Background: Osteoporosis is the most common metabolic bone disease with a high prevalence in the elderly population. The diagnosis is straightforward when a fragility fracture at major skeletal sites (hip, vertebrae, humerus, distal radius) occurs. However, the diagnosis may be challenging in the absence of fractures or when, even with a fracture (morphometric vertebral), no symptoms are reported by the patient. Summary: In recent years, there has been a huge advancement in diagnostic imaging modalities with particular interest in measuring skeletal resistance. Each technique has inherent advantages and disadvantages. In this narrative review, we discuss all diagnostic modalities from bone mineral density to more sophisticated techniques. Key Messages: It is hoped that a greater utilization of opportunistic CT will increase patient screening with consequent advantages for patient care and future fraction prevention.

1.
Cooper
C
,
Cole
ZA
,
Holroyd
CR
,
Earl
SC
,
Harvey
NC
,
Dennison
EM
, et al
.
Secular trends in the incidence of hip and other osteoporotic fractures
.
Osteoporos Int
.
2011
;
22
(
5
):
1277
88
.
2.
Nuti
R
,
Brandi
ML
,
Checchia
G
,
Di Munno
O
,
Dominguez
L
,
Falaschi
P
, et al
.
Guidelines for the management of osteoporosis and fragility fractures
.
Intern Emerg Med
.
2019
;
14
(
1
):
85
102
.
3.
Minisola
S
,
Cipriani
C
,
Colangelo
L
,
Pepe
J
.
At the intersection between skeletal and hematopoietic systems: incorporating hemoglobin in FRAX®
.
J Clin Endocrinol Metab
.
2024
;
109
(
2
):
e856
7
.
4.
Minisola
S
,
Cipriani
C
,
Colangelo
L
,
Pepe
J
.
Bone loss after discontinuation of denosumab: the devil is in the details
.
J Bone Miner Res
.
2024
;
39
(
1
):
3
7
.
5.
Link
TM
.
Osteoporosis imaging: state of the art and advanced imaging
.
Radiology
.
2012
;
263
(
1
):
3
17
.
6.
Slart
R
,
Punda
M
,
Ali
DS
,
Bazzocchi
A
,
Bock
O
,
Camacho
P
, et al
.
Updated practice guideline for dual-energy X-ray absorptiometry (DXA)
.
Eur J Nucl Med Mol Imaging
.
2025
;
52
(
2
):
539
63
.
7.
Engelke
K
,
Glüer
CC
.
Quality and performance measures in bone densitometry: part 1 – errors and diagnosis
.
Osteoporos Int
.
2006
;
17
(
9
):
1283
92
.
8.
Schousboe
JT
,
Shepherd
JA
,
Bilezikian
JP
,
Baim
S
.
Executive summary of the 2013 International Society for Clinical Densitometry Position Development Conference on bone densitometry
.
J Clin Densitom
.
2013
;
16
(
4
):
455
66
.
9.
Biamonte
F
,
Pepe
J
,
Colangelo
L
,
Desideri
G
,
Ettorre
E
,
Nieddu
L
, et al
.
Assessment of trabecular bone score (TBS) in the prediction of vertebral fracture in postmenopausal osteoporosis
.
Bone
.
2025
;
190
:
117307
.
10.
Genant
HK
,
Wu
CY
,
van Kuijk
C
,
Nevitt
MC
.
Vertebral fracture assessment using a semiquantitative technique
.
J Bone Miner Res
.
1993
;
8
(
9
):
1137
48
.
11.
Wáng
YXJ
,
Diacinti
D
,
Aparisi Gómez
MP
,
Santiago
FR
,
Becce
F
,
Tagliafico
AS
, et al
.
Radiological diagnosis of prevalent osteoporotic vertebral fracture on radiographs: an interim consensus from a group of experts of the ESSR osteoporosis and metabolism subcommittee
.
Skeletal Radiol
.
2024
;
53
(
12
):
2563
74
.
12.
Wang
L
,
Liu
Y
,
Li
K
,
Zhang
W
,
Yuan
Y
,
Ma
K
, et al
.
Age and BMI have different effects on subcutaneous, visceral, liver, bone marrow, and muscle adiposity, as measured by CT and MRI
.
Obesity
.
2024
;
32
(
7
):
1339
48
.
13.
Engelke
K
,
Chaudry
O
,
Bartenschlager
S
.
Opportunistic screening techniques for analysis of CT scans
.
Curr Osteoporos Rep
.
2023
;
21
(
1
):
65
76
.
14.
Wang
L
,
Museyko
O
,
Su
Y
,
Brown
K
,
Yang
R
,
Zhang
Y
, et al
.
QCT of the femur: comparison between QCTPro CTXA and MIAF femur
.
Bone
.
2019
;
120
:
262
70
.
15.
Bartenschlager
S
,
Cavallaro
A
,
Pogarell
T
,
Chaudry
O
,
Uder
M
,
Khosla
S
, et al
.
Opportunistic screening with CT: comparison of phantomless BMD calibration methods
.
J Bone Miner Res
.
2023
;
38
(
11
):
1689
99
.
16.
Wang
L
,
Ran
L
,
Zha
X
,
Zhao
K
,
Yang
Y
,
Shuang
Q
, et al
.
Adjustment of DXA BMD measurements for anthropometric factors and its impact on the diagnosis of osteoporosis
.
Arch Osteoporos
.
2020
;
15
(
1
):
155
.
17.
Pompe
E
,
Willemink
MJ
,
Dijkhuis
GR
,
Verhaar
HJJ
,
Mohamed Hoesein
FAA
,
de Jong
PA
.
Intravenous contrast injection significantly affects bone mineral density measured on CT
.
Eur Radiol
.
2015
;
25
(
2
):
283
9
.
18.
Kutleša
Z
,
Jerković
K
,
Ordulj
I
,
Budimir Mršić
D
.
The effect of contrast media on CT measures of bone mineral density: a systematic review
.
Skeletal Radiol
.
2022
;
52
(
4
):
687
94
.
19.
Leonhardt
Y
,
Gassert
FT
,
Feuerriegel
G
,
Gassert
FG
,
Kronthaler
S
,
Boehm
C
, et al
.
Vertebral bone marrow T2* mapping using chemical shift encoding-based water-fat separation in the quantitative analysis of lumbar osteoporosis and osteoporotic fractures
.
Quant Imaging Med Surg
.
2021
;
11
(
8
):
3715
25
.
20.
Jacobson
AM
,
Zhao
X
,
Sommer
S
,
Sadik
F
,
Warden
SJ
,
Newman
C
, et al
.
A comprehensive set of ultrashort echo time magnetic resonance imaging biomarkers to assess cortical bone health: a feasibility study at clinical field strength
.
Bone
.
2024
;
181
:
117031
.
21.
Azari
F
,
Uniyal
P
,
Soete
J
,
Coudyzer
W
,
Wyers
CE
,
Quintiens
J
, et al
.
Accuracy of photon-counting computed tomography for the measurement of bone quality in the knee
.
Bone
.
2024
;
181
:
117027
.
22.
Zhang
L
,
Wang
L
,
Fu
R
,
Wang
J
,
Yang
D
,
Liu
Y
, et al
.
In vivo assessment of age- and loading configuration-related changes in multiscale mechanical behavior of the human proximal femur using MRI-based finite element analysis
.
J Magn Reson Imaging
.
2021
;
53
(
3
):
905
12
.
23.
Schileo
E
,
Taddei
F
.
Finite element assessment of bone fragility from clinical images
.
Curr Osteoporos Rep
.
2021
;
19
(
6
):
688
98
.
24.
Mallio
CA
,
Volterrani
C
,
Bernetti
C
,
Stiffi
M
,
Greco
F
,
Beomonte Zobel
B
.
Exploring the interplay between paraspinal muscular status and bone health in osteoporosis and fracture risk: a comprehensive literature review on computed tomography (CT) and magnetic resonance imaging (MRI) studies
.
Quant Imaging Med Surg
.
2024
;
14
(
6
):
4189
201
.
25.
Jerban
S
,
Chang
DG
,
Ma
Y
,
Jang
H
,
Chang
EY
,
Du
J
.
An update in qualitative imaging of bone using ultrashort echo time magnetic resonance
.
Front Endocrinol
.
2020
;
11
:
555756
.
26.
Pu
X
,
Liu
B
,
Wang
D
,
Xiao
W
,
Liu
C
,
Gu
S
, et al
.
Opportunistic use of lumbar computed tomography and magnetic resonance imaging for osteoporosis screening
.
Osteoporos Int
.
2024
;
35
(
9
):
1625
31
.
27.
Din
RU
,
Wang
L
,
Cheng
X
,
Yang
H
.
Assessment of osteoporosis and vertebral fractures with T1- and T2-weighted MRI scans
.
Arch Osteoporos
.
2025
;
20
(
1
):
32
.
28.
Din
RU
,
Nishtar
T
,
Cheng
X
,
Yang
H
.
Magnetic resonance imaging phantom-based S1 vertebral scores are indicators of fat–water-like osteoporotic changes in postmenopausal women: a pilot study
.
Asian Spine J
.
2024
;
18
(
4
):
560
9
.
29.
Yasaka
K
,
Akai
H
,
Kunimatsu
A
,
Kiryu
S
,
Abe
O
.
Prediction of bone mineral density from computed tomography: application of deep learning with a convolutional neural network
.
Eur Radiol
.
2020
;
30
(
6
):
3549
57
.
30.
Pan
Y
,
Shi
D
,
Wang
H
,
Chen
T
,
Cui
D
,
Cheng
X
, et al
.
Automatic opportunistic osteoporosis screening using low-dose chest computed tomography scans obtained for lung cancer screening
.
Eur Radiol
.
2020
;
30
(
7
):
4107
16
.
31.
Wang
L
,
Yang
M
,
Ge
Y
,
Liu
Y
,
Su
Y
,
Guo
Z
, et al
.
Muscle size and density are independently associated with death after hip fracture: a prospective cohort study
.
J Cachexia Sarcopenia Muscle
.
2023
;
14
(
4
):
1824
35
.
32.
Wang
L
,
Yang
M
,
Ge
Y
,
Liu
Y
,
Wang
G
,
Su
Y
, et al
.
Risk prediction of second hip fracture by bone and muscle density of the hip varies with time after first hip fracture: a prospective cohort study
.
Bone Rep
.
2024
;
20
:
101732
.
33.
Yang
YY
,
Deng
YH
,
Sun
LH
,
Rejnmark
L
,
Wang
L
,
Pietschmann
P
, et al
.
Hypoparathyroidism: similarities and differences between western and eastern countries
.
Osteoporos Int
.
2025
;
36
(
3
):
391
402
.
34.
Turner
DA
,
Khioe
RFS
,
Shepstone
L
,
Lenaghan
E
,
Cooper
C
,
Gittoes
N
, et al
.
The cost-effectiveness of screening in the community to reduce osteoporotic fractures in older women in the UK: economic evaluation of the SCOOP study
.
J Bone Miner Res
.
2018
;
33
(
5
):
845
51
.
35.
Vadera
S
,
Osborne
T
,
Shah
V
,
Stephenson
JA
.
Opportunistic screening for osteoporosis by abdominal CT in a British population
.
Insights Imaging
.
2023
;
14
(
1
):
57
.
36.
Yang
G
,
Wang
H
,
Wu
Z
,
Shi
Y
,
Zhao
Y
.
Prediction of osteoporosis and osteopenia by routine computed tomography of the lumbar spine in different regions of interest
.
J Orthop Surg Res
.
2022
;
17
(
1
):
454
.
37.
Jang
S
,
Graffy
PM
,
Ziemlewicz
TJ
,
Lee
SJ
,
Summers
RM
,
Pickhardt
PJ
.
Opportunistic osteoporosis screening at routine abdominal and thoracic CT: normative L1 trabecular attenuation values in more than 20 000 adults
.
Radiology
.
2019
;
291
(
2
):
360
7
.
38.
Cheng
X
,
Zhao
K
,
Zha
X
,
Du
X
,
Li
Y
,
Chen
S
, et al
.
Opportunistic screening using low-dose CT and the prevalence of osteoporosis in China: a nationwide, multicenter study
.
J Bone Miner Res
.
2021
;
36
(
3
):
427
35
.
39.
Rühling
S
,
Navarro
F
,
Sekuboyina
A
,
El Husseini
M
,
Baum
T
,
Menze
B
, et al
.
Automated detection of the contrast phase in MDCT by an artificial neural network improves the accuracy of opportunistic bone mineral density measurements
.
Eur Radiol
.
2021
;
32
(
3
):
1465
74
.
40.
Rühling
S
,
Schwarting
J
,
Froelich
MF
,
Löffler
MT
,
Bodden
J
,
Hernandez Petzsche
MR
, et al
.
Cost-effectiveness of opportunistic QCT-based osteoporosis screening for the prediction of incident vertebral fractures
.
Front Endocrinol
.
2023
;
14
:
1222041
.
41.
Pickhardt
PJ
,
Correale
L
,
Hassan
C
.
AI-based opportunistic CT screening of incidental cardiovascular disease, osteoporosis, and sarcopenia: cost-effectiveness analysis
.
Abdom Radiol
.
2023
;
48
(
3
):
1181
98
.
42.
Ye
C
,
Guo
Y
,
Zheng
Y
,
Wu
Z
,
Chen
K
,
Zhang
X
, et al
.
Distal radial cortical bone thickness correlates with bone mineral density and can predict osteoporosis: a cohort study
.
Injury
.
2020
;
51
(
11
):
2617
21
.
43.
Wang
S
,
Tong
X
,
Cheng
Q
,
Xiao
Q
,
Cui
J
,
Li
J
, et al
.
Fully automated deep learning system for osteoporosis screening using chest computed tomography images
.
Quant Imaging Med Surg
.
2024
;
14
(
4
):
2816
27
.
44.
Agostini
A
,
Borgheresi
A
,
Mari
A
,
Floridi
C
,
Bruno
F
,
Carotti
M
, et al
.
Dual-energy CT: theoretical principles and clinical applications
.
Radiol Med
.
2019
;
124
(
12
):
1281
95
.
45.
Gruenewald
LD
,
Koch
V
,
Martin
SS
,
Yel
I
,
Eichler
K
,
Gruber-Rouh
T
, et al
.
Diagnostic accuracy of quantitative dual-energy CT-based volumetric bone mineral density assessment for the prediction of osteoporosis-associated fractures
.
Eur Radiol
.
2022
;
32
(
5
):
3076
84
.
46.
Willemink
MJ
,
Persson
M
,
Pourmorteza
A
,
Pelc
NJ
,
Fleischmann
D
.
Photon-counting CT: technical principles and clinical prospects
.
Radiology
.
2018
;
289
(
2
):
293
312
.
47.
Leng
S
,
Zhou
W
,
Yu
Z
,
Halaweish
A
,
Krauss
B
,
Schmidt
B
, et al
.
Spectral performance of a whole-body research photon counting detector CT: quantitative accuracy in derived image sets
.
Phys Med Biol
.
2017
;
62
(
17
):
7216
32
.
48.
Flohr
T
,
Petersilka
M
,
Henning
A
,
Ulzheimer
S
,
Ferda
J
,
Schmidt
B
.
Photon-counting CT review
.
Phys Med
.
2020
;
79
:
126
36
.
49.
Martini
ML
,
Mikula
AL
,
Lakomkin
N
,
Pennington
Z
,
Everson
MC
,
Hamouda
AM
, et al
.
Opportunistic CT-based Hounsfield units strongly correlate with biomechanical CT measurements in the thoracolumbar spine
.
Spine
.
2024
;
49
(
14
):
1021
8
.
50.
Händel
MN
,
Cardoso
I
,
von Bülow
C
,
Rohde
JF
,
Ussing
A
,
Nielsen
SM
, et al
.
Fracture risk reduction and safety by osteoporosis treatment compared with placebo or active comparator in postmenopausal women: systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials
.
BMJ
.
2023
:
381
:
e068033
.
You do not currently have access to this content.