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What is DEXA Scanning?

Dual Energy X-ray Absortiometry, or DEXA scanning, is currently the most widely used method to measure bone mineral density. For the test, a patient lies down on an examining table, and the scanner rapidly directs x-ray energy from two different sources towards the bone being examined in an alternating fashion at a set frequency. The mineral density of the patient's bone weakens, or prolongs the transmission of these two sources of x-ray energy through a filter onto a counter in a degree related to the amount of bone mass present. The greater the bone mineral density, the greater the signal picked up by the photon counter. The use of the two different x-ray energy sources rather than more traditional radioisotope studies (such that would be used for a bone scan) greatly improves the precision and accuracy of the measurements. DEXA scanning has become the most widely used method for measuring bone mineral density for several reasons. When compared with radiographic absortiometry or single energy x-ray absortiometry, DEXA scanning more precisely documents small changes in bone mass and is also more flexible since it can be used to examine both the spine and the extremities. A scan of the spine, hip or the total body requires only one, two or four minutes respectively. Qualitative computed tomography (QCT) is the only technique that can directly measure bone density and volume but can distinguish trabecular from cortical bone. DEXA scanning is less expensive, exposes the patient to less radiation and is more sensitive and accurate at measuring subtle changes in bone density over time or in response to drug therapy than is QCT. How are the results of DEXA scanning helpful? Studies using DEXA scanning have shown that people with osteoporosis have substantially lower bone density measurements than normal, age-matched people. Bone mineral density is widely accepted as a good indicator of bone strength. Thus low values can be compared against standard bone density measurements and help predict a patient's risk for fracture based upon the DEXA scan measurements. Who should have a DEXA scan? People with Gorhams vanishing bone disease / Lymphangiomatosis estrogen deficiency in women at clinical risk for osteoporosis evidence of vertebral abnormalities long term steroid use patients with primary hyperparathyroidism the need for monitoring to assess response to approved drug therapies for osteoporosis. How do you interpret the test results and who is a candidate for treatment? A DEXA scan report compares the patient's bone mineral density values with those of young

normal patient (T score) and with age matched normal patient (Z score). By comparing a patient's bone density against there peers, a low score indicates there may be a reason other than age related bone loss. Patients risk factors for osteoporosis that should play a part in the decision to begin treatment include: a maternal history of a hip fracture, any previous fracture after the age of fifty, tall height at age of 25, poor health, some sedatives and anticonvulsant drugs, and the inability to rise from a chair without the use of the arms. The current treatment recommendations are the start of drug therapy to reduce the risk fracture for all women with a bone mineral density T score of less than -2 without other risk factors and for those with a T score of less than -1.5 if other risk factors are present.

Dual energy X-ray absorptiometry


From Wikipedia, the free encyclopedia

Not to be confused with Bone scan.

A scanner used to measure bone density with dual energy X-ray absorptiometry.

Dual energy X-ray absorptiometry (DXA, previously DEXA) is a means of measuring bone mineral density (BMD). Two X-ray beams with differing energy levels are aimed at the patient's bones. When soft tissue absorption is subtracted out, the BMD can be determined from the absorption of each beam by bone. Dual energy X-ray absorptiometry is the most widely used and most thoroughly studied bone density measurement technology.

The DXA scan is typically used to diagnose and follow osteoporosis. It is not to be confused with the nuclear bone scan which is sensitive to certain metabolic diseases of bones in which bones are attempting to heal from infections, fractures, or tumors.
Contents
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1 Uses 2 Recommendations 3 Scoring 4 Current clinical practice in paediatrics 5 Notes 6 References 7 External links

[edit]Uses
DXA scans are primarily used to evaluate bone mineral density. DXA scans can also be used to measure total body composition and fat content with a high degree of accuracy comparable to hydrostatic weighing with a few important caveats [1][nb 1]. However, it has been suggested that while very accurately measuring minerals and lean soft tissue (LST), DXA may provide skewed results as a result of its method of indirectly calculating fat mass by subtracting it from the LST and-or body cell mass (BCM) that DXA actually measures
[2][nb 2]

[edit]Recommendations
Women over the age of 65 should get a DXA scan[3]. At risk women should consider getting a scan at age 60. 'At risk' includes many different clinical risk factors including: prior fragility fracture, use of glucocorticoids, heavy smoking, excess alcohol intake, rheumatoid arthritis, history of parental hip fracture, chronic renal and liver disease, chronic respiratory disease, long-term use of phenobarbitone or phenytoin, celiac disease, inflammatory bowel disease and other risks. The same clinical risk factors in men over 50y should prompt getting a DXA scan too.

[edit]Scoring
The World Health Organization has defined the following categories based on bone density in white women:

* * * *

Normal bone: T-score better than -1 Osteopenia: T-score between -1 and -2.5 Osteoporosis: T-score less than -2.5 Established (severe) osteoporosis

includes the presence of a non-traumatic fracture.

The WHO committee did not have enough data to create definitions for men or other ethnic groups [4]. This test is very reliable. Special considerations are involved in the use of DXA to assess bone mass in children. Specifically, comparing the bone mineral density of children to the reference data of adults (to calculate a T-score) will underestimate the BMD of children, because children have less bone mass than fully developed adults. This would lead to an over diagnosis of osteopenia for children. To avoid an overestimation of bone mineral deficits, BMD scores are commonly compared to reference data for the same gender and age (by calculating a Z-score). Also, there are other variables in addition to age which are suggested to confound the interpretation of BMD as measured by DXA. One important confounding variable is bone size. DXA has been shown to overestimate the bone mineral density of taller subjects and underestimate the bone mineral density of smaller subjects. This error is due to the way in which DXA calculates BMD. In DXA, bone mineral content (measured as the attenuation of the X-ray by the bones being scanned) is divided by the area (also measured by the machine) of the site being scanned. Because DXA calculates BMD using area (aBMD: areal Bone Mineral Density), it is not an accurate measurement of true bone mineral density, which is mass divided by a volume. In order to distinguish DXA BMD from volumetric bone-mineral density, researchers sometimes refer to DXA BMD as an areal bone mineral density (aBMD). The confounding effect of differences in bone size is due to the missing depth value in the calculation of bone mineral density. Despite DXA technology's problems with estimating volume, it is still a fairly accurate measure of bone mineral content. Methods to correct for this shortcoming include the calculation of a volume which is approximated from the projected area measure by DXA. DXA BMD results adjusted in this manner, are referred to as the bone mineral apparent density (BMAD) and are a ratio of the bone mineral content versus a cuboidal estimation of the volume of bone. Like aBMD, BMAD results do not accurately represent true bone mineral density, since they use approximations of the bone's volume. BMAD is used primarily for research purposes and is not yet used in clinical settings. Other imaging technologies such as Computed Quantitative Computer Tomography (QCT) are capable of measuring the bone's volume, and are therefore not susceptible to the confounding effect of bone-size in the way that DXA results are susceptible. DXA uses X-rays to assess bone mineral density. However, the radiation dose is approximately 1/10th that of a standard chest X-ray.[5] The quality of DXA operators varies widely. DXA is not regulated like other radiation based imaging techniques because of its low dosage. Each state has a different policy as to what certifications are needed to operate a

DXA machine. California, for example, requires coursework and a state-run test, whereas Maryland has no requirements for DXA technicians. Many states require a training course and certificate from the International Society of Clinical Densitometry (ISCD). Because BMD testing with DXA is very susceptible to operator error, it is important to find out what qualifies the technician to operate the machine.[citation needed] It is important for patients to get repeat BMD measurements done on the same machine each time, or at least a machine from the same manufacturer. Error between machines, or trying to convert measurements from one manufacturer's standard to another can introduce errors large enough to wipe out the sensitivity of the measurements.[citation needed] DXA results need to be adjusted if the patient is taking strontium supplements [6][7]

[edit]Current

clinical practice in paediatrics

DXA is, by far, the most widely used technique for bone measurements since it is considered to be cheap, accessible, easy to use, and able to provide an accurate estimation of bone mineral density in adults. [8] The official position of the ISCD (International Society for Clinical Densitometry) is that a patient may be tested for BMD if; he suffers from a condition which could precipitate bone loss or is going to be prescribed pharmaceuticals known to cause bone loss or he is being treated and needs to be monitored. The ISCD states that there is no clearly understood correlation between BMD and the risk of a child suffering a fracture; the diagnosis of osteoporosis in children cannot be made using the basis of a densitometry criteria. T-scores are prohibited with children and should not even appear on DXA reports, and thus, the WHO classification of osteoporosis and osteopenia in adults cannot be applied to children but Z-scores can be used to assist diagnosis.[9] Some clinics may routinely carry out DXA scans on paediatric patients with conditions such as nutritional rickets, lupus and Turner Syndrome.[10] DXA has been demonstrated to measure skeletal maturity[11] and body fat composition[12] and has been used to evaluate the effects of pharmaceutical therapy[13]. It may also aid paediatricians in diagnosing and monitoring treatment of disorders of bone mass acquisition in childhood.[14] However it seems that DXA is still in its early days in paediatrics and there are widely acknowledged limitations and disadvantages with DXA. A view exists[15] that DXA scans for diagnostic purposes should not even be performed outside specialist centres and if a scan is done outside one of these centres, it should not be interpreted without consultation with an expert in the field.[15] Furthermore, most of the pharmaceuticals that are given to adults with low bone mass can be given to children only in strictly monitored clinical trials. Whole-body calcium measured by DXA has been validated in adults using in-vivo neutron activation of total body calcium[16][17] but this is not suitable for paediatric subjects and studies have been carried out on paediatric-sized animals.[16][17]

The World Health Organization has developed definitions for low bone mass (osteopenia) and osteoporosis. These definitions are based on a T-score. The T-score is a measure of how dense a patient's bone is compared to a normal, healthy 30-year-old adult. Normal: A bone BMD is considered normal if the T-score is within 1 standard deviation of the normal young adult value. Thus a T-score between 0 and -1 is considered a normal result. Low bone mass (medically termed osteopenia): A BMD defines osteopenia as a T-score between -1 and -2.5. This signifies an increased fracture risk but does not meet the criteria for osteoporosis. Osteoporosis: A BMD greater than 2.5 standard deviations from the normal (T score less than or equal to -2.5) defines osteoporosis.

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