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Dr Barry Chatterton, Mr Chris Schultz
Dept Nuclear Medicine & 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 & Bone Densitometry - Royal Adelaide Hospital
2 Bone Densitometry - Investigation and Management of Osteoporosis
1995-2002 Nuclear Medicine & 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 & 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 & 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 & 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 & renal disease
hyperparathyroidism & 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 & Bone Densitometry - Royal Adelaide Hospital
4 Bone Densitometry - Investigation and Management of Osteoporosis
1995-2002 Nuclear Medicine & Bone Densitometry - Royal Adelaide Hospital
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 & 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
1995-2002 Nuclear Medicine & Bone Densitometry - Royal Adelaide Hospital
6 Bone Densitometry - Investigation and Management of Osteoporosis
1995-2002 Nuclear Medicine & Bone Densitometry - Royal Adelaide Hospital
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 <-0.7, particularly in peri-menopausal
women. A more conservative approach is to
use a T score of <-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 (& 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
> + 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
< -2.5 Treatment
1995-2002 Nuclear Medicine & Bone Densitometry - Royal Adelaide Hospital
8 Bone Densitometry - Investigation and Management of Osteoporosis
1995-2002 Nuclear Medicine & Bone Densitometry - Royal Adelaide Hospital
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 & 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 & 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 & Bone Densitometry - Royal Adelaide Hospital
10 Bone Densitometry - Investigation and Management of Osteoporosis
1995-2002 Nuclear Medicine & 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 & 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 & 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 < -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 > -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 > 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.
1995-2002 Nuclear Medicine & Bone Densitometry - Royal Adelaide Hospital
12 Bone Densitometry - Investigation and Management of Osteoporosis
1995-2002 Nuclear Medicine & 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
1995-2002 Nuclear Medicine & Bone Densitometry - Royal Adelaide Hospital
14 Bone Densitometry - Investigation and Management of Osteoporosis
1995-2002 Nuclear Medicine & Bone Densitometry - Royal Adelaide Hospital
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 & 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 < -2.5 SD or Z score < -1.5 SD)
[one service only in a period of 24 months]
12312 DEXA
Monitor prolonged glucocorticoid therapy or excess glucocorticoid treatment,
female (<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 & 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 & Bone Densitometry.
Suggested Action*: Strongly advise treatment to prevent further bone loss & fracture. Do not repeat study within 12 months
Dr Barry E Chatterton
Director - Nuclear Medicine & Bone Densitometry
* National Consensus Conference on osteoporosis, Med J Aust:167(Suppl) Jul-97 Apr-2001 RAH Nuclear Medicine & Bone Densitometry - ver 1.9.4.1 Apr-2001 RAH Nuclear Medicine & 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 & 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 & 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 & 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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