Michael Kleerekoper, MD, MACE, has joined the faculty at the University of Toledo Medical School where he is Professor in the Department of Internal Medicine and section chief of the Endocrinology Division. The author of numerous journal studies, Dr. Kleerekoper serves on the editorial boards for Endocrine Today, Endocrine Practice, Journal of Clinical Densitometry, Journal of Women's Health, Osteoporosis International and Calcified Tissue International. Dr. Kleerekoper is also a founding board member of the newly formed Academy of Women’s Health.

DXA and scoliosis

Back to back patients, both women in their late 50s, arrived at the clinic with their DXA reports in hand and both very concerned about the wording on the report. Both reports had the DXA images and in both, the spine images had clear evidence of scoliosis rendering interpretation difficult.

Careful examination of the first woman confirmed the scoliosis — a condition previously unknown to her. The scoliosis was mild and corrected on forward bending which she could do without difficulty. Correction of scoliosis with forward bending is suggestive of leg length discrepancy which I confirmed very simply by examining leg length. When she lay on her back with her legs extended, the left was shorter than the right by ~3/4”. With her knees bent, the difference was still apparent. When lying prone with her knees bent at 90° the difference was no longer apparent, confirming that the discrepancy was between the hip joint and the knee. Since she had no prior knowledge of this and no relevant symptoms, no intervention is necessary.

What effect does the scoliosis have on the validity of the DXA and its interpretation? The simple answer is that no one really knows, particularly with a mild degree of scoliosis such as seen in this patient. There are problems when attempting to use DXA for detection of vertebral fractures — more on that later.

The second patient had known about her scoliosis for many years and has long had both back trouble and difficulty walking. She had sustained more than her share of fragility fractures and did not really need a DXA to confirm her diagnosis of osteoporosis.

Not quite true! The correct diagnosis of osteogenesis imperfecta leapt out at me with the blueness of her sclerae along with the history of multiple fractures, but that’s a topic for another time.

DXA can accurately determine the bone mineral content (BMC) of the analyzed vertebrae even in a person with severe scoliosis and can equally accurately determine the area of bone analyzed (BA). BMC/BA provides the bone mineral density, but how to best interpret the data is the issue at hand. The technology will provide the BMD along with a T-score and a Z-score but at least to me, it cannot confidently relate the result to persons matched for age, sex, and ethnicity who do not have scoliosis.

The reference database is established from a population of subjects in whom the X-ray beam is passed through the vertebral body truly perpendicular to the orientation of the vertebra (both the vertebral body and the posterior elements). In a patient with scoliosis, it is not possible for all assessed vertebrae such the resultant T- and Z-score cannot be as accurately related to the reference database. This will of course vary with the degree of scoliosis and the extent to which there is spurring of the vertebral end plates. In some cases, such as the first patient discussed above, this is not a major problem, but in the second case it is.

The second case presented an even bigger technical issue because the DXA technique of vertebral fracture analysis (VFA) was applied. VFA is an excellent noninvasive, minimal radiation exposure method of evaluating whether or not a patient has sustained a vertebral fracture without experiencing any clinical symptoms. This simply does not work in patients with severe scoliosis. I only had to look at the images obtained to see that the vertebral body markings on the output were a “hit and miss” effort with respect to correctly identifying the edges of the vertebral body.

What’s the solution?

The technician performing a DXA scan can see the image of the scanned portion of the skeleton (forearm, lumbar spine, proximal femur) as the scan is proceeding. She/he would be unlikely to know before this that scoliosis is present since examination of the patient is appropriately not part of a DXA study. Any evidence that something about the image produced will interfere with the analysis and interpretation should alert the technician and reader to use caution with the subsequent interpretation and consider not providing an interpretation for a suspect scan.

Scoliosis is just one issue. I, and many colleagues, have seen DXA studies that included a replaced hip which is probably the most egregious error. Navel rings, zippers in slacks, coins in the pocket and many other things can interfere with a DXA.

From the perspective of the clinician ordering the scan and receiving the report, until you are satisfied that the DXA facility you are using is meticulous in the work, ask to have all of the images and ancillary data provided to you and not just the summary report. Most often you will be fully satisfied, but don’t rely on that up front!