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Osteoporosis and Bone Mineral Density

Variant: 1   Osteoporosis screening or initial imaging of clinically suspected low bone mineral density.
Procedure Appropriateness Category Relative Radiation Level
DXA lumbar spine and hip(s) Usually Appropriate ☢
DXA distal forearm May Be Appropriate ☢
QCT lumbar spine and hip May Be Appropriate ☢☢☢
QUS calcaneus Usually Not Appropriate O
SXA distal forearm Usually Not Appropriate ☢
TBS lumbar spine Usually Not Appropriate ☢
Radiography appendicular skeleton Usually Not Appropriate ☢☢
Radiography axial skeleton Usually Not Appropriate Varies

Variant: 2   Follow-up imaging of patients demonstrated to have risk for fracture or surveillance of established low bone mineral density.
Procedure Appropriateness Category Relative Radiation Level
DXA lumbar spine and hip(s) Usually Appropriate ☢
DXA distal forearm May Be Appropriate ☢
TBS lumbar spine May Be Appropriate ☢
QCT lumbar spine and hip May Be Appropriate ☢☢☢
QUS calcaneus Usually Not Appropriate O
DXA VFA Usually Not Appropriate ☢
SXA distal forearm Usually Not Appropriate ☢

Variant: 3   Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
Procedure Appropriateness Category Relative Radiation Level
DXA lumbar spine and hip(s) Usually Appropriate ☢
DXA VFA Usually Appropriate ☢
DXA distal forearm May Be Appropriate ☢
Radiography axial skeleton May Be Appropriate Varies
QCT lumbar spine and hip May Be Appropriate ☢☢☢
QUS calcaneus Usually Not Appropriate O
SXA distal forearm Usually Not Appropriate ☢
TBS lumbar spine Usually Not Appropriate ☢
Radiography appendicular skeleton Usually Not Appropriate ☢☢

Variant: 4   Initial imaging for premenopausal females or males less than 50 years of age. Individual with risk factors that could alter bone mineral density.
Procedure Appropriateness Category Relative Radiation Level
DXA lumbar spine and hip(s) Usually Appropriate ☢
DXA distal forearm May Be Appropriate ☢
QUS calcaneus Usually Not Appropriate O
SXA distal forearm Usually Not Appropriate ☢
TBS lumbar spine Usually Not Appropriate ☢
Radiography appendicular skeleton Usually Not Appropriate ☢☢
Radiography axial skeleton Usually Not Appropriate Varies
QCT lumbar spine and hip Usually Not Appropriate ☢☢☢

Variant: 5   Premenopausal females with risk factors. Males less than 50 years of age with risk factors. Follow-up to low bone mineral density.
Procedure Appropriateness Category Relative Radiation Level
DXA lumbar spine and hip(s) Usually Appropriate ☢
DXA distal forearm May Be Appropriate ☢
QCT lumbar spine and hip May Be Appropriate ☢☢☢
QUS calcaneus Usually Not Appropriate O
SXA distal forearm Usually Not Appropriate ☢
TBS lumbar spine Usually Not Appropriate ☢

Variant: 6   Males and females greater than or equal to 50 years of age. Suspected osteoporosis. Advanced degenerative changes of the spine with or without scoliosis, or other conditions that may spuriously elevate BMD. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
DXA distal forearm Usually Appropriate ☢
DXA lumbar spine and hip(s) Usually Appropriate ☢
QCT lumbar spine and hip(s) Usually Appropriate ☢☢☢
QUS calcaneus Usually Not Appropriate O
SXA distal forearm Usually Not Appropriate ☢
Radiography appendicular skeleton Usually Not Appropriate ☢☢
Radiography axial skeleton Usually Not Appropriate Varies

Panel Members
Joseph S. Yu, MDa; Nidhi G. Krishna, MDb; Michael G. Fox, MD, MBAc; Donna G. Blankenbaker, MDd; Matthew A. Frick, MDe; Shari T. Jawetz, MDf; Guibin Li, MDg; Charles Reitman, MDh; Nicholas Said, MD, MBAi; J. Derek Stensby, MDj; Naveen Subhas, MD, MPHk; Mark Tulchinsky, MDl; Eric A. Walker, MD, MHAm; Francesca D. Beaman, MDn.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Osteoporosis screening or initial imaging of clinically suspected low bone mineral density.
Variant 1: Osteoporosis screening or initial imaging of clinically suspected low bone mineral density.
A. DXA 
Variant 1: Osteoporosis screening or initial imaging of clinically suspected low bone mineral density.
B. QCT 
Variant 1: Osteoporosis screening or initial imaging of clinically suspected low bone mineral density.
C. QUS 
Variant 1: Osteoporosis screening or initial imaging of clinically suspected low bone mineral density.
D. Radiography appendicular skeleton
Variant 1: Osteoporosis screening or initial imaging of clinically suspected low bone mineral density.
E. Radiography axial skeleton
Variant 1: Osteoporosis screening or initial imaging of clinically suspected low bone mineral density.
F. SXA 
Variant 1: Osteoporosis screening or initial imaging of clinically suspected low bone mineral density.
G. TBS 
Variant 2: Follow-up imaging of patients demonstrated to have risk for fracture or surveillance of established low bone mineral density.
Variant 2: Follow-up imaging of patients demonstrated to have risk for fracture or surveillance of established low bone mineral density.
A. DXA
Variant 2: Follow-up imaging of patients demonstrated to have risk for fracture or surveillance of established low bone mineral density.
B. DXA VFA
Variant 2: Follow-up imaging of patients demonstrated to have risk for fracture or surveillance of established low bone mineral density.
C. QCT 
Variant 2: Follow-up imaging of patients demonstrated to have risk for fracture or surveillance of established low bone mineral density.
D. QUS 
Variant 2: Follow-up imaging of patients demonstrated to have risk for fracture or surveillance of established low bone mineral density.
E. SXA
Variant 2: Follow-up imaging of patients demonstrated to have risk for fracture or surveillance of established low bone mineral density.
F. TBS 
Variant 3: Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
Variant 3: Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
A. DXA 
Variant 3: Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
B. DXA VFA
Variant 3: Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
C. QCT 
Variant 3: Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
D. QUS 
Variant 3: Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
E. Radiography appendicular skeleton
Variant 3: Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
F. Radiography axial skeleton
Variant 3: Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
G. SXA 
Variant 3: Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
H. TBS
Variant 4: Initial imaging for premenopausal females or males less than 50 years of age. Individual with risk factors that could alter bone mineral density.
Variant 4: Initial imaging for premenopausal females or males less than 50 years of age. Individual with risk factors that could alter bone mineral density.
A. DXA 
Variant 4: Initial imaging for premenopausal females or males less than 50 years of age. Individual with risk factors that could alter bone mineral density.
B. QCT
Variant 4: Initial imaging for premenopausal females or males less than 50 years of age. Individual with risk factors that could alter bone mineral density.
C. QUS 
Variant 4: Initial imaging for premenopausal females or males less than 50 years of age. Individual with risk factors that could alter bone mineral density.
D. Radiography appendicular skeleton
Variant 4: Initial imaging for premenopausal females or males less than 50 years of age. Individual with risk factors that could alter bone mineral density.
E. Radiography axial skeleton
Variant 4: Initial imaging for premenopausal females or males less than 50 years of age. Individual with risk factors that could alter bone mineral density.
F. SXA 
Variant 4: Initial imaging for premenopausal females or males less than 50 years of age. Individual with risk factors that could alter bone mineral density.
G. TBS
Variant 5: Premenopausal females with risk factors. Males less than 50 years of age with risk factors. Follow-up to low bone mineral density.
Variant 5: Premenopausal females with risk factors. Males less than 50 years of age with risk factors. Follow-up to low bone mineral density.
A. DXA 
Variant 5: Premenopausal females with risk factors. Males less than 50 years of age with risk factors. Follow-up to low bone mineral density.
B. QCT 
Variant 5: Premenopausal females with risk factors. Males less than 50 years of age with risk factors. Follow-up to low bone mineral density.
C. QUS 
Variant 5: Premenopausal females with risk factors. Males less than 50 years of age with risk factors. Follow-up to low bone mineral density.
D. SXA 
Variant 5: Premenopausal females with risk factors. Males less than 50 years of age with risk factors. Follow-up to low bone mineral density.
E. TBS 
Variant 6: Males and females greater than or equal to 50 years of age. Suspected osteoporosis. Advanced degenerative changes of the spine with or without scoliosis, or other conditions that may spuriously elevate BMD. Initial imaging.
Variant 6: Males and females greater than or equal to 50 years of age. Suspected osteoporosis. Advanced degenerative changes of the spine with or without scoliosis, or other conditions that may spuriously elevate BMD. Initial imaging.
A. DXA 
Variant 6: Males and females greater than or equal to 50 years of age. Suspected osteoporosis. Advanced degenerative changes of the spine with or without scoliosis, or other conditions that may spuriously elevate BMD. Initial imaging.
B. QCT 
Variant 6: Males and females greater than or equal to 50 years of age. Suspected osteoporosis. Advanced degenerative changes of the spine with or without scoliosis, or other conditions that may spuriously elevate BMD. Initial imaging.
C. QUS 
Variant 6: Males and females greater than or equal to 50 years of age. Suspected osteoporosis. Advanced degenerative changes of the spine with or without scoliosis, or other conditions that may spuriously elevate BMD. Initial imaging.
D. Radiography appendicular skeleton
Variant 6: Males and females greater than or equal to 50 years of age. Suspected osteoporosis. Advanced degenerative changes of the spine with or without scoliosis, or other conditions that may spuriously elevate BMD. Initial imaging.
E. Radiography axial skeleton
Variant 6: Males and females greater than or equal to 50 years of age. Suspected osteoporosis. Advanced degenerative changes of the spine with or without scoliosis, or other conditions that may spuriously elevate BMD. Initial imaging.
F. SXA 
Summary of Recommendations
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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Disclaimer

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