Intended for healthcare professionals

Practice Rational Testing

Testing for secondary causes of osteoporosis

BMJ 2010; 341 doi: (Published 16 December 2010) Cite this as: BMJ 2010;341:c6959
  1. Melissa O Premaor, adjunct professor1,
  2. Juliet E Compston, professor of bone medicine2
  1. 1Department of Clinical Medicine, CCS (room 1337/building 26), Av Roraima, 1000, Campus Universitario, Federal University of Santa Maria, Santa Maria, Brazil 97105-900
  2. 2Department of Medicine, Box 157, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
  1. Correspondence to: J E Compston jec1001{at}

This article summarises what tests should be offered to patients with low bone mineral density to exclude secondary causes of osteoporosis

Learning points

  • Bone densitometry using dual energy x ray absorptiometry should be performed in patients with vertebral fractures to establish whether low bone mineral density is present

  • Secondary causes of osteoporosis are present in about 30% of women and 55% of men with vertebral crush fractures

  • Tests to exclude secondary causes include full blood count and erythrocyte sedimentation rate, bone biochemistry (serum calcium, phosphate, and alkaline phosphatase concentrations), liver and kidney function tests, serum thyroid stimulating hormone, and coeliac serology

  • In patients with vertebral fractures myeloma should be excluded using serum protein immunoelectrophoresis

A 62 year old woman consulted her general practitioner about low back pain that had started while gardening. She was otherwise healthy, had no notable medical history, and took no medications. Menopause had occurred when she was 51 years old. Clinical examination was normal apart from tenderness over the lower thoracic and upper lumbar spine. A lateral spine radiograph showed vertebral crush fractures at the T12 and L1 vertebrae.

What is the next investigation?

Although back pain in itself is not an indication for bone densitometry, bone density should be measured if vertebral fractures are present. Bone mineral density of the lumbar spine and hip should be measured by dual energy x ray absorptiometry. Osteoporosis is diagnosed if the bone mineral density T score (number of standard deviations above or below normal peak bone mass) is less than or equal to −2.5 at either site.1 However, fragility fractures often occur in individuals with osteopenia (T score −1 to −2.5.2 …

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