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9 Medical Imaging in the Diagnosis of Osteoporosis...

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These considerations nonwithstanding, finite-element models have become an important component in the toolkit of image analysis for bone. Whereas the analysis of texture may provide information on the bone structure, which may complement average bone density in an empirical fashion, finite-element models allow a more rigorous approach to examine the load distribution in bone.

9.4 Trends in Imaging of Bone

A focus of this chapter lies on the use of texture analysis methods to obtain densityindependent information on bone microarchitecture. The underlying idea, that the combination of bone density and microarchitecture leads to an improved assessment of the individual fracture risk, has been validated in many studies. However, none of the texture analysis methods has found its way into clinical practice. In fact, several studies found a low predictive value of structure analysis, and most of the fracture risk was explained by bone density. The key reasons are:

Bone density and microarchitectural/structural information cannot be truly orthogonal, because reduced bone density appears as a consequence of trabecular thinning.

Unless microscopic methods are used that can resolve individual trabeculae, images of trabecular bone are subject to the point-spread function and the noise contribution from the imaging device. These artifacts can influence the metrics obtained.

The same artifact prevents most metrics to be comparable between modalities or even between different scanners. No single universal (or even widely applicable) method has emerged.

Texture methods usually do not take into account the load-bearing capacity of the cortical shell.

Additional factors have a strong impact on the fracture risk. These include muscle mass and overall strength, age, body mass index, current medication, dementia, and ancillary diseases.

On the other hand, it is indisputable that bone density, whose measurement involves averaging over a relatively large volume, is associated with loss of information. In a frequency-domain interpretation, bone density contains only the very low-frequency components of the bone, and the high-frequency information is discarded. The latter component is related to the complexity of the trabecular network, and the complexity and interconnectedness of trabeculae have been linked to load-bearing capacity. Furthermore, bone density overlaps between patients with and without fractures, a fact that further supports the idea that more factors than bone density should be included to assess the fracture risk. In this respect, the inclusion of structural or textural parameters is certainly a step in the right direction.

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These observations define the future trends in imaging of bone. First, existing methods for obtaining more complete information on a specific bone can be refined and new methods developed. Second, those methods must become more universal to allow adoption independent of imaging parameters, devices, and modalities. Third, ancillary factors need to be identified and included in the fracture risk assessment.

Progress is in part driven by the availability of higher-resolution modalities. Over the last 10–15 years, mainstream clinical scanners have increased their spatial resolution by an order of magnitude. Three-dimensional constructs can be extracted from CT and – more recently – MRI [85] that strongly resemble actual trabecular structure. With this development, biomechanical modeling of the fracture load of individual peripheral bones comes within reach. For the thoracic and lumbar spine, this extreme resolution is not readily available. Furthermore, present trends in healthcare policies could prevent relatively expensive three-dimensional imaging modalities from becoming more widely adopted. It is more reasonable to assume that the diagnosis will continue to be based on relatively inexpensive bone density estimation with ultrasound or DEXA. For this reason, continued research on texture-based methods gains importance as a means to obtain information that complements gross bone density. These methods would particularly focus on lowresolution modalities, such as DEXA and possibly ultrasound imaging. In fact, the prediction of bone strength with ultrasonic techniques has recently received increased attention [8688].

An area where image-based assessment of bone strength becomes more attractive is the evaluation of anti-osteoporosis drugs [89]. A case in point is the controversial treatment of bone loss with fluoride, which leads to a rapid gain in bone density [90], but not to a matching gain in bone strength [13]. In fact, Riggs et al. found an increased fracture rate after fluoride treatment [13]. Grynpas [91] presumes that fluoride leads to the formation of larger bone mineral crystals, which make bone more brittle. This example highlights the importance of the microstructure particularly well. The methods to assess bone microstructure can therefore aid in drug development and evaluation: by providing information on the microstructure during treatment, and by providing the tools to noninvasively estimate or even compute bone strength. One recent example is a micro-CT study by Jiang et al. [92] on the effects of hormone therapy on bone microstructure.

In conclusion, there is wide agreement that bone density alone may be sufficient to diagnose early bone loss, but is insufficient to accurately predict the individual fracture risk. Bone microarchitecture holds complementary information. Microstructural information can be obtained from biopsies or, noninvasively, by suitable high-resolution imaging techniques. Depending on the resolution, the trabecular structure and its interface with the cortical shell can be directly reconstructed, or indirect quantitative metrics can be obtained that reflect the microarchitecture only to some extent. When the bone structure can be fully reconstructed, direct modeling of bone strength is possible, for example, with finite-element methods. Conversely, indirect metrics that are obtained from lowerresolution modalities or projection imaging can be combined with mineral density in an empirical fashion. The combined metrics often correlate better with age

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and existing fractures than density alone. Although it would be desirable to have assessment methods for the bone microarchitecture in routine, low-resolution modalities (e.g., DEXA), no single method has emerged as a routine complement for bone densitometry. Due to their costs, high-resolution modalities are rarely used in clinical practice, but could turn out to be promising in drug development.

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