Vertebral fractures are the hallmark of osteoporosis, and it has been shown that the presence of vertebral fractures adds to the risk of future osteoporotic fractures. Thus, the evaluation of spinal radiographs for prevalent or incident vertebral fractures is important in the clinical evaluation of patients with osteoporosis, in clinical drug trials for osteoporosis treatment and in the epidemiologic evaluation of populations at risk for osteoporosis. Traditionally, conventional lateral radiographs of the thoracolumbar spine have been analyzed visually by radiologists or experienced clinicians to identify vertebral fractures in patients with clinical indications. Epidemiologic studies or clinical drug trials in osteoporosis research have considerably different requirements and expectations. To reduce potential subjectivity in qualitative readings and to provide definable, reproducible and objective methods to detect vertebral fracture, and to accommodate the assessment of large numbers of radiographs, various morphometric approaches have been explored and employed. However, potential deficiencies in morphometry have led to a renewed interest in standardized qualitative visual approaches for defining vertebral fractures and visual criteria. Numerous studies have shown that semiquantitative interpretation, after careful centralized training and standardization, can produce results with excellent intra- and interobserver reproducibility. We firmly believe that the experience from several studies has shown that there is a major role for radiologists and clinicians alike to carefully assess and diagnose vertebral fractures using standardized grading schemes such as the one proposed in this review. In the context of epidemiologic studies and clinical drug trials, quantitative morphometry may be used; however, the studies would be flawed if quantitative morphometry were to be performed in isolation without additional adjudication by a trained and highly experienced radiologist or clinician.
