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BMC Musculoskeletal Disorders
Published in: BMC Musculoskeletal Disorders 1/2022

Open Access 01-12-2022 | Research

The value of Hounsfield units in predicting cage subsidence after transforaminal lumbar interbody fusion

Authors: Fang Xie, Zhiwei Yang, Zhipeng Tu, Peipei Huang, Zhe Wang, Zhuojing Luo, Xueyu Hu

Published in: BMC Musculoskeletal Disorders | Issue 1/2022

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Abstract

Background

Cage subsidence may occur following transforaminal lumbar interbody fusion (TLIF) and lead to nonunion, foraminal height loss and other complications. Low bone quality may be a risk factor for cage subsidence. Assessing bone quality through Hounsfield units (HU) from computed tomography has been proposed in recent years. However, there is a lack of literature evaluating the correlation between HU and cage subsidence after TLIF.

Methods

Two hundred and seventy-nine patients suffering from lumbar degenerative diseases from April, 2016 to August, 2018 were enrolled. All underwent one-level TLIF with a minimum of 1-year follow-up. Cage subsidence was defined as > 2 mm loss of disc height at the fusion level. The participants were divided into 2 groups: cage subsidence group (CS) and non-cage subsidence group (non-CS). Bone quality was determined by HU, bone mineral density of lumbar (BMD-l) and femoral (BMD-f) from dual-emission X-ray absorptiometry (DXA). HU of each vertebra from L1 to L4 (e.g., HU1 for HU of L1) and mean value of the four vertebrae (HUm) were calculated. Visual analog scale (VAS) of back/leg pain and Oswestry disability index (ODI) were used to report clinical outcomes.

Results

Cage subsidence occurred in 82 (29.4%) cases at follow-ups. Mean age was 50.8 ± 9.0 years with a median follow-up of 18 months (range from 12 to 40 months). A total of 90.3% patients presented fusion with similar fusion rate between the two groups. ODI and VAS in leg were better in non-CS group at last follow-ups. Using receiver operating characteristic curves (ROCs) to predict cage subsidence, HUm provided a larger area under the curve (AUC) than BMD-l (Z = 3.83, P <  0.01) and BMD-f (Z = 2.01, P = 0.02). AUC for HU4 was larger than BMD-f and close to HUm (Z = 0.22, P = 0.481).

Conclusions

Cage subsidence may indicate worse clinical outcomes. HU value could be a more effective predictor of lumbar cage subsidence compared with T-score of DXA after TLIF.
Literature
1.
2.
de Kunder SL, et al. Transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis: a systematic review and meta-analysis. Spine J. 2017;(11):1712–21.
3.
Seaman S, et al. Titanium vs. polyetheretherketone (PEEK) interbody fusion: Meta-analysis and review of the literature. J Clin Neurosci. 2017;44:23–9.CrossRefPubMed
4.
Lee JH, et al. Fusion rates and subsidence of morselized local bone grafted in titanium cages in posterior lumbar interbody fusion using quantitative three-dimensional computed tomography scans. Spine (Phila Pa 1976). 2010;35(15):1460–5.CrossRef
5.
Oh KW, et al. The correlation between cage subsidence, bone mineral density, and clinical results in posterior lumbar interbody fusion. Clin Spine Surg. 2017;30(6):E683–9.CrossRefPubMed
6.
Yao, Y.C., et al., Risk Factors of Cage Subsidence in Patients Received Minimally Invasive Transforaminal Lumbar Interbody Fusion. Spine (Phila Pa 1976), 2020.
7.
Samelson EJ, et al. Cortical and trabecular bone microarchitecture as an independent predictor of incident fracture risk in older women and men in the bone microarchitecture international consortium (BoMIC): a prospective study. Lancet Diabetes Endocrinol. 2019;7(1):34–43.CrossRefPubMed
8.
Muraki S, et al. Impact of degenerative spinal diseases on bone mineral density of the lumbar spine in elderly women. Osteoporos Int. 2004;15(9):724–8.CrossRefPubMed
9.
Schreiber JJ, et al. Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am. 2011;93(11):1057–63.CrossRefPubMed
10.
Bredow J, et al. Predictive validity of preoperative CT scans and the risk of pedicle screw loosening in spinal surgery. Arch Orthop Trauma Surg. 2016;136(8):1063–7.CrossRefPubMed
11.
Nguyen HS, et al. Posterolateral lumbar fusion: relationship between computed tomography Hounsfield units and symptomatic pseudoarthrosis. Surg Neurol Int. 2015;6(Suppl 24):S611–4.CrossRefPubMedPubMedCentral
12.
Du JY, et al. Vertebral body Hounsfield units as a predictor of incidental durotomy in primary lumbar spinal surgery. Spine (Phila Pa 1976). 2014;39(9):E593–8.CrossRef
13.
Mi J, et al. Vertebral body Hounsfield units are associated with cage subsidence after Transforaminal lumbar interbody fusion with unilateral pedicle screw fixation. Clin Spine Surg. 2017;30(8):E1130–6.CrossRefPubMed
14.
Kim MC, et al. Subsidence of polyetheretherketone cage after minimally invasive transforaminal lumbar interbody fusion. J Spinal Disord Tech. 2013;26(2):87–92.CrossRefPubMed
15.
Pisano AJ, et al. Lumbar disc height and vertebral Hounsfield units: association with interbody cage subsidence. Neurosurg Focus. 2020;49(2):E9.CrossRefPubMed
16.
Burkus JK, et al. Six-year outcomes of anterior lumbar interbody arthrodesis with use of interbody fusion cages and recombinant human bone morphogenetic protein-2. J Bone Joint Surg Am. 2009;91(5):1181–9.CrossRefPubMed
17.
Cutler AR, et al. Comparison of polyetheretherketone cages with femoral cortical bone allograft as a single-piece interbody spacer in transforaminal lumbar interbody fusion. J Neurosurg Spine. 2006;5(6):534–9.CrossRefPubMed
18.
Zhou QS, et al. Does vertebral end plate morphology affect cage subsidence after Transforaminal lumbar interbody fusion? World Neurosurg. 2019;130:e694–701.CrossRefPubMed
19.
Marchi L, et al. Radiographic and clinical evaluation of cage subsidence after stand-alone lateral interbody fusion. J Neurosurg Spine. 2013;19(1):110–8.CrossRefPubMed
20.
Bach K, et al. Morphometric analysis of lumbar intervertebral disc height: an imaging study. World Neurosurg. 2018.
21.
Lee N, et al. Comparison of outcomes of anterior, posterior, and Transforaminal lumbar interbody fusion surgery at a single lumbar level with degenerative spinal disease. World Neurosurg. 2017;101:216–26.CrossRefPubMed
22.
Park SH, et al. Minimally invasive anterior lumbar interbody fusion followed by percutaneous translaminar facet screw fixation in elderly patients. J Neurosurg Spine. 2009;10(6):610–6.CrossRefPubMed
23.
Landham PR, Don AS, Robertson PA. Do position and size matter? An analysis of cage and placement variables for optimum lordosis in PLIF reconstruction. Eur Spine J. 2017;26(11):2843–50.CrossRefPubMed
24.
Fukuta S, et al. 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):189–95.CrossRefPubMed
25.
Choi MK, Kim SM, Lim JK. Diagnostic efficacy of Hounsfield units in spine CT for the assessment of real bone mineral density of degenerative spine: correlation study between T-scores determined by DEXA scan and Hounsfield units from CT. Acta Neurochir. 2016;158(7):1421–7.CrossRefPubMed
26.
Ullrich BW, et al. Hounsfield units as predictor for cage subsidence and loss of reduction: following posterior-anterior stabilization in thoracolumbar spine fractures. Eur Spine J. 2018;27(12):3034–42.CrossRefPubMed
27.
Wang M, et al. Lower Hounsfield units on CT are associated with cage subsidence after anterior cervical discectomy and fusion. J Neurosurg Spine. 2020:1–8.
28.
Zou D, et al. The use of CT Hounsfield unit values to identify the undiagnosed spinal osteoporosis in patients with lumbar degenerative diseases. Eur Spine J. 2019;28(8):1758–66.CrossRefPubMed
29.
Xue H, Tu Y, Cai M. Comparison of unilateral versus bilateral instrumented transforaminal lumbar interbody fusion in degenerative lumbar diseases. Spine J. 2012;12(3):209–15.CrossRefPubMed
30.
Suk KS, et al. Unilateral versus bilateral pedicle screw fixation in lumbar spinal fusion. Spine (Phila Pa 1976). 2000;25(14):1843–7.CrossRef
31.
Gruskay JA, Webb ML, Grauer JN. Methods of evaluating lumbar and cervical fusion. Spine J. 2014;14(3):531–9.CrossRefPubMed
32.
Sugiyama S, et al. Reliability of clinical measurement for assessing spinal fusion: an experimental sheep study. Spine (Phila Pa 1976). 2012;37(9):763–8.CrossRef
Metadata
Title
The value of Hounsfield units in predicting cage subsidence after transforaminal lumbar interbody fusion
Authors
Fang Xie
Zhiwei Yang
Zhipeng Tu
Peipei Huang
Zhe Wang
Zhuojing Luo
Xueyu Hu
Publication date
01-12-2022
Publisher
BioMed Central
Published in
BMC Musculoskeletal Disorders / Issue 1/2022
Electronic ISSN: 1471-2474
DOI
https://doi.org/10.1186/s12891-022-05836-2

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