric region. Using 
the mean of several vertebrae (often L2-L4), 
the femoral neck or total hip probably obtains 
the best information. In the analysis of a study the operator will exclude vertebrae that 
appear crushed or have an excessive amount of sclerosis relating to degenerative 
change. As Z scores will be different for the same density as the patient ages, the BMD 
for DEXA (or forearm BMC) should be used in follow-up.

Consistency of reports
The RAH has developed an automated reporting system which provides uniform 
interpretation, and emphasises the most important data, but may not take into account 
unusual clinical situations. A sample report is given on the inside back page.

What about laterals?
Analysis of the density of the lumbar vertebral body imaged in the lateral position was 
seen as a method to reduce errors due to arthritic changes and calcifi cation in the aorta. 
Unfortunately, in patients who would best benefi t from this study it has been found that 
overlying pelvis and ribs and the greater path of soft tissues that the X-ray beam must 
penetrate, limit both the precision and number of vertebrae which may be studied. 
Routine use is not recommended, but it may have some value in the elderly. Lateral 
projections are obtained in morphometry, which is an image processing rather than a 
densitometric technique.

Quantitative Ultrasound estimates
Specialised ultrasound machines produce an index of the bony properties of the heel, 
tibia, phalanges and other sites. The degree to which the sound is attenuated gives 
an estimate of the quality of the bone (ie trabecular structure) and the speed of sound 
through the heel may indicate the amount of bone in the path of the sound beam. The 
combination of these results has been shown to stratify patients into their relative risk of 
future fracture at the hip almost as well as DEXA at the femoral neck. 

The result is not strictly bone density, and the precision is such that 
follow-up of treatment is not yet possible. Because of the imprecision 
in the method, and also because it measures a different bone, the 
correlation between DEXA measurements at other sites is only moderate. 
Medicare does not reimburse this study. Future developments may make 
it more applicable.

Morphometry
Vertebral crush fractures are a common, usually diagnostic, feature of 
osteoporosis. These have been previously diagnosed using standard X-ray 
techniques. Vertebral compression fractures are independent predictors of 
future fracture and may qualify patients for specifi c therapy under the PBS.

Some of the more recent generation of bone densitometers use multiple 
detectors to produce a high-resolution image from which semi-automated 
measurements of vertebral dimensions are obtained. The ratio of the 
vertical heights of the anterior and posterior edges of a vertebral body 
allows the diagnosis of a wedge fracture to be made, for example. This 

technique allows vertebral fracture to be diagnosed with much less radiation exposure 
than a standard radiograph. Morphometry may represent an independent method of 
following the progress of osteoporosis.

The output gives vertebral heights and A/P ratios relative to expected standard 
deviations. A single 4 SD or two or more 3 SD differences are generally regarded as a 
signifi cant fracture. The percent height loss is also displayed, and may be applied to the 
requirements of the PBS schedule.



 1995-2002 Nuclear Medicine &amp; Bone Densitometry - Royal Adelaide Hospital

10 Bone Densitometry - Investigation and Management of Osteoporosis

 1995-2002 Nuclear Medicine &amp; Bone Densitometry - Royal Adelaide Hospital

Bone Densitometry - Investigation and Management of Osteoporosis  11

Biochemistry
The aim in preventing or treating osteoporosis is to stop further bone loss, so the best form 
of monitoring is sequential bone density. However, because of the relationship between 
the precision of bone densitometry (1%) and the average annual rate of loss (1.2%) it is 
necessary to wait a year or more after treatment begins for densitometry to confi rm it is 
working. Biochemical markers for bone resorption &amp; formation show effects within weeks 
of starting treatment. Biochemical tests can also be used to select the most appropriate 
form of treatment. Intestinal malabsorption of calcium is common in osteoporosis and 
responds to calcitriol therapy (calcium absorption can be measured by a radiocalcium 
absorption test at the Institute of Medical &amp; Veterinary Science). Osteoporotic women 
with a high fasting urinary calcium excretion appear to best respond to hormone therapy. 
Women with low bone turnover may respond best to anabolic steroid therapy.

Tests currently being used in the management of osteoporosis include :
  Radiocalcium absorption test
  Fasting urinary Calcium/Creatinine
  Fasting urinary crosslinks/Creatinine (bone resorption marker)
  Plasma Alkaline Phosphatase (bone formation marker)
  Osteocalcin

Synopsis of Management
When should a patient be 
treated?
(see Consensus Statement 
recommendations, p 7)
Women more than 1 SD below 
(T &lt; -1) the young normal mean for 
bone density at the menopause can 
rapidly become osteoporotic since 
women lose over 10% of their bone 
mass within 5 years of the menopause. 

We recommend these women receive immediate prophylaxis to prevent further bone 
loss.

Women with bone density within 1 SD (T &gt; -1) of the young normal mean at the 
menopause should have their bone density remeasured after two years in case they are 
losing rapidly. Perimenopausal women in the top quartile of bone density (T &gt; 0.7) do not 
need to have another measurement for at least fi ve years.

Women with osteoporotic fractures should defi nitely be treated and women with a bone 
density more than 2.5 SD below the young normal range should probably be treated, 
but it is worth remembering that the lifetime risk of fracture depends on the number 
of remaining years of life. Thus there is much more value (and less inconvenience) in 
treating someone aged 65 with a low bone density than in treating someone aged 85. It is 
also worth remembering that 75% of hip and spine fractures occur in women with a bone 
density more than three standard deviations below the young normal mean.

Osteoporosis in men is less likely to be treated, although many of the risk factors are 
common to both sexes, and 25% of fractures occur in men.

What treatments are available?
General measures should include:

  adequate exercise (thirty to sixty minutes of moderate weight-bearing exercise 
  three to four days a week)

  adequate calcium intake (800mg per day for pre-menopausal women and 1 to 
  1.5 gram per day for postmenopausal women)

  minimising the use of medications which predispose to bone loss (eg. 
  Corticosteroids, excessive thyroxine therapy, anticonvulsants and loop 
  diuretics) and to falls (psychotropic and anti-hypertensive medication causing 
  postural hypotension). 

Specifi c medications to prevent further bone loss include:
Calcium

A calcium supplement of 1 gram daily (preferably taken at night) will often arrest 
bone loss but may be ineffective if intestinal calcium absorption is impaired.
Patients who excrete less than 3mmol per day of urinary calcium are likely to have 
calcium malabsorption.



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12 Bone Densitometry - Investigation and Management of Osteoporosis

 1995-2002 Nuclear Medicine &amp; Bone Densitometry - Royal Adelaide Hospital

Bone Densitometry - Investigation and Management of Osteoporosis  13

Oestrogens
Oestrogens will stop bone loss, help prevent heart disease, and may be indicated 
for women with postmenopausal symptoms. There may be a small increase in 
risk of breast cancer. They must be given with Progestagens in women who still 
have a uterus to protect against endometrial cancer. 

Available oestrogens include:
  Conjugated equine oestrogen 0.625 mg per day (Premarin), oestradiol valerate 2 

  mg per day (Progynova) and piperazine oestrone sulphate 1.25mg per day 
  (Ogen)

  Progestagens such as norethisterone 5 mg (Primolut-N) or medroxyprogesterone 
  acetate 5mg (Pro Vera) can be added daily for twelve to fourteen days each 
  month
  

Combined oestrogen and progestagen packs include:
  Kliovance
  Premia 5 continuous
  Estralis

Oestrogen skin patches or implants are available when oral oestrogens are not 
tolerated.

Progestagens
The progestagen, norethisterone (Primolut-N, 2.5mg daily), can prevent bone loss 
in its own right and investigations are under way to assess the relative benefi ts and 
side effects.

Calcitriol
Calcitriol (Rocaltrol, 0.25mg b.d. or 0.25mg daily with 1g Calcium) is 
available on the Pharmaceutical Benefi ts List (authority required) for patients 
with vertebral compression fractures or other fractures occurring with minimal trauma. 
It has been shown prospectively to reduce the incidence of fracture in women.

Bisphosphonates
Etidronate (Didrocal, 400mg daily for two weeks every three months), Alendronate 
(Fosamax, 10mg daily or 70mg per week) and Risedronate (Actonel, 5mg daily) 
are effective and are on the PBS (authority required for similar indications) for both 
men and women.

SERMS
Selective oestrogen receptor modulators are now available (PBS authority 
required and only for post menopausal osteoporosis). Raloxifene (Evista, 60mg 
daily) has been shown to reduce the risk of fractures and may also be shown to 
reduce the risk of breast cancer.

Anabolic steroids
Anabolic steroids are useful in patients with low bone turnover as they appear to
increase bone formation. They are limited by virilising side effects. After six 

months of therapy (50mg of nandrolone decanoate - Deca-Durabolin   given i.m. 
every 4 weeks) a signifi cant risk of voice change and hirsutism exists.

Calcitonin
Calcitonin injections are effective for pain relief following acute vertebral fracture, 
but are expensive and include side effects such as fl ushing and nausea. Calcitonin 
is not currently approved for the treatment of osteoporosis in Australia. 

Corticosteroid-induced osteoporosis
Bisphosphonates, Calcitriol, SERMS, HRT and Anabolic steroids have a role in the 
prevention and treatment of steroid induced osteoporosis.

Monitoring
Once therapy is commenced, it is best to ensure bone loss is controlled. A reduction of 
markers of bone reabsorption (urinary cross-links) is a useful early marker. A repeat bone 
mineral density measurement after twelve months to two years will usually suffi ce unless 
bone loss is expected to be rapid (eg. during corticosteroid therapy).

Referral
Patients with side effects from treatment, poor response to treatment or without access to 
densitometry services may benefi t from assessment by specialists in skeletal medicine. 

Injury reduction
Interventions to reduce the risk of falling include:

  modifi cation of the environment to reduce the risk of slipping and tripping 
  (slippery surfaces, loose rugs, narrow passageways, dangerous furniture)

  living habits (use of appropriate footwear; care with steps, especially with 
  bifocals)

  care at night
  installation of supportive hand rests; use of appropriate aids)
  modifi cation of medication predisposing to falls (see above)

Research studies have shown that use of padding around the hips signifi cantly reduces 
femoral neck fractures risk in those at risk of falling. The Health Promotion Unit of the 
Royal Adelaide Hospital supplies a Hip Safety kit, which includes:

  Two hip protector shields (one to go over each hip) 
  3 pairs of undergarments (male or female) with pockets to hold the shields 
  A booklet on osteoporosis and preventing falls 

Further information and assistance may be obtained from a number of sources listed at 
the end of this booklet



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14 Bone Densitometry - Investigation and Management of Osteoporosis

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Bone Densitometry - Investigation and Management of Osteoporosis  15

Medicare rebate for bone densitometry 
The schedule of benefi ts as of 1 November 2001 are reprinted below
Details may be found on pp 83-85 &amp; 95-96 of the  Medicare Benefi ts Schedule 
(1 November 2001) book.  The following notes should only be considered after referral 
to this section.

1. There are 7 items numbers, 4 for DEXA, 2 for QCT and 1 common.
2. Two sites (usually hip and spine) are reimbursed for each DEXA study, (except in 

   two circumstance) no more frequently than every 2 years.  
3. There are only minor changes in indications from the previous schedule. 
4. The Commonwealth limits the number of studies which may be reimbursed for 

   an individual

12306 DEXA/12309 QCT
  For the confi rmation of a presumptive diagnosis of low bone mineral density 

  made on the basis of one or more fractures occurring after minimal trauma.  
  To monitor low density proved on previous densitometry.  

  (T score &lt; -2.5 SD  or Z score &lt; -1.5 SD) 
  [one service only in a period of 24 months]

12312 DEXA
  Monitor prolonged glucocorticoid therapy or excess glucocorticoid treatment,  

  female (&lt;45), or male hypogonadism 
  [one service only in a period 12 consecutive months]

12315 DEXA/12318 QCT - monitoring
(where result will assist management)
  primary hyperparathyroidism
  chronic liver disease
  chronic renal disease
  proven malabsorptive disorders
  rheumatoid arthritis
  conditions associated with thyroxine excess
[one service only in a period 24 consecutive months]

12321 DEXA monitoring
  Signifi cant change in therapy for low bone density
[one service only in a period 12 consecutive months]

Note - screening at the time of the menopause remains specifi cally excluded.  

Department of Nuclear Medicine &amp; Bone Densitometry

Bone Densitometry Results
10-May-2002

Dear Dr. Ima-Physician 

Re: Any PATIENT  DOB: 24-Sep-1947  UR: 00123456  Episode: 01N005432

Summary: This patient attended on 10-Oct-2002 for bone densitometry of AP Spine, Hip, 
Total Body and Forearm on the LUNAR DPX-IQ at the RAH. The Young Normal Adult and Age Matched Z scores for BMD 
were:                                                                                          

Scan BMD (g/sq.cm) T score Fracture Risk Z(age) Peer 
Relationship

Lumbar Spine 1.037 -1.36 Moderate -0.96 lowest quartile   
Femoral Neck 0.792 -1.57 Moderate -1.10 lowest quartile   
Total Body 0.914 -2.64 Marked -1.97 lowest decile     
Forearm 0.631 -2.88 Marked -2.61 marked defi cit  

  

Lumbar Spine: Bone densities are usually averaged between L2-L4, and these values have been used in this analysis. This 
patient has a measurement of -1.36 std. dev. below the mean for young females (91% of young  normal adults have more bone 
at this site).  This density is in the lowest quartile for age.                  
This is a 0.8% fall since the Feb-1999 scan [-0.4%/year]. (To be 95% confi dent of a change a 2.8% change in density should 
occur)                                                                                         

Hip: The Neck region of the hip is the most reproducible individual femur measurement, with a predictive power as good as 
Ward s triangle or the Trochanteric region. This patient has a measurement of -1.57 std. dev. below the mean for young females 
(94% of young normal adults have more bone at this site).  This density is in the lowest quartile for age. 
This is a 2.3% fall since the Feb-1999 scan [-1.3%/year]. (To be 95% confi dent of a change a 5.0% change in  density should 
occur)                                                                                         

Total Body: The total body is the most reproducible measurement in bone density, but not as sensitive when monitoring change. 
This patient has a measurement of -2.64 std. dev. below the mean for young females (100% of young normal adults have more 
bone at this site).  This density is in the lowest 10% for age.                 
This is a 0.4% rise since the Feb-1999 scan [0.2%/year]. (To be 95% confi dent of a change a 2.8% change in density should 
occur)                                                                                         

Forearm: This patient has a measurement of -2.88 std. dev. below the mean (33% radius site) for young females (100% of 
young normal adults have more bone at this site).  This is a severe defi cit of bone with respect to age.                                        
                                                                  
Comment: Bone density results may vary from region to region, yet each of these values may have a similar predictive value for 
future fracture. A conservative approach may base decisions on the lowest density measured, which for this patient was in the 
forearm. This is in the osteoporotic range and the patient may be entitled to a Medicare benefi t for followup studies.                    
                                                    
Therapy should take into account all available clinical information, including bone density.                  
                                                                                                              
NOTE : The lumbar spine scan analysis may be affected by an apparent degenerative artifact, and the results should be 
considered with caution.                                                                            

The scanner generated reports are attached. More information is available from Nuclear Medicine &amp; Bone Densitometry. 
Suggested Action*: Strongly advise treatment to prevent further bone loss &amp; fracture. Do not repeat study within 12 months      
                                                                                        

Dr Barry E Chatterton
Director - Nuclear Medicine &amp; Bone Densitometry

* National Consensus Conference on osteoporosis, Med J Aust:167(Suppl) Jul-97           Apr-2001 RAH Nuclear Medicine &amp; Bone Densitometry - ver 1.9.4.1 Apr-2001 RAH Nuclear Medicine &amp; Bone Densitometry - ver 1.9.4.1 

Senior Director
Barry E Chatterton

Physicians
F Dylan L Batholomeusz
Ian D Kirkwood
C Ghee Chew

Telephone
61 8  8222 5407

Facsimile
 (08) 8222 5949

Email
Nucmed@mail.rah.sa.gov.au



 1995-2002 Nuclear Medicine &amp; Bone Densitometry - Royal Adelaide Hospital

16 Bone Densitometry - Investigation and Management of Osteoporosis

Further information

For Bone Densitometry, including AP Spine, femoral neck, forearm, total body 
DEXA, lateral morphometry, ultrasound and a rural Mobile DEXA service, please 
contact the staff in the Dept Nuclear Medicine &amp; Bone Densitometry at the Royal 
Adelaide Hospital. 

Phone:    (08) 8222 5408
E-mail:    nucmed@mail.rah.sa.gov.au
WWW:    www.rah.sa.gov.au/nucmed/

For biochemical diagnosis &amp; management, 
Dr Tony Roberts, Dept of Endocrinology, Royal Adelaide Hospital 

Phone   (08) 8222 5520

Relevant RAH clinics :
Osteoporosis  (08) 8222 5586
Endocrine   (08) 8222 5586
Women s Health Centre (08) 8222 5587

For information on fall prevention services and fall management:
http://www.joannabriggs.edu.au/FALLS

Health Promotion Unit, Royal Adelaide Hospital
Phone    (08) 8222 5193

Falls and Injury Assessment Clinic, Repatriation General Hospital
Phone :    (08) 8275 1103

Flinders Medical Centre Falls and Injury Prevention Service
Phone :    (08) 8204 5511

Homefront (for Dept of Veterans Affairs)
Phone    General Enquiries : (08) 8290 0478

   Veterans only :   1800 801 945

The full NIH consensus statement on Osteoporosis is available at:
http://www.consensus.nih.gov/

Acknowledgments : 
We thank Professor BEC Nordin for his constructive assistance in the preparation of 
this document.

rev 3   May 2002


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