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PurposeThe aim of this study was to determine the effects of diagnostic discordance with or without a thoracolumbar spine lateral view X-ray in patients with osteoporosis.MethodsWe randomly enrolled 368 women over 65 years old (74.3 ± 6.0 years) from Tianliao Township in 2009 (response rate: 75.7%). A diagnosis of osteoporosis was confirmed using one of these criteria: (1) a history of non-traumatic fracture, (2) vertebral fractures based on a thoracolumbar spine lateral view X-ray, or (3) a bone mineral density T-score ≤ -2.5 for the total hip, the femoral neck, the lumbar spine, or all 3 sites. The prevalence of osteoporosis in three groups was compared based on Model I (criteria 1+2) vs. Model II (criteria 1+3) vs. Model III (criteria 1+2+3). The role of thoracolumbar X-ray reflected by the diagnostic discordance of osteoporosis between Models II and III was evaluated.ResultsThe overall prevalence of osteoporosis was 78.3% (Model III, age-standardized 78.1%). The diagnostic discordance was 17.4% in the 368 participants. A logistic regression model showed that age was negatively associated with diagnostic discordance (odds ratio [OR] = 0.93, 95% confidence interval [CI]: 0.88–0.98, p < 0.05), but body mass index was positively associated (OR = 1.07, 95% CI: 1.00–1.15, p < 0.05).ConclusionsA thoracolumbar spine lateral view X-ray should be added for women ≥ 65 years old or with a body mass index ≥ 25 kg/m2 to minimize the diagnostic discordance in osteoporosis, especially in highly endemic regions.