Does bone loss (osteoporosis) show up on an MRI?

[FearFracture]

This might seem like a strange question but I've been curious about this for a while. Several years ago, I told my doctor that I had (still have) a weird burning sensation in the center of my back, in my thoracic spine. She she said she was going to order an MRI of my entire spine. In November 2017, I went to the imaging center to have my back MRI and they only scanned my lower spine (lumbar region). I guess my now former "doctor" has a hearing problem because she wrote on the MRI order that I was having lower back pain--I have NEVER had lower back--and she only ordered an MRI of my lumbar region. UGH!

Surprise, surprise, the MRI of the region of my back that was fine, came back fine. LOL.

Skip a head 1.5 years to July 2019, to my first DEXA, which showed that my total lumbar T-score was -3.9.

I went through an extremely yearly menopause (was 32) so given that I was 49 at the time of the MRI and 50.5 at the time of my first DEXA, I doubt there was anything causing major bone loss between the MRI and the DEXA, meaning the significant bone loss that happens at the time of menopause should have occurred around the time that I actually went through menopause not 15 years later.

What I can't quite figure out is why didn't my "severe" osteoporosis show up on the MRI?

I'm posting this now because I pulled up the MRI images today and read the radiologist report. It says:

FINDINGS:

The vertebrae are satisfactory alignment.

There is no fracture or evidence of destructive process.

The marrow signal intensity is within normal limits.

The disc heights are maintained.

The conus medullaris and cauda equina have a normal appearance.

The paraspinous soft tissues are within normal limits.

There is no abnormal enhancement.

T12-L1: NORMAL

L1-2: NORMAL

L2-3: NORMAL

L3-4: NORMAL

L4-5: NORMAL

L5-S1: Mild central disc bulging. No significant canal or foraminal narrowing.

LUMBAR SPINE w/wo contrast

IMPRESSION: Mild disc bulge L5-S1. Otherwise normal exam.

[Met00]

I've heard that MRI scans aren't particularly good at showing up osteoporosis, CT scans being better. Having said that, you say your spine score was -3.9, but I'm wondering what your total hip and neck of femur scores were? The three scores should be broadly similar, but sadly it's all too common to have errors with DEXA scans!

[FearFracture in reply to Met00]

Thank you for replying. I've had several DEXAs now and my T-scores are as follows:

July 2019, July 2021, December 2022, December 2023

LUMBAR SPINE

L1 -4.5 -3.8 -4.1 -4.2

L2 -4.3 -4.2 -4.2 -4.4

L3 -3.7 -3.3 -3.5 -3.3

L4 -3.4 -3.5 -2.9 -3.1

Total L Spine -3.9 -3.7 -3.6 -3.8

RIGHT HIP

Right Neck -2.7 -3.1 -2.9 -2.8

Total Right Femur -3.0 -3.0 -2.8 -2.6

LEFT HIP

Left Neck -3.3 -3.2 -3.1 -2.8

Total Left Femur -3.4 -2.9 -3.0 -3.0

The 1st 3 DEXAs (2019, 2021, and 2022) were done on the same GE LUNAR machine. Unfortunately, it broke and the facility is having to replace it, so my 2023 DEXA was done on a difference GE LUNAR scanner.

I also had a DEXA with TBS in December 2022. It was done on a Hologic and the data can't be compared with my other DEXAs but below are the results:

LUMBAR SPINE

L1 -3.9

L2 -3.9

L3 -4.1

L4 -3.8

Total L Spine -4.0

RIGHT HIP

Right Neck -2.9

Total Right Femur -2.3

LEFT HIP

Left Neck -3.3

Total Left Femur -2.6

On my 2022 Hologic DEXA and my 2023 GE Lunar DEXA they also scanned my arm:

LEFT RADIUS

2022 Hologic 2023 GE Lunar

UD -1.7 -3.8

MID -1.6 n/a

1/3 -2.3 -2.8

Total -1.9 -3.1

If you compare my DEC 2022 HOLOGIC and DEC 22 GE LUNAR results side by side (these scans were done 1 week apart).

LUMBAR SPINE

GE LUNAR HOLOGIC

L1 -4.1 -3.9

L2 -4.2 -3.9

L3 -3.5 -4.1

L4 -2.9 -3.8

Total -3.6 -4.0

GE LUNAR HOLOGIC

Right Neck -2.9 -2.9

Total Right Femur -2.8 -2.3

Left Neck -3.1 -3.3

Total Left Femur -3.0 -2.6

[Met00 in reply to FearFracture]

That's a very comprehensive set of scores! Bearing in mind that there's a fairly wide margin of error in DEXA scanning, your scores have stayed roughly unchanged since 2019. Your total spine score (-3.8 in 2023) is quite a bit worse than your total hip (R -2.6 L -3.0 in 2023) and neck of femur (R -2.8 L -2.8 in 2023). T-scores measure standard deviations from average at age 30 and there are a number of experts who say that a difference of more than 1.0 standard deviation between different sites suggest an error could have been made. Do you have arthritis in your hips (that could give better density measurements) or curvature of the spine (that could give worse density measurements)?

What's far more important than bone density is bone strength, which can be unrelated to density. For example, some people with osteopenia or even normal bone density suffer fragility fractures, while others with very poor bone density never fracture. The TBS score is supposed to give a more accurate estimate of bone strength, so it would be worth having a look at that. You can do a fracture risk calculation using your neck of femur score and TBS score with FRAX: frax.shef.ac.uk/frax/tool.a... (check that the correct country and, if the US, ethnicity is shown at the top of the form; if wrong click on Calculation Tool at the top and select from the drop down list).

[gerrirose in reply to Met00]

What is a TBS score and how do you get one?

[Met00 in reply to gerrirose]

It's a measure of trabecular bone, which is supposed to be a better indicator of bone strength. I'm in the UK, where it's very unlikely to be available as only a few DEXA scanners here have the necessary additional software required. I don't know about the US, but FearFracture may be able to answer that as she had one.

[FearFracture in reply to gerrirose]

If you go to this website medimapsgroup.com/find-a-cl... and complete the form, they will send you a list of the imaging centers in your state with TBS capabilities.

If you are interested in an REM scan in the US, in Feb 2022, I wrote to the company and they sent this list of places in the US with REM scanners:

Dr. Kimberly Zambito ( Orthopedic Surgeon)

Mercer-Bucks Orthopedics

Lawrenceville, NJ

855-896-0444

Dr Andy Bush ( Orthopedic Surgeon)

Central Carolina Orthopaedic Associates

Sanford, NC

919-774-1355 (ask for James)

Dr. Edmund Maclaughlin (Rhuematologist) and Dr. Curtis Foy (Family Medicine)

Rheumatology Associates of Delmarva

Easton, MD

410-819-6545

StrengthX

Dr. Mike Lewen (Chiropractor, Exercise Science)

Asheville, NC

828-505-7200

(Brand new location, call for scheduling information)

XBody Health, Wellness, and Spa (Bone Density only, Bone Quality currently not available)

Wayne, NJ

973-869-5806

Locations coming soon: Lubbock, TX; St. Louis, MO. As stated above we are in talks with many more and will update this list as they become avail.

[FearFracture in reply to Met00]

I don't have arthritis and there might be a slight curve in my spine or it could be that my positioning on the scanner has never been all that great Note, I am small: 4'11" current weight 108 lbs but for most of my adult life my weight ranged been 92 - 101 lbs. In 2016ish, I put on a few lbs and was then diagnosed with hypothyroidism (Hashimoto's) and I now take 88 mcg levothyroxine daily. Additionally, my wrists are about 5.5 inches around.

My December 2022 Hologic TBS scores are as follows:

TBS BMD t-score BMD T-Score Adjusted*

L1 1.278 -3.9

L2 1.323 -3.9

L3 1.342 -4.1

L4 1.205 -3.8

SPINE 1.287 -4.0 -4.8

FEMORAL NECK -3.3 -3.6

TOTAL HIP -2.6 -3.0

*Adjusted for TBS.

The report shows that my Total Lumbar TBS (1.287) = partially degraded microarchitecture.

The reference range for TBS:

Spine TBS of L1-L4 Normal microarchitecture > 1.31; Degraded <=1.23

According to the reference range, my L2 and L3 TBS are in the normal range because they are both greater than 1.31, my L1 is partially degraded, and my L4 is degraded because it is less than 1.23.

My gut feeling is that the TBS of my L4, 1.205, is incorrect.

I don't have any fragility fractures. I've been going to a gym for 2 years and I leg press over 300 lbs now (sometimes as much as 415 lbs). Note, I am careful about my movements (no forward flexion of my spine, bend at the hips) but I do "joke" that I'm either going to get stronger or one day at the gym there is just going to be a snap and I'll have to deal with it. I've "chatted" w/ another lady on this forum whose Lumbar t-score is -5.0 and she's also fracture free.

[Met00 in reply to FearFracture]

I've read that L2 and L3 are usually the most reliable vertebrae in terms of DEXA scans. I don't know whether that also applies to the TBS score. But I would hazard a guess that if you're doing that much exercise with weights, your bones are likely to be strong!

[Duol in reply to Met00]

What is the authority for saying that spine and hip results should be broadly similar? I thought that variations could be accounted for by different types of bone? My T scores (I’m a 77 year old female) are -3.7 spine a DPD -2.2 neck and -2.5 total hip . I have multiple mild to moderate vertebral fractures in my thoracic spine (identified on MRI) If there is error I hope it’s in the spinal readings thought the fractures suggest otherwise? When first diagnosed my experience was different from many here - no pill pushing, GP told me rather abruptly to stop calcium increase vit D and start weight lifting . She told me results « normal » but when I asked if spinal fractures without real trauma were normal she said of course not you have osteoporosis! I believe she only looked at hip and disregarded spinal results . A more recent fracture led to a different GP prescribing Alendronic acid

[Duol in reply to Duol]

Ignore DPD - not sure where that came from!

[Met00 in reply to Duol]

I've had both DEXA and REMS scans. My last DEXA scan gave a spine score of -3.6, hip -2.5, but a REMS scan 15 months later gave both scores as -2.6. REMS is more reliable than DEXA because it's more fully automated, making operator error far less likely. I've recently got hold of my full DEXA scan results and seen a couple of errors that should have been spotted by the consultant signing them off at the time, so that makes me even more certain that the REMS results are reliable, the DEXA ones not. I haven't seen any literature stating that spine and hip t-scores should be similar (it may exist, but I haven't found it), but some consultants do state this and I've come across someone having to have a repeat DEXA scan because the scores were considered unreliable due to more than 1 standard deviation difference.

[Lion321 in reply to Duol]

Hi sorry to hear of all your troubles. Unfortunately I have a couple of spinal fractures and it has been suggested I start on IV of Zoledronic acic. It would be extremely helpful knowing how you cope with Alendronic acid side effects etc.

thank you.

[Duol in reply to Lion321]

I started on alendronic acid (weekly tablet) seven weeks ago. No side effects that I’m aware of beyond a touch of dizziness/ vertigo which may or may not be connected

[FearFracture in reply to Lion321]

Have you had your bone turnover markers tested? Bisphosphonates work by reducing bone turnover. Bisphosphonates do not "grow" new bone, they simply slow down bone loss. If you BTMs are elevated bisphosphonates make sense.

[Lion321 in reply to FearFracture]

No I’ve not had that test. I’ll look into that. Thank you very much.

[FearFracture in reply to Lion321]

There are several different BTM (bone turnover marker) tests/labs. My endocrinologist didn't order any of them for me prior to putting me on bisphosphonates. I took alendronate for 1.5 years, due to gastro-issues that led to me need omeprazole, which turns out is bad for your bones, I quit the alendronate, took a 4 month bisphosphonate holiday, and in November 2021, I had one zoledronic acid infusion at my endocrinologist's urging.

I'm not anti-osteomeds. I am pro-natural remedies, for everything, meaning not just osteoporosis, when natural remedies are an option. However, from my research, it seems that most doctors/people who know what they are talking about when it comes to osteoporosis, once you start fracturing osteo-meds might be the best course of action.

My endocrinologist had wanted me to have a 2nd zoledronic acid infusion, one year after the 1st. However, in between doses or shortly after my 1st infusion, I started doing my own research and that is when I learned about BTMs. Optimally, to establish a baseline, you should have your BTMs tested prior to starting osteo-meds.

Here is a link that will give you a good deal of info about BTMs

s3.amazonaws.com/Food4Healt...

Dr. Brown at BetterBones.com recommends these tests for ppl diagnosed with osteoporosis betterbones.com/testing/wha...

Instead of having the 2nd dose of zoledronic acid that my endocrinologist had ordered, I had BTM labs done, at my request. The results showed that my BTMs were not elevated--note, bisphosphonates stay in your system long after you take them, so they could have been affecting my BTMs, but I had my BTMs tested again in December 2023 (over 2 years after my one and only Zoledronic acid infusion) and they are even better than in my first test. My bone turnover is not elevated.

Note, I have hypothyroidism, which my endocrinologist knows--he was "treating" my hypothyroidism before I was diagnosed with osteoporosis. Through my own research I learned that hypothyroidism reduces bone turn over--this is something that my endocrinologist show have known. At this point. I'm pretty convinced that he should never have prescribed bisphosphonates for me.

If your BTMs come back showing that you don't have elevated bone turnover, then it might be wise to consider a bone building osteo-med. When anabolics , osteo-meds that "grow new bone", for ex. Evenity, are taken after bisphosphonates, the bisphosphonates reduce the effectiveness of the anabolics.

I recently discovered Dr. Doug Lucas drdouglucas.com/optimalbone... I have know idea how I stumbled upon his youtube videos but I'm always looking up stuff about osteoporosis. I signed up for a FREE class from Dr. Lucas that I was supposed to attend on-line yesterday, but I never received a link to join. I did, however, receive a link to the on-line video tinyurl.com/3cje8nxv during the 1st half he talks a lot about diet and stuff but in the second half he talks about the BTMs that he monitors and he also mentioned something about women taking testosterone replacement, which I didn't know was an option--so it gave me another thing to research and to bring up with my primary care physician when I see her in February.

If your labs come back showing that you do have elevated BTMs, then bisphosphonates might be the best option for you. Regardless of which osteo-med you and your doctor determine will work best, having baseline BTMs will allow your doctor to test the effectiveness of the osteo-meds about 3 months after you start taking the meds, by retesting your BTMs to see if the osteo-meds are having the desired results.

[Lion321 in reply to FearFracture]

Wow what a reply thank you so much for the time and effort you have put into your reply.

There is so much help and advice I will definitely look into every thing you mentioned.

You are very kind and I I really appreciate it. Thank you.

[Yatzy]

I’m very interested in this topic as I’m due to have an MRI scan of my lower spine once I can get an appointment. My REM surgeon, Nick Birch at Osteoscan, suspects spinal stenosis, but moving from private to NHS proving a bit of a lengthy process. I see a GP tomorrow 🤞

[Duol in reply to Yatzy]

Im not sure an MRI would show osteoporosis as such but it can identify red flag issues such as the mild to moderate « wedge compression insufficiency fractures » that were identified on my scan as well as the mild to moderate spinal stenosis caused by disc bulges plus facet joint degeneration that plainly had triggered my extremely painful sciatica. The latter has been broadly resolved by physio and stretches tho can still nag at night

[FearFracture in reply to Duol]

With the issues your MRI brought to light, did you doctor say that any of those could be related to bone loss? Or are they completely separate issues?

[Duol in reply to FearFracture]

It was I who raised the question of osteoporosis, the doc (private consultant as wait too long on NHS and I’d just had a very painful fracture) only focused on trying to sell me a vertebroplasty (cement injection) which I wasn’t interested in. I had to ask for a DEXA referral. The spinal stenosis is down, I believe, to old age and a sedentary job rather than osteoporosis as such

[Duol in reply to Duol]

Should have added that MRI was to establish whether I’d had a fracture and to eliminate secondary cancer as a cause - no evidence of that thank heavens!

[Craftypainter]

I just wanted to add, osteoporosis can show up on a normal x-ray.

[FearFracture in reply to Craftypainter]

It's my understanding that osteoporosis can not be detected on xrays, unless it is severe and/or you are dealing with a true expert. In the few years before my osteoporosis diagnosis, I had at least 2 spine x-rays and no one every said "you have osteoporosis" based on the results of those xrays. Personally, I've come to feel that most doctors are not experts. Most are just people who are book smart or persistent, they tend to follow cookie-cutter templates, and most lack any sort of creativity. The main reason I go to doctors is that it's the only way to get labs and tests ordered and prescriptions written. There is no reason I need an endocrinologist to order my annual DEXA. Heck, I have copies of the full reports for all my DEXAs and they pretty much spell out everything--BMD, T-scores--anyone can compare the data from year to year and, if you use the same DEXA machine, the report does that for you. My endocrinologist has never once looked at the full report. He bases everything off the radiologist summary, which a novice could tell are flawed. Of course, my gastroenterologist and ob/gyn, both of whom I am happy with, provide needed and appreciated service.

[Craftypainter]

That is interesting. It was my last doctor. Perhaps it shows up in knees more easily? Or I just had a knowledgeable doctor.