Radiology of Osteoporosis

248 Pages·2008·9.218 MB·English

by  Reinhard Gruber PhD, Peter Pietschmann MD (auth.), Stephan Grampp MD (eds.)

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I
Contents
MEDICAL RADIOLOGY
Diagnostic Imaging
Editors:
A. L. Baert, Leuven
M. Knauth, Göttingen
K. Sartor, Heidelberg
III
Contents
S. Grampp (Ed.)
Radiology of
Osteoporosis
2nd Revised Edition
With Contributions by
J. E. Adams · R. Barkmann · P. M. Bernecker · D. Diacinti · K. Engelke · H. K. Genant
S. Grampp · R. Gruber · G. Guglielmi · G. Holzer · H. Imhof · M. Jergas · C. Krestan
T. M. Link · M. Peterlik · P. Pietschmann · S. Prevrhal · H. Resch · C. van Kuijk
R. R. van Rijn

Foreword by
A. L. Baert
With 169 Figures in 225 Separate Illustrations, 15 in Color and 17 Tables
123
IV
Contents
Stephan Grampp, MD
Univ. Dozent
Dr. Grampp & Dr. Henk OEG
Röntgenordination
Lenaustrasse 23
2000 Stockerau
Austria
Medical Radiology · Diagnostic Imaging and Radiation Oncology
Series Editors:
A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Knauth · M. Molls · C. Nieder · K. Sartor
Continuation of Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
ISBN 978-3-540-25888-9 e-ISBN 978-3-540-68604-0
DOI 10.007 / b 136255
Medical Radiology · Diagnostic Imaging and Radiation Oncology ISSN 0942-5373
Library of Congress Control Number: 2005934451
(cid:164) 2008 Springer-Verlag Berlin Heidelberg
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V
Contents
Foreword
It is a great pleasure to introduce this second fully revised and updated edition of
Radiology of Osteoporosis.
The need for the publication of this second edition, only 4 years following the fi rst
edition, indicates the great interest among radiologists, and several other medical
disciplines, in the diagnosis and management of this very common condition and its
possible complications.
One of the great merits of this book is that it deals with all aspects of osteoporosis,
including morphology and function.
The outstanding qualifi cations and high level of expertise of the editor, Prof.
S. Grampp, and of the contributing authors are a guarantee for the up-to-date and com-
prehensive contents of this outstanding volume.
I am confi dent that this volume will again meet with great interest among radiolo-
gists and all other clinicians involved in the care of patients with osteoporosis and that
it will enjoy the same success as the fi rst edition.
Leuven Albert L. Baert
VII
Contents
Preface
There is almost universal agreement among the clinical community that the measure-
ment of bone mineral density in potentially healthy individuals is the only means of
assessing fracture risk and skeletal status. In patients with risk factors, measurement of
BMD adds substantially to the assessment of fracture risk. For each of the methods and
related skeletal sites, there is a wealth of scientifi c data emphasising the relationship
between decreasing bone density and mass on the one hand and increasing fracture
risk on the other.
Indeed, all measurement techniques presented here are able to provide valuable
information in most clinical circumstances, as well as information that cannot be
obtained by other means.
Selection of any of the available methods for clinical practice can be governed by
practical considerations such as availability, cost and reimbursement, time and effort
involved, as well as patient acceptance.
We wrote this book to guide the clinical practitioner through this minefi eld of scien-
tifi c knowledge and it is our sincere hope that it will assist in daily practice.
Due to the success of the fi rst edition, we decided to update and upgrade this volume
to the very latest clinical and scientifi c knowledge. (Since the fi rst edition sold so rap-
idly, we are confi dent of continued success. We do not expect the same sort of popu-
lar movement to the bookstores as historically seen in the Nika insurrection of 532
[B yzantium], the Harry Potter craze [Europe, beginning of the millennium], or the
Cavalli Fashion Massacre [Central Europe 2007 – if you do not know about this and are
not female, ask someone who is]. But still an editor can hope.)
I am especially grateful to the authors who are amongst the most prominent and
knowledgeable in this particular scientifi c fi eld for their effort and dedication.
Stockerau Stephan Grampp
IX
Contents
Contents
1 Introduction to Bone Development, Remodelling and Repair
Reinhard Gruber, Peter Pietschmann, and Meinrad Peterlik . . . . . . 1
2 Pathophysiology and Aging of Bone
Peter Pietschmann, Reinhard Gruber, and Meinrad Peterlik . . . . . . 25
3 Pathophysiology of Rheumatoid Arthritis and Other Disorders
Heinrich Resch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4 Therapeutic Approaches and Mechanisms of Drug Action
Peter M. Bernecker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5 Orthopedic Surgery
Gerold Holzer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
6 Radiology of Osteoporosis
Michael Jergas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
7 Dual Energy X-Ray Absorptiometry
Judith E. Adams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
8 Vertebral Morphometry
Giuseppe Guglielmi and Daniele Diacinti . . . . . . . . . . . . . . . . . . . 125
9 Spinal Quantitative Computed Tomography
Rick R. van Rijn and Cornelis van Kuijk . . . . . . . . . . . . . . . . . . . . 137
10 pQCT: Peripheral Quantitative Computed Tomography
Sven Prevrhal, Klaus Engelke, and Harry K. Genant. . . . . . . . . . . . 143
11 Quantitative Ultrasound
Reinhard Barkmann. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
12 Magnetic Resonance Imaging
Thomas M. Link . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
X
Contents
13 Structure Analysis Using High-Resolution Imaging Techniques
Thomas M. Link . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
14 Densitometry in Clinical Practice
Stephan Grampp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
15 Practical Cases
Christian Krestan and Herwig Imhof . . . . . . . . . . . . . . . . . . . . . 205
Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
1
Introduction to Bone Development, Remodelling and Repair
1
Introduction to Bone Development,
Remodelling and Repair
Reinhard Gruber, Peter Pietschmann, and Meinrad Peterlik
CONTENTS 1.1
Introduction
1.1 Introduction 1
Bone is a specialized form of mineralized connective
1.2 Structure, Cells and Matrix 2 tissue that is build by various types of metabolically
1.2.1 Structural Organization and Parameters of active cells during embryonic and postnatal develop-
Bone Strength 2
ment. In the adult, the same cells contribute to the
1.2.2 The Bone Cells 3
maintenance of structural and functional integrity,
1.2.3 The Organic Matrix 4
and accomplish the healing process following injury.
1.3 Bone Development, Remodelling and Bone not only shows a marked rigidity and mechani-
Regeneration 5 cal stability while still maintaining some degree of
1.3.1 Bone Development 5
elasticity, but also constitutes the most important
1.3.2 Bone Remodelling 5
storage site for calcium and inorganic phosphate
1.3.3 Bone Regeneration 7
(Baron 1993). Osteoporosis is a systemic disease
1.4 Regulatory Mechanisms of Development where rigidity and mechanical stability of bone
and Function 8 declines, until bone loses the ability to withstand
1.4.1 Regulatory Mechanisms in
functional loading or weak traumata. A transient
Chondrocytes 9
1.4.2 Regulatory Mechanisms in Osteoblasts 10 but disproportional bone loss of 20%–30% trabecu-
1.4.3 Regulatory Mechanisms in Osteoclast lar and 5%–10% cortical bone is most apparent in
Development and Function 11 women during the fi rst postmenopausal decade. The
following slow phase accounts for 20%–30% of tra-
1.5 Local and Systemic Regulation of
becular and cortical bone loss in both sexes. Epide-
Bone Remodelling 13
1.5.1 Local Regulation of Bone Mass by miologic data show that the lifetime risk to acquire
Growth F actors, Cytokines and hip fractures is 17% for white women and 6% for
Prostaglandins 14 white men (Cummings and Melton 2002; Melton
1.5.2 Systemic Factors that
1995). Progress in medical care and education has
Regulate Bone Mass 14
contributed to an increased average life span, which
1.5.2.1 Parathyroid Hormone 14
1.5.2.2 1,25-Dihydroxyvitamin D 15
3
1.5.2.3 Calcitonin 15
1.5.2.4 Oestradiol 15
1.5.3 Sympathic Nervous System 16 R. Gruber, PhD
Associate Professor, Department of Oral Surgery, Vienna
1.6 Discussion of Current Status and University Clinic of Dentistry, Medical University of Vienna,
Perspectives 17 Waehringer Strasse 25a, 1090 Vienna, Austria
P. Pietschmann, MD
References 18 Associate Professor of Pathophysiology and Internal Medicine,
Department of Pathophysiology, Medical University of Vienna,
Waehringer Guertel 18–20, 1090 Vienna, Austria
and
Ludwig Boltzmann-Institute of Aging Research, Langobarden-
strasse 122, 1220 Vienna, Austria
M. Peterlik, MD, PhD
Professor and Head of the Department of P athophysiology,
Medical University of Vienna, Waehringer Guertel 18–20,
1090 Vienna, Austria
2
R. Gruber, P. Pietschmann, and M. Peterlik
is, however, associated with a higher risk of acquir- The outer bone surface is in contact with the sur-
ing age-related diseases such as osteoporosis. On the rounding soft tissue via the periosteum. The inner
other hand, progress has been made on diagnosing bone surface faces the medullary cavity and is cov-
osteoporosis and monitoring disease progression. ered by the endosteum. Both periosteum and end-
Potent drugs are available that help reduce the risk osteum are connective tissues organized in layers.
of fracture and new pharmacologic substances are The cambium layer is in intimate contact with the
already in the pipeline (Delmas 2002; Rodan and mineralized structure and provides a pool of mesen-
Martin 2000). Improvement in patient care is possi- chymal cells with the potential to differentiate into
ble because of a substantial increase in the functional the chondrogenic and the osteogenic lineage.
understanding of the genetic and molecular mecha- Trabecular bone and cortical bone are composed
nism on bone development, remodelling and repair, of the same microstructural elements: cells, organic
and as a result, the pathophysiology of osteoporosis. matrix, crystalline inorganic matrix and soluble fac-
The aim of this chapter is to give an update on the tors. The calcifi ed matrix of adult bone is built up
fundamental aspects of bone biology with regard to in multiple layers of oriented collagen fi bers, giving
the coordinated action of bone cells during devel- rise to the typical structure of lamellar bone. The
opment, remodelling and repair. We briefl y review lamellae are arranged parallel to each other, as on
the structural and cellular composition of the bone the surface of fl at bones and trabecular structures,
matrix and focus on genetic and molecular mecha- or in concentric layers around blood vessels and
nisms that control cell differentiation and activity. nerves, forming the haversian system synonymic for
This information is considered a scientifi c basis for osteons in the corticalis. The haversian canals are
the following chapters on the pathophysiology of connected to the periosteum and the endosteum by
age-related bone loss (see Chap. 2), bone loss associ- Volkmann’s canals. Blood fl ow in bone totals 200–
ated with chronic infl ammation (see Chap. 3), as well 400 ml/min in adult humans, indicating that bone is
as the chapter dealing with the current approaches a highly vascularized tissue.
in osteoporosis therapy (see Chap. 4). Under conditions in which rapid formation of
new bone is required, e.g. during skeletal growth in
early childhood and in periods of bone regeneration,
or in particular metabolic bone disorders, instead of
lamellar bone, immature “woven” bone is formed,
1.2 in which the collagen fi bers are randomly oriented
Structure, Cells and Matrix and the degree of mineralization is relatively low.
Woven bone is later remodelled into lamellar bone,
1.2.1 which has better mechanical properties. Formation,
Structural Organization and Parameters of remodelling, and repair of the structural elements
Bone Strength require the coordinated action of the bone cells:
osteoblasts, osteocytes, lining cells, and osteoclasts
At the structural level, two different forms of bone (Baron 1993; Marks 2002; Schenk and Hunziker
can be distinguished: cortical or compact bone, 1994).
which, for example, forms the diaphysis of long Bone strength is defi ned by the parameters mass,
bones, thus providing protection for the medul- geometry, material properties, and microstruc-
lary cavity. Trabecular, cancellous, or spongy bone, ture. The bone mass accounts for about half of the
which in long bones is found at their ends, at the decrease in bone strength in the elderly. The diame-
epiphyses, makes up the greater part of vertebral ter of the corticalis is a parameter of bone geometry.
bodies. The total skeleton comprises around 20% Material properties are modulated by the mineral
trabecular bone. Trabecular bone has a porosity crystals and the correct synthesis of the single com-
of 50%–90%, cortical bone of approximately 10% ponents of the bone matrix. The diameter of the tra-
(Sikavitsas et al. 2001). The high surface-to-volume beculae as well their horizontal and vertical inter-
ratio of trabecular bone involves its metabolic func- connectivity are further determinants that together
tion, whereas cortical bone has mainly a structural defi ne bone strength (Paris et al. 2000; Riggs and
and protective role. Parfi tt 2005).