Trabecular Bone Score: A New DXA–Derived Measurement for Fracture Risk Assessment

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Key points

  • Trabecular bone score (TBS) is a textural index based on evaluating pixel gray-level variations in the lumbar spine dual-energy x-ray absorptiometry (DXA) image.

  • TBS predicts the risk of major osteoporotic fracture (MOF) and hip fracture in women and men greater than 40 to 50 years of age.

  • TBS can be used to adjust World Health Organization Fracture Risk Assessment Tool (FRAX) probability of fracture in postmenopausal women and older men, assisting in treatment decisions in clinical practice.

Trabecular bone score: technical aspects

TBS is a textural index based on evaluating pixel gray-level variations in the lumbar spine (LS) DXA image, providing an indirect index of bone architecture. In general, well-structured bone generates a 2-D DXA image that is more homogeneous, with many gray-level variations of small amplitude. In contrast, deteriorated bone produces a 2-D image with a low number of pixel value variations of high amplitude.18 TBS is derived from an experimental variogram of those projected images, calculated as

In Vitro Studies

Ex vivo studies compared TBS to standard 3-D parameters of bone microarchitecture assessed by micro-CT (μCT) in specimens of human cadaveric bone.17, 18, 40, 41 In its first description, TBS was derived from simulated 2-D projection of μCT images of human cadaveric bones from different anatomic sites (LS, femoral neck, and distal radius).18 It was found a significant correlation between TBS of spine samples and direct 3-D measurements of trabecular microarchitecture by μCT, namely, trabecular

Cross-sectional Studies

Cross-sectional studies have shown an association between LS TBS and vertebral, hip, and overall osteoporotic fractures in postmenopausal women.50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60 Data in men, although limited, have confirmed an association between lower TBS and prevalent osteoporotic fractures.59, 61 In general, these retrospective case-control studies have demonstrated that TBS is able to differentiate fractured cases from controls, with odds ratio (OR) for fracture ranging from 1.3 to

Association of trabecular bone score with FRAX to enhance fracture prediction

Recent studies have indicated an incremental improvement in fracture prediction when TBS is used in combination with FRAX. The first such assessment, described previously, examined 33,352 women, ages 40 to 100 years, from the Canadian province of Manitoba, followed for 4.7 years.69 TBS was able to predict the risk of MOFs and death in models controlled for FRAX clinical risk factors and femoral neck BMD T score. The ability of TBS to predict MOFs remained after accounting for the increased

Antiosteoporotic Therapy

The effect of antiosteoporotic agents on TBS was explored in several studies (summarized in Table 3). For detailed review, see Silva and colleagues19 and Harvey and colleagues.75 In general, changes in TBS due to diverse antiosteoporotic agents tend to be much smaller than those observed in LS BMD. In addition, compared with LS BMD, a lower proportion of patients experience improvements in TBS above the least significant change. Assessments of the use of bisphosphonates for up to approximately

Diabetes Mellitus

Using the Manitoba database, Leslie and colleagues83 assessed 29,407 women greater than or equal to 50 years old, of whom 2356 (8.1%) had diabetes mellitus. Compared with controls, diabetic women had higher baseline BMDs at all sites, but lower TBS, even after adjusting for multiple clinical risk factors (age, BMI, GCs, prior major fracture, rheumatoid arthritis, chronic obstructive pulmonary disease as a smoking proxy, alcohol abuse, and osteoporosis therapy). Over 4.7 years of follow-up, 175

Summary

TBS is a textural index from spine DXA images that predicts fracture risk independent of DXA-derived BMD and clinical risk factors. TBS is associated with incident vertebral, hip, and MOFs in postmenopausal women and with hip and MOFs in men greater than 50 years of age. TBS can be used to adjust FRAX probabilities of fracture, directing treatment recommendations in clinical practice. Although TBS improves on diverse antiosteoporotic treatments, these changes are usually smaller than

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