Bone Densitometry Cases

1. Bone Densitometry Cases Back to the real world…

2. QAPositioning? Numbering? T-scores? Artifacts?

3. Positioning, centered, see iliac crests and mid T12 and almost mid L5, so okay. Typically only include L1-L4 ROI, not L5.Numbering? Look at iliac crests, L5 should be L4. As is currently numbered, T-scores jump, drop L3 and L4. Artifacts, none. L1 L4

4. QA Positioning? Artifacts?

5. Femoral necks centered, lesser trochanter is not seen or small=good internal rotation, straight shafts, symmetric left and right. No artifacts.

6. QA Positioning? Numbering? T-scores? Artifacts? Comparison?

7. QA Positioning? Ok. Numbering? Hard to see endplates especially L3 and L4. L1-2 too high? Exclude T12 ROI. T-scores? All over the place, what to drop, what to keep. L3 and L4 clearly sclerotic, so drop. Still big jump between L1 and L2. Need to think about doing bilateral hips and adding forearm. Comparison—huge change, double check old vs. new. No artifacts.

8. Same patient as prior slide. L3 biconcave compression fracture. If no significant trauma or secondary cause, then it is a fragility fracture = osteoporosis. (T-scores normal!)

9. QA ROI? T-scores? Artifacts?

10. QA ROI? L1, L2 and L4 look compressed/short. L1 and L2 dense. T-scores variable but would favor dropping L1 and L2. Think of adding bilateral hips and forearm. No artifacts. See big spur at around T10-11, would consider smoothing that out if it occurred in the lumbar region. Careful when modifying edge detection and bone margins because hard to reproduce consistently.

11. Same patient as the previous slide Severe wedge compression L1, moderate wedge compression L2. L3 okay. Mild inferior concave fracture L4? Aortic calcification circled in blue.

12. QA Positioning? Numbering? T-scores? Artifacts?

13. QA Positioning? Ok. Numbering? Ok. T-scores? Clearly sclerosis at L3 and L4, maybe inferior L2. Leaves only L1 and maybe L2 to measure but big T-score jump between the L1 and L2. Think—bilateral hips & FOREARM! Artifacts, none.

14. QA Positioning? Artifacts?

15. QA Shafts not straight. Good internal rotation and minimal lesser trochanter showing. Femoral neck not as well-centered in the right image. Artifacts, none.

16. QA Positioning? Numbering? T-scores? Artifacts?

17. QA Positioning ok, or move slightly to left. Numbering ok. T-scores with big jump between L2 and L3. L3 and L4 sclerotic, so drop and use only L1 and L2. Consider bilateral hips and forearm! No artifacts.

18. QA Positioning? Numbering? T-scores? Artifacts?

19. QA Positioning ok. Numbering ok but uncertain if line dividing L3 and L4 is correct. Is that L3 endplate really lower and same thing with inferior L4 endplate? See red lines. Inferior L4 difficult to define. T-scores> 1.0 change between L2 and L3, sclerosis at L3 for sure. Drop L3 and L4. Artifacts, none. Consider bilateral hips and forearm.

20. QAPositioning? Numbering? T-score? Artifacts?

21. QAPositioning reasonable. Numbering, okay. T-scores, L1 -1.7 and L2 -1.3. ? sclerosis L2. Artifact—yes! Screws and underwires, neutralize!! Screws not quite completely masked. Needs bilateral hips and forearm as well.

22. QAPositioning? Numbering? T-scores? Artifacts?

23. QAAll good, except iliac crests not well seen but contrast setting may be the reason. Artifact--paired linear density L1, belt? If so, remove and rescan! T-scores next slide.

24. T-scores > 1.0 jump between L2 and L3. 1.4 difference. L4 sclerotic, but L3 less conspicuous. Drop L4 and probably L3.

25. Same patient No clear explanation for jump in T-score between L2 and L3.

26. QA Positioning? Numbering? T-scores? Artifacts?

27. QA All okay except artifact. L1 level, two densities adjacent to lowest rib on left side of image. Remove or neutralize.

28. QA

29. Don’t see iliac crests or rib well but may be contrast setting. NOT well-centered. T12-L1 & L1-2 lines slightly off, otherwise reasonable positioning.

30. QA

31. Hologic® QA3 corners of femoral neck box are in soft tissue but the 4th corner of neck box should be anchored on bone, along the greater trochanter medial margin. Otherwise reasonable positioning.

32. QA Numbering?

33. QA L4-5 disk space as labeled is well above iliac crests, but next level down is well below iliac crests. L3 usually has longest transverse processes. Transitional vertebrae? Someone made a decision and let’s stick with it to be consistent. Reminder, check the prior images!

34. QA Numbering?

35. Numbering?L4-5 disk space as labeled is well above iliac crests, but next level down is well below iliac crests. L3 usually has longest transverse processes. Transitional vertebrae? Reminder, check the prior images!Probably would have chosen next level down as L4-5. Scan is supposed to include mid T12, does not as currently numbered.

36. QA Positioning? Numbering? T-scores? Artifacts?

37. QA Positioning ok. Exclude T12 ROI. Agree with numbering but not sure if L3-4 and L4-5 lines are correct, looks like both should be moved inferior—see red lines. Note T12 compression fx and probably L2 as well. Agree with dropping at least L1 due to degenerative sclerosis and high T-score. All these challenges, think bilateral hips & forearm.

38. QA Positioning? Numbering? T-scores? Artifacts?

39. QA Positioning ok, maybe could shift more to the left side of image. Agree with numbering. Big jump in T-score between L2 and L3. Drop L3 and L4. What is the artifact that was neutralized? Could it have been a navel ring or snap? Maybe underwire artifact at top of the image especially left side of image. Remove, remove, remove and rescan!

40. QA Positioning? Numbering? T-scores? Artifacts

41. QA Positioning ok. Agree with numbering. T-scores not provided. Artifacts!!!! Bra hooks at T12 level. What is next to L2-3 on the left side of the image?! Remove or neutralize. Consider smoothing out the spur at the superior L3 level. Remove, remove, remove artifacts and rescan!

42. QA Positioning ok, maybe could shift more to the right side of the image. Agree with numbering. Big jump in T-score between L2 and L3. Drop L1 and L2 due to degenerative sclerosis. Continued…

43. QA Positioning ok, maybe could shift more to right side of image. Agree with numbering. Big jump in T-score between L2 and L3. Drop L1 and L2 due to degenerative sclerosis. Superior aspect of box should be angled. Smooth out defect in ROI inferior L4. Expanded results summary allows radiologist to select appropriate levels—L3-L4.

44. GE: Femoral neck box is moved up the slope to avoid ischium. But need to keep 4 corners in soft tissue. May have to neutralize a portion of ischium. This as far as you should move the box superiorly.

45. QA Positioning? Artifacts?

46. QA Positioning: Neck not centered in the image, should include more medial structures right and left. Shaft not straight, especially on right-sided image. Hard to reproduce positioning year to year if not correctly positioned. Positioning not symmetric left and right, inconsistent and poor precision.

47. QA Positioning? Artifacts?

48. QA GE: Necks relatively well-centered in image, shafts fairly straight. Neck box touching bone? Should move it down and neutralize ischium. Not much room in this patient. Artifact?? Remove, remove, remove and rescan.

49. QAPositioning? Artifacts?

50. GE: Neck relatively well-centered on left image but not so much on the right image. On right image, need to include more medial structures. Shafts pretty straight, slightly abducted on the left.Artifact bilaterally!! Remove, remove, remove and rescan.