Osteoporosis is a major cause of spinal insufficiency fractures but often remains underdiagnosed. Dual-energy CT (DECT) enables reliable assessment of bone mineral density (BMD), but its limited accessibility highlights the need for alternative metrics. This study investigates the association between vertebral fracture status, DECT-derived BMD and alternative bone quality assessments, including Hounsfield Unit (HU)-based assessment and cortical thickness ratio.