The use of CT Hounsfield unit values to identify the undiagnosed spinal osteoporosis in patients with lumbar degenerative diseases

  • Da Zou
  • Weishi LiEmail author
  • Chao Deng
  • Guohong Du
  • Nanfang Xu
Original Article



Our purpose was to use computed tomography (CT) Hounsfield unit (HU) values to identify the undiagnosed spinal osteoporosis in patients with lumbar degenerative diseases.


A total of 334 patients with lumbar degenerative diseases were retrospectively reviewed and divided into two groups according to the degree of lumbar degenerative changes in preoperative lumbar CT images. Patients who had at least three vertebrae with severe degeneration at L1–L4 were placed in the degenerative group, and others were placed in the control group. HU value of trabecular bone in middle axial CT image of vertebral body, T-score and bone mineral density (BMD) at L1–L4 and hips were measured. CT HU thresholds for osteoporosis were obtained from control group and then applied to identify undiagnosed spinal osteoporosis.


There were 182 patients in the degenerative group and 152 patients in the control group. CT HU value had a positive correlation with T-score and BMD of lumbar spine in both groups (P < 0.001), while the correlation coefficients at L1–L4 were higher in the control group (> 0.7) than in the degenerative group (< 0.7). T-score and BMD of lumbar spine were higher in the degenerative group (P < 0.05), while CT HU value, T-score and BMD of hips had no significant difference between two groups. According to the linear regression equations of vertebral T-score and CT HU value in the control group, the thresholds matching T-score of − 2.5 were 110, 100, 85 and 80HU for L1, L2, L3 and L4, respectively. Defining CT osteoporosis as L1 ≤ 110HU or L2 ≤ 100HU or L3 ≤ 85HU or L4 ≤ 80HU was 88.5% (69/78) specific and 60.8% (45/74) sensitive for distinguishing DXA osteoporosis of lumbar spine in the control group. The rate of undiagnosed spinal osteoporosis was higher in the degenerative group than in the control group according to CT HU thresholds (38.7% vs. 11.5%, P < 0.05).


Degenerative changes in the lumbar spine can increase BMD and T-score provided by lumbar DXA, leading to an underestimation of vertebral osteoporosis. Thresholds for osteoporosis based on CT HU values can be used as a complementary method to identify undiagnosed spinal osteoporosis in patients with lumbar degenerative diseases.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Lumbar degenerative disease Osteoporosis CT Hounsfield unit value Dual-energy X-ray absorptiometry 



This study was funded by Capital’s Funds for Health Improvement and Research (2016-1-4096).

Compliance with ethical standards

Conflict of interest

The authors declared that they have no conflict of interest.

Ethical approval

All data collection and analysis conducted in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Supplementary material

586_2018_5776_MOESM1_ESM.pptx (144 kb)
Supplementary material 1 (PPTX 144 kb)


  1. 1.
    WHO Scientific Group on the Prevention and Management of Osteoporosis (2000: Geneva, Switzerland) (2003) Prevention and management of osteoporosis: report of a WHO scientific group. Geneva: World Health Organization.
  2. 2.
    Peng C, Li Z, Hu Y (2016) Prevalence of osteoporosis in china: a meta-analysis and systematic review. BMC Public Health 16(1):1039. CrossRefGoogle Scholar
  3. 3.
    Lubelski D, Choma TJ, Steinmetz MP, Harrop JS, Mroz TE (2015) Perioperative medical management of spine surgery patients with osteoporosis. Neurosurgery 77(Suppl4(4)):S92–S97. CrossRefPubMedGoogle Scholar
  4. 4.
    Chin DK, Park JY, Yoon YS, Kuh SU, Jin BH, Kim KS, Cho YE (2007) Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease. Osteoporos Int 18(9):1219–1224. CrossRefPubMedGoogle Scholar
  5. 5.
    Pappou IP, Girardi FP, Sandhu HS, Parvataneni HK, Cammisa FP Jr, Schneider R, Frelinghuysen P, Lane JM (2006) Discordantly high spinal bone mineral density values in patients with adult lumbar scoliosis. Spine (Phila Pa 1976) 31(14):1614–1620. CrossRefGoogle Scholar
  6. 6.
    Celi M, Rao C, Scialdoni A, Tempesta V, Gasbarra E, Pistillo P, Tarantino U (2013) Bone mineral density evaluation in osteoporosis: why yes and why not? Aging Clin Exp Res 25(1):47–49. CrossRefGoogle Scholar
  7. 7.
    Muraki S, Yamamoto S, Ishibashi H, Horiuchi T, Hosoi T, Orimo H, Nakamura K (2004) Impact of degenerative spinal diseases on bone mineral density of the lumbar spine in elderly women. Osteoporos Int 15(9):724–728. CrossRefPubMedGoogle Scholar
  8. 8.
    Adams MA, Pollintine P, Tobias JH, Wakley GK, Dolan P (2006) Intervertebral disc degeneration can predispose to anterior vertebral fractures in the thoracolumbar spine. J Bone Miner Res 21(9):1409–1416. CrossRefPubMedGoogle Scholar
  9. 9.
    Alacreu E, Moratal D, Arana E (2017) Opportunistic screening for osteoporosis by routine CT in Southern Europe. Osteoporos Int 8(3):983–990. CrossRefGoogle Scholar
  10. 10.
    Pickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ, Binkley N (2013) Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med 158(8):588–595. CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Pickhardt PJ, Lauder T, Pooler BD, Muñoz Del Rio A, Rosas H, Bruce RJ, Binkley N (2016) Effect of IV contrast on lumbar trabecular attenuation at routine abdominal CT: correlation with DXA and implications for opportunistic osteoporosis screening. Osteoporos Int 27(1):147–152. CrossRefPubMedGoogle Scholar
  12. 12.
    Schreiber JJ, Anderson PA, Rosas HG, Buchholz AL, Au AG (2011) Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Jt Surg Am 93(11):1057–1563. CrossRefGoogle Scholar
  13. 13.
    Pompe E, de Jong PA, de Jong WU, Takx RA, Eikendal AL, Willemink MJ, Oudkerk M, Budde RP, Lammers JW, Mohamed Hoesein FA (2016) Inter-observer and inter-examination variability of manual vertebral bone attenuation measurements on computed tomography. Eur Radiol 26(9):1–8. CrossRefGoogle Scholar
  14. 14.
    Wagner SC, Formby PM, Helgeson MD, Kang DG (2016) Diagnosing the undiagnosed: osteoporosis in patients undergoing lumbar fusion. Spine (Phila Pa 1976) 41(21):E1279–E1283. CrossRefGoogle Scholar
  15. 15.
    Hamdy RC, Petak SM, Lenchik L (2002) Which central dual x-ray absorptiometry skeletal sites and regions of interest should be used to determine the diagnosis of osteoporosis? J Clin Densitom 5(3):S11–S18CrossRefGoogle Scholar
  16. 16.
    Nathan H, Israel J (1962) Osteophytes of the vertebral column. J Bone Jt Surg 44(2):243–268CrossRefGoogle Scholar
  17. 17.
    Kim JY, Ryu DS, Paik HK, Ahn SS, Kang MS, Kim KH, Park JY, Chin DK, Kim KS, Cho YE, Kuh SU (2016) Paraspinal muscle, facet joint, and disc problems: risk factors for adjacent segment degeneration after lumbar fusion. Spine J 16(7):867–875. CrossRefPubMedGoogle Scholar
  18. 18.
    Weishaupt D, Zanetti M, Boos N, Hodler J (1999) MR imaging and CT in osteoarthritis of the lumbar facet joints. Skelet Radiol 28(4):215–219CrossRefGoogle Scholar
  19. 19.
    Lehman RA Jr, Kang DG, Wagner SC (2015) Management of osteoporosis in spine surgery. J Am Acad Orthop Surg 23(4):253–263. CrossRefPubMedGoogle Scholar
  20. 20.
    Arabi A, Baddoura R, Awada H, Khoury N, Haddad S, Ayoub G, El-Hajj Fuleihan G (2007) Discriminative ability of dual-energy x-ray absorptiometry site selection in identifying patients with osteoporotic fractures. Bone 40(4):1060–1065. CrossRefPubMedGoogle Scholar
  21. 21.
    Engelke K, Adams JE, Armbrecht G, Augat P, Bogado CE, Bouxsein ML, Felsenberg D, Ito M, Prevrhal S, Hans DB, Lewiecki EM (2008) Clinical use of quantitative computed tomography and peripheral quantitative computed tomography in the management of osteoporosis in adults: the 2007 ISCD official positions. J Clin Densitom 11(1):123–162. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Gausden EB, Nwachukwu BU, Schreiber JJ, Lorich DG, Lane JM (2017) Opportunistic use of CT imaging for osteoporosis screening and bone density assessment: a qualitative systematic review. J Bone Jt Surg Am 99(18):1580–1590. CrossRefGoogle Scholar
  23. 23.
    Choi MK, Kim SM, Lim JK (2016) Diagnostic efficacy of Hounsfield units in spine CT for the assessment of real bone mineral density of degenerative spine: correlation study between T-scores determined by DEXA scan and Hounsfield units from CT. Acta Neurochir (Wien) 158(7):1421–1427. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Da Zou
    • 1
    • 2
  • Weishi Li
    • 1
    Email author
  • Chao Deng
    • 1
  • Guohong Du
    • 1
  • Nanfang Xu
    • 1
  1. 1.Orthopaedic DepartmentPeking University Third HospitalBeijingChina
  2. 2.Peking University Health Science CenterBeijingChina

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