Bone Mineral Density T-Scores Derived from CT Attenuation Numbers (Hounsfield Units): Clinical Utility and Correlation with Dual-energy X-ray Absorptiometry

Nathan R. Hendrickson, Perry J. Pickhardt, Alejandro Munoz Del Rio, Humberto G. Rosas, Paul A. Anderson

Research output: Contribution to journalArticlepeer-review

74 Scopus citations


Background: Clinical computed tomography (CT) studies performed for other indications can be used to opportunistically assess vertebral bone without additional radiation or cost. Reference values for young women are needed to evaluate diagnostic accuracy and track changes in CT bone mineral density values across the lifespan. The purpose of this study was to determine reference values for lumbar trabecular CT attenuation (Hounsfield units [HU]) and determine the diagnostic accuracy of HU T-scores (T-scoreHU) for identifying individuals with osteoporosis. Methods: We performed a retrospective single-center cohort study of patients undergoing CT of the lumbar spine. Reference values for lumbar spine Hounsfield units were determined from a reference sample of 190 young women aged 20-30 years undergoing CT scan of the lumbar spine. A separate sample of 252 older subjects undergoing CT and dual-energy X-ray absorptiometry (DXA) within a 6-month period that served as a validation cohort. Osteoporosis was defined by T-scoreDXA ≤ -2.5. Reference values were determined for lumbar HU from L1 to L4 from the reference cohort (24.0 ± 2.9 years). T-scoreHU was calculated in the validation cohort (58.9 ± 7.5 yrs). Receiver operating characteristic (ROC) curves were used to assess sensitivity and specificity of T-scoreHU for this task. Results: Reference group HU ranged from 227 ± 42 at L3 to 236 ± 42 at L1 (P < 0.001). Validation group T-scoreDXA was -0.7 ± 1.5 and -0.9 ± 1.2 at lumbar and femoral sites respectively. Mean T-scoreHU was -2.3. T-scoreHU of -3.0, corresponding to 110 HU, was 48% sensitive and 91% specific for osteoporosis in the validation group. ROC area under the curve ranged from 0.825 to 0.853 depending on lumbar level assessed. Conclusions: Although lumbar trabecular HU T-scores are lower than DXA T-scores, thresholds can be selected to achieve high sensitivity and specificity when screening for osteoporosis. Patients with a lumbar T-scoreHU ≤ -3.0 should be referred for additional evaluation. Further research into HU T-scores and clinical correlates may also provide a tool to assess changes in vertebral bone and the relationship to fracture risk across the lifespan.

Original languageEnglish (US)
Pages (from-to)25-31
Number of pages7
JournalThe Iowa orthopaedic journal
StatePublished - 2018
Externally publishedYes


  • computed tomography
  • dual-energy x-ray absorptiometry
  • osteoporosis
  • screening


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