Title: September 2018 – To Delete or Not to Delete a Vertebral Body Case #3

Submitted By: Lawrence G. Jankowski, CBDT
Illinois Bone and Joint Institute, LLC. Morton Grove, Illinois. USA

Patient History:
Editors Note:

The second part of the previous two-part series had already “gone to press” when this following related case presented itself. This will become a continuing series since entitling this as “Part 3 of 2” would be awkward. If you have an interesting case regarding the inclusion or deletion of vertebral levels, please send in your submission using our downloadable Microsoft Word template.

Patient History:

Morbidly obese (BMI 47.7) 60 yr. white female with chronic low back pain referred for bone mineral density testing. Indications: post-menopausal (last menstrual period at age 52, and a maternal history of multiple fractures after age 50 but not a hip fracture). Lowest T-score was at the right femur neck (-1.3) and FRAX 10-year fracture risk scores of 6.6% MOF, and 0.5% hip. (image not shown). PA spine revealed the increased density of the L4 posterior elements and elevated T-score more than 1 SD higher than L3.

Figure 1

PA spine image and corresponding BMD values. The visual presentation of increased relative density in the image corresponds well with the elevated T-score of this level compared to L3.


  1. Would you exclude L4 from the analysis?
  2. Would you order additional imaging in this patient based on these scan results?
  3. What is the most likely cause of the visual and densitometric discordance?

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