Recommended X-ray Views for Glucocorticoid-Induced Osteoporosis
For patients with suspected acute vertebral fracture on glucocorticoids, obtain standard 2-view X-rays of the spine area of interest as the first-line imaging study. 1
Initial Assessment Imaging
For Screening and Baseline Evaluation
- Obtain BMD testing with DXA of lumbar spine and hip(s) plus vertebral fracture assessment (VFA) or dedicated spinal X-rays as soon as possible after starting glucocorticoids ≥2.5 mg/day for >3 months 1
- This applies to all adults ≥40 years initiating or continuing chronic glucocorticoids 1
- For adults <40 years, obtain BMD with VFA or spinal X-ray without FRAX calculation 1
- For children <18 years, only obtain imaging if they have back pain or clinically significant fracture 1
When Acute Vertebral Fracture is Suspected
Standard X-ray spine (2 views) of the area of interest receives the highest appropriateness rating (9/9) for first examination 1
The ACR Appropriateness Criteria specifically addresses this scenario for patients treated with corticosteroids >3 months with acute or subacute symptoms:
- X-ray spine area of interest (includes 2 views): Rating 9 (usually appropriate) 1
- CT spine without IV contrast: Rating 5 (may be appropriate, with panel disagreement) 1
- MRI spine without IV contrast: Rating 2 (usually not appropriate) 1
- DXA VFA: Rating 1 (usually not appropriate for acute fracture evaluation) 1
If Initial X-rays are Negative but Suspicion Remains High
Proceed to MRI lumbar spine without IV contrast (Rating 9/9) as the next step 1
- CT lumbar spine without IV contrast is an alternative (Rating 7/9) 1
- This sequence is critical because glucocorticoid-induced fractures can be occult on plain radiographs initially 1
Ongoing Monitoring Imaging
Fracture Risk Reassessment Schedule
Perform BMD with VFA or spinal X-rays every 1-2 years for all patients continuing chronic glucocorticoids ≥2.5 mg/day 1
This strong recommendation applies to:
- Low-risk adults on GC <7.5 mg/day who were not started on osteoporosis therapy 1
- All moderate, high, and very high-risk patients on osteoporosis therapy 1
- Yearly BMD assessment may be preferred in very high-risk patients until stable BMD is achieved 1
The reassessment includes clinical fracture risk history, new symptomatic fractures, FRAX (for those ≥40 years), BMD, VFA, and/or spine X-rays 1
Key Clinical Pitfalls
Common Errors to Avoid
- Do not rely solely on DXA BMD values - glucocorticoids increase fracture risk beyond what BMD predicts due to effects on bone quality and microarchitecture 2, 3
- Do not skip baseline vertebral imaging - asymptomatic vertebral fractures are common and change risk stratification to very high risk 1, 2
- Do not delay imaging - bone loss and fracture risk increase rapidly within the first 3-6 months of glucocorticoid therapy 4, 3, 5
- Do not use MRI as first-line for suspected acute fracture - standard X-rays are more appropriate and cost-effective initially 1
Specific Views and Technique
The "2 views" referenced in ACR guidelines typically means: