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The British Journal of Radiology logoLink to The British Journal of Radiology
. 2024 Jan 30;97(1156):705–715. doi: 10.1093/bjr/tqae023

Dual-energy CT applications in musculoskeletal disorders

Sook Chuei W Cheong 1,2,✉, Yet Yen Yan 3,4, Adnan Sheikh 5, Hugue A Ouellette 6, Peter L Munk 7, Nicolas Murray 8, Paul I Mallinson 9
PMCID: PMC11027318  PMID: 38291893

Abstract

Dual-energy CT (DECT) is an exciting application in CT technology conferring many advantages over conventional single-energy CT at no additional with comparable radiation dose to the patient. Various emerging and increasingly established clinical DECT applications in musculoskeletal (MSK) imaging such as bone marrow oedema detection, metal artefact reduction, monosodium urate analysis, and collagen analysis for ligamentous, meniscal, and disc injuries are made possible through its advanced DECT post-processing capabilities. These provide superior information on tissue composition, artefact reduction and image optimization. Newer DECT applications to evaluate fat fraction for sarcopenia, Rho/Z application for soft tissue calcification differentiation, 3D rendering, and AI integration are being assessed for future use. In this article, we will discuss the established and developing applications of DECT in the setting of MSK radiology as well as the basic principles of DECT which facilitate them.

Keywords: Dual Energy CT (DECT), Musculoskeletal (MSK), Bone marrow oedema (BMO), Monosodium Urate (MSU), Metal artefact reduction, Collagen analysis, Bone mineral density

Introduction

The key imaging modalities in MSK imaging are radiographs, ultrasound, MRI, and CT. MRI is considered the gold standard for soft tissue imaging, whilst CT is fast and widely available, with superior bony detail. Dual-energy CT (DECT) has emerged as the technology that can provide supplementary information for both osseous and soft tissues.1

Basic overview of DECT

The clinical utility of DECT is increasingly established with the advent of technological advancements permitting practicable application of this technique that was first introduced in the 1970s.2,3 Dual-energy CT exploits the differential energy-dependent attenuation profiles exhibited by different tissues acquired with two X-ray energy levels, typically at 80-90 and 140-150 keV.2–4 The attenuation of X-ray photons during a CT scan comprises predominantly photoelectric effect and Compton scatter. Compton scatter is less applicable in DECT as it is not affected by the X-ray beam energy, whereas photoelectric effect plays a more important role in DECT. In photoelectric effect, the X-ray photons are absorbed when they interact with electrons from the inner K-shell of the atoms of the material. When the energy level of the photon is equal to or just greater than the K-shell binding energy of the electron in its shell (K-edge), there is a significant increase in absorption of photons. The probability of photoelectric effect or photoelectric linear attenuation coefficient is inversely proportionate to the energy of the X-ray photon (E) and is proportionate to the atomic number (Z) and mass density (ρ). Linear attenuation coefficient is calculated as ρZ3/E3. Elements of a high atomic number such as iodine and calcium have an associated K-edge that approximates the mean energy of the low-kilovoltage energy source and consequently absorbs more low-energy photons. The elements in the human body such as carbon, oxygen, hydrogen, and nitrogen are of low atomic numbers. These elements have low K-edge values that do not approximate the mean energy of the low and high-kilovoltage sources and consequently show similar photon absorption at both low- and high-kilovoltage sources. Dual-energy index value (DEI) is used in dual-source DECT system to quantity and show the differential attenuation of different materials at the low- and high-energy levels, and this allows for differentiation of various materials. Each material has a specific DEI, and the differentiation is superior if the differences between the DEIs are greater.4

Apart from the atomic number, the molecular structure of certain tissues, such as collagen and urate, can also display distinctive spectral properties with varying energy levels.4

Post-processing tools are required to generate clinically useful material-specific or energy-specific images from the DECT datasets.

Material-specific images are generated after methodical computational comparison of attenuation values between the low- and high-kilovoltage datasets. It allows for detection and colour coding of different materials, such as monosodium urate (MSU) crystals for gout arthropathy, and collagen for tendon mapping. Virtual non-calcium (VNCa) images can be generated by colour coding or subtracting calcium which is a powerful tool to assess for bone marrow oedema (BMO) and infiltrating bone lesions. Virtual non-contrast (VNC) images with complementary iodine-enhanced images are created by subtracting or mapping iodine.

Energy-specific images are reconstructed after extrapolation of the attenuation values of each voxel at a different energy level. This creates virtual monoenergetic spectral (VMS) images, as if the images were acquired with a monoenergetic energy beam. Monoenergetic images can be selected from 40 to 200 keV which is beyond the range of mean kilovolt levels available on current CT tube technology. This technique is useful for metal artefact reduction or increasing the attenuation of iodinated contrast material.

Different vendors had developed several hardware designs to obtain DECT, such as sequential scanning, dual-source scanning, rapid energy switching, multilayer detector, and photon-counting CT. In sequential scanning technique, the patient is scanned sequentially at two different energy levels. The major drawback of this technique is image misregistration due to motion between the two sequential scans. In dual-source technique, two X-ray sources, which can be independently controlled for different scan parameters and energy levels, and their respective detectors are placed on the same gantry orthogonally. Excellent temporal resolution can be obtained as the two X-ray sources can be operated simultaneously and there is improved signal-to-noise ratio. The disadvantage of this technique is scattered radiation from one X-ray source to another detector, requiring scatter correction algorithm. Dual-source scanning is the current market leader in DECT technology. As the name implies, rapid energy switching involves rapidly switching between high- and low-energy levels during scan acquisition. This technique is associated with spectral contamination between the two energy levels. In multilayer detector, a layered or “sandwich” scintillation detector is used to distinguish the different energy levels from a single X-ray energy source, by collecting the low-energy data from the inner layer of detector and the high-energy data from the outer layer of detector. Therefore, dual-energy analysis is always available with this technique.5,6 Photon-counting CT is an emerging new CT technology. The photon-counting detector converts deposited X-ray energy directly to an electronic signal whereas the current CT technology utilizes scintillator-based energy-integrated detector. The photon-counting detector can discriminate different energy levels, allowing multi-energy image acquisition from a single X-ray energy source. The difference in detector technology also permits a reduction in detector pixel size whilst maintaining geometric detection efficiency. Thus, there is improved contrast to noise radio, better spatial resolution, reduced radiation dose, and reduced beam hardening and metal artefact.5,7

Although DECT was associated with higher radiation dose in the past, advances in technology, especially the newer generations of dual-source DECT, have allowed for preserved image quality at comparable or lower radiation dose than conventional single-energy CT.8–11

The established applications

Bone marrow oedema

Radiography is the first line investigation in acute bony trauma. However, radiographically occult fractures and lesions are commonly encountered in MSK imaging. Conventional CT has a higher sensitivity than radiographs in depicting fractures and is commonly performed in the acute setting for surgical planning.12,13 Nonetheless, subtle fractures and lesions may still be missed on conventional CT as it is not equipped to remove fine bone trabeculations which are inseparable from marrow and thus provides suboptimal visualization of BMO).14–16

Bone marrow oedema following acute bony trauma can represent a bone bruise or bone marrow contusion secondary to varying degree of haemorrhage, infarction, and oedema following microscopic cancellous bone fractures and is historically diagnosed with MRI.14,17 Other non-traumatic bone pathologies that cause BMO include inflammation, infections, and tumours.18–20 Despite the superior contrast resolution of MRI, it may not be routinely performed in the acute bony trauma due to its variable availability and longer acquisition times that may be inappropriate for an unstable patient or those with severe pain.

Dual-energy CT has emerged as a promising tool by identifying and subtracting the calcium of the trabecular bone which obscures BMO, thus generating the VNCa images. BMO is readily demonstrated against the lower-density yellow marrow within the medullary cavity on VNCa images.16 Abrupt change in attenuation in the bone marrow within the same region or with the contralateral normal side raises suspicion of BMO which can be depicted as colour imaging, greyscale overlay or 3D on VNCa images (Figure 1A-D).

Figure 1.

Figure 1.

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(A) Elderly patient tripped and fell with left knee tenderness. Frontal and horizontal beam lateral radiographs showed no acutely displaced fracture. However, there is a small suprapatellar lipohemathrosis (arrowhead). (B) Conventional CT (bone window) of the knee in coronal and sagittal plane revealed a subtle undisplaced fracture of the lateral tibial plateau with intra-articular extension (arrows). (C) Dual-energy analysis in the same planes confirmed bone marrow oedema (coded green) in the lateral tibial plateau (dotted arrows). (D) 3D reconstruction of dual-energy analysis demonstrated bone marrow oedema (coded green) in the lateral tibial plateau (dashed arrow).

Dual-energy CT VNCa has been validated by multiple studies for detection of BMO with high sensitivity and specificity.1,16,21–27 In addition, depiction of BMO improves detection of acute undisplaced fractures in osteoporotic bone.1,23 The utilization of DECT in the emergency setting would allow for assessment of microfractures and serve as an alternative modality to MRI.

There are emerging studies which support the use of BMO in non-traumatic bone pathologies. Chen et al and Wu et al found that there is favourable evidence for use of DECT VNCa images in demonstrating sacroiliitis (Figure 2A-D).28,29

Figure 2.

Figure 2.

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(A) Young patient presented with radicular lower back pain and 1 week of fever. Conventional CT (bone window) of the pelvis in axial plane showed subchondral sclerosis (arrow) in the left iliac bone with asymmetrical widening of the SI joint (arrowhead). (B) Conventional CT (soft tissue window) of the pelvis showed soft tissue thickening at the anterior and posterior aspect of the left SI joint (dotted arrows). (C) Dual-energy CT analysis showed evidence of bone marrow oedema (coded green) at the left iliac bone where the subchondral sclerosis was appreciated (dashed arrow). Combined findings are suspicious for severe left unilateral sacroiliitis. (D) Contrast-enhanced T1 fat-saturated MRI confirmed bone marrow oedema in the left iliac bone (dashed arrow), enhancement and widening of the left SI joint (arrowhead), and soft tissue thickening around the SI joint (dotted arrows). The patient was subsequently diagnosed with ankylosing spondylitis.

A recent study by Yan et al has assessed the sensitivity and specificity of DECT VNCa for osteomyelitis and found that there is improved sensitivity in the diagnosis of osteomyelitis when DECT VNCa images are used in conjunction with bone and soft tissue reconstructions (Figure 3A-C).30

Figure 3.

Figure 3.

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(A) Middle-aged patient with diabetes presented with ulcers at the tarsometatarsal amputation site. Conventional CT (bone window) in axial plane showed irregular contour (arrow) and sclerosis (dotted arrow) residual base of the first metatarsal bone. (B) Dual-energy CT analysis showed evidence of bone marrow oedema (coded green) at the residual base of the first metatarsal bone (dashed arrow). Overall findings are suspicious for osteomyelitis. (C) Technetium labelled white blood cell scan showed soft tissue inflammation within the plantar aspect of the left foot with white blood cell activity extending into the base of the residual left first metatarsal compatible with osteomyelitis (arrowhead).

Although DECT has not been validated for detection and follow-up of osseous metastases, multiple studies have shown favourable evidence for the utilization of DECT to distinguish osseous metastases from benign bone lesions. A retrospective study by Zheng et al showed that vertebral body metastases can be differentiated from Schmorl nodes through quantitative tissue decomposition of the BMO algorithm.31 Osseous metastases were found to have significantly higher water content and lower bone content than Schmorl nodes.31 Utilization of qualitative tissue decomposition can make osseous metastases more apparent by detecting, colour coding, or subtracting cortical and trabecular bone (Figure 4A-C).32 VNC and complementary iodine mapping can potentially show enhancing soft tissues within lucent lesions that would raise suspicion for osseous metastases.32 Kraus et al found improved image quality and detection of spinal metastases through monoenergetic reconstruction.33 Dong et al also showed that VMS reconstruction can differentiate osteoblastic metastases from bone islands.34

Figure 4.

Figure 4.

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(A) Middle-aged patient with metastatic non-small cell lung cancer presented with left hip pain. Sequential conventional CT (bone window) of the pelvis in axial plane demonstrates left iliac crest, right sacral ala, and lower sacral segment subtle lucent bone lesions (arrows). (B) Sequential DECT analysis showed bone marrow oedema (coded green) in these areas (dotted arrows). (C) Review of previous PET-CT performed 3 months prior to CT pelvis showed that these lesions were hypermetabolic (dashed arrows), consistent with osseous metastases.

One of the limitations of DECT VNCa algorithm is the loss of data and suboptimal BMO detection just adjacent to the cortex due to spatial averaging effect.17 Therefore, BMO detection may be challenging in small and thin bones or bones with thick cortex.23,35 Walstra et al suggest that the maximum HU can be adjusted from 800 HU to up to 3000 HU in the application profile for small bones to minimize the spatial averaging artefact.36 Dual-energy CT VNCa image accuracy may also be limited by sclerosis and air.22,23 Red marrow may also mimic BMO, but the location and morphology should aid the differentiation between the two.

Metal artefact reduction

Metal implants such as joint replacements are more prevalent in an ageing population. Imaging metal orthopaedic implants for complications is a significant challenge for radiologist as radiographs have low sensitivity and specificity whilst both MRI and conventional CT are marred with artefacts.37–42 The low-energy photons from polychromatic source conventional CT are preferentially absorbed by the metal implants and therefore produces beam hardening artefacts. Less beam hardening is observed with the higher 140 keV energy beam with improved bone-metal interface assessment, whereas soft tissue contrast is better at the lower 80-100 keV energy beam. Photon starvation artefact occurs in thicker areas, such as in the pelvis, where there are reduced photons reaching the detector. Metal density is well beyond the normal body range which results in incomplete attenuation profiles and artefacts. Two closely opposing dense objects in a particular plane, for example in the case of bilateral joint replacements, will result in even more variable attenuation profile and increased beam hardening artefact between the two objects. Dual-energy CT VMS images created from post-processing software allow the reader to adjust and pick the optimal energy level with the least artefact on the dedicated dual-energy CT workstation (Figure 5A and B). Current research suggests that 105-133 keV range offers the most efficient beam hardening artefact reduction with preserved soft tissue detail.43–45

Figure 5.

Figure 5.

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(A) Unenhanced dual-energy CT of the pelvis was performed for a patient who presented with right hip pain following a recent right bipolar hip hemiarthroplasty. Dual-energy CT VMS images at 70 and 130 keV (arrow) were reconstructed. (B) Efficient beam-hardening artefact reduction can be seen at higher keV (130 keV) without significant soft tissue resolution loss.

Monosodium urate

Gout is the most commonly diagnosed inflammatory arthropathy with a prevalence of <1%-6.8% worldwide.46 MSU crystals may deposit in both intra- and extra-articular tissues.47 Prompt diagnosis is important to prevent long-term complications such as joint destruction, cardiovascular disease, and chronic kidney disease.47–49 The gold standard for gout diagnosis is joint aspiration and polarization microscopy for detection of MSU, but this invasive procedure is not commonly performed, carries the risk of complications, and is found to be unreliable in small joints.50,51 Plain radiographs have limited utility in early stages of gout.52 MRI, ultrasound, and conventional CT do not have adequate specificities for widespread implementation.53 Dual-energy CT has been validated as an accurate and reliable non-invasive investigation with a sensitivity of 78-100% and a specificity of 89-100%.54–58 The different dual-energy indices of calcium and urate allow for material-specific mapping, colour-coded to overlay the greyscale CT images32 (Figure 6A-C). The potential applications are: (1) diagnosing gout in challenging cases such as differentiating tumour, infection, or gouty tophus;32 (2) defining the anatomical distribution of gout;53,54,57 (3) determining the subclinical disease burden; and (4) monitoring disease progression and response to treatment.32

Figure 6.

Figure 6.

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(A) Elderly patient presented with atraumatic right forefoot pain at the tarsometatarsal and metatarsophalangeal joints. He has a history of gout. Conventional CT (bone window) of the left foot showed extensive erosive changes in the intertarsal and tarsometatarsal joints (arrows). (B) Dual-energy CT revealed monosodium urate crystal deposition (coded green) in the affected joints (dotted arrows). (C) 3D reconstruction with colour coding allows easy visualization of monosodium urate deposition.

It is important to be aware of artefacts and pitfalls on DECT gout protocols to avoid false-positive results. There should usually be corresponding mineralization of MSU crystal on conventional CT images. Nail bed artefact is the most commonly encountered artefact, especially in the feet (Figure 7A and B). Skin artefact is also more commonly detected in the feet than the hand, especially where calluses are present. Two opposing cutaneous surfaces also cause skin artefact. Skin artefact is rarely seen in the knees or elbows.59 Small foci (less than 1-2 mm) or scattered single pixels may be artefactual from noise.59,60 Beam hardening from metal (either within or external to the patient) or dental cement can mimic MSU deposition. Beam-hardening artefact is usually linear and follows the path of the hardened beam. Motion artefact may also simulate MSU deposition, but the distribution along the non-anatomic plane where the images are degraded by motion is the key to distinguish gout from motion artefact.59 False-negative results on DECT may occur during the initial flare of gout or when the concentration of MSU is low or diluted in the joint.61 MSU and other arthropathy, including infection, can coexist, and caution should be exercised in some clinical scenarios.61

Figure 7.

Figure 7.

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(A) Dual-energy CT of the foot showed nailbed and skin artefact in the left toe (arrows). (B) There was no corresponding mineralization on the conventional CT.

Developing applications entering practice

Collagen analysis

As previously mentioned, MRI is superior in soft tissue characterization. Dual-energy CT material decomposition algorithms are able to provide analysis of collagenous structures because molecular structures and atomic characteristics may also give tissues a unique dual-energy signature. Dense hydroxylysin and hydroxyproline molecule side chains within the collagen molecules found in ligaments and tendon can be mapped and colour-coded on DECT.4 Multiple studies have supported the use of DECT in collagen analysis in different joints.62–65

Ligamentous characterization by DECT started in 2008 when Sun et al assessed the knee ligaments with DECT. The larger ligaments such as anterior and posterior cruciate ligaments were well demonstrated, whilst the thinner and smaller structures such as the tibial collateral ligaments and patellar retinaculum were poorly visualized.65 Fickert et al found that DECT and MRI have similar ACL visualization, specificity, and sensitivity for partial ACL tears, but complete ACL tears are better depicted on MRI (Figures 8A-D and 9A and B).63

Figure 8.

Figure 8.

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(A) Middle aged patient presented after a fall with knee pain. Horizontal beam lateral knee radiograph showed cortical irregularity at the posterior aspect of the tibial plateau (arrow) with a small suprapatellar effusion (arrowhead). (B) Conventional CT (bone window) of the knee in sagittal plane revealed an avulsion fracture at the PCL attachment (arrow). (C) Dual-energy analysis confirmed bone marrow oedema (coded green) in the PCL attachment (dotted arrow). (D) The quadriceps and patellar tendon, as well as ACL and PCL of the same patient are well demonstrated on collagen analysis (arrowheads).

Figure 9.

Figure 9.

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(A) Young patient presented with knee pain following a twisting injury. Dual-energy CT collagen analysis of the knee in sagittal plane showed a possible ACL tear (dotted arrow). (B) This was subsequently confirmed on MRI (arrow).

Tendon analysis is not as well established as ligamentous assessment. Nonetheless, the same application may be utilized for tendon analysis. Again, larger tendons such as Achilles and patellar tendons are better visualized than the smaller tendons.65–67

Intervertebral discs and menisci which are similarly rich in collagen can be visualized with DECT material decomposition algorithm (Figure 10A-C).32 Displaced meniscal, disc fragments, and disc bulges can be demonstrated on DECT but finer details such as small tears are not optimally demonstrated. The clinical utilization of DECT in the evaluation of collagenous structures is still developing, and further studies is required to optimize and support the use of DECT in assessment of these structures in acute traumatic setting.

Figure 10.

Figure 10.

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(A) Elderly patient presented with atraumatic back pain. Conventional CT lumbar spine (soft tissue window) in sagittal plane depicted multilevel disc bulges (arrows). There was better visualization of the disc outline at the level of L2-3, but the discs were not well seen at L3-4 and L4-5. (B). Dual-energy CT collagen analysis of the lumbar spine showed superior demonstration of the discs (dotted arrow). (C) T2W MRI lumbar spine confirmed the presence of multilevel disc protrusions (dashed arrow) with multilevel spinal canal stenosis, corresponding well with DECT collagen analysis.

Iodine overlay

Iodine overlap map may be utilized to increase conspicuity of enhancing tissues and is useful in CT arthrography. Conventional CT is limited in distinguishing iodine contrast from nearby bone and calcium, whilst DECT can overcome this by tissue decomposition to differentiate calcium, urate, and iodine. The complementary iodine mapping improves detection of contrast material within minimally displaced tears on CT arthrography and vascular contrast extravasation in trauma.32,68 Differentiation between joint mineralization and contrast filled tears or extravasated contrast can be achieved through the virtual non-contrast (VNC) and complementary iodine overlay mapping.32 CT arthrography has been shown to be comparable or better than MR arthrography in the knee especially in post-operative menisci evaluation, hip cartilage, and shoulder cartilage.69–73 Improved 3-dimensional reconstruction for surgical planning can be created via separation of iodine from cortical bone.

Bone mineral density

Osteoporosis and osteopenia are prevalent in ageing population, requiring a cost-effective and safe diagnostic test.74 The gold standard for bone mineral density assessment is dual X-ray absorptiometry (DEXA).75 However, image distortion due to overlying structures and osteo-degenerative changes are commonly encountered issues with DEXA. Two-dimensional average for DEXA over the vertebral body leads to inaccuracies due to the difference in volume and soft tissue contribution.74–78 DECT may be a good alternative as it can obtain images in three-dimensional plane with focus on trabecular bone, not requiring phantom calibration. Material decomposition algorithm can be utilized for true bone mineral content, not distorted by fatty marrow.79 This algorithm may also be applied retrospectively on DECT studies the patient underwent, such as DECT of the abdomen and pelvis, to save cost and radiation exposure.80 A recently published systemic review article in 2023 by Deshpande N et al explored alternatives to DEXA for assessment of bone density which included MRI, opportunistic CT (oCT), and quantitative CT (qCT). Twenty-four oCT or QCT studies were correlated with spinal BMD and found that Hounsfield unit (HU) of <110 were significantly correlated with osteoporosis.81 In 2020, Booz C et al found that the diagnostic accuracy of quantitative DECT-based BMD has a higher correlation to DEXA values (r = 0.780) using Pearson product-moment correlation as compared to HU measurement on CT and DEXA values (r = 0.528) (P < .001).82

Future developments under investigation

Fat fraction for sarcopenia

A recent study published in 2021 by Molwitz et al quantify the proportion of fat within skeletal muscle to measure muscle quality using DECT validated with MRI to diagnose and monitor sarcopenia. 21 patients who had both contrast-enhanced DECT of the abdomen and 3 T MR imaging were enrolled. Dual-energy CT fat fraction was determined by material decomposition and HU values on VNC. MR fat fraction was assessed by chemical shift relaxometry. The results showed that there was an excellent correlation between DECT and MR fat fraction analysis. This study concluded that DECT is feasible and reliable to quantify fat within skeletal muscle. Determination of muscle quality with this novel technique will be pivotal in the diagnosis and therapeutic monitoring of sarcopenia which is associated with poor outcome.83

Rho/Z for soft tissue calcification

A recent study by Hennebry J et al in 2022 found that atomic number (Z) obtained by DECT Rho/Z application (Syngo.via, version VB40, Siemens Healthineers) can differentiate between different types of peri-articular mineralized foci such as MSU, calcium pyrophosphate deposition disease (CPPD), and calcium hydroxyapatite deposition disease (HADD). This application may be applied clinically to narrow the differential diagnosis when peri-articular mineralized foci are encountered clinically.84

DECT and cinematic rendering

A study by Yu et al in 2022 reviewed the use of DECT and cinematic rendering in pelvic fracture instability assessment. This retrospective study reviewed 54 adult patients with pelvic fractures which were stabilized with pelvic binders. Cinematic rendering for iliolumbar, pelvic floor ligaments, and rectus muscle tendon was performed in addition to BMO assessment at the sacroiliac joints, pubic symphysis, L5 transvers processes, and inferolateral sacrum or ischial spines. They found that combined use of conventional CT, DECT, and cinematic rendering improves instability assessment for pelvic fracture.85

DECT and AI

AI is the fourth industrial revolution and is gaining momentum in clinical application in recent years. Park C et al assessed the diagnostic performance of a deep learning model (DL) compared with musculoskeletal physicians and radiologists for detecting BMO on DECT in a retrospective study of 73 patients. This study showed that DL model has a better diagnostic performance than less-experienced physicians but is comparable to a trained radiologist in BMO detection on DECT.86

Conclusion

Dual-energy CT analysis greatly advances the scope of CT in musculoskeletal imaging. It offers an alternative non-invasive investigation for MSU detection, BMO assessment to improve detection of fracture, metastases, infectious and inflammatory conditions, and metal artefact reduction. There is improved visualization for major collagenous structures and enhanced evaluation of CT arthrography compared to conventional CT. Dual-energy CT is also demonstrating exciting new potential in sarcopenia and mineral deposition analysis. Combination with AI and cinematic rendering may further enhance rates of pathology detection.

The disadvantages of CT when compared to MRI should be acknowledged. It involves ionizing radiation, and the collagen/soft tissue detail remains inferior to MRI, especially in small and thin structures. However, DECT offers additional applications and tools which can provide useful additional information when compared to conventional single-energy CT. Red marrow can mimic BMO on DECT, and BMO detection is challenging in small tubular bones. The radiologist should also be aware of mimickers and artefacts when using the DECT algorithms to reduce false positives.

Dual-energy CT is of great utility in musculoskeletal radiology with a mixture of clinically established and promising ongoing developments. It has and will continue to improve the scope and standard of radiological practice in years to come.

Contributor Information

Sook Chuei W Cheong, Musculoskeletal section, Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, V5Z 1M9 Canada; Department of Radiology, Changi General Hospital, Singapore 529889, Singapore.

Yet Yen Yan, Musculoskeletal section, Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, V5Z 1M9 Canada; Department of Radiology, Changi General Hospital, Singapore 529889, Singapore.

Adnan Sheikh, Musculoskeletal section, Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, V5Z 1M9 Canada.

Hugue A Ouellette, Musculoskeletal section, Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, V5Z 1M9 Canada.

Peter L Munk, Musculoskeletal section, Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, V5Z 1M9 Canada.

Nicolas Murray, Musculoskeletal section, Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, V5Z 1M9 Canada.

Paul I Mallinson, Musculoskeletal section, Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, V5Z 1M9 Canada.

Funding

No funding received for this manuscript.

Conflicts of interest

University of British Columbia has a master research agreement with Siemens Healthineers.

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