Objective Existing evidence indicates that MRI-based vertebral bone quality (VBQ) provides a tool for primary screening of bone density. However, the diagnostic accuracy of this tool is not well understood. The study aims to investigate whether metabolic symptom (MetS) affects the accuracy of VBQ in determining bone mineral density (BMD) in patients undergoing lumbar fusion surgery. Methods In this retrospective study, patients with preoperative non-contrast T1-weighted MRI were included. Patients' demographics and medical profiles were identified and analyzed. Patients were separated into two groups according the presence of MetS. Pearson correlation analysis and linear regression were used to analyze the correlation between VBQ and the BMD in different groups. Receiver operating characteristic (ROC) analysis to calculate the area under the curve (AUC) was used to assess diagnostic efficacy. Results A total of 536 patients (241 female and 295 male patients) with a mean age of 66.5 +/- 5.1 years were included in the final analysis. Sufficient intra- and interobserver reliability were determined for VBQ measures (>= 0.8). Patients with MetS have higher lumbar BMD T-score and MetS increases the MRI-based VBQ score in patients with normal BMD. However, patients with MetS present higher proportion of history of fragility fracture. The correlation coefficient between VBQ and the lumbar BMD was - 0.42 for patients with MetS and - 0.54 for patients without MetS. VBQ demonstrated statistically significant differences among patients across the two subgroups (p < 0.001). The ROC analysis revealed indicated that there was significant better diagnostic accuracy in determining osteoporosis based on VBQ in patients without MetS than patients with MetS (AUC 0.84 vs. 0.63, p = 0.011). Conclusions In the study, we found better performance among patients without MetS and the correlation between VBQ and BMD was stronger in patients without MetS. Interestingly, although higher lumbar T-score, there was significant more patients with a history of fragility fracture in patients with MetS.