BMD as assessed by DXA constitutes the gold standard for osteoporosis diagnosis. However, it does not take into account deterioration in bone micro-architecture. Trabecular Bone Score (TBS), a new grey-level texture measurement that can be extracted from the DXA image, correlates with 3D parameters of bone microarchitecture. Previous cross-sectional studies reported the ability of spine TBS to discriminate fractured women from age- and BMD-matched controls. The aim of our study was to prospectively evaluate the ability of lumbar spine TBS to predict osteoporotic fractures.22,234 women age 50 years and older at the time of baseline hip and spine DXA were identified in a database containing all clinical results for the Province of Manitoba, Canada. Health service records were assessed for the presence of non-trauma osteoporotic fracture codes subsequent to BMD testing. Lumbar spine TBS was derived by the Bone Disease Unit, University of Lausanne, for each spine DXA examination using anonymized files (blinded from clinical parameters and outcomes). We used Cox proportional hazard regression to model the hazard of first hip, spine or any osteoporotic fracture (hip, clinical spine, humerus, forearm). Age-adjusted HRs for fracture per SD decrease in TBS and/or BMD are reported. Incremental gain in prediction information when TBS was added to age and BMD was assessed using the log-likelihood ratio test.The mean age of the population was 65.0 ± 9.5 y and the numbers of fractures during mean 4.6 y of follow up were: all osteoporotic 946 (4.3%), hip 194 (0.9%) and clinical spine 297 (1.3%). Significantly lower spine BMD, total hip BMD and spine TBS parameters were found in fracture than non fracture women for all fracture definitions (all p<.0001). Correlation between spine BMD and spine TBS was modest (r=.32) and less than correlation between spine and hip BMD (r=.72), consistent with a skeletal parameter largely unrelated to BMD. Spine BMD and TBS predicted fractures equally well and independently. Total hip BMD was the best predictor of hip fracture but addition of spine TBS significantly improved hip fracture prediction.In conclusion, we have demonstrated that spine TBS predicts fractures (hip, clinical spine and all osteoporotic). Furthermore, TBS provided information that was independent of spine and hip BMD. Combining the TBS micro-architecture index with BMD from conventional DXA incrementally improved fracture prediction in postmenopausal women.