TBS (trabecular bone score) and diabetes-related fracture risk

J Clin Endocrinol Metab. 2013 Feb;98(2):602-9. doi: 10.1210/jc.2012-3118. Epub 2013 Jan 22.


Context: Type 2 diabetes is associated with increased fracture risk but paradoxically greater bone mineral density (BMD). Trabecular bone score (TBS) is derived from the texture of the spine dual x-ray absorptiometry (DXA) image and is related to bone microarchitecture and fracture risk, providing information independent of BMD.

Objective: This study evaluated the ability of lumbar spine TBS to account for increased fracture risk in diabetes.

Design and setting: We performed a retrospective cohort study using BMD results from a large clinical registry for the province of Manitoba, Canada.

Patients: We included 29,407 women 50 years old and older with baseline DXA examinations, among whom 2356 had diagnosed diabetes.

Main outcome measures: Lumbar spine TBS was derived for each spine DXA examination blinded to clinical parameters and outcomes. Health service records were assessed for incident nontraumatic major osteoporotic fractures (mean follow-up 4.7 years).

Results: Diabetes was associated with higher BMD at all sites but lower lumbar spine TBS in unadjusted and adjusted models (all P < .001). The adjusted odds ratio (aOR) for a measurement in the lowest vs the highest tertile was less than 1 for BMD (all P < .001) but was increased for lumbar spine TBS [aOR 2.61, 95% confidence interval (CI) 2.30-2.97]. Major osteoporotic fractures were identified in 175 women (7.4%) with and 1493 (5.5%) without diabetes (P < .001). Lumbar spine TBS was a BMD-independent predictor of fracture and predicted fractures in those with diabetes (adjusted hazard ratio 1.27, 95% CI 1.10-1.46) and without diabetes (hazard ratio 1.31, 95% CI 1.24-1.38). The effect of diabetes on fracture was reduced when lumbar spine TBS was added to a prediction model but was paradoxically increased from adding BMD measurements.

Conclusions: Lumbar spine TBS predicts osteoporotic fractures in those with diabetes, and captures a larger portion of the diabetes-associated fracture risk than BMD.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Bone Density*
  • Diabetes Mellitus, Type 2 / complications*
  • Diabetes Mellitus, Type 2 / diagnostic imaging
  • Female
  • Humans
  • Lumbar Vertebrae / diagnostic imaging*
  • Lumbar Vertebrae / injuries*
  • Middle Aged
  • Osteoporotic Fractures / diagnostic imaging
  • Osteoporotic Fractures / etiology*
  • Predictive Value of Tests
  • Radiography
  • Retrospective Studies
  • Risk
  • Spinal Fractures / diagnostic imaging
  • Spinal Fractures / etiology*