Abstract
Purpose
A growing number of studies have demonstrated that Hounsfield units (HU) value can effectively assess bone quality and predict cage subsidence (CS) after spinal surgery. The purpose of this review is to provide an overview of the utility of the HU value for predicting CS after spinal surgery and to raise some of the unresolved questions in this field.
Methods
We searched on PubMed, EMBASE, MEDLINE, and Cochrane Library for studies correlating HU value to CS.
Results
Thirty-seven studies were included in this review. We found that HU value can predicted the risk of CS effectively after spinal surgery. Moreover, the HU value of the cancellous vertebral body and the cortical endplate were used for predicting CS, in comparison, the measurement method of HU value in the cancellous vertebral body was more standardized, but which region is more important to CS remains unknown. Different cutoff thresholds of HU value have been established in different surgical procedures for predicting CS. The HU value may be superior to dual-energy X-ray absorptiometry (DEXA) for CS prediction; however, the usage standard of HU value has not been well established.
Conclusions
The HU value shows great potential for predicting CS and constitutes an advantage over DEXA. However, general consensuses about how CS is defined and HU is measured, which part of HU value is more important, and the appropriate cutoff threshold of the HU value for osteoporosis and CS still require exploration.
Similar content being viewed by others
References
Dantas F, Dantas FLR, Botelho RV (2022) Effect of interbody fusion compared with posterolateral fusion on lumbar degenerative spondylolisthesis: a systematic review and meta-analysis. Spine J 22:756–768
Mobbs RJ, Phan K, Malham G, Seex K, Rao PJ (2015) Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. J Spine Surg 1:2–18
Wu H, Shan Z, Zhao F, Cheung JPY (2021) Poor bone quality, multilevel surgery, and narrow and tall cages are associated with intraoperative endplate injuries and late-onset cage subsidence in lateral lumbar interbody fusion: a systematic review. Clin Orthop Relat Res 480(1):163–188
Marchi L, Abdala N, Oliveira L, Amaral R, Coutinho E, Pimenta L (2013) Radiographic and clinical evaluation of cage subsidence after stand-alone lateral interbody fusion. J Neurosurg Spine 19:110–118
Xie F, Yang Z, Tu Z et al (2022) The value of Hounsfield units in predicting cage subsidence after transforaminal lumbar interbody fusion. BMC Musculoskelet Disord 23:882
Zhao L, Xie T, Wang X et al (2022) Clinical and radiological evaluation of cage subsidence following oblique lumbar interbody fusion combined with anterolateral fixation. BMC Musculoskelet Disord 23:214
Yao Y-C, Chou P-H, Lin H-H, Wang S-T, Liu C-L, Chang M-C (2020) Risk factors of cage subsidence in patients received minimally invasive transforaminal lumbar interbody fusion. Spine 45:E1279–E1285
Soliman MAR, Aguirre AO, Kuo CC et al (2022) Vertebral bone quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion. Spine J 22(12):2017–2023
Muraki S, Yamamoto S, Ishibashi H et al (2004) Impact of degenerative spinal diseases on bone mineral density of the lumbar spine in elderly women. Osteoporos Int 15:724–728
Choi MK, Kim SM, Lim JK (2016) 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 (Wien) 158:1421–1427
Schreiber JJ, Anderson PA, Rosas HG, Buchholz AL, Au AG (2011) Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am 93:1057–1063
Ran L, Xie T, Zhao L, Huang S, Zeng J (2022) Low Hounsfield units on computed tomography are associated with cage subsidence following oblique lumbar interbody fusion (OLIF). Spine J 22:957–964
Wang M, Mummaneni PV, Xi Z et al (2020) Lower Hounsfield units on CT are associated with cage subsidence after anterior cervical discectomy and fusion. J Neurosurg Spine 33(4):425–432
Lee SJ, Binkley N, Lubner MG, Bruce RJ, Ziemlewicz TJ, Pickhardt PJ (2016) Opportunistic screening for osteoporosis using the sagittal reconstruction from routine abdominal CT for combined assessment of vertebral fractures and density. Osteoporos Int 27:1131–1136
Hiyama A, Sakai D, Katoh H, Nomura S, Sato M, Watanabe M (2022) Comparative study of cage subsidence in single-level lateral lumbar interbody fusion. J Clin Med 11(5):1374
Wang Y, Battié MC, Videman T (2012) A morphological study of lumbar vertebral endplates: radiographic, visual and digital measurements. Eur Spine J 21:2316–2323
Okano I, Jones C, Salzmann SN et al (2020) Endplate volumetric bone mineral density measured by quantitative computed tomography as a novel predictive measure of severe cage subsidence after standalone lateral lumbar fusion. Eur Spine J 29:1131–1140
Lee JS, Son DW, Lee SH et al (2022) The effect of Hounsfield unit value with conventional computed tomography and intraoperative distraction on postoperative intervertebral height reduction in patients following stand-alone anterior cervical discectomy and fusion. J Korean Neurosurg Soc 65:96–106
Wang Hui ZD, Zhuoran S, Longjie W, Shuai J, Weishi Li (2021) Predictive value of vertebral trabecular and endplate Hounsfield Units on cage subsidence followed posterior lumbar interbody fusion. Chin J Orthop 41:864–871
Wu H, Cheung JPY, Zhang T et al (2021) The Role of Hounsfield Unit in Intraoperative Endplate Violation and Delayed Cage Subsidence with Oblique Lateral Interbody Fusion. Glob Spine J. https://doi.org/10.1177/21925682211052515
Wang Z, Mei J, Feng X et al (2022) Low cervical vertebral CT value increased early subsidence of titanium mesh cage after anterior cervical corpectomy and fusion. J Orthop Surg Res 17:355
Engelke K, Libanati C, Liu Y et al (2009) Quantitative computed tomography (QCT) of the forearm using general purpose spiral whole-body CT scanners: accuracy, precision and comparison with dual-energy X-ray absorptiometry (DXA). Bone 45:110–118
Nekkanty S, Yerramshetty J, Kim D-G et al (2010) Stiffness of the endplate boundary layer and endplate surface topography are associated with brittleness of human whole vertebral bodies. Bone 47:783–789
Jones C, Okano I, Salzmann SN et al (2021) Endplate volumetric bone mineral density is a predictor for cage subsidence following lateral lumbar interbody fusion: a risk factor analysis. Spine J 21:1729–1737
Cheng C, Wang K, Zhang C, Wu H, Jian F (2021) Clinical results and complications associated with oblique lumbar interbody fusion technique. Ann Transl Med 9:16
Zhou J, Yuan C, Liu C, Zhou L, Wang J (2021) Hounsfield unit value on CT as a predictor of cage subsidence following stand-alone oblique lumbar interbody fusion for the treatment of degenerative lumbar diseases. BMC Musculoskelet Disord 22:960
Xi Z, Mummaneni PV, Wang M et al (2020) The association between lower Hounsfield units on computed tomography and cage subsidence after lateral lumbar interbody fusion. Neurosurg Focus 49:E8
Pisano AJ, Fredericks DR, Steelman T, Riccio C, Helgeson MD, Wagner SC (2020) Lumbar disc height and vertebral Hounsfield units: association with interbody cage subsidence. Neurosurg Focus 49:E9
Mi J, Li K, Zhao X, Zhao CQ, Li H, Zhao J (2017) Vertebral body hounsfield units are associated with cage subsidence after transforaminal lumbar interbody fusion with unilateral pedicle screw fixation. Clinical Spine Surg 30:E1130-e1136
Formby PM, Kang DG, Helgeson MD, Wagner SC (2016) Clinical and radiographic outcomes of transforaminal lumbar interbody fusion in patients with osteoporosis. Glob Spine J 6:660–664
Ji C, Yu S, Yan N et al (2020) Risk factors for subsidence of titanium mesh cage following single-level anterior cervical corpectomy and fusion. BMC Musculoskelet Disord 21:1–8
Liu J, Ding W, Yang D et al (2020) Modic changes (MCs) associated with endplate sclerosis can prevent cage subsidence in oblique lumbar interbody fusion (OLIF) stand -alone. World Neurosurg 138:E160–E168
Guha D, Mushlin HM, Muthiah N et al (2022) Computed tomography Hounsfield units as a predictor of reoperation and graft subsidence after standalone and multilevel lateral lumbar interbody fusion. World Neurosurg 161:e417–e426
Pickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ, Binkley N (2013) Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med 158:588–595
Buckens CF, Dijkhuis G, de Keizer B, Verhaar HJ, de Jong PA (2015) Opportunistic screening for osteoporosis on routine computed tomography? An external validation study. Eur Radiol 25:2074–2079
Wagner SC, Formby PM, Helgeson MD, Kang DG (2016) Diagnosing the undiagnosed: osteoporosis in patients undergoing lumbar fusion. Spine 41:E1279–E1283
Lee S, Chung CK, Oh SH, Park SB (2013) Correlation between bone mineral density measured by dual-energy X-ray absorptiometry and hounsfield units measured by diagnostic CT in lumbar spine. J Korean Neurosurg Soc 54:384–389
Acknowledgements
We would like to thank Sudan Tang MD (Department of Radiology, Daping Hospital of Army Military Medical University, China) for her suggestions and valuable guidance.
Funding
No funding.
Author information
Authors and Affiliations
Corresponding authors
Ethics declarations
Conflict of interest
All authors state that we have no conflicts of interest.
Ethical approval
Institutional review board approval was not required because it is a review paper.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Pu, X., Wang, D. & Gu, S. Advances in Hounsfield units value for predicting cage subsidence on spinal interbody fusion surgery. Eur Spine J 32, 3149–3157 (2023). https://doi.org/10.1007/s00586-023-07805-2
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-023-07805-2