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Lumbar spine texture enhances 10-year fracture probability assessment



We found that lumbar spine texture analysis using trabecular bone score (TBS) is a risk factor for MOF and a risk factor for death in a retrospective cohort study from a large clinical registry for the province of Manitoba, Canada.


FRAX® estimates the 10-year probability of major osteoporotic fracture (MOF) using clinical risk factors and femoral neck bone mineral density (BMD). Trabecular bone score (TBS), derived from texture in the spine dual X-ray absorptiometry (DXA) image, is related to bone microarchitecture and fracture risk independently of BMD. Our objective was to determine whether TBS provides information on MOF probability beyond that provided by the FRAX variables.


We included 33,352 women aged 40–100 years (mean 63 years) with baseline DXA measurements of lumbar spine TBS and femoral neck BMD. The association between TBS, the FRAX variables, and the risk of MOF or death was examined using an extension of the Poisson regression model.


During the mean of 4.7 years, 1,754 women died and 1,872 sustained one or more MOF. For each standard deviation reduction in TBS, there was a 36 % increase in MOF risk (HR 1.36, 95 % CI 1.30–1.42, p < 0.001) and a 32 % increase in death (HR 1.32, 95 % CI 1.26–1.39, p < 0.001). When adjusted for significant clinical risk factors and femoral neck BMD, lumbar spine TBS was still a significant predictor of MOF (HR 1.18, 95 % CI 1.12–1.23) and death (HR 1.20, 95 % CI 1.14–1.26). Models for estimating MOF probability, accounting for competing mortality, showed that low TBS (10th percentile) increased risk by 1.5–1.6-fold compared with high TBS (90th percentile) across a broad range of ages and femoral neck T-scores.


Lumbar spine TBS is able to predict incident MOF independent of FRAX clinical risk factors and femoral neck BMD even after accounting for the increased death hazard.

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The authors are indebted to Manitoba Health for the provision of data (HIPC 2012/2013-18). The results and conclusions are those of the authors, and no official endorsement by Manitoba Health is intended or should be inferred. This article has been reviewed and approved by the members of the Manitoba Bone Density Program Committee.

Conflicts of interest

William D. Leslie: Speaker bureau: Amgen, Eli Lilly, Novartis. Research grants: Amgen, Genzyme. John A. Kanis: Nothing to declare for FRAX and the context of this paper, but numerous ad hoc consultancies for: Industry: Abiogen, Italy; Amgen, USA, Switzerland and Belgium; Bayer, Germany; Besins-Iscovesco, France; Biosintetica, Brazil; Boehringer Ingelheim, UK; Celtrix, USA; D3A, France; Gador, Argentina; General Electric, USA; GSK, UK, USA; Hologic, Belgium and USA; Kissei, Japan; Leiras, Finland; Leo Pharma, Denmark; Lilly, USA, Canada, Japan, Australia and UK; Merck Research Labs, USA; Merlin Ventures, UK; MRL, China; Novartis, Switzerland and USA; Novo Nordisk, Denmark; Nycomed, Norway; Ono, UK and Japan; Organon, Holland; Parke-Davis, USA; Pfizer USA; Pharmexa, Denmark; Procter and Gamble, UK, USA; ProStrakan, UK; Roche, Germany, Australia, Switzerland, USA; Rotta Research, Italy; Sanofi-Aventis, USA; Schering, Germany and Finland; Servier, France and UK; Shire, UK; Solvay, France and Germany; Strathmann, Germany; Tethys, USA; Teijin, Japan; Teva, Israel; UBS, Belgium; Unigene, USA; Warburg-Pincus, UK; Warner-Lambert, USA; Wyeth, USA Governmental and NGOs: National Institute for health and clinical Excellence (NICE), UK; International Osteoporosis Foundation; INSERM, France; Ministry of Public Health, China; Ministry of Health, Australia; National Osteoporosis Society (UK); WHO. Didier Hans: Co-ownership in the TBS patent. Stock options or royalties: Med-Imaps. Research grants: Amgen, Eli Lilly, Servier, Nycomed-Takeda. Eugene McCloskey: Nothing to declare for FRAX and the context of this paper, but numerous ad hoc consultancies/ speking honoraria and/or research funding from Amgen, Bayer, General Electric, GSK, Hologic, Lilly, Merck Research Labs, Novartis, Novo Nordisk, Nycomed, Ono, Pfizer, ProStrakan, Roche, Sanofi-Aventis, Servier, Tethys, UBS and Warner-Chilcott. H. Johansson, O Lamy, A. Oden declare that they have no conflict of interest.

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Correspondence to W. D. Leslie.

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Leslie, W.D., Johansson, H., Kanis, J.A. et al. Lumbar spine texture enhances 10-year fracture probability assessment. Osteoporos Int 25, 2271–2277 (2014).

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  • Bone mineral density
  • Osteoporosis
  • Post-menopausal women
  • Texture analysis
  • Trabecular bone score