Osteoporosis has historically been defined as “a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.”1 Subsequently, use of dual-energy x-ray absorptiometry (DXA) to define osteoporosis based upon bone mineral density (BMD) T-score has become widely accepted. However, the majority of “osteoporosis-related” fractures occur in those with a BMD T-score better than –2.52,3 it is logical that the inability of DXA to identify poor bone structure contributes to this suboptimal ability to identify those who will fracture. To enhance the capability of DXA, trabecular bone score (TBS), a software program (TBS iNsight, Medimaps Group, Geneva, Switzerland), was developed. This software program is used to assess bone texture by evaluating gray scale variation in the lumbar spine DXA image. TBS is increasingly used to provide additional clinical insight as a surrogate measure of bone architecture. TBS has been extensively studied and enhances fracture prediction independent of BMD.4 Subsequently, TBS has been incorporated into an adjustment of the FRAX® tool outputs to modify fracture risk and, as such, may alter pharmacologic treatment initiation decisions by increasing, or decreasing, estimated 10-year fracture probability.5

Clinical use of TBS has been reviewed at prior ISCD Position Development Conferences (PDC) in 2015 and 2019.6,7 As a result, the ISCD Official Positions regarding TBS as of January 2023 are as follows:

TBS is associated with vertebral, hip and major osteoporotic fracture risk in postmenopausal women.

TBS is associated with hip fracture risk in men over the age of 50 years.

TBS is associated with major osteoporotic fracture risk in men over the age of 50 years.

TBS should not be used alone to determine treatment recommendations in clinical practice.

TBS can be used in association with FRAX and BMD to adjust FRAX-probability of fracture in postmenopausal women and older men.

In patients receiving anti-fracture therapy:

The role of TBS in monitoring anti-resorptive therapy is unclear.

TBS is potentially useful for monitoring anabolic therapy.

TBS is associated with major osteoporotic fracture risk in postmenopausal women with type 2 diabetes.

Given increasing clinical utilization and reimbursement for TBS, a 2023 ISCD Position Development Conference (PDC) task force was assembled to review the expanding data regarding TBS and to make recommendations to assist clinicians regarding when and how to perform, report and utilize TBS. The purpose of this report is to describe updated ISCD Official Positions regarding TBS developed at the 2023 PDC in Chicago, IL, March 28-29, 2023.