IMAGING IN OSTEOPOROSIS.pptx

IMAGING IN OSTEOPOROSIS.

1. IMAGING IN OSTEOPOROSIS DR. VANDANA BANSAL MS, D.phil. (Gold Medalist), DGO, FCGP Infertility & IVF Specialist & Advance Laparoscopic Surgeon DIRECTOR Arpit Test Tube Baby Centre, Prayagraj Jeevan Jyoti Hospital, Prayagraj (U.P.)

2. INTRODUCTION OF OSTEOPOROSIS Osteoporosis and associated fractures are the most common chronic metabolic bone disease and represent a major global health problem, contributing to 8.9 million fractures worldwide on an annual basis. Worldwide, there are marked variations in the rates of hip fracture and major osteoporotic fractures. Fractures associated with osteoporosis cause not only increased morbidity but also an increased mortality. Osteoporosis may significantly affect life expectancy and quality of life. Osteoporosis is often thought of as an older person’s disease, it can strike at any age.

3. DEFINITION Osteoporosis is a systemic skeletal disease characterized by low bone mass and deterioration of bone microarchitecture with a consequent increase in fragility and susceptibility to insufficiency fracture. It can be classified as primary or secondary. Primary osteoporosis includes post-menopausal osteoporosis (type I), osteoporosis in the elderly (type II), and idiopathic osteoporosis (including in adolescents). Secondary osteoporosis refers to patients with underlying metabolic disease and/or drug induced or from other obvious causes of osteoporosis. This consensus document mainly applies to the diagnosis of primary osteoporosis. The vertebrae .wrists ,and hips are the most common sites of fractures

4. Fragility fracture is one caused by a degree of trauma not expected to cause a fracture; for example, a fall from standing height or lower. Fragility fractures, such as vertebral compression fractures and distal forearm fractures, are common in the elderly but can occur at any age. Exclusions: toes, fingers, face, skull, and ribs. Major osteoporotic fracture is a fracture of the hip, spine (clinical), wrist, or humerus. Osteoporosis is defined as a history of fragility fracture and/or a T-score of -2.5 or lower on dual energy X-ray absorptiometry (DEXA). Osteopenia (or low bone mass) is defined as a T-score between -1.0 and -2.5 on DEXA. DEFINITIONS

5. STAGES OF OSTEOPOROSIS

6. India is home to more than 1.3 billion people, with approximately 230 million Indians over 50 years. About 20% of the 230 million Indian women over age 50 have osteoporosis Prevalence of osteoporosis ranging from 8 to 62% in Indian women of different age groups has been reported in several studies The current Indian population as a whole, the number of hip fractures every year would be more than 440,000, with a female to male ratio of about 3:1, with a projected incidence of more than 600,000 in 2020 and over 1 million in 2050. Prevalence of Osteoporosis

7. Result of prolonged imbalance of Bone Rent (/ deling ; • Mechanisms causing osteoporosis Imbalance between rate of resorption and formation Failure to complete stages of remodeling - Bone remodeling occurs throughout an individual’s lifetime. - In normal adults, the activity of osteoclasts (bone resorption) is balanced by that of osteoblasts (bone formation). - normal bone remodeling in the adult result in gradually increase bone mass until the early 30s. * With ageing the peak bone mass is gradually decrease and 1. Calicitonin which inhibit bone resorption and promote bone formation, (decrease) 2. Estrogen which inhibit bone breakdown, (decrease) 3. PTH increase bone turnover and resorption, (increase) PATHOPHYSIOLOGY

8. CLASSIFICATION Primary Postmenopausal (Type I) Caused by lack of estrogen Causes PTH to overstimulate osteoclast Bone loss - 2-3% per year of total bone mass Most com men fx : vertebral, distal forearm Age related (Type II) Bone loss due to increased bone turnover Malabsorption Mineral and vitamin deficiency - 3 rd decade of life starts slow decline in bone mass at rate of 0.5-1% per year Most common types of fx : hip and radius > F>M IDIOPATHIC (Including adolescence) Secondary

9. SECONDARY OSTEOPOROSIS DISEASE STATES Acromegaly Addison’s disease Amyloidosis Anorexia COPD Hemochromatosis Hyperparathyroidism Lymphoma and leukemia Malabsorption states Multiple myeloma Multiple sclerosis Rheumatoid arthritis Sarcoidosis Severe liver dz , esp. PBC Thalassemia Thyrotoxicosis

10. SECONDARY OSTEOPOROSIS DRUGS Aluminum Anticonvulsants, Excessive thyroxine Depo Provera (decreased bone mass reversible after stopping medication) Glucocorticoids, GnRH agonists Heparin, Lithium

11. Incidence of osteoporotic Fx

12. Risk Factors For Osteoporosis And Osteoporotic Fractures Women aged > 65 Caucasian or Asian race Low body weight; (< 127 lbs or BMI < 20) Family history of Osteoporosis Personal history of fragility fracture and/or fracture as an adult History of fragility fracture in a first-degree relative Long-term use of Glucocorticoids or others Current tobacco smoking Alcohol in amounts > 2-3 drinks per day Estrogen deficiency at an early age (< 45yrs) Low calcium intake (lifelong) and/or Vitamin D deficiency Sedentary lifestyle Testosterone/Estrogen depletion in men Increased risk of falling due to: Dementia Poor health/frailty Recent falls Poor vision

13. Summarizing the non-modifiable and modifiable risk factors for primary osteoporosis

14. Diagnosis of Osteoporosis The aim is to – To diagnose osteoporosis and osteopenia Predicting fracture risk Evaluating management

15. Diagnosing Osteoporosis Outcome of interest: Fracture Risk Outcome measured (surrogate): BMD - Key: Older women at higher risk of fracture than younger women with SAME BMD. - Other factors: risk of falling, bone fragility not all related to BMD

16. Diagnostic criteria of Osteoporosis The principle of diagnosing osteoporosis is to combine clinical history, risk factors, clinical manifestations, imaging findings, BMD measurement and laboratory results together. Osteoporosis can be diagnosed if BMD measurements and clinical manifestations indicate osteoporotic status. Imaging findings and BMD measurements play a critical role here. Once various imaging studies (such as X-ray, CT, MRI, and nuclear medicine studies) demonstrate an insufficiency fracture, osteoporosis can be diagnosed regardless of the findings of a BMD measurement. However, before the occurrence of insufficiency fracture, the diagnosis is mainly based on BMD measurement. It is important to differentiate primary, secondary, or idiopathic osteoporosis, which should be based on age, sex, history, clinical manifestations, laboratory results, and imaging findings. Biochemistry laboratory results can reflect bone formation and bone resorption, aiding classification, differential diagnose and early evaluation of treatment. However, biochemistry cannot be used alone for diagnosing osteoporosis.

17. Diagnosis of Osteoporosis The aim is to – Physical examination Measurement of bone mineral content Dual X-ray absorptiometry (DXA) Ultrasonic measurement of bone CT scan Radiography Nuclear medicine studies MRI QCT measurement of BMD

18. Physical examination Height loss Body Weight Kyphosis Human back Tooth loss Skinfold Thickness Grip strength Osteoporosis Vertebral fracture Arm span-height difference Wall- occiput distance Rib-pelvis distance

19. Physical examination

20. Physical examination No single maneuver is sufficient to rule in or rule out osteoporosis or vertebral fracture without further testing.

21. W or k- u p Screen for secondary causes Serum calcium, phosphorus, alk phos PTH if calcium is high 25-hydroxyvitamin D if low ca, low phos and high alk . phos Thyroid function tests SPEP, UPEP 24-hour urinary calcium Serum testosterone (hyperparathyroidism) ( osteomalacia ) (thyrotoxicosis) (multiple myeloma) (hyper or hypo calciuria ) (hypogonadism)

22. Plan radiography Low sensitivity High availability If there is bone loss on a plain X-ray, further evaluation with a BMD measurement is warranted. Subclinical vertebral fracture is a strong risk factor for subsequent fractures at new vertebral site and other sites if there is subtle vertebral compression, the recommendation is to combine an X-ray with CT and/or MRI

23. The main radiographic features of generalized osteoporosis are cortical thinning and increased radiolucency

24. Singh Index The Singh index describes the trabecular patterns in the bone at the top of the thighbone (femur). X-rays are graded 1 through 6 according to the disappearance of the normal trabecular pattern. Studies have shown a link between a Singh index of less than 3 and fractures of the hip, wrist, and spine.

25. When to Measure BMD in Postmenopausal Women All women 65 years and older Postmenopausal women <65 years of age: If result might influence decisions about intervention One or more risk factors History of fracture

26. When Measurement of BMD Is Not Appropriate Healthy premenopausal women Healthy children and adolescents Women initiating ET/HT for menopausal symptom relief (other osteoporosis therapies should not be initiated without BMD measurement)

27. BMD MESURMENT AND DIAGNOSTIC CRITERIA BMD measurement and diagnostic criteria. The technique of BMD measurement utilizes the principle that there are different degrees of X-ray attenuation when X-rays pass through different media. It is a non-invasive measurement of human bone mineral content, bone density and composition. The current commonly used methods include DXA, QCT peripheral DXA.

28. DEXA DXA uses high and low energy X-rays to scan the human body and measure BMD Dual Energy X-ray Absorptiometry (DEXA) ?”gold standard" Measurements vary by site Heel and forearm: easy but less reliable (outcome of interest is fracture of vertebra or hip) The lumbar spine, hip and forearm are the most common sites for measurement. Hip site: best correlation with future risk hip fracture Vertebral spine: predict vertebral fractures; risk of falsely HIGH scores if underlying OA/osteophytes

29. Dual X-ray absorptiometry 2-dimensional study BMD = Amount of mineral Area Accuracy at hip > 90% Low radiation exposure Error in Osteomalacia Osteoarthritis Previous fracture

30. How to interpret the BMD T score: standard deviation of the BMD from the average sex matched 35-year-old Z score: less used; standard deviation score compared to age matched control For every 1 decrease in T score, double risk of fracture 1 SD decrease in BMD -14 year increase in age for predicting hip fracture risk Regardless of BMD, patients with prior osteoporotic fracture have up to 5 times risk of future fracture.

31. WHO CRITERIA FOR THE DIAGNOSIS OF OSTEOPOROSIS USING DUAL-ENERGY X-RAY ABSORPTIOMETRY

32. The WHO criteria are suitable for use in post-menopausal women and men over the age of 50. WHO T-scores should never be used to diagnose osteoporosis in children and adolescents. For children, adolescents, pre-menopausal women, and men under the age of 50, the Z-score value is recommended for interpreting BMD measurements. Z-scores are calculated using BMD reference data derived from healthy subjects of the same age, race and sex. A Z-score <=−2.0 SD (standard deviation) is defined as “lower than expected range of the same age group” or low bone density (2,8). The normal reference data for children and adolescents should be derived from data for the Chinese population (18). Women with a history of ovariectomy are regarded as equivalent to “post-menopausal” and the T-score can be used for diagnosis. How to interpret the BMD

33. -scanners are readily available and relatively inexpensive. -The radiation dose is negligible -The T-score scale, defined by the WHO specifically for DXA, provides a standardized classification. Clinicians and researchers favor DXA because

34. LIMITATION OF DEXA BMD measurements are influenced by osteoarthritis, scoliosis, osteophytes, vertebral body fracture, vascular calcification and obesity, and these decrease the accuracy of the measurements and may lead to misdiagnosis (19,20). When patients are underweight, overweight or have scoliosis or degenerative changes, QCT is recommended for BMD measurement to minimize their influence or search for evidence of insufficiency fracture.

35. The trabecular BMD is indicated as the most important parameter, and interpreted using the Felsenberg classification, based on the following cut-off values: Normal BMD > 120 mg/cc Osteopenia < 120 mg/cc Osteoporosis < 80 mg/cc Very high fracture risk < 50 mg/cc Trabecular BMD

36. Ability to separate cortical and trabecular bone Provides true volumetric density in units of mg/cc No errors due to spinal degenerative changes or aortic calcification Advantages over DXA:

37. Ultrasonic measurement Broad-band ultrasound attenuation No radiation exposure Cannot be used for diagnosis Preferred use in assessment of fracture risk

38. The calcaneus is the most common skeletal site for quantitative ultrasound assessment because -It has a high percentage of trabecular bone that is replaced more often than cortical bone, providing early evidence of metabolic change. - Also, the calcaneus is fairly flat and parallel, reducing repositioning errors. Ultrasonic measurement

39. The McCue CUBA: Ultrasonometry Technology That Can Assess Osteoporosis

40. Heel BUA is Significantly Lower in Subjects With Future Hip Fracture.

41. CT-SCAN True volumetric study It is More sensitive for diagnosing subtle fracture. Quantitative Computed Tomography (QCT) utilizes CT technology to detect low bone mass and monitors the effects of therapy in patients undergoing treatment. It is a fast, non-invasive exam that detects low bone mass earlier and more accurately than other bone density exams It is helpful for differentiating osteoporosis from bone tumor and other pathologies.

42. QCT in a 62-year-oid female patient

43. Peripheral BMD measurement X-ray measurement of BMD in the peripheral skeleton include peripheral QCT ( pQCT ), peripheral DXA ( pDXA ) and single energy BMD measurements. The sites measured include the forearm, calcaneus, phalanges, and distal tibia. High-resolution pQCT is used for the evaluation of bone microarchitecture. Since there is less soft tissue around peripheral bone the accuracy and repeatability of the measurements are better. The radiation dose from peripheral BMD measurement equipment is also extremely low, offering better protection for the patient and operator. Quantitative ultrasound can also be used for measuring bone, with the advantage of no radiation exposure. The measurements are related to bone density, but not directly to BMD. Currently, the recommendation is not to use peripheral BMD for diagnosis and evaluation of therapy response in osteoporosis. It can be used only for screening of osteoporosis and the fracture risk assessment. Equipment for measuring peripheral BMD has the advantages of being small, easy to transport, low cost, low radiation dose, portable and suitable for osteoporosis screening in smaller hospital and community settings

44. MRI MRI can be used to evaluate the osteoporosis quantitatively Currently MRI is not suitable for clinical diagnosis or screening for osteoporosis, but it is used for the evaluation of osteoporosis insufficiency fracture and providing differential diagnosis. MRI quantitative measurement of bone marrow fat and quantitative evaluation of bone cortex using UTE have the potential to provide a new strategy for diagnosis and screening of osteoporosis in the future.

45. FRAX CALCULATOR The FRAX calculator This tool estimates the 10-year probability of osteoporotic fracture for postmenopausal women and men aged 50 years and older who have not been previously treated for osteoporosis. Risk factors included in the FRAX are: age, gender, low body weight, height, previous fracture, parent with hip fracture, smoking status, glucocorticoid use, history of rheumatoid arthritis, menopausal status, and excessive alcohol consumption. The FRAX calculator is available online at http://www.shef.ac.uk/FRAX/ . Use the drop-down list under “Calculation Tool.” Limitations: The FRAX calculator may over- or underestimate fracture risk in patients with a history of vertebral fracture, hip fracture, or multiple fractures, as well as in patients who are Black, Latino, or from other races or ethnicities. Some risk factors, such as frailty and dementia, cannot be readily quantified and are not included in the calculation.

46. ASSESSMENT OF FRACTURE RISK DXA and quantitative ultrasound Clinical risk factors Markers of bone turnover Bone formation Bone resorption

47. ASSESSMENT OF FRACTURE RISK DXA Risk of fracture = 1.5-3.0 for each SD decrease in BMD Low sensitivity ( comparable to BP in predicting stroke ) Screening is not recommended Quantitative ultrasound Risk of fracture - 1.5-2.0 for each SD decrease in BMD

48. Indications for vertebral fracture assessment (International Society of Clinical Densitometry, 2019) Lateral spine imaging with standard radiography or densitometric vertebral fracture assessment is indicated: When T -score is < -1.0 standard deviations and one or more of the following is present. • Women aged ≥ 70 years or men aged ≥ 80 years • Historical height loss > 4 cm (>1.5 inches) • Self-reported but undocumented prior vertebral fracture • Glucocorticoid therapy equivalent to ≥ 5 mg of prednisone or equivalent per day for ≥ 3 months

49. A guide to stratification of fractures. Low risk of fracture (all must be present) • No fragility fractures • DXA-derived T -score < -1 and > -2.5 standard deviations • FRAX 10-year probability of fracture (adjusted for trabecular bone score): – Any major osteoporotic fracture: < 20% – Hip fracture: < 3% – Or less than the country-specific threshold for intervention High risk of fracture (any one of the following) • Presence of fragility fracture • DXA- derived T -score ≤ -2.5 standard deviations • FRAX 10-year probability of fracture (adjusted for trabecular bone score): – Any major osteoporotic fracture: > 20% – Hip fracture: > 3% – Or exceeding the country-specific threshold for intervention Very high risk of fracture (any one of the following) • Recent fracture • Multiple fractures • Severe fracture • Fracture while on treatment • Fracture while on bone-toxic drug such as corticosteroids • T -score ≤ -3.0 standard deviations • FRAX 10-year probability of fracture (adjusted for trabecular bone score): – Any major osteoporotic fracture: > 30% – Hip fracture: > 4.5% – Or exceeding the country-specific upper threshold for high risk – Other factors such as an extremely high risk for falls.

50. Management of fragility fractures Link TM. Radiology of osteoporosis. Canadian Association of Radiologists' Journal. 2016 Feb;67(1):28-40

51. Management of fragility fractures Acute change in stiffness may provoke fractures in adjacent levels. 3-D computer models of L2 and L3 were developed, adapting material properties to simulate osteoporosis and cement augmentation restored strength of treated vertebra but clearly altered the load transfer in adjacent vertebra. Fribourg et al demonstrated higher rate of subsequent fracture after kyphoplasty compared with natural history data for untreated fractures. Most of these occurred at adjacent level within 2 months of index procedure. After this 2-month period, there were only occasional subsequent fractures, which occurred at remote levels. It is recommended that patients with increase in back pain after kyphoplasty should be evaluated carefully for subsequent adjacent fractures, especially during first 2 months after index procedure. Sacroplasty is similar to vertebroplasty and is usually performed under CT guidance as it provides more accurate needle placement, but ideally with fluoroscopy monitoring to assess leakage of bone cement or vascular embolization. Bone cement is injected into fracture area and usually provides pain relief within 24 hours. Sacroplasty is considered safe and practical, and provides effective pain relief. Link TM. Radiology of osteoporosis. Canadian Association of Radiologists' Journal. 2016 Feb;67(1):28-40

52. A suggested treatment guideline based on fracture risk Low fracture risk Optimize calcium and vitamin D status Bone-friendly lifestyle High fracture risk Optimize calcium and vitamin D status Bone-friendly lifestyle Falls prevention Start appropriate antiresorptive therapy Very high fracture risk Optimize calcium and vitamin D status Bone-friendly lifestyle Falls prevention Consider appropriate anabolic treatment for 12–18 months followed by antiresorptive therapy.

53. New technology and future direction of development. DXA trabecular bone score (TBS): Spectral CT and dual-energy CT MRI measurement of fat Nuclear medicine imaging Artificial intelligence

54. Conclusion Osteoporosis is a severely debilitating disease. It is critical to identify patients with prevalent fragility fractures, as they are at high risk for future severe fractures and not misinterpret these findings as malignant disease prompting costly and unsafe interventions. Diagnose and monitor osteoporosis using quantitative techniques such as DXA and be familiar with complications of medical treatments. Need to perform interventional procedures to treat vertebral and sacral insufficiency fractures in concert with other clinicians adding supportive pharmacotherapies. Link TM. Radiology of osteoporosis. Canadian Association of Radiologists' Journal. 2016 Feb;67(1):28-40

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