Results suggest that T1-VBQFAT may serve as a potential adjunct for predicting PSL in patients with LSS, and HU values and several modified VBQ scores showed numerically higher AUCs without statistical significance.
Abstract
Rationale
AND
Objectives
Evaluating and Comparing the Predictive Ability of computed tomography (CT)-based Hounsfield units (HU), Magnetic resonance imaging (MRI)-based vertebral bone quality score (VBQ) and modified VBQ scores for pedicle screw loosening (PSL) in patients with lumbar degenerative diseases.
Materials And Methods
Retrospective study of patients undergoing transforaminal lumbar interbody fusion (TLIF) for degenerative diseases (Dec 2019 - Jan 2021). Screw loosening was assessed using 12-month postoperative lumbar radiographs and defined by a ≥1 mm radiolucent halo surrounding the screw. Various VBQ scores and HU value were measured using preoperative MRI and CT, respectively. Predictive performance was evaluated using receiver operating characteristic (ROC) curve analysis.
Results
Among all patients (n = 185), several modified VBQ scores showed higher areas under the curve (AUCs) than the VBQ score (0.776, 95% CI: 0.701-0.851) and CT HU value (0.770, 95% CI: 0.684-0.857), without statistical significance (PAUC>0.05). No significant differences were observed in lumbar disc herniation (LDH) or spondylolisthesis (LS) subgroups. In lumbar spinal stenosis (LSS) patients, the AUC of T1-VBQFAT (0.876, 95% CI: 0.788-0.965) was significantly higher than that of CT HU value (0.718, 95% CI: 0.583-0.852) (PAUC=0.040).
Conclusion
In the overall cohort and other subgroups, HU values and several modified VBQ scores showed numerically higher AUCs without statistical significance (PAUC>0.05). In the LSS subgroup, T1-VBQFAT demonstrated superior predictive performance compared with HU values (PAUC=0.040); notably, this finding did not remain statistically significant after correction for multiple comparisons (PAUC>0.0026). These exploratory results suggest that T1-VBQFAT may serve as a potential adjunct for predicting PSL in patients with LSS.
Endplate HU values indicated a relatively higher predictive performance for CS compared with EBQ scores and served as the most discriminative BMD indicator in patients who underwent PLIF.
Peng Du, Minghui Liang, Ruiyuan Chen et al.· Journal of Neurosurgery : Sp...· 0 citations
Radiographic pedicle screw loosening (PSL) remains a frequent postoperative finding and potential marker of screw-bone interface compromise after degenerative lumbar fusion, yet preoperative risk stratification remains inconsistent. This systematic review and meta-analysis aims to compare the association and discriminative performance of preoperative imaging-derived bone quality and paraspinal muscle metrics for predicting radiographic PSL after degenerative lumbar fusion.
PubMed, Embase, and CENTRAL were searched until January 2026. Observational studies reporting radiographic PSL and evaluating preoperative imaging-based bone or muscle metrics were included. Bone metrics comprised CT-derived Hounsfield units (HU), CT-derived bone mineral density (CT-BMD), MRI-based vertebral bone quality (VBQ), and DEXA T-scores. Muscle measures included psoas and posterior paraspinal cross-sectional area (CSA) and composition. Radiographic PSL definitions and adjudication modalities (plain radiograph versus CT) varied across included studies and were considered explicitly during synthesis and interpretation. Continuous outcomes were synthesized using random-effects inverse-variance models. Diagnostic accuracy was evaluated using bivariate (Reitsma) generalized linear mixed models, with summary receiver operating characteristic (SROC)-derived area under the curve (AUC) used to quantify discrimination. Risk of bias was assessed using QUADAS-2.
Twenty-nine studies (4711 patients; 25.4% PSL) were included. Patients with PSL demonstrated poorer preoperative bone quality across modalities, including lower HU (MD -24.7;
P
< 0.01), lower CT-BMD (MD -28.05;
P
< 0.05), lower DEXA T-scores (MD -0.18;
P
< 0.01), higher VBQ (MD 0.46;
P
< 0.01). Diagnostic discrimination was moderate and comparable across metrics (SROC-derived pooled AUC 0.71–0.76; meta-regression
P
= 0.08), although pooled estimates reflect a composite radiographic endpoint with heterogeneous adjudication conventions rather than a single uniform reference standard. Among muscle measures, reduced psoas CSA showed consistent association with PSL, whereas posterior paraspinal metrics were heterogeneous and largely non-significant. Nomogram analyses demonstrated clinically meaningful risk reclassification but limited rule-in and rule-out capacity.
Imaging-derived bone quality metrics identify substrate-level vulnerability to radiographic PSL and provide moderate preoperative discrimination. Because pooled discrimination reflects a composite radiographic endpoint rather than a uniform reference standard, these metrics are moderate risk stratifiers for radiographic PSL, not validated stand-alone tests for clinically meaningful construct failure. Limited and heterogeneous evidence suggests psoas size may represent a complementary frailty marker. Prospective validation and standardized thresholds are required.
Shaan Patel, S. Nischal, Lorenzo Ceccon et al.· Acta Neurochirurgica· 0 citations
Among lipid parameters evaluated, only high-density lipoprotein cholesterol (HDLC) was positively associated with VBQ scores; however, this weak association did not significantly compromise the diagnostic performance of VBQ for osteoporosis.
Fangke Hu, Da-Peng Yu, Penghe Li et al.· Asian Spine Journal· 0 citations
In patients undergoing cervical spine surgery, C-VBQ demonstrates consistent associations with C-HU and DXA T-scores, supporting its potential for opportunistic preoperative bone quality assessment and Integrating radiological indicators such as C-VBQ and C-HU with DXA and BTMs may enable a more comprehensive, but still cautiously interpreted, perioperative bone health evaluation.
Xiaoteng Feng, Xiu-Jia Xia, Ze-Lin Shen et al.· European spine journal· 0 citations
BACKGROUND
Hounsfield Units (HU) derived from CT scans are a promising bone mineral density surrogate in pediatrics, yet their reliability in patients with scoliosis and significant lumbar tilt remains unknown. We investigated the reliability of HU measurements in adolescent idiopathic scoliosis (AIS), particularly addressing the impact of spinal tilt.
METHODS
We retrospectively reviewed lumbar CT images of 11- to 19-year-old AIS patients who underwent posterior spinal fusion (July 2007-March 2024). HU values and lumbar tilt were measured at L1, L3, and L5. Reliability was assessed using intra-rater (N = 36), inter-rater (N = 30), and equivalence datasets (N = 62) comparing standard pelvis-parallel images versus images reconstructed parallel to the vertebral body.
RESULTS
Both intra-rater (ICC(1,1) > 0.95) and inter-rater (ICC(2,1) > 0.80) reliability were excellent. Measurements from standard pelvis-parallel images and reconstructed images showed stable overall equivalence (ICC(3,1) = 0.96). However, the percentage of cases with an HU value difference of 20 or more was 11.3% when the lumbar tilt angle was 10 degrees or greater, compared to 5.6% when the tilt angle was below 9 degrees.
CONCLUSION
Our analyses for AIS patients showed that vertebral HU measurements are reliable when using vertebral-parallel reconstructed images but standard pelvis-parallel images lose reliability with significant tilt. While our findings do not promote routine CT usage, our validated methodology provides a baseline technique that could potentially be applied to complex, high-risk cases where osteoporosis is prevalent and critical for surgical planning.
Kosei Nagata, K. Nakajima, Hiroyuki Nakarai et al.· Spine Deformity· 0 citations
Both HU and VBQ offer useful assessments of vertebral bone quality, but HU provides higher and more stable diagnostic accuracy, demonstrating higher sensitivity, specificity, and accuracy for detecting osteopenia and osteoporosis.
Omar Lubbad, Akram Hagos, Laila Lubbad et al.· European Radiology· 0 citations
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