COPD, although primarily a disease of the lungs, is associated with extra pulmonary effects such as muscle weakness and osteoporosis. Fractures due to osteoporosis cause significant morbidity and mortality, particularly in patients with COPD. To prevent osteoporotic fractures, it is important to diagnose osteoporosis in an early stage and to start anti-osteoporotic therapy in at risk patients. Because routine chest Computed Tomography (CT) is increasingly used to assess the extent of emphysema and airways disease in patients with COPD, we investigated whether simple attenuation measurement of the thoracic spine on routine chest CT may provide useful information on bone health in patients with COPD. Fifty-eight patients with moderate to very severe COPD were included in our study. The average attenuation of thoracic vertebrae 4, 7 and 10 on chest CT was correlated with the lowest bone mineral density (BMD) of the hip and lumbar spine (L1 to L4) on dual-energy X-ray absorptiometry (DXA) in patients with COPD. The inter and intra-observer variabilities of the attenuation measurements were low as shown by Bland Altman plots. Pearson’s correlation coefficient between the average attenuation of the three thoracic vertebrae and the lowest BMD of the hip and lumbar spine was high (r = 0.827, p < 0.001). A ROC analysis of the area under the curve for osteoporosis was 0.969 (p < 0.001) corresponding to an attenuation threshold of 147 HU. In conclusion, our data demonstrated that bone attenuation measured on routine chest CT correlated strongly with BMD assessed on DXA in patients with COPD. Routine chest CT may provide useful information on bone health in patients with COPD. (c) 2012 American Society for Bone and Mineral Research.