Bone Density Measurement Sites: Standard Protocol
Bone mineral density measurement should be performed at the lumbar spine (L1-L4), total hip, and femoral neck in all patients, with the one-third radius added only when indicated by specific clinical circumstances. 1
Core Skeletal Sites for Standard DXA Protocol
The 2025 European guidelines establish a clear hierarchy for bone density assessment:
Lumbar spine (L1-L4) is a mandatory measurement site and should be included in every standard DXA examination alongside hip measurements. 1, 2
Both total hip and femoral neck must be measured as part of the standard protocol, as these sites provide complementary diagnostic information. 1
The one-third radius is measured only when indicated, specifically when hip or spine measurements cannot be accurately obtained due to artifacts, hardware, or severe degenerative changes. 1
Why the Spine Cannot Be Omitted
The evidence strongly supports mandatory spine inclusion:
Spine-only osteoporosis is common and clinically significant. Research demonstrates that relying solely on hip measurements fails to identify 13-16% of patients with osteoporosis who have low bone density exclusively at the spine. 3, 4
Differential bone loss occurs at different skeletal sites. The spine and hip lose bone at different rates, making single-site measurement inadequate for comprehensive fracture risk assessment. 3
Vertebral fracture risk is missed without spine measurement. The majority of patients with normal hip BMD but low spine BMD are at significantly increased risk for vertebral fractures. 3
Diagnostic classification requires the lowest T-score from any measured site. The WHO operational definition of osteoporosis (T-score ≤ -2.5) applies to the lumbar spine, femoral neck, total hip, or one-third radius, with diagnosis based on the lowest value. 1
When Vertebral Levels Can Be Excluded
While the spine must be measured, specific vertebral bodies may be omitted under limited circumstances:
Up to 2 vertebral levels from L1-L4 can be excluded when structural artifacts are present, such as compression fractures, severe facet joint osteoarthritis, or spondylosis. 2
The same vertebral levels must be used for all follow-up scans to ensure valid longitudinal comparison. 2
Bilateral Hip Measurement Consideration
Recent evidence suggests potential benefit of measuring both hips:
Measuring both hips identifies an additional 13-16% of osteoporotic patients compared to single hip measurement, with only 55 seconds of additional scan time. 4
Current guidelines recommend measuring either hip, though bilateral measurement may be considered when resources permit. 1
Common Clinical Pitfalls
Do not rely on hip measurement alone, as this misses a substantial proportion of patients with spine-predominant osteoporosis who require treatment. 3
Do not use Ward's area for diagnosis, as this region should not be included in diagnostic assessment. 5
Do not use lateral spine BMD for osteoporosis diagnosis. 5
Forearm measurement is reserved for specific situations where central sites cannot be accurately measured, not as a routine screening site. 1