The assessment of vertebral fracture by conventional radiography has been refined and improved using either semiquantitative or quantitative criteria. The inter- and intraobserver variability was determined for a semiquantitative visual approach that we routinely use in clinical studies for assessing prevalent and incident vertebral fractures. In addition, the semiquantitative approach was compared with a quantitative morpho-metric approach. The incidence and prevalence of vertebral fractures were determined in 57 postmenopausal women (age 65–75 years) by three independent observers. The radiographic basis for fracture definitions and the source of interpretative errors are illustrated. The results show excellent intraobserver agreement and good interobserver agreement for the semiquantitative technique. We conclude that the semiquantitative approach can be applied reliably in vertebral fracture assessment when performed using well-defined criteria.