Clinical presentation: Most patients may be
in some asymptomatic until there is a massive
fracture of either the vertebrae or maybe
perhaps the hip that I had mentioned earlier.
There are greater than one inch loss of height;
kyphosis because of issues within the vertebrae
and with that kyphosis may then cause restriction
of your thoracic cavity, thoracic cage.
So, therefore, breathing becomes difficult;
may result in even restrictive lung disease
because of literally physical, mechanical
restriction of your lung.
Focused exam looking for signs of secondary
causes, always is in endocrinopathy; is your
patient corticoid, so on and so forth.
Imaging: plain film, not sensitive for detecting
early disease, not early on, your bone may
actually still look rather normal.
Lateral films used for-for visualizing spine
Remember osteopenia, would mean decreased
or thinning out of your trabeculae.
There is something called dual-energy X-ray
absorp-absorptiometry known as the DXA scan.
So, DXA scan, calculated bone mineralized
density; bottom-line, that is what a DXA
scan will do.
It will find out as to how dense your bone
So, therefore, once, let?s say a female,
has hit menopause, you can expect the DXA
scan to show you decreased bone density.
Measures bone-bone density; mineralization
at the spine and your hip, two major sites
that you worried about major fractures in
a patient with osteoporosis.
Low bone mineralization density correlates
with increased risk of fracture.
Results express in the following two scores:
we have a T-score.
You want to be at least familiar with what
these mean and when you would even use this
or apply this.
A T-score will be used in a patient who you
suspect an osteoporosis with your bone mineralization
density, expressed in number of standard deviation
above or below the mean of normal 30-year
Then you have the Z-score, expressed relative
to adults of the same age and gender as the
So, more or less you?re comparing this individual
with the rest of the population; T, Z-score
being expressed for proper bone mineralization
The scan that you will be using here is called
a DXA scan, a dual-energy X-ray absorptiometry.
WHO criteria for osteoporosis include the
It?s important that you pay attention to
Remember that the T-score is then going to
measure as to what your bone mineralization
density would be.
If it?s greater than -1 and then it will
be normal; if it?s -1 to -2.5, you start
getting into trabeculae thinning out.
This is referred to as being your osteopenia.
If it?s less than -2.5, osteoporosis increased
porosity and if it gets much less than -2.5,
this is important because now you are increased
in risk of fractures in two major places - the
hip and the spine.
Indications for DXA scan: postmenopausal.
Remember, what is DXA scan measuring for?
Bone mineralization density.
Therefore, in a postmenopausal woman, above
the age of 50; here we are above 65, for sure.
Postmenopausal less than 65 years with clinical
risk factors, definitely.
So, now, there?s a family history of osteoporosis
in this female and she?s at menopause, clinical
risk factors, DXA.
Aid in decision regarding hormone replacement
therapy, if required and by hormone, of course,
we are replacing our estrogen.
Radiologic evidence of osteopenia, meaning
to say that you find your trabeculae to be
thinned out and there?s prior osteoporotic
All these would be indications and your monitoring
therapy for osteoporosis.
The biochemical assessment osteoporosis, what
are you looking for?
A good place to start would be a CBC and chemistry panel
The chemistry panel normally includes calcium, phosphorous and alkaline phosphatase.
In other words, are not these electrolytes
and such and enzymes that you are looking
for when you are referring to proper bone
Screen, hyperthyroidism could be an issue.
So, screen for TSH.
Also, screen for 25.
Why not 125?
Because the major Vitamin D that is circulating
in our bodies right now is the 25-type that
was hydroxylated by the liver.
Other tests sent based on history, physical,
initial lab; we have something called SPEP
and UPEP, 24-urine calcium, intact PTH and
testosterone, especially in men.
These are things that you want to keep in
mind as you get into further differentials.