Novel MRI-based vertebral bone quality score as a predictor of cage subsidence following transforaminal lumbar interbody fusion

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  • 1 Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou;
  • | 2 Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou;
  • | 3 College of Medicine, Chang Gung University, Taoyuan; and
  • | 4 Department of Orthopedic Surgery, Chung Shan Hospital, Taipei, Taiwan
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OBJECTIVE

Decreased bone mineral density as measured by dual-energy x-ray absorptiometry (DEXA) has been reported to be associated with cage subsidence following transforaminal lumbar interbody fusion (TLIF). However, DEXA is not often available or routinely performed before surgery. A novel MRI-based vertebral bone quality (VBQ) score has been developed and reported to be correlated with DEXA T-scores. The authors investigated the ability of the VBQ score to predict cage subsidence and other risk factors associated with this complication.

METHODS

In this retrospective study, the authors reviewed the records of patients who had undergone single-level TLIF from March 2014 to October 2015 and had a follow-up of more than 2 years. Cage subsidence was measured as postoperative disc height loss and was graded according to the system proposed by Marchi et al. The MRI-based VBQ score was measured on T1-weighted images. Univariable analysis and multivariable binary logistic regression analysis were performed. Ad hoc analysis with receiver operating characteristic curve analysis was performed to assess the predictive ability of the significant continuous variables. Additional analyses were used to determine the correlations between the VBQ score and T-scores and between the significant continuous variables and the amount of cage subsidence.

RESULTS

Among 242 patients eligible for study inclusion, 111 (45.87%) had cage subsidence after the index operation. Multivariable logistic regression analyses demonstrated that an increased VBQ score (OR 14.615 ± 0.377, p < 0.001), decreased depth ratio (OR 0.011 ± 1.796, p = 0.013), and the use of kidney-shaped cages instead of bullet-shaped cages (OR 2.766 ± 0.358, p = 0.008) were associated with increased cage subsidence. The VBQ score was shown to significantly predict cage subsidence with an accuracy of 85.6%. The VBQ score was found to be moderately correlated with DEXA T-scores of the total hip (r = −0.540, p < 0.001) and the lumbar spine (r = −0.546, p < 0.001). The amount of cage subsidence was moderately correlated with the VBQ score (r = 0.512, p < 0.001).

CONCLUSIONS

Increased VBQ scores, posteriorly placed cages, and kidney-shaped cages were risk factors for cage subsidence. The VBQ score was shown to be a good predictor of cage subsidence, was moderately correlated with DEXA T-scores for the total hip and lumbar spine, and also had a moderate correlation with the amount of cage subsidence.

ABBREVIATIONS

AUC = area under the curve; BMD = bone mineral density; BMI = body mass index; CSF = cerebrospinal fluid; DEXA = dual-energy x-ray absorptiometry; ICC = intraclass correlation coefficient; ODI = Oswestry Disability Index; PEEK = polyetheretherketone; ROC = receiver operating characteristic; ROI = region of interest; SI = signal intensity; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale; VBQ = vertebral bone quality.

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  • 1

    Harms J, Rolinger H. A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion. Article in German. Z Orthop Ihre Grenzgeb. 1982;120(3):343347.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Makanji H, Schoenfeld AJ, Bhalla A, Bono CM. Critical analysis of trends in lumbar fusion for degenerative disorders revisited: influence of technique on fusion rate and clinical outcomes. Eur Spine J. 2018;27(8):18681876.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Aoki Y, Yamagata M, Nakajima F, et al. Examining risk factors for posterior migration of fusion cages following transforaminal lumbar interbody fusion: a possible limitation of unilateral pedicle screw fixation. J Neurosurg Spine. 2010;13(3):381387.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Zhao FD, Yang W, Shan Z, et al. Cage migration after transforaminal lumbar interbody fusion and factors related to it. Orthop Surg. 2012;4(4):227232.

  • 5

    Pan FM, Wang SJ, Yong ZY, Liu XM, Huang YF, Wu DS. Risk factors for cage retropulsion after lumbar interbody fusion surgery: Series of cases and literature review. Int J Surg. 2016;30:5662.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Li H, Wang H, Zhu Y, Ding W, Wang Q. Incidence and risk factors of posterior cage migration following decompression and instrumented fusion for degenerative lumbar disorders. Medicine (Baltimore). 2017;96(33):e7804.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Hu YH, Niu CC, Hsieh MK, Tsai TT, Chen WJ, Lai PL. Cage positioning as a risk factor for posterior cage migration following transforaminal lumbar interbody fusion - an analysis of 953 cases. BMC Musculoskelet Disord. 2019;20(1):260.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Fukuta S, Miyamoto K, Hosoe H, Shimizu K. Kidney-type intervertebral spacers should be located anteriorly in cantilever transforaminal lumbar interbody fusion: analyses of risk factors for spacer subsidence for a minimum of 2 years. J Spinal Disord Tech. 2011;24(3):189195.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Lim TH, Kwon H, Jeon CH, et al. Effect of endplate conditions and bone mineral density on the compressive strength of the graft-endplate interface in anterior cervical spine fusion. Spine (Phila Pa 1976). 2001;26(8):951956.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Beutler WJ, Peppelman WC Jr. Anterior lumbar fusion with paired BAK standard and paired BAK Proximity cages: subsidence incidence, subsidence factors, and clinical outcome. Spine J. 2003;3(4):289293.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Abbushi A, Cabraja M, Thomale UW, Woiciechowsky C, Kroppenstedt SN. The influence of cage positioning and cage type on cage migration and fusion rates in patients with monosegmental posterior lumbar interbody fusion and posterior fixation. Eur Spine J. 2009;18(11):16211628.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Choi WS, Kim JS, Hur JW, Seong JH. Minimally invasive transforaminal lumbar interbody fusion using banana-shaped and straight cages: radiological and clinical results from a prospective randomized clinical trial. Neurosurgery. 2018;82(3):289298.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Yao YC, Chou PH, Lin HH, Wang ST, Liu CL, Chang MC. Risk factors of cage subsidence in patients received minimally invasive transforaminal lumbar interbody fusion. Spine (Phila Pa 1976). 2020;45(19):E1279E1285.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Oh KW, Lee JH, Lee JH, Lee DY, Shim HJ. The correlation between cage subsidence, bone mineral density, and clinical results in posterior lumbar interbody fusion. Clin Spine Surg. 2017;30(6):E683E689.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Park MK, Kim KT, Bang WS, et al. Risk factors for cage migration and cage retropulsion following transforaminal lumbar interbody fusion. Spine J. 2019;19(3):437447.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Ehresman J, Pennington Z, Schilling A, et al. Novel MRI-based score for assessment of bone density in operative spine patients. Spine J. 2020;20(4):556562.

  • 17

    Ehresman J, Ahmed AK, Lubelski D, et al. Vertebral bone quality score and postoperative lumbar lordosis associated with need for reoperation after lumbar fusion. World Neurosurg. 2020;140:e247e252.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Ehresman J, Schilling A, Yang X, et al. Vertebral bone quality score predicts fragility fractures independently of bone mineral density. Spine J. 2021;21(1):2027.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Farfan HF. Mechanical Disorders of The Low Back. Lea & Febiger; 1973.

  • 20

    Marchi L, Abdala N, Oliveira L, Amaral R, Coutinho E, Pimenta L. Radiographic and clinical evaluation of cage subsidence after stand-alone lateral interbody fusion. J Neurosurg Spine. 2013;19(1):110118.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Ito Z, Matsuyama Y, Sakai Y, et al. Bone union rate with autologous iliac bone versus local bone graft in posterior lumbar interbody fusion. Spine (Phila Pa 1976). 2010;35(21):E1101E1105.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Behrbalk E, Uri O, Parks RM, Musson R, Soh RC, Boszczyk BM. Fusion and subsidence rate of stand alone anterior lumbar interbody fusion using PEEK cage with recombinant human bone morphogenetic protein-2. Eur Spine J. 2013;22(12):28692875.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Hou Y, Yuan W. Influences of disc degeneration and bone mineral density on the structural properties of lumbar end plates. Spine J. 2012;12(3):249256.

  • 24

    Dipaola CP, Bible JE, Biswas D, Dipaola M, Grauer JN, Rechtine GR. Survey of spine surgeons on attitudes regarding osteoporosis and osteomalacia screening and treatment for fractures, fusion surgery, and pseudoarthrosis. Spine J. 2009;9(7):537544.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Halvorson TL, Kelley LA, Thomas KA, Whitecloud TS III, Cook SD. Effects of bone mineral density on pedicle screw fixation. Spine (Phila Pa 1976). 1994;19(21):24152420.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312(7041):12541259.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Bandirali M, Di Leo G, Papini GD, et al. A new diagnostic score to detect osteoporosis in patients undergoing lumbar spine MRI. Eur Radiol. 2015;25(10):29512959.

  • 28

    Meunier P, Aaron J, Edouard C, Vignon G. Osteoporosis and the replacement of cell populations of the marrow by adipose tissue. A quantitative study of 84 iliac bone biopsies. Clin Orthop Relat Res. 1971;80(80):147154.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Ehresman J, Schilling A, Pennington Z, et al. A novel MRI-based score assessing trabecular bone quality to predict vertebral compression fractures in patients with spinal metastasis. J Neurosurg Spine. 2020;32(4):499506.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30

    Grant JP, Oxland TR, Dvorak MF. Mapping the structural properties of the lumbosacral vertebral endplates. Spine (Phila Pa 1976). 2001;26(8):889896.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31

    Zhang X, Wu H, Chen Y, et al. Importance of the epiphyseal ring in OLIF stand-alone surgery: a biomechanical study on cadaveric spines. Eur Spine J. 2021;30(1):7987.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32

    Zhou QS, Chen X, Xu L, et al. Does vertebral end plate morphology affect cage subsidence after transforaminal lumbar interbody fusion?. World Neurosurg. 2019;130:e694e701.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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