Dual-Energy X-Ray Absorptiometry for Osteoporosis Screening: AJR Expert Panel Narrative Review

Dual-energy x-ray absorptiometry (DXA) is an established method for osteoporosis screening and treatment monitoring, providing results that predict fracture risk. DXA is used not only to measure bone mineral density (BMD) in various anatomic sites, but also to perform vertebral fracture analysis, trabecular bone score (TBS) determination, and whole-body composition analysis. Although DXA is central in osteoporosis screening, the test has limitations, and other factors beyond BMD measurements must be considered when planning treatments and follow-up strategies. For example, sex, race and ethnicity, prior fragility fractures, glucocorticoid use, and prior falls affect fracture risk. Despite a growing population of older individuals and growing evidence of variations in fracture risk, osteoporosis screening recommendations have not evolved significantly. Moreover, despite the existence of screening recommendations, DXA remains underutilized, and osteoporosis is underdiagnosed. This AJR Expert Panel Narrative Review discusses the current status of osteoporosis screening by DXA, addressing current practice recommendations, the use of BMD results to guide risk predictions and management decisions, as well as the challenges and limitations along with evolving solutions. Topics explored include DXA reporting and screening recommendations; fragility fracture risk assessment tools; the role of TBS; race, ethnicity, and sex considerations; application in children; and CT-based BMD measurements and opportunistic screening.