Aug 2026· Academic Radiology· 0 citations· 28 references
Medicine
TL;DR
L1 attenuation ≤160 HU on 100-kVp LDCT identified postmenopausal women at three-fold higher fragility fracture risk, with performance comparable to Fracture Risk Assessment Tool without BMD.
Abstract
Rationale
AND
Objectives
Low-dose computed tomography (LDCT) is standard for lung cancer screening, yet validated fracture risk thresholds for 100-kVp protocols have not been established in health check-up cohorts. We evaluated whether L1 vertebral attenuation on 100-kVp LDCT predicts 10-year fragility fracture incidence.
Materials And Methods
This retrospective cohort study included 1464 women age ≥50 years (median follow-up: 10.1 years). L1 Hounsfield Units (HU) were measured on 100-kVp LDCT by two independent readers. References value for normal and low bone mineral density (BMD) was derived from a separate calibration cohort (n = 246) with paired LDCT-Dual-energy X-ray absorptiometry (DXA) data (AUC 0.841). Endpoints included incident vertebral fractures and composite major fragility fractures.
Results
HU = 160 (AUC = 0.841) stratified the whole group into normal BMD (>160 HU; n = 952) and low BMD (≤160 HU; n = 512). At 10 years, cumulative vertebral fracture incidence was 38.2 vs. 2.8% in low vs. normal BMD groups; composite fractures reached 48.1% vs. 6.3%. The incidence rate ratio was 3.46 (95% CI: 2.62-4.57) for vertebral fractures and 2.72 (95% CI: 2.14-3.46) for all fragility fractures. On multivariable Cox regression adjusting for age, body mass index, and comorbidities, low BMD (≤160 HU) remained an independent predictor of vertebral fracture (adjusted HR: 2.54; 95% CI: 1.33-4.85; p = 0.005).
Conclusion
L1 attenuation ≤160 HU on 100-kVp LDCT identified postmenopausal women at three-fold higher fragility fracture risk, with performance comparable to Fracture Risk Assessment Tool without BMD. In this healthy screenee cohort, L1 HU serves as the primary bone health signal, enabling early identification of at-risk individuals within existing LDCT workflows at no additional cost.
Multilevel lumbar, reference-adjusted HU assessment beyond isolated L1 improves the identification of QCT-defined osteoporosis and the discrimination of prevalent fragility fracture status and provides a practical marker of trabecular bone quality beyond isolated L1.
J. R. Andresen, S. Heisinger, Thomas Haider et al.· Diagnostics· 0 citations
This study assessed variation of automated CT-based L1 trabecular attenuation for opportunistic CT screening across multiple U.S.-based healthcare systems. L1 HU measurements demonstrated similar behavior among the five sites, including relative relationships according to age, sex, race, and CT scanner, and < 100 HU was generalizable for practical opportunistic CT screening and diagnosis.
PURPOSE
To assess variability of automated population-based L1 trabecular attenuation (HU) measurement at abdominal CT among five US-based medical systems and consider a practical 100 HU threshold for opportunistic CT-based osteoporosis screening and diagnosis.
METHODS
Heterogeneous adult patient cohorts undergoing abdominal CT evaluation for any indication at five US medical systems were included for L1 vertebral body trabecular attenuation (L1 HU) assessment using a validated AI pipeline that places a fully automated ROI. Exclusion criteria included IV contrast, non-120 kVp setting, and non-physiologic outliers. All results were normalized to White patient ranges after age and sex matching. Thresholds of 100 HU and 120 HU were considered.
RESULTS
The final multi-center cohort included 123,001 adults (51.1% women, 79.6% White). For White women age 50+, 15% had L1 attenuation values ≤ 100 HU, and 30% ≤ 120 HU. For White men, the equivalent percentages were 12% and 26%; for Black women, 7% and 17%, and for Black men, 5% and 11%. For 20-49-year-olds, only about 1% were below the L1 100 HU threshold. L1 HU measurements showed similar distributions among the five medical systems and similar relative relationships according to age, sex, race, and CT scanner. After Bonferroni correction, none of the differences among different medical systems were significant.
CONCLUSION
For opportunistic CT screening and diagnosis, automated assessment of L1 trabecular attenuation was generalizable in a multi-center setting. A 100 HU threshold maintains specificity with a prevalence that is age-, sex-, and race-dependent, ranging from 1% in adults under 50 to up to 15% in White women.
P. Pickhardt, Glen M. Blake, Matthew H. Lee et al.· Osteoporosis International· 0 citations
In patients undergoing cervical spine surgery, C-VBQ demonstrates consistent associations with C-HU and DXA T-scores, supporting its potential for opportunistic preoperative bone quality assessment and Integrating radiological indicators such as C-VBQ and C-HU with DXA and BTMs may enable a more comprehensive, but still cautiously interpreted, perioperative bone health evaluation.
Xiaoteng Feng, Xiu-Jia Xia, Ze-Lin Shen et al.· European spine journal· 0 citations
Purpose To develop and validate an AI algorithm that enables dual-site (spine and hip) BMD assessment for opportunistic osteoporosis screening using a single kidney-ureter-bladder (KUB) radiograph. Materials and methods In this institutional review board approved prospective study, we developed the SHield pipeline for opportunistic osteoporosis screening. From an initial dataset of 15,175 KUB images, a final cohort of 4,436 patients (mean age 69.0 ± 12.2 years) was included for model development after exclusions for suboptimal quality or incomplete region of interests. The pipeline analyzes both the spine and hip regions on a single KUB to predict site-specific BMD values. Finally, it integrates these dual-site predictions to determine the lowest T-score, mimicking the standard clinical DXA reporting protocol which evaluates both the lumbar spine and proximal femur. Results On the internal test set (628 patients), the hip and spine AI models demonstrated Pearson correlation coefficients of 0.887 and 0.921 and RMSEs of 0.057 and 0.062, respectively, compared to DXA-measured BMD, achieving AUCs of 0.894 and 0.956 for predicting T-scores ≤-2.5. In a subsequent prospective feasibility study (51 patients), we employed a conservative detection threshold of Tm-score ≤-2.8 to minimize false positives and unnecessary referrals. The final AI pipeline achieved a Pearson correlation of 0.959, an AUC of 0.969, 100% PPV, 100% specificity, and 83.8% NPV. Conclusion This paper presents the first AI pipeline that enables gold-standard-aligned, dual-site BMD estimation and opportunistic osteoporosis screening from a single KUB radiograph. Validated prospectively, its high accuracy and specificity confirm its potential to significantly increase early detection rates without overwhelming clinical workflows.
Hsuan-Yin Lin, J. Chai, Qingzong Tseng et al.· Frontiers in Endocrinology· 0 citations
No routinely measured biomarker demonstrated clinical utility for identifying BMD trajectory in this cohort of Saudi dual-energy X-ray absorptiometry patients, suggesting future studies with explicit treatment tracking and repeated bone-turnover measurements are required for confirmation.
L. Jambi, S. Kabrah· Journal of Clinical Medicine· 0 citations
VBQ can serve as an opportunistic exploratory screening marker of low BMD and FBQcsf may complement VBQ by identifying early marrow-related changes, although further validation is required.
M. Müller, João Paulo Ferreira, Laura Mulazzani Minuzzi Macedo et al.· Skeletal Radiology· 0 citations
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