Diagnostic accuracy of MRI-Based vertebral bone quality score for detecting low bone mass and osteoporosis: A systematic review and meta-analysis.

INTRODUCTION Dual-energy X-ray absorptiometry (DXA) is the reference standard for osteoporosis diagnosis, but access remains limited in many settings. MRI-based vertebral bone quality (VBQ) has emerged as an opportunistic screening tool derived from routine lumbar imaging; however, its diagnostic performance is uncertain.

Methods

A PRISMA-DTA-compliant systematic review and meta-analysis (PROSPERO CRD420251264768) was conducted across five databases (2020-December 2025). Studies evaluating lumbar VBQ against DXA were included. Pooled sensitivity, specificity, likelihood ratios, and hierarchical summary ROC curves were estimated using a bivariate random-effects model for two contrasts: (1) normal vs. low bone mass and (2) non-osteoporosis vs. osteoporosis.

Results

Thirty-six studies (6521 participants) were included. For detecting low bone mass, pooled sensitivity was 72% and specificity 67% (AUC 0.75). For diagnosing osteoporosis, sensitivity was 67% and specificity 75% (AUC 0.77). Likelihood ratios were modest (LR+ 2.19-2.73; LR- 0.42-0.43), indicating limited rule-in and rule-out capability. Substantial heterogeneity (I2 98-99%) and publication bias were observed. Test performance varied with disease prevalence and sex distribution.

Conclusion

VBQ demonstrated only moderate diagnostic accuracy, with substantial heterogeneity and modest likelihood ratios limiting its rule-in and rule-out capability. Accordingly, it is best suited for opportunistic case-finding rather than definitive diagnosis. IMPLICATIONS FOR PRACTICE VBQ is best used for opportunistic case-finding during routine lumbar MRI. Elevated VBQ values should prompt confirmatory DXA rather than guide treatment decisions independently. Incorporating VBQ into routine reporting may improve early identification of at-risk patients, particularly when lumbar MRI has already been performed for another clinical indication.