Skeletal muscle cutoff values for sarcopenia diagnosis using T10 to L5 measurements in a healthy US population

Abstract

Measurements of skeletal muscle cross-sectional area, index, and radiation attenuation utilizing clinical computed tomography (CT) scans are used in assessments of sarcopenia, the loss of skeletal muscle mass and function associated with aging. To classify individuals as sarcopenic, sex-specific cutoffs for 'low' values are used. Conventionally, cutoffs for skeletal muscle measurements at the level of the third lumbar (L3) vertebra are used, however L3 is not included in several clinical CT protocols. Non-contrast-enhanced CT scans from healthy kidney donor candidates (age 18-40) at Michigan Medicine were utilized. Skeletal muscle area (SMA), index (SMI), and mean attenuation (SMRA) were measured at each vertebral level between the tenth thoracic (T10) and the fifth lumbar (L5) vertebra. Sex-specific means, standard deviations (s.d.), and sarcopenia cutoffs (mean-2 s.d.) at each vertebral level were computed. Associations between vertebral levels were assessed using Pearson correlations and Tukey's difference test. Classification agreement between different vertebral level cutoffs was assessed using overall accuracy, specificity, and sensitivity. SMA, SMI, and SMRA L3 cutoffs for sarcopenia were 92.2 cm², 34.4 cm²/m², and 34.3 HU in females, and 144.3 cm², 45.4 cm²/m², and 38.5 HU in males, consistent with previously reported cutoffs. Correlations between all level pairs were statistically significant and high, ranging from 0.65 to 0.95 (SMA), 0.64 to 0.95 (SMI), and 0.63 to 0.95 (SMRA). SMA peaks at L3, supporting its use as the primary site for CT sarcopenia measurements. However, when L3 is not available alternative levels (in order of preference) are L2, L4, L5, L1, T12, T11, and T10. Healthy reference values reported here enable sarcopenia assessment and sex-specific standardization of SMA, SMI, and SMRA in clinical populations, including those whose CT protocols do not include L3.

Figure 1

Box plots of healthy reference population SMA, SMI, and SMRA values by sex and vertebra. EWGSOP sarcopenia cutoffs (mean − 2 s.d.) shown as horizontal red lines.

Figure 2

Tukey mean difference and 95% confidence interval for SMA, SMI, and SMRA at each vertebral level pair, by sex. Differences with p < 0.01 (orange circles), p < 0.05 (purple diamonds), and p > 0.05 (grey triangles) are shown.

Figure 3

Example of healthy 20 y/o male T10-L5 axial CT slices showing SMA (blue-shaded area) between outer abdominal fascia (yellow line) and inner muscle wall (red line).