Beyond Bone Density Alone: Opportunistic Identification of Vertebral Compression Fractures in Breast Cancer Survivors Using Artificial Intelligence-Derived Vertebral Bone Density and Paraspinal Muscle–Fat Metrics
Aug 2026· Journal of Clinical Medicine· 0 citations· 33 references
Abstract
Background/Objectives: This study aimed to evaluate whether artificial intelligence-derived vertebral volumetric bone mineral density (AI-vBMD) and paraspinal intermuscular adipose tissue (IMAT) ratio from routine computed tomography (CT) could identify moderate-to-severe vertebral compression fractures (VCFs) in breast cancer survivors, and whether paraspinal IMAT ratio and routinely available clinical variables improved diagnostic performance. Methods: This retrospective study included 275 women with breast cancer who underwent routine non-contrast CT and lumbar quantitative computed tomography (QCT). Hounsfield unit-derived volumetric bone mineral density (HU-vBMD) was derived using a QCT-referenced HU-to-vBMD conversion equation, whereas AI-vBMD and paraspinal IMAT ratio were extracted using automated software. Moderate-to-severe VCF was defined as Genant grade ≥ 2. Agreement with QCT-vBMD was assessed using correlation, intraclass correlation coefficient (ICC), and Bland–Altman analysis. Model discrimination was evaluated using receiver operating characteristic analysis and DeLong tests. Results: Moderate-to-severe VCF was present in 75 patients (27.3%). HU-vBMD and AI-vBMD showed excellent agreement with QCT-vBMD (ICC, 0.978 and 0.987, respectively). AI-vBMD outperformed HU-vBMD for identifying VCFs (AUC, 0.738 vs. 0.714; p < 0.001). IMAT ratio showed comparable standalone discrimination to AI-vBMD (AUC, 0.760 vs. 0.738; p = 0.604). Adding IMAT ratio to AI-vBMD improved discrimination (AUC, 0.786 vs. 0.738; p = 0.038). The full model incorporating clinical covariates achieved the highest AUC (0.828; 95% CI, 0.778–0.878). Conclusions: AI-vBMD and paraspinal IMAT ratio automatically extracted from routine CT improved the diagnostic assessment of prevalent moderate-to-severe VCFs in breast cancer survivors. This study supports an automated CT-based approach that integrates vertebral bone density and paraspinal muscle–fat information for opportunistic identification of clinically relevant VCFs.
VBQ can serve as an opportunistic exploratory screening marker of low BMD and FBQcsf may complement VBQ by identifying early marrow-related changes, although further validation is required.
M. Müller, João Paulo Colhado Ferreira, Laura Mulazzani Minuzzi Macedo et al.· Skeletal Radiology· 0 citations
OBJECTIVES
Accurate detection of impaired vertebral bone quality (VBQ) is essential for identifying patients at risk of osteoporosis-related fractures and for optimising surgical planning. Dual-energy X-ray absorptiometry (DXA) is the gold standard but is limited by degenerative artefacts and restricted availability. CT-derived Hounsfield units (HU) and MRI-derived VBQ scores provide alternatives for assessing bone quality. This meta-analysis compared HU and VBQ performance for identifying osteopenia and osteoporosis.
MATERIALS AND METHODS
PubMed, EMBASE, MEDLINE, and Cochrane Library were searched to September 2025. Studies reporting HU or VBQ referenced to DXA or quantitative CT were included. Continuous outcomes were pooled as standardised mean differences (SMD), and diagnostic accuracy was evaluated using bivariate hierarchical summary receiver operating characteristic models, threshold synthesis, meta-regression, and bootstrap validation.
RESULTS
Forty-two studies (9214 participants) were included. Both HU and VBQ distinguished impaired from normal bone quality, although HU demonstrated larger SMDs (osteopenia/osteoporosis -2.62; osteoporosis -1.53) than VBQ (0.77 and 0.81). For osteopenia, pooled areas under the ROC curve (AUCs) were 0.87 for HU and 0.75 for VBQ; for osteoporosis, AUCs were 0.86 and 0.79, respectively. Threshold synthesis identified pooled cut-offs for both modalities: 138.9 HU (osteopenia), 104.6 HU (osteoporosis), and VBQ thresholds of 2.83 and 3.14. Validation analyses consistently favoured HU, while VBQ demonstrated greater variability.
CONCLUSION
Both HU and VBQ offer useful assessments of vertebral bone quality, but HU provides higher and more stable diagnostic accuracy. HU thresholds may support opportunistic osteoporosis screening, but their clinical applicability remains uncertain given inter-study heterogeneity, while further refinement of MRI-based VBQ methods is warranted.
KEY POINTS
Question How do computed tomography attenuation and magnetic resonance imaging vertebral bone quality scoring compare in identifying osteopenia and osteoporosis on routine imaging? Findings Computed tomography attenuation measurements outperformed magnetic resonance imaging bone quality scoring, demonstrating higher sensitivity, specificity, and accuracy for detecting osteopenia and osteoporosis. Clinical relevance Routine CT and MRI can support opportunistic detection of low bone density, enabling earlier intervention, improved fracture risk stratification, and more informed preoperative assessment without additional imaging or radiation.
Omar Lubbad, Akram Hagos, Laila Lubbad et al.· European Radiology· 0 citations
Objectives Osteoporotic vertebral compression fractures (OVCFs) are a major health burden, especially with aging populations. While percutaneous vertebroplasty (PVP) is effective, new vertebral compression fractures (NVCFs) are a common complication. Current NVCF prediction models focus on cement factors or bone density alone, ignoring the critical role of paraspinal muscles. To address this gap, our study integrates preoperative CT imaging of bone density and muscle area with clinical data to develop a visualized early prediction model for NVCF risk, aiming to improve patient outcomes. Methods A total of 423 patients who underwent PVP at Guangzhou University of Chinese Medicine Dongguan hospital were retrospectively analyzed and were allocated into a training set and a validation set in an 8:2 ratio. The study employed multivariate logistic regression analysis and the Least Absolute Shrinkage and Selection Operator (Lasso) to develop predictive models and generate nomogram. Receiver Operating Characteristic (ROC) curves and calibration curves were plotted to evaluate the models’ discriminatory and calibration capabilities, Decision Curve Analysis (DCA) and Clinical Impact Curve(CIC)were used to assess the models’ clinical applicability and utility. Results Lasso regression analysis identified age, albumin (ALB), paravertebral muscle area, bone CT value, low-energy trauma, and single-segment fracture as significant predictors. AUC of the nomogram model in the training set was 0.893 (95% CI: 0.858–0.928) and in the validation set was 0.952 (95% CI: 0.903–1), demonstrating its robust predictive capability. DCA and CIC further suggest that this nomogram model possesses substantial clinical application value. Conclusion The nomogram developed based on conventional clinical data in this study, has undergone internal validation and demonstrated efficacy in predicting NVCF following PVP. It serves as a valuable decision-making tool for clinicians. However, further multicenter studies are required for external validation to confirm its generalizability.
Yiqi Wu, Qing Song, Canwei Hu et al.· Frontiers in Medicine· 0 citations
Background/Objectives: CT-based trabecular attenuation in Hounsfield units (HU) is used as a surrogate marker of bone quality, but most approaches rely on a single vertebral level, usually L1, where local abnormalities may limit reliability and availability. This study evaluated whether multilevel lumbar, reference-adjusted HU assessment beyond isolated L1 improves the identification of QCT-defined osteoporosis and the discrimination of prevalent fragility fracture status. Methods: Between 2021 and March 2024, 800 patients referred for evaluation of bone mineral density underwent QCT of the lumbar spine with a calibration phantom. Cancellous attenuation was measured in HU at L1–L3 using manually positioned ellipsoid regions of interest, with predefined adjacent levels (T12, L4) substituted when a target vertebra was unsuitable. Single-level HU, the mean multilevel HU value and the lowest valid HU value were compared with QCT-defined osteoporosis and prevalent fragility fracture status (vertebral or sacral) using ROC analyses and pairwise DeLong testing. Results: Mean multilevel HU correlated closely with mean vBMD (Spearman ρ = 0.988; p < 0.001); as both derive from the same acquisition, the same vertebral bodies and the same phantom, this reflects a strong association between two related measurements rather than validation against an independent standard. Osteoporosis was present in 483 patients (60.4%). Mean multilevel HU was associated with osteoporosis with an AUC of 0.996 (95% CI, 0.993–0.998) at an internally derived cut-off of ≤99.6 HU. In the 699 patients with a valid L1 measurement, in whom a paired comparison was possible, mean multilevel HU exceeded isolated L1-HU (0.992; p = 0.0028). For fracture status, the AUC was 0.975 (0.966–0.983) at ≤80.5 HU, without advantage over L1-HU (p = 0.816). A valid value was obtainable in all 800 patients versus 699 (87.4%) with L1 alone. All patients with a fracture had a vBMD below the osteoporosis threshold, so this endpoint is structurally dependent on the densitometric one. Conclusions: Multilevel lumbar HU assessment provides a practical marker of trabecular bone quality beyond isolated L1. Its principal advantage is measurement availability rather than a clinically meaningful gain in discrimination. The reported thresholds are internally derived, cohort- and protocol-specific, and require external validation.
J. R. Andresen, S. Heisinger, T. Haider et al.· Diagnostics· 0 citations
OBJECTIVE
This study investigated the association between the fat infiltration rate (FIR) of lumbar paraspinal muscles-specifically the multifidus, erector spinae, and psoas major-and bone mineral density (BMD) in postmenopausal women. By examining muscular and segmental (L2-L4) adiposity variations, we aimed to identify imaging biomarkers for early osteoporosis detection and to inform integrated "bone-muscle" therapeutic strategies.
METHODS
A retrospective analysis was performed on 120 postmenopausal women who underwent dual-energy X-ray absorptiometry (DXA) and lumbar computed tomography (CT) between 2024 and 2025. Participants were categorized into three cohorts-normal bone mass, osteopenia, and osteoporosis-based on DXA T-scores. Demographic data, including BMI, were recorded and subsequently utilized as a covariate in the regression models to ensure robust statistical adjustment. The L2-L4 paraspinal musculature was automatically segmented in 3D using 3D Slicer software with the MuscleMap plug-in to determine the FIR for each muscle group. Data normality was assessed using Shapiro-Wilk tests, while inter-group differences were compared via one-way ANOVA or Kruskal-Wallis H tests. Correlations were quantified using Pearson or Spearman analyses.
RESULTS
Age was comparable across groups ( P = 0. 160 ), but BMI and average BMD differed significantly. Multifidus FIR showed a significant inverse correlation with BMD ( P < 0. 001 ). After adjusting for BMI, multifidus fat infiltration remained an independent predictor of BMD. At the segmental level, the L3 multifidus displayed the greatest inter-group variance and the strongest negative correlation with BMD ( r = -0. 689, P < 0. 001 ).
CONCLUSIONS
Lumbar paraspinal muscle adiposity, particularly in the L3 multifidus, is inversely associated with BMD in postmenopausal women. Consequently, L3 multifidus FIR is a statistically significant auxiliary imaging metric for proactive osteoporosis screening and the assessment of osteosarcopenia risk.
Renhai Feng, Binqiang Pan, Lushuang Ye et al.· BMC Medical Imaging· 0 citations
OBJECTIVE
This study aimed to develop a novel 3D Hounsfield unit (HU) technique for assessing volumetric bone mineral density (vBMD) using routine preoperative CT scans. It was designed to enable opportunistic osteoporosis screening by leveraging existing imaging data. The diagnostic accuracy of this approach was rigorously evaluated against quantitative CT (QCT).
METHODS
The authors retrospectively analyzed the records of spine surgery patients who underwent both spinal CT and QCT within a 1-week period. Patients were divided into 3 groups (osteoporosis, osteopenia, and normal bone mineral density [BMD]) based on QCT-vBMD. Baseline characteristics and radiological parameters were compared among the 3 groups. Three-dimensional HU measurements were obtained from lumbar CT scans. Multivariable logistic regression, Pearson correlation analysis, and receiver operating characteristic (ROC) analysis were used to assess the relationships between vBMD and 3D-HU. To evaluate interscanner reliability, a subset of patients received additional CT scanning using both GE and Philips systems. Bland-Altman analysis was used to assess agreement between 3D-HU measurements from different scanner platforms.
RESULTS
Among 264 enrolled patients, 94 were classified as osteoporotic, 114 as osteopenic, and 56 as having normal BMD. Multivariable logistic regression analyses identified lower 3D-HU as an independent predictor of both osteoporosis (OR 0.723, 95% CI 0.618-0.806; p < 0.0001) and osteopenia (OR 0.698, 95% CI 0.564-0.799; p < 0.0001). Three-dimensional HU demonstrated a strong correlation with QCT-vBMD (T12, r = 0.979; L1, r = 0.968; L2, r = 0.962). ROC analysis demonstrated that 3D-HU achieved diagnostic accuracy comparable to QCT for both osteoporosis and osteopenia. Specifically, for osteoporosis, the area under the ROC curve (AUC) was 99.1% (sensitivity 94.7%, specificity 98.3%); for osteopenia, the AUC was 98.5% (sensitivity 93.9%, specificity 94.6%). Bland-Altman analysis demonstrated excellent interscanner agreement (mean difference 0.13; 95% limits of agreement -8.23 to 8.50), with only 2% of measurements falling outside the agreement limits.
CONCLUSIONS
Three-dimensional HU represents a novel vBMD assessment methodology that achieves diagnostic parity with QCT. Crucially, this precision is attained using conventional CT scanners without extra radiation exposure or specialized equipment. This study demonstrated that precise, universally accessible osteoporosis screening is now achievable, promising a transformative advance in public bone health.
Rongkun Chang, Jinxin Gu, Yumei Ding et al.· Journal of Neurosurgery : Sp...· 0 citations