Skip to main content
SpringerLink
Log in

Quantitative dual-energy CT for phantomless evaluation of cancellous bone mineral density of the vertebral pedicle: correlation with pedicle screw pull-out strength

  • Musculoskeletal
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

To evaluate quantitative dual-energy computed tomography (DECT) for phantomless analysis of cancellous bone mineral density (BMD) of vertebral pedicles and to assess the correlation with pedicle screw pull-out strength.

Methods

Twenty-nine thoracic and lumbar vertebrae from cadaver specimens were examined with DECT. Using dedicated post-processing software, a pedicle screw vector was mapped (R1, intrapedicular segment of the pedicle vector; R2, intermediate segment; R3, intracorporal segment; global, all segments) and BMD was calculated. To invasively evaluate pedicle stability, pedicle screws were drilled through both pedicles and left pedicle screw pull-out strength was measured. Resulting values were correlated using the paired t test and Pearson’s linear correlation.

Results

Average pedicle screw vector BMD (R1, 0.232 g/cm3; R2, 0.166 g/cm3; R3, 0.173 g/cm3; global, 0.236 g/cm3) showed significant differences between R1–R2 (P < 0.002) and R1–R3 (P < 0.034) segments while comparison of R2–R3 did not reach significance (P > 0.668). Average screw pull-out strength (639.2 N) showed a far stronger correlation with R1 (r = 0.80; P < 0.0001) than global BMD (r = 0.42; P = 0.025), R2 (r = 0.37; P = 0.048) and R3 (r = −0.33; P = 0.078) segments.

Conclusions

Quantitative DECT allows for phantomless BMD assessment of the vertebral pedicle. BMD of the intrapedicular segment shows a significantly stronger correlation with pedicle screw pull-out strength than other segments.

Key points

• Quantitative dual-energy CT enables evaluation of pedicle bone mineral density.

• Intrapedicular segments show significant differences regarding bone mineral density.

• Pedicle screw pull-out strength correlated strongest with R1 values.

• Dual-energy CT may improve preoperative assessment before transpedicular screw fixation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Amoretti N, Amoretti M-E, Hovorka I et al (2013) Percutaneous facet screw fixation of lumbar spine with CT and fluoroscopic guidance: a feasibility study. Radiology 268:548–555

    Article  PubMed  Google Scholar 

  2. Murtagh RD, Quencer RM, Castellvi AE, Yue JJ (2011) New techniques in lumbar spinal instrumentation: what the radiologist needs to know. Radiology 260:317–330

    Article  PubMed  Google Scholar 

  3. Soshi S, Shiba R, Kondo H, Murota K (1991) An experimental study on transpedicular screw fixation in relation to osteoporosis of the lumbar spine. Spine 16:1335–1341

    Article  CAS  PubMed  Google Scholar 

  4. Inceoğlu S, Montgomery WH Jr, St Clair S, McLain RF (2011) Pedicle screw insertion angle and pullout strength: comparison of 2 proposed strategies. J Neurosurg Spine 14:670–676

    PubMed  Google Scholar 

  5. Wu Z, Gao M, Sang H et al (2012) Surgical treatment of osteoporotic thoracolumbar compressive fractures with open vertebral cement augmentation of expandable pedicle screw fixation: a biomechanical study and a 2-year follow-up of 20 patients. J Surg Res 173:91–98

    Article  PubMed  Google Scholar 

  6. Cho W, Wu C, Erkan S et al (2011) The effect on the pullout strength by the timing of pedicle screw insertion after calcium phosphate cement injection. J Spinal Disord Tech 24:116–120

    Article  PubMed  Google Scholar 

  7. Chen L-H, Tai C-L, Lee D-M et al (2011) Pullout strength of pedicle screws with cement augmentation in severe osteoporosis: a comparative study between cannulated screws with cement injection and solid screws with cement pre-filling. BMC Musculoskelet Disord 12:33

    Article  PubMed Central  PubMed  Google Scholar 

  8. Okuyama K, Abe E, Suzuki T et al (2001) Influence of bone mineral density on pedicle screw fixation: a study of pedicle screw fixation augmenting posterior lumbar interbody fusion in elderly patients. Spine J 1:402–407

    Article  CAS  PubMed  Google Scholar 

  9. Halvorson TL, Kelley LA, Thomas KA et al (1994) Effects of bone mineral density on pedicle screw fixation. Spine 19:2415–2420

    Article  CAS  PubMed  Google Scholar 

  10. Wichmann JL, Booz C, Wesarg S et al (2014) Dual-energy CT-based phantomless in vivo three-dimensional bone mineral density assessment of the lumbar spine. Radiology 271:778–784

    Article  PubMed  Google Scholar 

  11. Wesarg S, Kirschner M, Becker M et al (2012) Dual-energy CT-based assessment of the trabecular bone in vertebrae. Methods Inf Med 51:398–405

    Article  CAS  PubMed  Google Scholar 

  12. Antonacci MD, Hanson DS, Heggeness MH (1996) Pitfalls in the measurement of bone mineral density by dual energy x-ray absorptiometry. Spine 21:87–91

    Article  CAS  PubMed  Google Scholar 

  13. Lehman RA Jr, Helgeson MD, Dmitriev AE et al (2012) What is the best way to optimize thoracic kyphosis correction? A micro-CT and biomechanical analysis of pedicle morphology and screw failure. Spine 37:E1171–E1176

    Article  PubMed  Google Scholar 

  14. Yoganandan N, Pintar FA, Stemper BD et al (2006) Trabecular bone density of male human cervical and lumbar vertebrae. Bone 39:336–344

    Article  PubMed  Google Scholar 

  15. Zhang QH, Tan SH, Chou SM (2004) Investigation of fixation screw pull-out strength on human spine. J Biomech 37:479–485

    Article  CAS  PubMed  Google Scholar 

  16. Hirano T, Hasegawa K, Takahashi HE et al (1997) Structural characteristics of the pedicle and its role in screw stability. Spine 22:2504–2509, discussion 2510

    Article  CAS  PubMed  Google Scholar 

  17. Cook SD, Salkeld SL, Stanley T et al (2004) Biomechanical study of pedicle screw fixation in severely osteoporotic bone. Spine J 4:402–408

    Article  PubMed  Google Scholar 

  18. Defino HL, Vendrame JR (2001) Role of cortical and cancellous bone of the vertebral pedicle in implant fixation. Eur Spine J 10:325–333

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  19. Zindrick MR, Wiltse LL, Widell EH et al (1986) A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop 99–112

  20. Bernard TN Jr, Seibert CE (1992) Pedicle diameter determined by computed tomography. Its relevance to pedicle screw fixation in the lumbar spine. Spine 17:S160–S163

    Article  PubMed  Google Scholar 

  21. Cho W, Cho SK, Wu C (2010) The biomechanics of pedicle screw-based instrumentation. J Bone Joint Surg (Br) 92:1061–1065

    Article  CAS  Google Scholar 

  22. Kim Y-Y, Choi W-S, Rhyu K-W (2012) Assessment of pedicle screw pullout strength based on various screw designs and bone densities-an ex vivo biomechanical study. Spine J 12:164–168

    Article  PubMed  Google Scholar 

  23. Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936

    Article  PubMed  Google Scholar 

  24. Link TM (2012) Osteoporosis imaging: state of the art and advanced imaging. Radiology 263:3–17

    Article  PubMed Central  PubMed  Google Scholar 

  25. Engelke K, Adams JE, Armbrecht G et al (2008) Clinical use of quantitative computed tomography and peripheral quantitative computed tomography in the management of osteoporosis in adults: the 2007 ISCD official positions. J Clin Densitom 11:123–162

    Article  PubMed  Google Scholar 

  26. Bolotin HH (2007) DXA in vivo BMD methodology: an erroneous and misleading research and clinical gauge of bone mineral status, bone fragility, and bone remodelling. Bone 41:138–154

    Article  CAS  PubMed  Google Scholar 

  27. Link TM, Koppers BB, Licht T et al (2004) In vitro and in vivo spiral CT to determine bone mineral density: initial experience in patients at risk for osteoporosis. Radiology 231:805–811

    Article  PubMed  Google Scholar 

  28. Pickhardt PJ, Lee LJ, del Rio AM et al (2011) Simultaneous screening for osteoporosis at CT colonography: bone mineral density assessment using MDCT attenuation techniques compared with the DXA reference standard. J Bone Miner Res 26:2194–2203

    Article  PubMed Central  PubMed  Google Scholar 

  29. Budoff MJ, Malpeso JM, Zeb I et al (2013) Measurement of phantomless thoracic bone mineral density on coronary artery calcium CT scans acquired with various CT scanner models. Radiology 267:830–836

    Article  PubMed  Google Scholar 

  30. Marin D, Boll DT, Mileto A, Nelson RC (2014) State of the art: dual-energy CT of the abdomen. Radiology 271:327–342

    Article  PubMed  Google Scholar 

  31. Wang C-K, Tsai J-M, Chuang M-T et al (2013) Bone marrow edema in vertebral compression fractures: detection with dual-energy CT. Radiology 269:525–533

    Article  PubMed  Google Scholar 

  32. Bierry G, Venkatasamy A, Kremer S et al (2014) Dual-energy CT in vertebral compression fractures: performance of visual and quantitative analysis for bone marrow edema demonstration with comparison to MRI. Skelet Radiol 43:485–492

    Article  Google Scholar 

Download references

Acknowledgments

The scientific guarantor of this publication is Konstantinos Kafchitsas. The authors of this manuscript declare relationships with the following companies: Dr. Ralf W. Bauer and Dr. J. Matthias Kerl are on the speakers’ bureau of Siemens Healthcare, Computed Tomography division. However, all data was controlled by authors (e.g. the corresponding author) without any potential conflict of interest.

All other authors have nothing to disclose. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Three cadavers were obtained from the local anatomy institute and used with institutional review board approval for cadaver research. Written informed consent was waived by the institutional review board. No study subjects or cohorts have been previously reported. Methodology: prospective, diagnostic or prognostic study, performed at one institution.

Author information

Authors and Affiliations

  1. Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany

    Julian L. Wichmann, Christian Booz, Ralf W. Bauer, J. Matthias Kerl, Sebastian Fischer, Thomas Lehnert, Thomas J. Vogl & M. Fawad Khan

  2. Fraunhofer IGD, Cognitive Computing & Medical Imaging, Fraunhoferstr. 5, 64283, Darmstadt, Germany

    Stefan Wesarg

  3. Asklepios Klinik Lindenlohe, Spine Center, Lindenlohe 18, 92421, Schwandorf, Germany

    Konstantinos Kafchitsas

Authors
  1. Julian L. Wichmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christian Booz
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stefan Wesarg
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ralf W. Bauer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. J. Matthias Kerl
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sebastian Fischer
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Thomas Lehnert
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Thomas J. Vogl
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. M. Fawad Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Konstantinos Kafchitsas
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Julian L. Wichmann.

Additional information

M. Fawad Khan and Konstantinos Kafchitsas contributed equally to this work and share senior authorship

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wichmann, J.L., Booz, C., Wesarg, S. et al. Quantitative dual-energy CT for phantomless evaluation of cancellous bone mineral density of the vertebral pedicle: correlation with pedicle screw pull-out strength. Eur Radiol 25, 1714–1720 (2015). https://doi.org/10.1007/s00330-014-3529-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-014-3529-7

Keywords

Search

Navigation