Preoperative Imaging Predictors of Subsidence of 3D-Printed Artificial Cervical Vertebral Bodies: A Cohort Study of 102 Patients With Nomogram Development and Validation

Preoperative Imaging Predictors of Subsidence of 3D-Printed Artificial Cervical Vertebral Bodies: A Cohort Study of 102 Patients With Nomogram Development and Validation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Preoperative Imaging Predictors of Subsidence of 3D-Printed Artificial Cervical Vertebral Bodies: A Cohort Study of 102 Patients With Nomogram Development and Validation Xin Xu, Kun Wang, Zheng Zhang, Fuxin Wang, Ang Li, Junlin Han, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8209819/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Mar, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 20 You are reading this latest preprint version Abstract Background Subsidence of an interbody implant, defined as its sinking into adjacent bone, is a common complication that can compromise spinal fusion outcomes and may require revision surgery. Custom 3D-printed titanium vertebral bodies are increasingly used for anterior spinal reconstruction. However, their reported subsidence incidence (15–30%) remains comparable to conventional cages. Early identification of high-risk patients is therefore crucial. This study aimed to identify preoperative imaging predictors of 3D-printed vertebral body subsidence and develop a nomogram for individualized risk prediction. Methods We retrospectively analyzed 102 patients (2020–2024) who underwent single-level anterior corpectomy and fusion with a custom 3D-printed titanium vertebral body. Preoperative CT and MRI metrics—including lower adjacent vertebral Hounsfield units (HU), endplate concavity depth, endplate angle, and Modic changes—were assessed as candidate risk factors. Subsidence was defined as implant sinking ≥ 3 mm at final follow-up (≥ 3 months postoperatively). Independent predictors were identified by multivariate logistic regression, and a nomogram was constructed. Model performance was evaluated by area under the ROC curve (AUC), along with calibration and decision curve analysis, and internally validated via bootstrap resampling. Results Subsidence occurred in 32 of 102 patients (31.4%). Multivariate logistic regression identified lower adjacent vertebral HU, greater endplate concavity depth, and presence of Modic changes as independent predictors of subsidence. The predictive model showed excellent discrimination (AUC = 0.896, 95% CI 0.821–0.970) and remained robust after internal validation (bootstrap-corrected AUC ~ 0.886). It also demonstrated good calibration and a positive net clinical benefit on decision curve analysis. Conclusions The major risk factors for 3D-printed vertebral body subsidence (poor bone quality and weak endplate integrity) are similar to those for conventional cages. Our imaging-based nomogram provides accurate risk stratification to guide personalized surgical strategies—such as bone density optimization or use of larger implants in high-risk cases—while avoiding unnecessary interventions in low-risk patients. 3D-printed vertebral body subsidence computed tomography magnetic resonance imaging nomogram spinal reconstruction Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Mar, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 17 Dec, 2025 Reviews received at journal 16 Dec, 2025 Reviews received at journal 15 Dec, 2025 Reviewers agreed at journal 15 Dec, 2025 Reviewers agreed at journal 14 Dec, 2025 Reviews received at journal 14 Dec, 2025 Reviews received at journal 12 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviewers agreed at journal 10 Dec, 2025 Reviews received at journal 10 Dec, 2025 Reviews received at journal 09 Dec, 2025 Reviewers agreed at journal 09 Dec, 2025 Reviewers agreed at journal 09 Dec, 2025 Reviewers agreed at journal 09 Dec, 2025 Reviewers agreed at journal 09 Dec, 2025 Reviewers invited by journal 09 Dec, 2025 Editor invited by journal 28 Nov, 2025 Editor assigned by journal 27 Nov, 2025 Submission checks completed at journal 27 Nov, 2025 First submitted to journal 26 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8209819","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":559073925,"identity":"8ce1b03d-fef7-44e4-b302-094e87c9e4a6","order_by":0,"name":"Xin Xu","email":"","orcid":"","institution":"Affiliated 960th Hospital of PLA, Shandong Second Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Xu","suffix":""},{"id":559073930,"identity":"59a87733-9fef-4804-977a-64192adabeb9","order_by":1,"name":"Kun Wang","email":"","orcid":"","institution":"Affiliated 960th Hospital of PLA, 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Validation","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"3D-printed vertebral body, subsidence, computed tomography, magnetic resonance imaging, nomogram, spinal reconstruction","lastPublishedDoi":"10.21203/rs.3.rs-8209819/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8209819/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSubsidence of an interbody implant, defined as its sinking into adjacent bone, is a common complication that can compromise spinal fusion outcomes and may require revision surgery. Custom 3D-printed titanium vertebral bodies are increasingly used for anterior spinal reconstruction. However, their reported subsidence incidence (15\u0026ndash;30%) remains comparable to conventional cages. Early identification of high-risk patients is therefore crucial. This study aimed to identify preoperative imaging predictors of 3D-printed vertebral body subsidence and develop a nomogram for individualized risk prediction.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively analyzed 102 patients (2020\u0026ndash;2024) who underwent single-level anterior corpectomy and fusion with a custom 3D-printed titanium vertebral body. Preoperative CT and MRI metrics\u0026mdash;including lower adjacent vertebral Hounsfield units (HU), endplate concavity depth, endplate angle, and Modic changes\u0026mdash;were assessed as candidate risk factors. Subsidence was defined as implant sinking\u0026thinsp;\u0026ge;\u0026thinsp;3 mm at final follow-up (\u0026ge;\u0026thinsp;3 months postoperatively). Independent predictors were identified by multivariate logistic regression, and a nomogram was constructed. Model performance was evaluated by area under the ROC curve (AUC), along with calibration and decision curve analysis, and internally validated via bootstrap resampling.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSubsidence occurred in 32 of 102 patients (31.4%). Multivariate logistic regression identified lower adjacent vertebral HU, greater endplate concavity depth, and presence of Modic changes as independent predictors of subsidence. The predictive model showed excellent discrimination (AUC\u0026thinsp;=\u0026thinsp;0.896, 95% CI 0.821\u0026ndash;0.970) and remained robust after internal validation (bootstrap-corrected AUC\u0026thinsp;~\u0026thinsp;0.886). It also demonstrated good calibration and a positive net clinical benefit on decision curve analysis.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe major risk factors for 3D-printed vertebral body subsidence (poor bone quality and weak endplate integrity) are similar to those for conventional cages. Our imaging-based nomogram provides accurate risk stratification to guide personalized surgical strategies\u0026mdash;such as bone density optimization or use of larger implants in high-risk cases\u0026mdash;while avoiding unnecessary interventions in low-risk patients.\u003c/p\u003e","manuscriptTitle":"Preoperative Imaging Predictors of Subsidence of 3D-Printed Artificial Cervical Vertebral Bodies: A Cohort Study of 102 Patients With Nomogram Development and Validation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-13 18:29:41","doi":"10.21203/rs.3.rs-8209819/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-17T12:39:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T09:35:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T04:37:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118811493672332704683644604806675037429","date":"2025-12-15T09:44:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"269733244345799015965973621687161502419","date":"2025-12-14T21:44:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-14T05:20:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-13T02:05:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157024481700326735866963247724946074407","date":"2025-12-13T00:58:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50708781820470331479978172678156665884","date":"2025-12-11T01:39:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-10T13:17:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-10T01:41:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182769559351417672494150991937707181702","date":"2025-12-09T23:55:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138499365309841419311865960375230490857","date":"2025-12-09T21:16:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329554816701906542255274839718914085187","date":"2025-12-09T15:06:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74491286012494716237982770034078550909","date":"2025-12-09T13:56:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-09T12:32:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-28T17:56:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-27T10:14:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-27T10:13:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-11-26T07:11:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a7b4647c-12a3-48fb-88f1-f7a709ff1de8","owner":[],"postedDate":"December 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:07:12+00:00","versionOfRecord":{"articleIdentity":"rs-8209819","link":"https://doi.org/10.1186/s12891-026-09676-2","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2026-03-06 15:57:27","publishedOnDateReadable":"March 6th, 2026"},"versionCreatedAt":"2025-12-13 18:29:41","video":"","vorDoi":"10.1186/s12891-026-09676-2","vorDoiUrl":"https://doi.org/10.1186/s12891-026-09676-2","workflowStages":[]},"version":"v1","identity":"rs-8209819","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8209819","identity":"rs-8209819","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}