In people with acromegaly, higher IGF‑1 levels were linked to more vertebral fractures, and a special CT scan (QCT) was better at spotting weak bones than the usual DXA scan. This suggests that too much IGF‑1 can hurt bone health, and standard bone density tests might miss the problem.

To investigate the prevalence and risk factors of vertebral fractures (VFs) and to compare bone mineral density (BMD) assessments by dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) in patients with acromegaly. This cross-sectional study included 149 patients with acromegaly. Clinical, biochemical, and imaging data were collected, and logistic regression analyses were performed to identify VF risk factors. VFs were detected in 39.6% of patients and were associated with older age, longer disease duration, higher body mass index(BMI), elevated IGF-1 levels, and lower serum phosphorus. QCT-derived volumetric BMD (vBMD) was significantly lower in patients with VFs, whereas DXA-based lumbar areal BMD (aBMD) did not differ between groups. Elevated IGF-1 (%ULN) and reduced vBMD were identified as independent risk factors for VFs. Vertebral fractures are common in acromegaly. In one of the largest Chinese acromegaly cohorts to date, QCT demonstrated superior discrimination of VF risk compared with DXA, supporting its potential complementary role in skeletal fragility assessment in acromegaly.