Case finding of osteoporosis according to the Dutch practice guidelines detects only a small group of patients. Only patients with severe risk factors for osteoporotic fractures are screened because the sensitivity of the case finding method is too low to screen moderate or low risk patients. The assessment of vertebral fractures will improve the prediction of the fracture risk. Including a spinal radiograph in the screening program is likely to be cost-ineffective because a vertebral deformity without low bone mineral density is at most only a moderate risk factor for future fractures. Extending the screening program with dual energy X-ray morphometry might be a good alternative regarding cost, effort and radiation dosage.