Clinical integration of trabecular bone score in precision osteoporosis care: a position statement by the Egyptian academy of bone and muscle health

Abstract Background Dual-energy X-ray absorptiometry (DXA)-derived bone mineral density (BMD) has long been the gold standard for osteoporosis diagnosis, yet its inability to account for bone quality leads to a significant “sensitivity gap” in fracture risk prediction. This position paper presents an up-to-date review of the evidence base, which informs the implementation of Trabecular Bone Score (TBS) in clinical practice. 2. This review explores the paradigm shift toward a dual Quantity + Quality model in bone health assessment, centred on the TBS. Methods Databases including PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library were queried using a combination of MeSH terms and keywords. The evolution of TBS from a basic texture index to an AI-driven spatial mapping tool (TBS-Reveal) was examined. Results The integration of TBS into the FRAX algorithm significantly improves the identification of high-risk individuals within the “osteopenic grey zone”. Furthermore, TBS provides critical diagnostic clarity in secondary osteoporosis, such as Type 2 Diabetes and Primary Hyperparathyroidism, where BMD often remains paradoxically high despite severe microarchitectural decay. Technical advancements, including direct soft tissue thickness correction and the renormalized L1-only model, have enhanced accuracy in complex patients with high BMI or degenerative spinal disease. Conclusion Trabecular Bone Score is no longer an optional research tool but a clinical necessity. By analyzing the variogram of the DXA image, TBS allows clinicians to see “the architecture of resilience” within the bone. Its seamless integration into the clinical workflow is essential for the delivery of proactive, personalized, and precision osteoporosis management.