Reduced bone mass and microarchitectural degradation of bone tissue are hallmarks of osteoporosis, a common skeletal condition that increases the risk of fracture and bone fragility1.Over 200 million people worldwide suffer from this illness, with a higher frequency in women and those over 802. Approximately 15–30% of men and 30–50% of women worldwide suffer from osteoporosis at any given moment. In India, the largest prevalence occurs between the ages of 50 and 60; in western nations, it occurs between the ages of 70 and 803.

It is anticipated that more than six million hip fractures due to osteoporosis would occur by 20504. For osteoporosis to be effectively prevented and managed, early and precise diagnosis is essential3,4.

Two popular diagnostic methods for evaluating bone health and identifying osteoporosis are dual-energy X-ray absorptiometry (DXA) and traditional X-ray imaging5. Because DXA provides quantitative measurements of bone mineral density (BMD) at many skeletal locations, it is presently regarded as the gold standard for diagnosing osteoporosis. It provides the ability to forecast fracture risk, high precision, and minimal radiation exposure6.

Particularly at the lumbar spine, femoral neck, and hip—areas crucial for osteoporosis diagnosis and fracture risk prediction—DXA has demonstrated a high degree of reliability in evaluating bone mineral density7. Even though DXA is still the gold standard, structural bone abnormalities can still be diagnosed by traditional X-ray imaging. It is particularly useful for detecting spinal fractures, which frequently go unnoticed by the patient8.

DEXA is a rapid, non-invasive procedure with a precision inaccuracy of 1 to 2.5% and a minimal radiation dosage. The study's field, the patient's age, and their physical and medical conditions all affect precision9,10.

In addition to differentiating between neoplastic and osteoporotic lesions, spine radiographs can be used to detect rarefactions in the spine and hip, pencil-thinning long bone cortices, Kummel's lesion, trabecular loss, biconvex vertebral endplates, and vertebral height loss. Vertebral anomalies can only be accurately qualitatively characterized by visual inspection and expert radiological interpretation11. On the other hand, a lateral X-ray of the lumbar and thoracic spine has an exposure dose of roughly 600 µSv. Moreover, radiographs lack the sensitivity to pick up on minute alterations that take place before fractures. Furthermore, they cannot measure the changes associated with osteoporosis correctly. Radiographs don't show bone loss until 25–30% of bone density has been lost. Only when there is acute pain after small impact can radiographs be used to diagnose fragility fractures due to their low sensitivity12.

According to some research, radiological indices are an excellent way to diagnose osteoporosis and have a strong relationship with the T scores determined by a DEXA scan. In order to predict the probability of a fracture resulting from low bone mineral density, Nayak et al. (2017) examined plain X-ray films of 168 patients' pelvises using morphometric parameters of the femur-proximal end. They measured the femur's neck shaft angle, hip axis length, and femur neck axis length, and compared them to the femur neck's DEXA T Score. The morphometric characteristics of the proximal end of the femur and the bone density of the neck of the femur were shown to be highly correlated13. At the same time, Burli et al., 2020 discovered a strong association between the radiological indices and the T scores determined by the DEXA scan, indicating that it might be used to diagnose osteoporosis14. According to a different study, the gold standard for identifying older women with osteoporosis based on DXA values of the femoral neck includes spinal DXA, calcaneal QUS, and spinal QCT15.

The validity of using the Singh Index to diagnose osteoporosis has long been a topic of intense debate. According to Sah et al. (2007), the Singh Index and DEXA scan do not significantly correlate16. Similar findings were made by Hitesh Vora et al., who concluded that the Singh Index is unreliable after finding no significant connection and a fair level of agreement with kappa=0.34817.

The primary methods for diagnosing osteoporosis are quantitative computed tomography, dual-energy X-ray absorptiometry (DEXA), radiographic single energy X-ray absorptiometry, and quantitative ultrasound. These methods are among the many ways to measure bone mass and femoral neck trabecular morphology. One of these techniques, DEXA, which has a comparatively low radiation dose, has been presented as an objective way to measure bone mineral density and predict fracture risk18.

Several alternative imaging methods, including quantitative ultrasound (QUS), quantitative computed tomography (QCT), radiographic absorptiometry (RA), and radiofrequency echographic multi-spectrometry (REMS), have been developed to increase accessibility and lower radiation exposure, even though DEXA is still the gold standard for diagnosing osteoporosis. However, due to differences in methodology, demographic characteristics, and threshold definitions, the diagnostic performance of these modalities in comparison to DEXA is still variable between studies. The necessity for a systematic study that summarizes the data on the relative diagnostic accuracy of DEXA and other radiographic modalities in identifying osteoporosis is highlighted by this knowledge gap.

This systematic review and aimed to assess the diagnostic performance of DXA and other radiological modalities in osteoporosis detection.