6.4 Standardized DXA Reporting per ISCD Guidelines
Key Takeaways
An adult DXA report identifies the patient, indication, requesting provider, instrument, measured sites and applicable scores, and explains any clinically relevant limitations.
Give one overall densitometric classification when WHO criteria apply. Name the valid measurement that supports the impression.
When reporting absolute fracture risk, identify the calculator and its positive inputs. FRAX estimates fracture probability and cannot measure treatment response.
Identify the prior comparison and region, state the applicable facility LSC, and quantify a significant change in g/cm² and percent.
Recommend whether and when to repeat testing. Exact timing depends on available clinical information.
State what was measured and how to interpret it
The International Society for Clinical Densitometry (ISCD) identifies content for adult baseline and follow-up dual-energy X-ray absorptiometry (DXA) reports. The clinical indication explains why the test was done. The results document the bone mineral density (BMD) measurements that can support a diagnosis or comparison. The impression translates those results into a clear diagnostic category, fracture-risk context, and follow-up recommendation.
| Report component | What to include or clarify |
|---|---|
| Identification and indication | Patient identifiers, date of birth, sex, requesting clinician, and reason for testing. Add relevant history, such as a prior fracture or medication exposure, when it affects interpretation. |
| Procedure and limitations | Identify the manufacturer, model, sites, regions of interest (ROIs), and side where applicable. Explain an acquired result that cannot be reported or a technical issue that may confound an otherwise interpretable result. Software version can be useful for comparability and is a specified item in certain other contexts, such as pediatric reports. |
| Measurements and impression | Report BMD in g/cm² at each valid reported site and the applicable T-score or Z-score. ISCD prefers three decimals for BMD and one for scores. Give one overall diagnostic classification when the World Health Organization criteria apply. |
| Fracture risk | Identify the calculator used and the positive risk factors entered. When reporting FRAX, distinguish 10-year hip fracture probability from 10-year major osteoporotic fracture probability. |
| Prior study and follow-up | Identify the prior study and matching ROI, explain whether an outside study is comparable, give the applicable LSC, and report significant change in g/cm² and percent. Recommend the need and timing for the next assessment. Give precise timing when clinical information supports it. |
Phantom logs support quality assurance. Confirmation of the daily phantom result is not a minimum field for the adult clinical report. Additional imaging, laboratory evaluation for secondary causes, or treatment and prevention recommendations can be helpful where indicated. ISCD lists them as optional adult report elements. Avoid unsupported claims about bone loss from a baseline exam, severity adjectives such as “mild osteopenia,” separate diagnoses for each ROI, and numeric findings from technically invalid sites.
Keep fracture probability separate from the diagnosis
The U.S. sample report illustrates using FRAX in patients with low bone mass and listing the positive inputs used. FRAX accepts femoral neck BMD if BMD is supplied. A prior fracture may be a positive risk input. A densitometric osteoporosis result or prior hip or vertebral fracture can already support consideration of therapy in the relevant U.S. guideline population. A calculator result is not a prerequisite in that situation. The FRAX developers distinguish using the tool to estimate risk if a change in therapy is being considered from tracking treatment effectiveness, for which FRAX is unsuitable.
For a U.S. postmenopausal woman or man aged 50 or older with low bone mass at the femoral neck or total hip, the Bone Health and Osteoporosis Foundation uses a hip probability of at least 3% or major osteoporotic fracture probability of at least 20% as a treatment consideration. Other countries may use different thresholds. In younger adults, use the appropriate score and clinical context. A Z-score category describes BMD for age.
Worked follow-up report
A 68-year-old postmenopausal woman is referred after a prior low-trauma wrist fracture. Her mother had a hip fracture, and her measured height is 4.5 cm below her historical height. She has not started osteoporosis medication. Both studies used the same DXA scanner. The current PA lumbar spine has marked osteophytosis at L3. Exclude L3 and confirm that the prior scan can also be analyzed using L1, L2 and L4. These three levels need their own applicable LSC.
| Valid ROI | BMD (g/cm²) | T-score |
|---|---|---|
| PA lumbar spine (L1, L2 and L4) | 0.835 | −2.3 |
| Left femoral neck | 0.665 | −2.6 |
| Left total hip | 0.742 | −2.2 |
Impression. Osteoporosis by the lowest valid T-score, −2.6 at the left femoral neck. L3 was excluded because of degenerative artifact. Comparison is made to the study from two years earlier on the same system. There is no statistically significant change at L1, L2 and L4 (facility LSC 0.030 g/cm² for those levels). The left femoral neck shows a statistically significant decrease of 0.037 g/cm² (5.3%), with an LSC of 0.032 g/cm².
Calculation check. For the same spine levels, the previous BMD was 0.862 g/cm², so the change magnitude of 0.027 g/cm² falls below 0.030. Report the significance conclusion without the numeric subthreshold change. The prior left neck was 0.702 g/cm². The change is −0.037 g/cm², or , which meets the applicable threshold.
Clinical context and recommendation. The low T-score and historical height loss over 4 cm meet the ISCD adult indication for lateral spine imaging. A statement recommending vertebral fracture assessment or lateral spine radiography is appropriate. If the treating clinician starts or changes therapy, a follow-up DXA in one to two years can be considered under BHOF guidance, with exact timing based on the clinical circumstances. In a different patient where FRAX will guide a decision, a report might record a supplied estimate of 12% for major osteoporotic fracture and 3.1% for hip fracture, identify the U.S. FRAX model, state whether femoral neck BMD was included, and list any positive clinical inputs. These percentages illustrate report wording and are not calculated from this case.
ISCD Adult Official Positions · ISCD U.S. Adult DXA Sample Report · FRAXplus FAQ · BHOF Clinician’s Guide
Which proposed use of FRAX is inappropriate in an adult DXA report?
Estimate baseline fracture probability in a 66-year-old untreated woman with a femoral neck T-score of −1.9.
Use the difference between two FRAX estimates as the measure of a 72-year-old woman’s response to denosumab.
Estimate risk in a 58-year-old smoker using clinical inputs without BMD when a valid femoral neck measurement is unavailable.
Estimate risk in an untreated 64-year-old woman and record parental hip fracture as a positive input.
Which technical details are part of the ISCD minimum content for an adult baseline DXA report?
The X-ray tube serial number and exam-room temperature.
The scanner operator’s license number and billing code.
The manufacturer, model, skeletal sites, regions of interest and applicable sides, with an explanation of relevant confounding or omitted results.
The latest phantom value and the copyright date of the T-score reference database.
A 54-year-old postmenopausal woman has valid T-scores of −1.8 at the spine, −2.7 at the femoral neck, and −2.2 at the total hip. Which impression follows ISCD reporting guidance?
Mild osteopenia of the spine and hip with localized severe osteoporosis at the neck.
Low bone mass because the mean T-score across the three measurements is about −2.23.
BMD within the expected range for age based on an inferred Z-score.
Osteoporosis, based on the valid femoral neck T-score of −2.7.
Sections you finish are checked off in the contents.