Trabecular Bone Score: From Over a Decade of Evidence to a Connected Bone Health Ecosystem

Abstract

Effective assessment of bone health requires evaluation of both bone mass and bone microarchitecture. Osteoporosis is characterised not only by reduced bone mineral density (BMD) but also by deterioration of trabecular microstructure, both of which contribute independently to fracture risk. Despite this, clinical evaluation often focuses solely on BMD, which fails to capture many individuals at risk. Indeed, the majority of fragility fractures occur in patients with BMD values above the osteoporotic threshold, underscoring the importance of incorporating additional measures of bone quality. Trabecular bone score (TBS) is a validated, non-invasive index of bone microarchitecture derived from lumbar spine DXA images. By providing complementary and additive information, TBS improves the detection of individuals at elevated fracture risk who may be missed by BMD alone. For more than a decade, TBS has been extensively validated as an independent predictor of fracture risk, for both the assessment and management of osteoporosis. This article reviews the clinical evidence supporting TBS and its integration into routine practice. We also introduce a broader vision for future connected bone health ecosystem, in which next-generation TBS solutions, including TBS Reveal™ for opportunistic screening from X-rays and TBS Ortho™ for pre-operative fragility assessment, expand the clinical reach of bone quality assessment. Together, these technologies provide scalable, AI-enabled tools to support precision bone fragility evaluation across diverse clinical settings and patient populations.

Zusammenfassung

Deutsch: Eine effektive Beurteilung der Knochengesundheit erfordert die Bewertung sowohl der Knochenmasse als auch der Knochenmikroarchitektur. Osteoporose ist nicht nur durch eine verringerte Knochenmineraldichte (BMD), sondern auch durch eine Verschlechterung der trabekulären Mikrostruktur gekennzeichnet – beides trägt unabhängig zum Frakturrisiko bei. Dennoch konzentriert sich die klinische Bewertung häufig ausschließlich auf die BMD, wodurch viele gefährdete Personen nicht erfasst werden. Tatsächlich treten die meisten Fragilitätsfrakturen bei Patientinnen und Patienten mit BMD-Werten oberhalb der osteoporotischen Schwelle auf, was die Bedeutung zusätzlicher Parameter zur Bewertung der Knochenqualität unterstreicht. Der Trabecular Bone Score (TBS) ist ein validierter, nicht-invasiver Index der Knochenmikroarchitektur, der aus DXA-Bildern der Lendenwirbelsäule abgeleitet wird. TBS liefert komplementäre und zusätzliche Informationen zur BMD und verbessert die Erkennung von Personen mit erhöhtem Frakturrisiko, die allein durch die BMD möglicherweise nicht identifiziert würden. Seit über einem Jahrzehnt ist TBS als unabhängiger Prädiktor für das Frakturrisiko umfassend validiert worden – sowohl zur Beurteilung als auch zum Management der Osteoporose. Dieser Artikel fasst die klinischen Evidenzen zur Anwendung von TBS zusammen und diskutiert seine Integration in die tägliche Praxis. Darüber hinaus wird eine erweiterte Vision für ein vernetztes Ökosystem der Knochengesundheit vorgestellt, in dem neue TBS-basierte Lösungen – darunter TBS Reveal™ für opportunistisches Screening anhand konventioneller Röntgenaufnahmen und TBS Ortho™ für die präoperative Beurteilung der Knochenfragilität – die klinische Reichweite der Beurteilung der Knochenqualität ausweiten. Gemeinsam stellen diese Technologien skalierbare, KI-gestützte Werkzeuge dar, die eine präzise Bewertung der Knochenfragilität in unterschiedlichen klinischen Kontexten und Patientengruppen ermöglichen.

Keywords

trabecular bone score - bone microarchitecture - fracture risk assessment - osteoporosis diagnostics

Schlüsselwörter

Trabekulärer Knochenscore - Knochenmikroarchitektur - Frakturrisikoabschätzung - Osteoporosediagnostik

Publication History

Received: 10 July 2025

Accepted: 17 July 2025

Article published online:
19 August 2025

• References

• 1 Schuit SCE, van der Klift M, Weel AEAM, de Laet CEDH, Burger H, Seeman E. et al. Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam Study. Bone. 2004; 34: 195-202
• 2 Siris ES, Chen YT, Abbott TA, Barrett-Connor E, Miller PD, Wehren LE. et al. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med 2004; 164: 1108-1112
• 3 Trémollieres FA, Pouillès JM, Drewniak N, Laparra J, Ribot CA, Dargent-Molina P. Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: sensitivity of the WHO FRAX tool. J Bone Miner Res 2010; 25: 1002-1009
• 4 Hillier TA, Cauley JA, Rizzo JH, Pedula KL, Ensrud KE, Bauer DC. et al. WHO absolute fracture risk models (FRAX): Do clinical risk factors improve fracture prediction in older women without osteoporosis?. Journal of Bone and Mineral Research 2011; 26: 1774-1782
• 5 Kanis JA, Svedbom A, Harvey N, McCloskey EV. The Osteoporosis Treatment Gap. Journal of Bone and Mineral Research 2014; 29: 1926-1928
• 6 Naik-Panvelkar P, Norman S, Elgebaly Z, Elliott J, Pollack A, Thistlethwaite J. et al. Osteoporosis management in Australian general practice: an analysis of current osteoporosis treatment patterns and gaps in practice. BMC Fam Pract 2020; 21: 32
• 7 Fuggle NR, Curtis B, Clynes M, Zhang J, Ward K, Javaid MK. et al. The treatment gap: The missed opportunities for osteoporosis therapy. Bone. 2021; 144: 115833
• 8 Solutions for Fracture Prevention in Germany.
• 9 Kanis JA, Norton N, Harvey NC, Jacobson T, Johansson H, Lorentzon M. et al. SCOPE 2021: a new scorecard for osteoporosis in Europe. Archives of Osteoporosis [Internet]. 2021 [cited 2024 Apr 3] 16. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8172408/
• 10 Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009; 301: 513-521
• 11 Norring-Agerskov D, Laulund AS, Lauritzen JB, Duus BR, van der Mark S, Mosfeldt M. et al. Metaanalysis of risk factors for mortality in patients with hip fracture. Dan Med J. 2013; 60: A4675
• 12 Pothuaud L, Carceller P, Hans D. Correlations between grey-level variations in 2D projection images (TBS) and 3D microarchitecture: applications in the study of human trabecular bone microarchitecture. Bone. 2008; 42: 775-787
• 13 Pothuaud L, Barthe N, Krieg MA, Mehsen N, Carceller P, Hans D. Evaluation of the potential use of trabecular bone score to complement bone mineral density in the diagnosis of osteoporosis: a preliminary spine BMD-matched, case-control study. J Clin Densitom 2009; 12: 170-176
• 14 Hans D, Barthe N, Boutroy S, Pothuaud L, Winzenrieth R, Krieg MA. Correlations between trabecular bone score, measured using anteroposterior dual-energy X-ray absorptiometry acquisition, and 3-dimensional parameters of bone microarchitecture: an experimental study on human cadaver vertebrae. J Clin Densitom 2011; 14: 302-312
• 15 Silva BC, Walker MD, Abraham A, Boutroy S, Zhang C, McMahon DJ. et al. Trabecular Bone Score Is Associated With Volumetric Bone Density and Microarchitecture as Assessed by Central QCT and HRpQCT in Chinese American and White Women. Journal of Clinical Densitometry 2013; 16: 554-561
• 16 Winzenrieth R, Michelet F, Hans D. Three-dimensional (3D) microarchitecture correlations with 2D projection image gray-level variations assessed by trabecular bone score using high-resolution computed tomographic acquisitions: effects of resolution and noise. J Clin Densitom 2013; 16: 287-296
• 17 Muschitz C, Kocijan R, Haschka J, Pahr D, Kaider A, Pietschmann P. et al. TBS reflects trabecular microarchitecture in premenopausal women and men with idiopathic osteoporosis and low-traumatic fractures. Bone. 2015; 79: 259-266
• 18 Ramalho J, Marques IDB, Hans D, Dempster D, Zhou H, Patel P. et al. The trabecular bone score: Relationships with trabecular and cortical microarchitecture measured by HR-pQCT and histomorphometry in patients with chronic kidney disease. Bone. 2018; 116: 215-220
• 19 Gama EMF, Mendonça LMC, Paranhos-Neto FP, Vieira Neto L, Madeira M, Farias MLF. TBS correlates with bone density and microstructure at trabecular and cortical bone evaluated by HR-pQCT. J Bone Miner Metab 2024; 42: 352-360
• 20 Shevroja E, Reginster JY, Lamy O, Al-Daghri N, Chandran M, Demoux-Baiada AL. et al. Update on the clinical use of trabecular bone score (TBS) in the management of osteoporosis: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and the International Osteoporosis Foundation (IOF) under the auspices of WHO Collaborating Center for Epidemiology of Musculoskeletal Health and Aging. Osteoporos Int. 2023
• 21 Swiss Association against Osteoporosis – Tools/Documents [Internet]. [cited 2025 Jul 4]. Available from https://www.svgo.ch/en/?Tools%2FDocuments
• 22 Dimai HP, Muschitz C, Amrein K, Bauer R, Cejka D, Gasser RW. et al. Osteoporose – Definition, Risikoerfassung, Diagnose, Prävention und Therapie (Update 2024): Leitlinie der Österreichischen Gesellschaft für Knochen- und Mineralstoffwechsel. Wien Klin Wochenschr 2024; 136: 599-668
• 23 Schmidmaier R, Hadji P, Kern P, Drey M, Jakob F, Thomasius F. Recommendations for the Pharmacological Treatment of Osteoporosis – Update 2023 of the German Osteoporosis Guideline. Osteologie 2023; 32: 115-122
• 24 Choksi P, Jepsen KJ, Clines GA. The challenges of diagnosing osteoporosis and the limitations of currently available tools. Clin Diabetes Endocrinol 2018; 4: 12
• 25 Binkley N, Morin SN, Martineau P, Lix LM, Hans D, Leslie WD. Frequency of normal bone measurement in postmenopausal women with fracture: a registry-based cohort study. Osteoporos Int 2020; 31: 2337-2344
• 26 Kadri A, Binkley N, Daffner SD, Anderson PA. Fracture in Patients with Normal Bone Mineral Density: An Evaluation of the American Orthopaedic Association’s Own the Bone Registry. J Bone Joint Surg Am 2023; 105: 128-136
• 27 Bandaru S, Hare K, Krueger D, Binkley N. Do patients that fracture with normal DXA-measured BMD have normal bone?. Arch Osteoporos 2020; 15: 70
• 28 Harvey NC, Glüer CC, Binkley N, McCloskey EV, Brandi ML, Cooper C. et al. Trabecular bone score (TBS) as a new complementary approach for osteoporosis evaluation in clinical practice. Bone. 2015; 78: 216-224
• 29 Boutroy S, Hans D, Sornay-Rendu E, Vilayphiou N, Winzenrieth R, Chapurlat R. Trabecular bone score improves fracture risk prediction in non-osteoporotic women: the OFELY study. Osteoporos Int 2013; 24: 77-85
• 30 Briot K, Paternotte S, Kolta S, Eastell R, Reid DM, Felsenberg D. et al. Added value of trabecular bone score to bone mineral density for prediction of osteoporotic fractures in postmenopausal women: the OPUS study. Bone. 2013; 57: 232-236
• 31 Iki M, Tamaki J, Kadowaki E, Sato Y, Dongmei N, Winzenrieth R. et al. Trabecular bone score (TBS) predicts vertebral fractures in Japanese women over 10 years independently of bone density and prevalent vertebral deformity: the Japanese Population-Based Osteoporosis (JPOS) cohort study. J Bone Miner Res 2014; 29: 399-407
• 32 Leslie WD, Aubry-Rozier B, Lix LM, Morin SN, Majumdar SR, Hans D. Spine bone texture assessed by trabecular bone score (TBS) predicts osteoporotic fractures in men: the Manitoba Bone Density Program. Bone. 2014; 67: 10-14
• 33 Iki M, Tamaki J, Sato Y, Winzenrieth R, Kagamimori S, Kagawa Y. et al. Age-related normative values of trabecular bone score (TBS) for Japanese women: the Japanese Population-based Osteoporosis (JPOS) study. Osteoporos Int 2015; 26: 245-252
• 34 McCloskey EV, Odén A, Harvey NC, Leslie WD, Hans D, Johansson H. et al. A Meta-Analysis of Trabecular Bone Score in Fracture Risk Prediction and Its Relationship to FRAX. J Bone Miner Res 2016; 31: 940-948
• 35 Popp AW, Meer S, Krieg MA, Perrelet R, Hans D, Lippuner K. Bone mineral density (BMD) and vertebral trabecular bone score (TBS) for the identification of elderly women at high risk for fracture: the SEMOF cohort study. Eur Spine J 2016; 25: 3432-3438
• 36 Schousboe JT, Vo T, Taylor BC, Cawthon PM, Schwartz AV, Bauer DC. et al. Prediction of Incident Major Osteoporotic and Hip Fractures by Trabecular Bone Score (TBS) and Prevalent Radiographic Vertebral Fracture in Older Men. Journal of Bone and Mineral Research 2016; 31: 690-697
• 37 Martineau P, Silva BC, Leslie WD. Utility of trabecular bone score in the evaluation of osteoporosis. Curr Opin Endocrinol Diabetes Obes 2017; 24: 402-410
• 38 Su Y, Leung J, Hans D, Lamy O, Kwok T. The added value of trabecular bone score to FRAX^® to predict major osteoporotic fractures for clinical use in Chinese older people: the Mr. OS and Ms. OS cohort study in Hong Kong. Osteoporos Int 2017; 28: 111-117
• 39 Su Y, Leung J, Hans D, Aubry-Rozier B, Kwok T. Added clinical use of trabecular bone score to BMD for major osteoporotic fracture prediction in older Chinese people: the Mr. OS and Ms. OS cohort study in Hong Kong. Osteoporos Int 2017; 28: 151-160
• 40 Schousboe JT, Vo TN, Langsetmo L, Taylor BC, Cawthon PM, Schwartz AV. et al. Association of Trabecular Bone Score (TBS) with Incident Clinical and Radiographic Vertebral Fractures Adjusted for Lumbar Spine BMD in Older Men: A Prospective Cohort Study. J Bone Miner Res 2017; 32: 1554-1558
• 41 Leslie WD, Johansson H, McCloskey EV, Harvey NC, Kanis JA, Hans D. Comparison of Methods for Improving Fracture Risk Assessment in Diabetes: The Manitoba BMD Registry. Journal of Bone and Mineral Research [Internet]. 2018 [cited 2018 Jul 6];0(ja). Available from http://onlinelibrary.wiley.com/doi/abs/10.1002/jbmr.3538
• 42 Martineau P, Leslie WD, Johansson H, Harvey NC, McCloskey EV, Hans D. et al. In which patients does lumbar spine trabecular bone score (TBS) have the largest effect?. Bone. 2018; 113: 161-168
• 43 Tamaki J, Iki M, Sato Y, Winzenrieth R, Kajita E, Kagamimori S. et al. Does Trabecular Bone Score (TBS) improve the predictive ability of FRAX® for major osteoporotic fractures according to the Japanese Population-Based Osteoporosis (JPOS) cohort study?. J Bone Miner Metab 2019; 37: 161-170
• 44 Shevroja E, Aubry-Rozier B, Hans G, Gonzalez- Rodriguez E, Stoll D, Lamy O. et al. Clinical Performance of the Updated Trabecular Bone Score (TBS) Algorithm, Which Accounts for the Soft Tissue Thickness: The OsteoLaus Study. J Bone Miner Res 2019; 34: 2229-2237
• 45 Shevroja E, Mo Costabella F, Gonzalez Rodriguez E, Lamy O, Hans D. The fracture predictive ability of lumbar spine BMD and TBS as calculated based on different combinations of the lumbar spine vertebrae. Arch Osteoporos 2022; 17: 83
• 46 Kuzma M, Hans D, Koller T, Nemethova E, Jackuliak P, Killinger Z. et al. Less strict intervention thresholds for the FRAX and TBS-adjusted FRAX predict clinical fractures in osteopenic postmenopausal women with no prior fractures. J Bone Miner Metab. 2017
• 47 Hans D, Goertzen AL, Krieg MA, Leslie WD. Bone microarchitecture assessed by TBS predicts osteoporotic fractures independent of bone density: the Manitoba study. J Bone Miner Res 2011; 26: 2762-2769
• 48 Leslie WD, Shevroja E, Johansson H, McCloskey EV, Harvey NC, Kanis JA. et al. Risk-equivalent T-score adjustment for using lumbar spine trabecular bone score (TBS): the Manitoba BMD registry. Osteoporos Int 2018; 29: 751-758
• 49 Gatineau G, Hind K, Shevroja E, Gonzalez-Rodriguez E, Lamy O, Hans D. Advancing trabecular bone score (TBS): clinical performance of TBS version 4.0 with direct correction for soft tissue thickness-the osteolaus study. Osteoporos Int 2025; 36: 715-724
• 50 Briot K, Paternotte S, Kolta S, Eastell R, Felsenberg D, Reid DM. et al. FRAX®: Prediction of Major Osteoporotic Fractures in Women from the General Population: The OPUS Study. PLoS One [Internet]. 2013 [cited 2019 Sep 10] 8. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3875449/
• 51 Chuang MH, Chuang TL, Koo M, Wang YF. Trabecular Bone Score Reflects Trabecular Microarchitecture Deterioration and Fragility Fracture in Female Adult Patients Receiving Glucocorticoid Therapy: A Pre-Post Controlled Study. Biomed Res Int 2017; 2017: 4210217
• 52 Corrado A, Rotondo C, Mele A, Cici D, Maruotti N, Sanpaolo E. et al. Influence of glucocorticoid treatment on trabecular bone score and bone remodeling regulators in early rheumatoid arthritis. Arthritis Research & Therapy 2021; 23: 180
• 53 Rymuza J, Pelewicz K, Przedlacki J, Miśkiewicz P. Therapy With Intravenous Methylprednisolone Pulses Is Associated With Loss of Bone Microarchitecture in Trabecular Bone Score -Assessment Among Patients With Moderate-to-Severe Graves’ Orbitopathy: A Pilot Study. Front Endocrinol (Lausanne) 2022; 13: 893600
• 54 Belaya ZE, Hans D, Rozhinskaya LY, Dragunova NV, Sasonova NI, Solodovnikov AG. et al. The risk factors for fractures and trabecular bone-score value in patients with endogenous Cushing’s syndrome. Arch Osteoporos 2015; 10: 44
• 55 Tan E, Guignat L, Dellal A, Winzenrieth R, Cormier C, Koumakis E. Trabecular bone score (TBS) in Cushing’s disease: TBS gain after hypercortisolism normalization. Bone. 2024: 117109
• 56 Pedrazzoni M, Casola A, Verzicco I, Abbate B, Vescovini R, Sansoni P. Longitudinal changes of trabecular bone score after estrogen deprivation: effect of menopause and aromatase inhibition. J Endocrinol Invest 2014; 37: 871-874
• 57 Hong AR, Kim JH, Lee KH, Kim TY, Im SA, Kim TY. et al. Long-term effect of aromatase inhibitors on bone microarchitecture and macroarchitecture in non-osteoporotic postmenopausal women with breast cancer. Osteoporos Int 2017; 28: 1413-1422
• 58 Mariotti V, Page DB, Davydov O, Hans D, Hudis CA, Patil S. et al. Assessing fracture risk in early stage breast cancer patients treated with aromatase-inhibitors: An enhanced screening approach incorporating trabecular bone score. Journal of Bone Oncology 2017; 7: 32-37
• 59 Kim D, Cho SK, Kim JY, Choi YY, Sung YK. Association between trabecular bone score and risk factors for fractures in Korean female patients with rheumatoid arthritis. Mod Rheumatol 2016; 26: 540-545
• 60 Choi YJ, Chung YS, Suh CH, Jung JY, Kim HA. Trabecular bone score as a supplementary tool for the discrimination of osteoporotic fractures in postmenopausal women with rheumatoid arthritis. Medicine. 2017; 96: e8661
• 61 Kang KY, Kim IJ, Park SH, Hong YS. Associations between trabecular bone score and vertebral fractures in patients with axial spondyloarthritis. Rheumatology (Oxford) 2018; 57: 1033-1040
• 62 Lai EL, Huang WN, Chen HH, Chen JP, Chen DY, Hsieh TY. et al. Degraded microarchitecture by low trabecular bone score is associated with prevalent vertebral fractures in patients with systemic lupus erythematosus. Arch Osteoporos 2020; 15: 54
• 63 Richards C, Hans D, Leslie WD. Trabecular Bone Score (TBS) Predicts Fracture in Ankylosing Spondylitis: The Manitoba BMD Registry. Journal of Clinical Densitometry [Internet]. 2020 [cited 2020 Jan 22]; Available from http://www.sciencedirect.com/science/article/pii/S1094695019302185
• 64 Lee SH, Kim JS, Koh JM. The Fracture Risk Assessment Tool Probability and Trabecular Bone Score Mediate the Relationship between Sphingosine 1-phosphate Levels and Fracture Risk. J Bone Metab 2023; 30: 355-364
• 65 Killinger Z, Kužma M, Tomková S, Brázdilová K, Jackuliak P, Payer J. Prediction of Vertebral Fractures by Trabecular Bone Score in Patients With Ankylosing Spondylitis. Physiol Res 2021; 70: S53-S60
• 66 Shuhart C, Cheung A, Gill R, Gani L, Goel H, Szalat A. Executive Summary of the 2023 Adult Position Development Conference of the International Society for Clinical Densitometry: DXA Reporting, Follow-up BMD Testing and Trabecular Bone Score Application and Reporting. Journal of Clinical Densitometry. 2023: 101435
• 67 Kaya A, Ozgocmen S, Kamanli A, Ardicoglu O. Bone loss in ankylosing spondylitis: does syndesmophyte formation have an influence on bone density changes?. Med Princ Pract 2009; 18: 470-476
• 68 Grigorie D, Coles D, Sucaliuc A. Trabecular Bone Score (Tbs) Has A Poor Discriminative Power For Vertebral Fractures In 153 Romanian Patients With Primary Hyperparathyroidism. Acta Endocrinol (Buchar) 2018; 14: 208-212
• 69 Sakane EN, Camargo Vieira MC, Lazaretti-Castro M, Maeda SS. Predictors of Poor Bone Microarchitecture Assessed by Trabecular Bone Score (TBS) in Postsurgical Hypoparathyroidism. J Clin Endocrinol Metab. 2019
• 70 Jones AR, Simons K, Harvey S, Grill V. Bone Mineral Density Compared to Trabecular Bone Score in Primary Hyperparathyroidism. J Clin Med 2022; 11: 330
• 71 Saha S, Mannar V, Kandasamy D, Sreenivas V, Goswami R. Vertebral fractures, trabecular bone score and their determinants in chronic hypoparathyroidism. J Endocrinol Invest [Internet]. 2022; [cited 2022 Jun 6]; Available from
• 72 Vendrami C, Marques-Vidal P, Gonzalez Rodriguez E, Hans D, Waeber G, Lamy O. Thyroid-stimulating hormone is associated with trabecular bone score and 5-year incident fracture risk in euthyroid postmenopausal women: the OsteoLaus cohort. Osteoporos Int [Internet] 2021; [cited 2021 Dec 7]; Available from
• 73 Bisceglia N, Malagrinò M, Cantone C, Capra S, Piazza A, Vandi G. et al. Trabecular bone score as a possible new surgical recommendation in patients with asymptomatic primary hyperparathyroidism. J Endocrinol Invest. 2025
• 74 Ciullini L, Pennica A, Argento G, Novarini D, Teti E, Pugliese G. et al. Trabecular bone score (TBS) is associated with sub-clinical vertebral fractures in HIV-infected patients. J Bone Miner Metab 2018; 36: 111-118
• 75 Watanabe R, Tai N, Hirano J, Ban Y, Inoue D, Okazaki R. Independent association of bone mineral density and trabecular bone score to vertebral fracture in male subjects with chronic obstructive pulmonary disease. Osteoporos Int 2017; 29: 615-623
• 76 Kužma M, Vaňuga P, Ságová I, Pávai D, Jackuliak P, Killinger Z. et al. Non-invasive DXA-derived bone structure assessment of acromegaly patients: a cross-sectional study. Eur J Endocrinol 2019; 180: 201-211
• 77 Teawtrakul N, Chukanhom S, Charoensri S, Somboonporn C, Pongchaiyakul C. The Trabecular Bone Score as a Predictor for Thalassemia-Induced Vertebral Fractures in Northeastern Thailand. Anemia [Internet] 2020; [cited 2020 Aug 17] 2020: e4634709 Available from https://www.hindawi.com/journals/anemia/2020/4634709/
• 78 Ogiso Y, Hanai T, Nishimura K, Miwa T, Maeda T, Imai K. et al. Usefulness of the Trabecular Bone Score in Assessing the Risk of Vertebral Fractures in Patients with Cirrhosis. J Clin Med 2022; 11: 1562
• 79 Al-Hashimi L, Klotsche J, Ohrndorf S, Gaber T, Hoff P. Trabecular Bone Score Significantly Influences Treatment Decisions in Secondary Osteoporosis. Journal of Clinical Medicine. 2023; 12: 4147
• 80 Dufour R, Winzenrieth R, Heraud A, Hans D, Mehsen N. Generation and validation of a normative, age-specific reference curve for lumbar spine trabecular bone score (TBS) in French women. Osteoporos Int 2013; 24: 2837-2846
• 81 Krueger D, Libber J, Binkley N. Spine Trabecular Bone Score Precision, a Comparison Between GE Lunar Standard and High-Resolution Densitometers. J Clin Densitom 2015; 18: 226-232
• 82 Messina C, Piodi LP, Rinaudo L, Emili I, Porro F, Buonomenna C. et al. Bone strain index reproducibility and soft tissue thickness influence: a dual x-ray photon absorptiometry phantom study. Eur Radiol Exp 2019; 3: 33
• 83 Kang T, Park SY, Lee SH, Park JH, Suh SW. Comparison of Denosumab and Zoledronic Acid in Postmenopausal Women With Osteoporosis: Bone Mineral Density (BMD) and Trabecular Bone Score (TBS). Journal of Korean Medical Science [Internet] 2022; [cited 2022 Apr 12] 37 Available from
• 84 Guan W, Pan W, Yu W, Cao W, Lin Q, Zhang Z. et al. Long-term trabecular bone score and bone mineral density changes in Chinese antiretroviral-treated HIV-infected individuals. Arch Osteoporos 2021; 16: 41
• 85 Sandeep NV, Joseph A, Cherian KE, Kapoor N, Paul TV. Impact of teriparatide therapy in Indian postmenopausal women with osteoporosis with regard to DXA-derived parameters. Therapeutic Advances in. Endocrinology. 2022; 13 20420188221112903
• 86 Baron R, Ferrari S, Russell RGG. Denosumab and bisphosphonates: different mechanisms of action and effects. Bone. 2011; 48: 677-692
• 87 Di Gregorio S, Del Rio L, Rodriguez-Tolra J, Bonel E, Garcia M, Winzenrieth R. Comparison between different bone treatments on areal bone mineral density (aBMD) and bone microarchitectural texture as assessed by the trabecular bone score (TBS). Bone. 2015; 75: 138-143
• 88 Shin MS, Cho EH, Kim HY. Longitudinal Change in Trabecular Bone Score during and after Treatment of Osteoporosis in Postmenopausal Korean Women. J Bone Metab 2017; 24: 117-124
• 89 Sooragonda B, Cherian KE, Jebasingh FK, Dasgupta R, Asha HS, Kapoor N. et al. Longitudinal changes in bone mineral density and trabecular bone score following yearly zoledronic acid infusion in postmenopausal osteoporosis – a retrospective-prospective study from southern India. Arch Osteoporos 2019; 14: 79
• 90 Kim KY, Kim KM. Similarities and differences between bone quality parameters, trabecular bone score and femur geometry. PLOS ONE 2022; 17: e0260924
• 91 Hans D, McDermott M, Huang S, Kim M, Shevroja E, McClung M. Long-term Effect of Denosumab on Bone Microarchitecture as Assessed by Tissue Thickness-Adjusted Trabecular Bone Score (TBS) in Postmenopausal Women with Osteoporosis: Results from the Freedom and Open-Label Extension (OLE). Journal of Clinical Densitometry 2022; 25: 272
• 92 Hans D, McDermott M, Huang S, Kim M, Shevroja E, McClung M. Long-term effect of denosumab on bone microarchitecture as assessed by tissue thickness–adjusted trabecular bone score in postmenopausal women with osteoporosis: results from FREEDOM and its open-label extension. Osteoporos Int 2023; 34: 1075-1084
• 93 Bilezikian JP, Hattersley G, Fitzpatrick LA, Harris AG, Shevroja E, Banks K. et al. Abaloparatide-SC improves trabecular microarchitecture as assessed by trabecular bone score (TBS): a 24-week randomized clinical trial. Osteoporos Int 2017; 29: 323-328
• 94 Cosman F, Hans D, Shevroja E, Wang Y, Mitlak B. Effect of Abaloparatide on Bone Microarchitecture Assessed by Trabecular Bone Score in Women With Osteoporosis: Post Hoc Analysis of ACTIVE and ACTIVExtend. Journal of Bone and Mineral Research 2023; 38: 464-470
• 95 Jeong C, Kim J, Lim Y, Ha J, Kang MI, Baek KH. Effect of Romosozumab on Trabecular Bone Score Compared to Anti-Resorptive Agents in Postmenopausal Women with Osteoporosis. J Bone Metab 2021; 28: 317-323
• 96 Kusakabe T, Ishihara Y, Kitamura T, Yasoda A, Nanba K, Tsuiki M. et al. Beneficial effects of romosozumab on bone mineral density and trabecular bone score assessed by dual-energy X-ray absorptiometry in a family with osteogenesis imperfecta. Osteoporos Int. 2024
• 97 Ferrari S, Betah D, Feldman RG, Langdahl BL, Oates M, Timoshanko J. et al. Romosozumab Improves Tissue Thickness–Adjusted Trabecular Bone Score in Women With Osteoporosis and Diabetes. The Journal of Clinical Endocrinology & Metabolism. 2025: dgae862
• 98 Lee S, Hong N, Cho SJ, Shin S, Rhee Y. Effect of romosozumab on bone mineral density and trabecular bone score in premenopausal women with low bone mass. Osteoporos Int [Internet] 2025; [cited 2025 Jan 30]; Available from
• 99 McClung MR, Betah D, Leder BZ, Kendler DL, Oates M, Timoshanko J. et al. Romosozumab Improves Microarchitecture as Assessed by Tissue Thickness-Adjusted Trabecular Bone Score in Postmenopausal Women with Osteoporosis. J Bone Miner Res. 2024: zjae194
• 100 Curtis EM, Reginster JY, Al-Daghri N, Biver E, Brandi ML, Cavalier E. et al. Management of patients at very high risk of osteoporotic fractures through sequential treatments. Aging Clin Exp Res 2022; 34: 695-714
• 101 Tsai JN, Jiang LA, Lee H, Hans D, Leder BZ. Effects of Teriparatide, Denosumab, or Both on Spine Trabecular Microarchitecture in DATA-Switch: a Randomized Controlled Trial. J Clin Densitom 2017; 20: 507-512
• 102 Hayden AC, Binkley N, Krueger D, Bernatz JT, Kadri A, Anderson PA. Effect of degeneration on bone mineral density, trabecular bone score and CT Hounsfield unit measurements in a spine surgery patient population. Osteoporos Int [Internet] 2022; [cited 2022 Jun 6]; Available from
• 103 Leslie WD, Binkley N, Hans D. Effects of Lumbar Spine Vertebral Fractures on Trabecular Bone Score (TBS): The Manitoba BMD Registry. Journal of Clinical Densitometry 2024; 27: 101533
• 104 White R, Krueger D, De Guio F, Michelet F, Hans D, Anderson P. et al. An Exploratory Study of the Texture Research Investigational Platform (TRIP) to Evaluate Bone Texture Score of Distal Femur DXA Scans – A TBS-Based Approach. Journal of Clinical Densitometry 2021; 24: 112-117
• 105 Bernatz JT, Sandhu KP, Krueger D, Borchardt G, Knurr KA, Binkley NC. et al. Trabecular bone score predicts distal femur screw pull-out strength better than DXA bone mineral density, CT Hounsfield units, and cortical density. Osteoporos Int. 2025