Opportunistic screening uses existing imaging studies for additional diagnostic insights without imposing further burden on patients. We explore the potential of opportunistic computed tomography (CT) screening for osteoporosis, a condition affecting 500 million people globally and leading to significant health care costs and fragility fractures. Although dual-energy X-ray absorptiometry (DXA) remains the gold standard for diagnosing osteoporosis, > 50% of fractures occur in individuals not screened previously with DXA. With recent advancements in technology, CT has emerged as the most promising tool for opportunistic screening due to its wide use and the ability to provide quantitative measurements of bone attenuation, a surrogate of bone mineral density. This article discusses the technical considerations, calibration methods, and potential benefits of CT for osteoporosis screening. It also explores the role of automation, supervised and unsupervised, in streamlining the diagnostic process, improving accuracy, and potentially developing new biomarkers of bone health. The potential addition of radiomics and genomics is also highlighted, showcasing the synergy between genetic and imaging data for a more comprehensive understanding of osteoporosis pathophysiology and with it possible novel osteoporosis therapies. The future of opportunistic CT screening holds significant promise, with automation and advanced image processing ultimately enhancing patient care, reducing rates of osteoporotic fractures, and improving patient outcomes.
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