Although dual-energy X-ray absorptiometry (DXA) is regarded as the gold-standard technique for diagnosing osteoporosis, bone mineral density (BMD) alone by DXA is not sufficient for bone strength assessment. Trabecular bone score (TBS) is a texture analysis parameter that evaluates pixel gray-level variations in DXA images of the lumbar spine and allows to assess bone microarchitectural status that is one of the determinants of bone strength. Recent clinical evidences show that TBS is associated with fracture risk in primary and secondary osteoporosis, has a complementary role to lumbar spine BMD and responds to osteoporosis medications somewhat differently than BMD. Thus TBS has the potential to become a valuable clinical tool in the diagnosis of osteoporosis and in fracture risk assessment.