Modified vertebral bone quality score is a better predictor of cage subsidence after transforaminal lumbar interbody fusion and is superior to vertebral bone quality score

Modified vertebral bone quality score is a better predictor of cage subsidence after transforaminal lumbar interbody fusion and is superior to vertebral bone quality score | 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 Modified vertebral bone quality score is a better predictor of cage subsidence after transforaminal lumbar interbody fusion and is superior to vertebral bone quality score Xingyu Shao, Youwei Ai, Chen Qian, Ce Zhu, Juehan Wang, Hong Ding, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6320872/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Jul, 2025 Read the published version in European Spine Journal → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose This study aimed to compare the effectiveness of the modified vertebral bone quality (MVBQ) score and the traditional vertebral bone quality (VBQ) score in predicting cage subsidence following transforaminal lumbar interbody fusion (TLIF), using quantitative computed tomography (QCT) for validation. Methods W We performed a retrospective analysis of patients who underwent single-level TLIF surgery for spinal degeneration between 2014 and 2022. VBQ and MVBQ scores are calculated based on T1-weighted MRI. Standard L1/2 volume bone mineral density (vBMD) was measured using preoperative lumbar CT images. Disc height and cage sinking were measured using mid-sagittal CT images. All patients were divided into cage sedimentation group and non-sedimentation group, and statistical analysis was performed. Results A total of 359 patients were included in the study, and 55 (15.3%) experienced cage sedimentation. There were significant differences in gender, QCT, VBQ, and MVBQ scores between the cage subsidence and no cage subsidence groups. Multivariate logistic regression analysis revealed that gender, QCT-vBMD, VBQ score, and MVBQ score were important factors for cage subsidence. Both VBQ and MVBQ scores were inversely correlated with QCT - vBMD, with MVBQ showing a better correlation (r = -0.300 p < 0.001 vs r = -0.376 p < 0.001). ROC analysis showed that the MVBQ score was superior to the VBQ score in predicting cage subsidence (AUC 0.802vs 0.780). Conclusion Both MVBQ and VBQ scores are effective in predicting postoperative cage subsidence after TLIF and can serve as simple, convenient, and reliable preoperative assessment tools. The MVBQ score demonstrates a relatively better predictive effect than the VBQ score. MVBQ VBQ QCT cage subsidence TILF Figures Figure 1 Figure 2 Introduction Lumbar degenerative diseases are among the common spinal conditions. With the advancements in spinal surgery, numerous effective procedures have developed, including transforaminal lumbar interbody fusion (TLIF), which is favored for its lower complication rate and rapid postoperative recovery[ 1 – 4 ]. Cage subsidence is one of the most common postoperative complications, occurring in more than 14.8% of TLIF surgery[ 4 , 5 ]. This complication is a major factor in symptom recurrence and surgical revision [ 6 , 7 ], causing cumbersome financial burden and physical and psychological distress to patients. Low bone mineral density (BMD) is widely recognized as a risk factor for cage subsidence in many studies [ 8 , 9 ]. BMD has been shown to correlate with vertebral loading and structural properties and to relate to cage stabilization through biomechanical studies[ 8 , 10 , 11 ]. Therefore, accurate preoperative evaluation of BMD can reduce postoperative complications and accelerate perioperative recovery [ 8 ]. The current gold standard for assessing BMD is dual-energy x-ray absorptiometry (DEXA) [ 12 ]. However, it is a two-dimensional measurement with some limitations; for example, lumbar degenerative diseases can lead to DEXA results higher than the actual value[ 13 – 15 ]. Additionally, patients’ nonadherence resulted in a low BMD screening [ 16 , 17 ]. An alternative measurement is quantitative computed tomography (QCT), which is a three-dimensional measurement that is not affected by lumbar degenerative disease or vascular calcification [ 14 , 18 ], but it has higher radiation exposure and is more expensive. Ehresman et al. proposed a magnetic resonance imaging (MRI) based vertebral bone quality (VBQ) score [ 19 , 20 ]. Previous studies have shown that VBQ score is correlated with QCT-measured BMD and can predict postoperative complications following lumbar fusion [ 21 – 23 ]. Moreover, almost all patients underwent MRI before surgery, avoiding an additional financial burdens and potential radiation exposure. However, considering the anatomical structure of the vertebral body and the spatial distribution of intramedullary fat, and the fact that intramedullary fat tend to move to the posterior half of the vertebral body with age[ 24 , 25 ], it can affect the accuracy of conventional VBQ score measurement. Therefore, a modified VBQ (MVBQ) was proposed, which more comprehensively takes into account the anatomical structure of the vertebral body and fat distribution [ 26 ]. Previous studies have demonstrated that the MVBQ scores correlate with BMD[ 26 , 27 ]. There is a lack of research exploring the relationship between MVBQ and cage subsidence. Based on the anatomy of the vertebral body, the objective of this study was to compare the effectiveness of VBQ and MVBQ in predicting cage subsidence following TLIF by assessing BMD, using QCT for validation. Methods Patient population This study retrospectively analyzed patients who underwent single-level TLIF surgery for spinal degeneration at our medical institution between 2014 and 2022. The study was approved by our institutional review board, which waived the requirement for informed consent, as all patients agreed at the time of surgery to have their anonymous medical data analyzed and published for research purposes. Inclusion criteria were (1) patients > 18 years of age, (2) single-level TLIF for the treatment of degenerative lumbar spine disease, and (3) completion of preoperative x-ray, computed tomography (CT) and MRI examinations. Patients with previous history of lumbar spine surgery, metabolic bone disease, obligatory spondylolisthesis, history of tumor, history of radiotherapy, spinal infection, and spinal trauma were excluded. Patients were followed for at least 12 months, and all procedures were performed by a senior spine surgeon. Measurement and calculation of VBQ and MVBQ Scores Both scores were calculated from T1-weighted MRIs. The VBQ score was measured by placing an elliptical ROI in the medullary portion of the L1-L4 vertebral bodies and cerebrospinal fluid at the L3 level on midsagittal T1-weighted MRI images as in Fig. 1 A Equation 1: VBQ score L1−4 = \(\:\frac{{SIL\:}_{L1-4}}{{SI}_{CSF}}\) The MVBQ score is measured by placing the elliptical ROI in the anterior 1/2 portion of the L1-L4 vertebral body and the L3 level of the cerebrospinal fluid on a mid-sagittal T1-weighted MRI image, as in Fig. 1 B. Equation 2: MVBQ score L1−4 = \(\:\frac{{Median\:SI\:}_{L1-4}}{{SI\:}_{CSF}}\) Measurement of BMD We measured the standard L1/2 volumetric BMD (vBMD), utilizing lumbar spine CT images obtained before surgery. Calibration was performed with a Mindways calibration phantom (Mindways Software Inc., Austin, USA). The ROI was selected in the median plane of the L1/2 vertebral body. Adjusting the ROI region avoids the cortical bone of the vertebral body and the veins posteriorly. If one of the vertebral bodies in L1-L2 does not meet the measurement requirements due to abnormal conditions (such as wedge compression, surgery, bone destruction, etc.), a neighboring vertebral body is selected as an alternative. Determination of disc height and cage subsidence Disc height and subsidence were measured using midsagittal CT images preoperatively, 3 days postoperatively, 6 months postoperatively, and at the last follow-up. Disc height (DH) was calculated using Farfan’s index with the formula: DH=[(a + b)/c] * 100%, (a is the anterior disc height, b is the posterior disc height, and c is the sagittal width of the disc). Cage subsidence was defined as the distance between the midpoint of the cage and the posterior edge of the superior endplate of the inferior vertebral body when the cage protrudes more than 2 mm from the endplate. All imaging scores were averaged after being independently measured by two orthopedic surgeons who were not involved in the surgery and had no information about the outcome of interest. Data collection We collected data on gender, age, BMI, hypertension, diabetes mellitus, history of smoking, history of alcohol consumption, Charlson co-morbidity index (CCI), Modic changes, diagnosis, surgical level of the patients, and volumetric BMD measured by QCT (QCT-vBMD). Additionally, MVBQ and 3D-MVBQ scores, DH, cage position and cage subsidence were measured based on perioperative and follow-up imaging. Statistical analysis All data were analyzed using SPSS Statistics version 27.0 (IBM Corp) software. Results for continuous variables were expressed as mean ± standard deviation (SD). While quantitative variables were expressed as percentage. All patients were divided into two groups: cage subsidence group and non-subsidence group. Descriptive statistics were used to compare demographic data between the two groups, with continuous variables assessed the t-test and categorical variables using chi-squared test or Fisher's exact test. A p < 0.05 was considered statistically significant. Multivariate logistic regression analysis was conducted to explore the potential risk factors for cage subsidence, with the results reported as odds ratios (ORs) and 95% confidence intervals (CIs). The VBQ score and MVBQ was compared with the QCT-vBMD using Pearson’s correlation. Receiver operating characteristic (ROC) curves were calculated to determine separation criteria between the subsidence and non-subsidence groups, and the ability to predict subsidence was assessed based on factors that assessed based on the area under the curve (AUC). Result A total of 359 patients (60.4% female) who underwent single-level TLIF met our inclusion criteria, with a mean age of 57.8 ± 12.5 years and a mean follow-up of 21.7 ± 10.2 months. Of the 359 patients, 55 patients (15.3%) experienced cage subsidence while 304 patients (84.7%) did not. There was a statistically significant difference between the subsidence and non-subsidence groups in terms of gender (p = 0.043), QCT (p < 0.001), VBQ (p < 0.001) and MVBQ (p < 0.001). However, there was no significant difference in age, BMI, cigarette smoking, alcohol consumption, type 2 diabetes mellitus, hypertension, Modic change, CCI, diagnosis, surgical level there was no significant difference ( Table 1 ) . Table 1. Demographics data of the study population (n=359), grouping according to whether they experienced cage subsidence or not Demographics data All (n=359) No subsidence (n=304) Subsidence (n=55) P Gender, Male Female 142 (39.6) 217 (60.4) 127 (41.8) 177 (58.2) 15 (27.3) 40 (72.7) 0.043 Age 57.8±12.5 57.2±12.8 60.7±10.5 0.078 BMI (kg/m²) 24.1±3.3 24.1±3.3 23.7±3.1 0.589 Smoke, Yes No 71 (19.8) 288 (80.2) 63 (20.7) 241 (79.3) 8 (14.5) 47 (85.5) 0.290 Alcohol consumption, Yes No 61 (17.0) 298 (83.0) 53 (17.4) 251 (82.6) 8 (14.5) 47 (85.5) 0.600 Diabetes 50 (13.9) 42 (13.8) 8 (14.5) 0.780 Hypertension 120 (33.4) 97 (31.9) 23 (41.8) 0.152 Modic change, 0 1 2 3 193 (53.8) 67 (18.7) 80 (22.3) 19 (5.3) 159 (52.3) 61 (20.1) 69 (22.7) 15 (4.9) 34 (61.8) 6 (10.9) 11 (20.0) 4 (7.3) 0.301 CCI, 0 1 2 and over 44 (12.3) 107 (29.8) 208 (57.9) 37 (12.2) 91 (29.9) 176 (57.9) 7 (12.7) 16 (29.1) 32 (58.2) 0.998 Diagnosis, Lumbar stenosis Degenerative spondylolisthesis Spondylolytic spondylolisthesis Herniated intervertebral disc 211 (58.8) 73 (20.3) 50 (13.9) 25 (7.0) 181 (59.5) 61 (20.1) 41 (13.5) 21 (6.9) 30 (54.5) 12 (21.8) 9 (16.4) 4 (7.3) 0.866 Surgical level, L1-2 L2-3 L3-4 L4-5 L5-S1 7 (1.9) 4 (1.1) 20 (5.6) 188 (52.4) 140 (39.0) 6 (2.0) 2 (0.7) 16 (5.3) 162 (53.3) 118 (38.8) 1 (1.8) 2 (3.6) 4 (7.3) 26 (47.3) 22 (40.0) 0.332 Preop disc height 52.3±15.6 52.6±15.2 50.3±17.5 0.161 Postop disc height 70.7±20.1 71.1±20.3 68.1±18.5 0.955 Change of disc height 1.4±0.5 1.4±0.5 1.5±0.6 0.467 QCT-vBMD 128.3±28.3 132.8±27.4 103.5±18.6 ＜ 0.001 VBQ score 3.2±0.6 3.1±0.6 3.178±0.662 ＜ 0.001 MVBQ score 3.1±0.6 2.968±0.6 3.598±0.570 ＜ 0.001 BMI, body mass index; QCT, quantitative computed tomography; VBQ, vertebral bone mass score; MVBQ, modified vertebral bone mass score Change of disc height = (preop disc height + postop disc height)/postop disc height Bold font indicates statistically significant In multivariate logistic regression, sex (OR 0.402, 95% CI 0.185–0.870, p = 0.021), QCT-vBMD (OR 0.962, 95% CI 0.945–0.980, p < 0.001), VBQ score (OR 2.034, 95% CI 1.179–3.507, p = 0.011), and MVBQ score (OR 2.277, 95% CI 1.279–4.055, p = 0.005) were significant factors for cage subsidence (Table 2 ). Both VBQ (r = -0.300 p < 0.001) and MVBQ scores (r = -0.376 p < 0.001) were negatively correlated with QCT-vBMD. MVBQ correlates better with QCT-vBMD. Table 2 Multivariable logistic regression analysis of patients Odds ratio 95% Confidence interval P Sex 0.402 0.185, 0.870 0.021 Age 0.997 0.966, 1.029 0.865 Preop disc height 0.994 0.967, 1.021 0.647 Postop disc height 0.999 0.976, 1.023 0.965 Change of disc height 1.400 0.751, 2.609 .385 VBQ score 2.034 1.179, 3.507 .011 MVBQ score 2.277 1.279, 4.055 .005 QCT-vBMD 0.962 0.945, 0.980 <.001 Bold font indicates statistically significant For ROC analysis, the QCT-vBMD cut-off value was 117.1, with sensitivity 0.818 and specificity 0.818 (p < 0.001); the VBQ cut-off value was 3.335, with sensitivity 0.782 and specificity 0.711 (p = 0.011); the MVBQ cut-off value was 3.252, with sensitivity 0.818 and specificity 0.740 (p = 0.005) (Fig. 2 ). MVBQ score was relatively better than the VBQ score for predicting cage subsidence (AUC 0.802vs 0.780). Discussion To our knowledge, this is the first study to evaluate the MVBQ score for predicting cage subsidence after TLIF based on QCT. Meanwhile, we first introduced the 3D-MVBQ score, which was based on the three-dimensional structure of the vertebral body, and compared its predictive value for cage subsidence after TLIF with that of the MVBQ score. Both scores can effectively predict postoperative cage subsidence, with the 3D-MVBQ may perform better with higher sensitivity and specificity (Fig. 2 ). Previous studies have reported that age, gender, smoking, low BMD, disc height, and cage position are risk factors for cage subsidence[ 28 – 31 ]. In our study, the subsidence group had a higher proportion of females and a lower BMD, which is consistent with previous studies. It is not surprising that lower BMD decreases, secondary to decreased estrogen levels in postmenopausal women [ 32 – 34 ] is associated with lower biomechanical properties of the vertebral body[ 18 , 34 ]. Although the prevalence of osteoporosis increased with age[ 35 ], age was not a risk factor for cage subsidence in our study (p = 0.078). Because the main risk factor for cage subsidence is low BMD[ 36 ], older patients are more likely to develop cage subsidence because of low BMD, not age. A previous study found no significant difference between VBQ and MVBQ scores when BMI values were low[ 26 ]. This may be because both VBQ and MVBQ scores measure the degree of fat infiltration and are somewhat influenced by BMI. Numerous studies have demonstrated that BMD is a crucial predictor of bone strength [ 37 – 39 ]. Subsidence has been proven to result from an imbalance in the strength matching between the bone interface and the cage [ 40 ].The lower BMD observed in the subsidence group in the present study (103.5 ± 18.6 vs. 132.8 ± 27.4, p < 0.001), along with the logistic regression analysis indicating that BMD was one of the risk factors for cage subsidence (QCT-vBMD (OR 0.962, 95% CI 0.945–0.980, p < 0.001)), were both consistent with this view. Considering patient non-adherence, degenerative factors, and radiation exposure, the low screening rate and accuracy of BMD measurement based on existing modalities will undoubtedly increase the additional risk to patients [ 12 , 41 , 42 ]. In recent years, researchers have found that osteoporosis was accompanied by adipocyte infiltration of bone, and the degree of adipocyte infiltration reflected the severity of osteoporosis[ 43 ]. It is based on the premise that the trabecular bone of the vertebral body partially atrophies and is replaced by adipocytes in osteoporosis. Fat-substituted bone appears more compact on T1-weighted images. Ehresman et al. proposed VBQ score [ 44 ], where higher VBQ scores were associated with more fat replacement and lower bone quality. However, it has been shown that the fat in the vertebral bone marrow migrates posteriorly with age[ 25 , 45 ] and the presence of a large number of venous vessels in the posterior aspect of the vertebral body all affect the signal intensity of T1-weighted images at L1 to L4, leading to over-scoring of the VBQ. Therefore, based on the VBQ score, Li et al. proposed the MVBQ score to better reflect the characteristics of vertebral fat infiltration[ 26 ]. In our study, both MVBQ and VBQ scores were negatively correlated with BMD, with MVBQ score showing a better correlation (-0.376 vs. -0.300, p < 0.001). The results were comparable with those of previous studies [ 46 , 47 ]. Since almost all patients undergo MRI before spinal surgery, the use of the VBQ and MVBQ to assess BMD provides an excellent screening rate without additional financial burden or radiation exposure to the patient. Therefore, BMD can be assessed by using VBQ scores and MVBQ scores to predict cage subsidence. Previous studies have also demonstrated that the VBQ score was a good identifier of osteoporosis and a good predictor of cage subsidence, screw loosening and proximal junctional kyphosis[ 48 – 50 ]. These indicated that the VBQ score not only correlated well with BMD but also demonstrated an excellent ability to predict BMD-related complications after lumbar surgery. In our study, both MVBQ and VBQ scores were identified as risk factors for cage subsidence following TLIF (p<0.001;p<0.001). Furthermore, to our knowledge, it was the first study to assess the ability of the MVBQ score to predict cage subsidence following TLIF and the first to compare the validity of the VBQ score with the MVBQ score using ROC analysis. Our results demonstrated that MVBQ score outperformed better than VBQ score (AUC 0.802 sensitivity 0.818 and specificity 0.740 vs AUC 0.780 sensitivity 0.782 and specificity 0.711). This is not surprising. Firstly, the MVBQ score avoids the influence of factors in the posterior part of the vertebral body, making the measured value more reflective of the patient’s BMD. Additionally, the VBQ scores of most patients were higher than the MVBQ score, which is a good validation that the MVBQ score is more in line with vertebral anatomy and individual differences. Study limitations This study has some limitations. Firstly, it is a retrospective and single-center study and requiring supplementation by prospective studies. Secondly, this study lacked a longer follow-up period to examine the relationship of cage subsidence and other complications with preoperative VBQ score and MVBQ score. Thirdly, we did not compare patient reported outcome measures (PROMs) such as the Visual Analogue Scale (VSA) and the Oswestry Disability Index (ODI). Finally, we did not analyze the position of the cage in the intervertebral disc. Conclusions In this study, based on QCT, we compared the ability of the MVBQ score and the VBQ score to predict cage subsidence after single-level TLIF. Both scores showed a good correlation with BMD and can be used as simple, convenient, and reliable tools for preoperative prediction of cage subsidence after TLIF. The MVBQ score demonstrates a relatively better predictive effect. Declarations Ethics approval and consent to participate Ethical approval was obtained from the Ethics Committee on Biomedical Research West China Hospital of Sichuan University. 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Eur Spine J, 2024. 33 (1): p. 289-297. Wang, J., et al., Vertebral bone quality score as a novel predictor of proximal junctional kyphosis after thoracic adolescent idiopathic scoliosis surgery. Eur Spine J, 2023. 32 (11): p. 3996-4002. Additional Declarations No competing interests reported. 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University","correspondingAuthor":false,"prefix":"","firstName":"Youwei","middleName":"","lastName":"Ai","suffix":""},{"id":439912870,"identity":"2c2be647-5d49-488e-9b3a-671fe0ac0835","order_by":2,"name":"Chen Qian","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Chen","middleName":"","lastName":"Qian","suffix":""},{"id":439912871,"identity":"ef9977a1-8960-4e6a-83c7-cc5b7385e47b","order_by":3,"name":"Ce Zhu","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Ce","middleName":"","lastName":"Zhu","suffix":""},{"id":439912872,"identity":"0ef43fed-838f-48fa-89b2-d7900d97d3c7","order_by":4,"name":"Juehan Wang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Juehan","middleName":"","lastName":"Wang","suffix":""},{"id":439912873,"identity":"bddaf52d-0db2-4fc9-8174-5113f799a708","order_by":5,"name":"Hong Ding","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Ding","suffix":""},{"id":439912874,"identity":"3947fe12-8b06-4038-a169-e7a678afd5b5","order_by":6,"name":"Dun Luo","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Dun","middleName":"","lastName":"Luo","suffix":""},{"id":439912875,"identity":"d3a1f300-7ad1-4c88-8b7e-901e4b130512","order_by":7,"name":"Zhuojie Xiao","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Zhuojie","middleName":"","lastName":"Xiao","suffix":""},{"id":439912876,"identity":"8ba1814b-9e0f-49d1-8e23-b37c52113107","order_by":8,"name":"Yongdi Wang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Yongdi","middleName":"","lastName":"Wang","suffix":""},{"id":439912877,"identity":"f9cbc8e9-f0da-4929-91dd-38acde97e9ca","order_by":9,"name":"Chunguang Zhou","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Chunguang","middleName":"","lastName":"Zhou","suffix":""},{"id":439912879,"identity":"65c17d58-bc79-45ea-8461-ad2365b260ff","order_by":10,"name":"Lei Wang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Wang","suffix":""},{"id":439912881,"identity":"2e5ea5d8-fcf4-4210-9843-210171230058","order_by":11,"name":"Jing Tang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Tang","suffix":""},{"id":439912884,"identity":"8bd17158-b87a-4b8f-8795-dcd9e94e9566","order_by":12,"name":"Limin Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIie2PsQqCUBSGj1yw5dRdFXoItwokX0UJmkSEloaIC0LPYI/R4nzlQpPWAzj5BkpTS3SxkiZ1DLrfdH74P/gPgELxg0wIaNwFowkcwEZKWbeiE9n8UtZTM+Y9yqvZImyLuT3KCC1e+vMAaJ6KcHtFC7hW1X7XMKl4ibEBI3BFnBU4I4yYx6Rf8ZiBlhgfClwwrpPxIIVmUnlcZHSHKuBLhfEhih6+h8lf8LxCM06jzl8oFafynuzlsFzccLd0KI3Squ5QWhyOn1NjA/oN2F9RKBSK/+QJj35Nzm4pw98AAAAASUVORK5CYII=","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Limin","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-03-27 13:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6320872/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6320872/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00586-025-09178-0","type":"published","date":"2025-07-26T15:57:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81014838,"identity":"4335014b-7183-4c7f-b745-c53a1eaa9054","added_by":"auto","created_at":"2025-04-21 08:45:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":406696,"visible":true,"origin":"","legend":"\u003cp\u003eOrtho-sagittal, T1-weighted, MRI images. An ellipse is used to represent the region of interest for the calculation of VBQ and MVBQ scores “Area” refers to the area (cm²) of the region of interest; “Mean,” mean value; “Max,” maximum grayscale values in the region of interest; “min,” minimum grayscale values in the region of interest; “SDev,” standard deviation of the grayscale values within the region of interest.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6320872/v1/ee95cda8cb00699c1e875e38.png"},{"id":81013593,"identity":"69915972-d9cc-42fa-b8aa-ef0093c9bb8c","added_by":"auto","created_at":"2025-04-21 08:37:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":90042,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operating characteristic curves to assess the ability of MVBQ, 3D-MVBQ, QCT-vBMD to predict cage subsidence among patients\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6320872/v1/b647a324ae4e34e96a157bbe.png"},{"id":87756849,"identity":"6230736d-b4c1-4ce1-90d6-7be45acc4231","added_by":"auto","created_at":"2025-07-28 16:09:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1593038,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6320872/v1/40b1ba06-1dd8-44f0-834d-e2870a9d246f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eModified vertebral bone quality score is a better predictor of cage subsidence after transforaminal lumbar interbody fusion and is superior to vertebral bone quality score\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLumbar degenerative diseases are among the common spinal conditions. With the advancements in spinal surgery, numerous effective procedures have developed, including transforaminal lumbar interbody fusion (TLIF), which is favored for its lower complication rate and rapid postoperative recovery[\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Cage subsidence is one of the most common postoperative complications, occurring in more than 14.8% of TLIF surgery[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This complication is a major factor in symptom recurrence and surgical revision [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], causing cumbersome financial burden and physical and psychological distress to patients.\u003c/p\u003e \u003cp\u003eLow bone mineral density (BMD) is widely recognized as a risk factor for cage subsidence in many studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. BMD has been shown to correlate with vertebral loading and structural properties and to relate to cage stabilization through biomechanical studies[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, accurate preoperative evaluation of BMD can reduce postoperative complications and accelerate perioperative recovery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current gold standard for assessing BMD is dual-energy x-ray absorptiometry (DEXA) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, it is a two-dimensional measurement with some limitations; for example, lumbar degenerative diseases can lead to DEXA results higher than the actual value[\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Additionally, patients\u0026rsquo; nonadherence resulted in a low BMD screening [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. An alternative measurement is quantitative computed tomography (QCT), which is a three-dimensional measurement that is not affected by lumbar degenerative disease or vascular calcification [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], but it has higher radiation exposure and is more expensive. Ehresman et al. proposed a magnetic resonance imaging (MRI) based vertebral bone quality (VBQ) score [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Previous studies have shown that VBQ score is correlated with QCT-measured BMD and can predict postoperative complications following lumbar fusion [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Moreover, almost all patients underwent MRI before surgery, avoiding an additional financial burdens and potential radiation exposure. However, considering the anatomical structure of the vertebral body and the spatial distribution of intramedullary fat, and the fact that intramedullary fat tend to move to the posterior half of the vertebral body with age[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], it can affect the accuracy of conventional VBQ score measurement. Therefore, a modified VBQ (MVBQ) was proposed, which more comprehensively takes into account the anatomical structure of the vertebral body and fat distribution [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies have demonstrated that the MVBQ scores correlate with BMD[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. There is a lack of research exploring the relationship between MVBQ and cage subsidence. Based on the anatomy of the vertebral body, the objective of this study was to compare the effectiveness of VBQ and MVBQ in predicting cage subsidence following TLIF by assessing BMD, using QCT for validation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient population\u003c/h2\u003e \u003cp\u003eThis study retrospectively analyzed patients who underwent single-level TLIF surgery for spinal degeneration at our medical institution between 2014 and 2022. The study was approved by our institutional review board, which waived the requirement for informed consent, as all patients agreed at the time of surgery to have their anonymous medical data analyzed and published for research purposes. Inclusion criteria were (1) patients \u0026gt; 18 years of age, (2) single-level TLIF for the treatment of degenerative lumbar spine disease, and (3) completion of preoperative x-ray, computed tomography (CT) and MRI examinations. Patients with previous history of lumbar spine surgery, metabolic bone disease, obligatory spondylolisthesis, history of tumor, history of radiotherapy, spinal infection, and spinal trauma were excluded. Patients were followed for at least 12 months, and all procedures were performed by a senior spine surgeon.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasurement and calculation of VBQ and MVBQ Scores\u003c/h3\u003e\n\u003cp\u003eBoth scores were calculated from T1-weighted MRIs. The VBQ score was measured by placing an elliptical ROI in the medullary portion of the L1-L4 vertebral bodies and cerebrospinal fluid at the L3 level on midsagittal T1-weighted MRI images as in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA\u003c/p\u003e\n\u003ch3\u003e\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cem\u003eEquation 1: VBQ score\u003c/em\u003e \u003csub\u003e\u003cem\u003eL1−4\u003c/em\u003e\u003c/sub\u003e \u003cem\u003e=\u003c/em\u003e \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{{SIL\\:}_{L1-4}}{{SI}_{CSF}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/div\u003e \u003cp\u003eThe MVBQ score is measured by placing the elliptical ROI in the anterior 1/2 portion of the L1-L4 vertebral body and the L3 level of the cerebrospinal fluid on a mid-sagittal T1-weighted MRI image, as in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB.\u003c/p\u003e\n\u003ch3\u003e \u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cem\u003eEquation 2: MVBQ score\u003c/em\u003e \u003csub\u003e\u003cem\u003eL1−4\u003c/em\u003e\u003c/sub\u003e \u003cem\u003e=\u003c/em\u003e \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{{Median\\:SI\\:}_{L1-4}}{{SI\\:}_{CSF}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/div\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eMeasurement of BMD\u003c/h3\u003e\n\u003cp\u003eWe measured the standard L1/2 volumetric BMD (vBMD), utilizing lumbar spine CT images obtained before surgery. Calibration was performed with a Mindways calibration phantom (Mindways Software Inc., Austin, USA). The ROI was selected in the median plane of the L1/2 vertebral body. Adjusting the ROI region avoids the cortical bone of the vertebral body and the veins posteriorly. If one of the vertebral bodies in L1-L2 does not meet the measurement requirements due to abnormal conditions (such as wedge compression, surgery, bone destruction, etc.), a neighboring vertebral body is selected as an alternative.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDetermination of disc height and cage subsidence\u003c/h2\u003e \u003cp\u003eDisc height and subsidence were measured using midsagittal CT images preoperatively, 3 days postoperatively, 6 months postoperatively, and at the last follow-up. Disc height (DH) was calculated using Farfan’s index with the formula: DH=[(a + b)/c] * 100%, (a is the anterior disc height, b is the posterior disc height, and c is the sagittal width of the disc). Cage subsidence was defined as the distance between the midpoint of the cage and the posterior edge of the superior endplate of the inferior vertebral body when the cage protrudes more than 2 mm from the endplate.\u003c/p\u003e \u003cp\u003eAll imaging scores were averaged after being independently measured by two orthopedic surgeons who were not involved in the surgery and had no information about the outcome of interest.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eWe collected data on gender, age, BMI, hypertension, diabetes mellitus, history of smoking, history of alcohol consumption, Charlson co-morbidity index (CCI), Modic changes, diagnosis, surgical level of the patients, and volumetric BMD measured by QCT (QCT-vBMD). Additionally, MVBQ and 3D-MVBQ scores, DH, cage position and cage subsidence were measured based on perioperative and follow-up imaging.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll data were analyzed using SPSS Statistics version 27.0 (IBM Corp) software. Results for continuous variables were expressed as mean ± standard deviation (SD). While quantitative variables were expressed as percentage.\u003c/p\u003e \u003cp\u003eAll patients were divided into two groups: cage subsidence group and non-subsidence group. Descriptive statistics were used to compare demographic data between the two groups, with continuous variables assessed the t-test and categorical variables using chi-squared test or Fisher's exact test. A p \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003eMultivariate logistic regression analysis was conducted to explore the potential risk factors for cage subsidence, with the results reported as odds ratios (ORs) and 95% confidence intervals (CIs). The VBQ score and MVBQ was compared with the QCT-vBMD using Pearson’s correlation. Receiver operating characteristic (ROC) curves were calculated to determine separation criteria between the subsidence and non-subsidence groups, and the ability to predict subsidence was assessed based on factors that assessed based on the area under the curve (AUC).\u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eA total of 359 patients (60.4% female) who underwent single-level TLIF met our inclusion criteria, with a mean age of 57.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5 years and a mean follow-up of 21.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 months. Of the 359 patients, 55 patients (15.3%) experienced cage subsidence while 304 patients (84.7%) did not. There was a statistically significant difference between the subsidence and non-subsidence groups in terms of gender (p\u0026thinsp;=\u0026thinsp;0.043), QCT (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), VBQ (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and MVBQ (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, there was no significant difference in age, BMI, cigarette smoking, alcohol consumption, type 2 diabetes mellitus, hypertension, Modic change, CCI, diagnosis, surgical level there was no significant difference \u003cstrong\u003e(\u003c/strong\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Demographics data of the study population (n=359), grouping according to whether they experienced cage subsidence or not\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"529\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographics data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll (n=359)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo subsidence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=304)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubsidence (n=55)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender,\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Male\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Female\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e142 (39.6)\u003c/p\u003e\n \u003cp\u003e217 (60.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e127 (41.8)\u003c/p\u003e\n \u003cp\u003e177 (58.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (27.3)\u003c/p\u003e\n \u003cp\u003e40 (72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.043\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e57.8\u0026plusmn;12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e57.2\u0026plusmn;12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e60.7\u0026plusmn;10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u0026sup2;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e24.1\u0026plusmn;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e24.1\u0026plusmn;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e23.7\u0026plusmn;3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.589\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoke,\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Yes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; No\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e71 (19.8)\u003c/p\u003e\n \u003cp\u003e288 (80.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63 (20.7)\u003c/p\u003e\n \u003cp\u003e241 (79.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (14.5)\u003c/p\u003e\n \u003cp\u003e47 (85.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.290\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol consumption,\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Yes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; No\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e61 (17.0)\u003c/p\u003e\n \u003cp\u003e298 (83.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53 (17.4)\u003c/p\u003e\n \u003cp\u003e251 (82.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (14.5)\u003c/p\u003e\n \u003cp\u003e47 (85.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.600\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e50 (13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e42 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e8 (14.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.780\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e120 (33.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e97 (31.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e23 (41.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.152\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModic change,\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e193 (53.8)\u003c/p\u003e\n \u003cp\u003e67 (18.7)\u003c/p\u003e\n \u003cp\u003e80 (22.3)\u003c/p\u003e\n \u003cp\u003e19 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e159 (52.3)\u003c/p\u003e\n \u003cp\u003e61 (20.1)\u003c/p\u003e\n \u003cp\u003e69 (22.7)\u003c/p\u003e\n \u003cp\u003e15 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34 (61.8)\u003c/p\u003e\n \u003cp\u003e6 (10.9)\u003c/p\u003e\n \u003cp\u003e11 (20.0)\u003c/p\u003e\n \u003cp\u003e4 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.301\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI,\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 2 and over\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e44 (12.3)\u003c/p\u003e\n \u003cp\u003e107 (29.8)\u003c/p\u003e\n \u003cp\u003e208 (57.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (12.2)\u003c/p\u003e\n \u003cp\u003e91 (29.9)\u003c/p\u003e\n \u003cp\u003e176 (57.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (12.7)\u003c/p\u003e\n \u003cp\u003e16 (29.1)\u003c/p\u003e\n \u003cp\u003e32 (58.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis,\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Lumbar stenosis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDegenerative spondylolisthesis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSpondylolytic spondylolisthesis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHerniated intervertebral disc\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e211 (58.8)\u003c/p\u003e\n \u003cp\u003e73 (20.3)\u003c/p\u003e\n \u003cp\u003e50 (13.9)\u003c/p\u003e\n \u003cp\u003e25 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e181 (59.5)\u003c/p\u003e\n \u003cp\u003e61 (20.1)\u003c/p\u003e\n \u003cp\u003e41 (13.5)\u003c/p\u003e\n \u003cp\u003e21 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30 (54.5)\u003c/p\u003e\n \u003cp\u003e12 (21.8)\u003c/p\u003e\n \u003cp\u003e9 (16.4)\u003c/p\u003e\n \u003cp\u003e4 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.866\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical level,\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; L1-2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; L2-3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; L3-4\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; L4-5\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; L5-S1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (1.9)\u003c/p\u003e\n \u003cp\u003e4 (1.1)\u003c/p\u003e\n \u003cp\u003e20 (5.6)\u003c/p\u003e\n \u003cp\u003e188 (52.4)\u003c/p\u003e\n \u003cp\u003e140 (39.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (2.0)\u003c/p\u003e\n \u003cp\u003e2 (0.7)\u003c/p\u003e\n \u003cp\u003e16 (5.3)\u003c/p\u003e\n \u003cp\u003e162 (53.3)\u003c/p\u003e\n \u003cp\u003e118 (38.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003cp\u003e2 (3.6)\u003c/p\u003e\n \u003cp\u003e4 (7.3)\u003c/p\u003e\n \u003cp\u003e26 (47.3)\u003c/p\u003e\n \u003cp\u003e22 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.332\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreop disc height\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e52.3\u0026plusmn;15.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e52.6\u0026plusmn;15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e50.3\u0026plusmn;17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.161\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostop disc height\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e70.7\u0026plusmn;20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e71.1\u0026plusmn;20.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e68.1\u0026plusmn;18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.955\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange of disc height\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1.4\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1.4\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.5\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e0.467\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQCT-vBMD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e128.3\u0026plusmn;28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e132.8\u0026plusmn;27.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e103.5\u0026plusmn;18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVBQ\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003escore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3.2\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3.1\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.178\u0026plusmn;0.662\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMVBQ\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e3.1\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e2.968\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.598\u0026plusmn;0.570\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eBMI, body mass index; QCT, quantitative computed tomography; VBQ, vertebral bone mass score; MVBQ, modified vertebral bone mass score\u003c/p\u003e\n \u003cp\u003eChange of disc height = (preop disc height + postop disc height)/postop disc height\u003c/p\u003e\n \u003cp\u003eBold font indicates statistically significant\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eIn multivariate logistic regression, sex (OR 0.402, 95% CI 0.185\u0026ndash;0.870, p\u0026thinsp;=\u0026thinsp;0.021), QCT-vBMD (OR 0.962, 95% CI 0.945\u0026ndash;0.980, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), VBQ score (OR 2.034, 95% CI 1.179\u0026ndash;3.507, p\u0026thinsp;=\u0026thinsp;0.011), and MVBQ score (OR 2.277, 95% CI 1.279\u0026ndash;4.055, p\u0026thinsp;=\u0026thinsp;0.005) were significant factors for cage subsidence (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Both VBQ (r = -0.300 p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and MVBQ scores (r = -0.376 p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were negatively correlated with QCT-vBMD. MVBQ correlates better with QCT-vBMD.\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMultivariable logistic regression analysis of patients\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOdds ratio\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% Confidence interval\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.402\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.185, 0.870\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.021\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.997\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.966, 1.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.865\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreop disc height\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.994\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.967, 1.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.647\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostop disc height\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.976, 1.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.965\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChange of disc height\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.751, 2.609\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.385\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVBQ score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.179, 3.507\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e.011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMVBQ score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.277\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.279, 4.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQCT-vBMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.962\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.945, 0.980\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eBold font indicates statistically significant\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\n\u003cp\u003eFor ROC analysis, the QCT-vBMD cut-off value was 117.1, with sensitivity 0.818 and specificity 0.818 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); the VBQ cut-off value was 3.335, with sensitivity 0.782 and specificity 0.711 (p\u0026thinsp;=\u0026thinsp;0.011); the MVBQ cut-off value was 3.252, with sensitivity 0.818 and specificity 0.740 (p\u0026thinsp;=\u0026thinsp;0.005) (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). MVBQ score was relatively better than the VBQ score for predicting cage subsidence (AUC 0.802vs 0.780).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first study to evaluate the MVBQ score for predicting cage subsidence after TLIF based on QCT. Meanwhile, we first introduced the 3D-MVBQ score, which was based on the three-dimensional structure of the vertebral body, and compared its predictive value for cage subsidence after TLIF with that of the MVBQ score. Both scores can effectively predict postoperative cage subsidence, with the 3D-MVBQ may perform better with higher sensitivity and specificity (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrevious studies have reported that age, gender, smoking, low BMD, disc height, and cage position are risk factors for cage subsidence[\u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In our study, the subsidence group had a higher proportion of females and a lower BMD, which is consistent with previous studies. It is not surprising that lower BMD decreases, secondary to decreased estrogen levels in postmenopausal women [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] is associated with lower biomechanical properties of the vertebral body[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Although the prevalence of osteoporosis increased with age[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], age was not a risk factor for cage subsidence in our study (p\u0026thinsp;=\u0026thinsp;0.078). Because the main risk factor for cage subsidence is low BMD[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], older patients are more likely to develop cage subsidence because of low BMD, not age. A previous study found no significant difference between VBQ and MVBQ scores when BMI values were low[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This may be because both VBQ and MVBQ scores measure the degree of fat infiltration and are somewhat influenced by BMI.\u003c/p\u003e \u003cp\u003eNumerous studies have demonstrated that BMD is a crucial predictor of bone strength [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Subsidence has been proven to result from an imbalance in the strength matching between the bone interface and the cage [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].The lower BMD observed in the subsidence group in the present study (103.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6 vs. 132.8\u0026thinsp;\u0026plusmn;\u0026thinsp;27.4, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), along with the logistic regression analysis indicating that BMD was one of the risk factors for cage subsidence (QCT-vBMD (OR 0.962, 95% CI 0.945\u0026ndash;0.980, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)), were both consistent with this view. Considering patient non-adherence, degenerative factors, and radiation exposure, the low screening rate and accuracy of BMD measurement based on existing modalities will undoubtedly increase the additional risk to patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, researchers have found that osteoporosis was accompanied by adipocyte infiltration of bone, and the degree of adipocyte infiltration reflected the severity of osteoporosis[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. It is based on the premise that the trabecular bone of the vertebral body partially atrophies and is replaced by adipocytes in osteoporosis. Fat-substituted bone appears more compact on T1-weighted images. Ehresman et al. proposed VBQ score [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], where higher VBQ scores were associated with more fat replacement and lower bone quality. However, it has been shown that the fat in the vertebral bone marrow migrates posteriorly with age[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] and the presence of a large number of venous vessels in the posterior aspect of the vertebral body all affect the signal intensity of T1-weighted images at L1 to L4, leading to over-scoring of the VBQ. Therefore, based on the VBQ score, Li et al. proposed the MVBQ score to better reflect the characteristics of vertebral fat infiltration[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In our study, both MVBQ and VBQ scores were negatively correlated with BMD, with MVBQ score showing a better correlation (-0.376 vs. -0.300, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The results were comparable with those of previous studies [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Since almost all patients undergo MRI before spinal surgery, the use of the VBQ and MVBQ to assess BMD provides an excellent screening rate without additional financial burden or radiation exposure to the patient. Therefore, BMD can be assessed by using VBQ scores and MVBQ scores to predict cage subsidence.\u003c/p\u003e \u003cp\u003ePrevious studies have also demonstrated that the VBQ score was a good identifier of osteoporosis and a good predictor of cage subsidence, screw loosening and proximal junctional kyphosis[\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. These indicated that the VBQ score not only correlated well with BMD but also demonstrated an excellent ability to predict BMD-related complications after lumbar surgery. In our study, both MVBQ and VBQ scores were identified as risk factors for cage subsidence following TLIF (p\u0026lt;0.001;p\u0026lt;0.001). Furthermore, to our knowledge, it was the first study to assess the ability of the MVBQ score to predict cage subsidence following TLIF and the first to compare the validity of the VBQ score with the MVBQ score using ROC analysis. Our results demonstrated that MVBQ score outperformed better than VBQ score (AUC 0.802 sensitivity 0.818 and specificity 0.740 vs AUC 0.780 sensitivity 0.782 and specificity 0.711). This is not surprising. Firstly, the MVBQ score avoids the influence of factors in the posterior part of the vertebral body, making the measured value more reflective of the patient\u0026rsquo;s BMD. Additionally, the VBQ scores of most patients were higher than the MVBQ score, which is a good validation that the MVBQ score is more in line with vertebral anatomy and individual differences.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eThis study has some limitations. Firstly, it is a retrospective and single-center study and requiring supplementation by prospective studies. Secondly, this study lacked a longer follow-up period to examine the relationship of cage subsidence and other complications with preoperative VBQ score and MVBQ score. Thirdly, we did not compare patient reported outcome measures (PROMs) such as the Visual Analogue Scale (VSA) and the Oswestry Disability Index (ODI). Finally, we did not analyze the position of the cage in the intervertebral disc.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this study, based on QCT, we compared the ability of the MVBQ score and the VBQ score to predict cage subsidence after single-level TLIF. Both scores showed a good correlation with BMD and can be used as simple, convenient, and reliable tools for preoperative prediction of cage subsidence after TLIF. The MVBQ score demonstrates a relatively better predictive effect.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Committee on Biomedical Research West China Hospital of Sichuan University. For this type of study (retrospective study), formal consent is not required in China.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDevice Status/Drug Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Manuscript submitted does not contain information about medical device(s)/drug(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Competing Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no competing financial interests or personal relationships which might appear to influence the work reported in this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ede Kunder, S.L., et al., \u003cem\u003eTransforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis: a systematic review and meta-analysis.\u003c/em\u003e Spine J, 2017. \u003cstrong\u003e17\u003c/strong\u003e(11): p. 1712-1721.\u003c/li\u003e\n\u003cli\u003eHouten, J.K., et al., \u003cem\u003eClinical and radiographically/neuroimaging documented outcome in transforaminal lumbar interbody fusion.\u003c/em\u003e Neurosurg Focus, 2006. \u003cstrong\u003e20\u003c/strong\u003e(3): p. 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VBQ and MVBQ scores are calculated based on T1-weighted MRI. Standard L1/2 volume bone mineral density (vBMD) was measured using preoperative lumbar CT images. Disc height and cage sinking were measured using mid-sagittal CT images. All patients were divided into cage sedimentation group and non-sedimentation group, and statistical analysis was performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 359 patients were included in the study, and 55 (15.3%) experienced cage sedimentation. There were significant differences in gender, QCT, VBQ, and MVBQ scores between the cage subsidence and no cage subsidence groups. Multivariate logistic regression analysis revealed that gender, QCT-vBMD, VBQ score, and MVBQ score were important factors for cage subsidence. Both VBQ and MVBQ scores were inversely correlated with QCT - vBMD, with MVBQ showing a better correlation (r = -0.300 p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 vs r = -0.376 p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). ROC analysis showed that the MVBQ score was superior to the VBQ score in predicting cage subsidence (AUC 0.802vs 0.780).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBoth MVBQ and VBQ scores are effective in predicting postoperative cage subsidence after TLIF and can serve as simple, convenient, and reliable preoperative assessment tools. The MVBQ score demonstrates a relatively better predictive effect than the VBQ score.\u003c/p\u003e","manuscriptTitle":"Modified vertebral bone quality score is a better predictor of cage subsidence after transforaminal lumbar interbody fusion and is superior to vertebral bone quality score","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 08:37:13","doi":"10.21203/rs.3.rs-6320872/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-10T08:50:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-06T17:09:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2756618366249804727213978141138633147","date":"2025-05-18T15:10:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33832478127459867312180062458689083965","date":"2025-04-21T04:36:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-07T00:42:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155387736853713088279890003710127769143","date":"2025-04-06T12:29:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-29T06:50:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-28T07:45:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-28T07:45:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2025-03-27T13:04:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"63366f8e-64d1-4249-94ed-5da1c6979540","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-28T16:05:53+00:00","versionOfRecord":{"articleIdentity":"rs-6320872","link":"https://doi.org/10.1007/s00586-025-09178-0","journal":{"identity":"european-spine-journal","isVorOnly":false,"title":"European Spine Journal"},"publishedOn":"2025-07-26 15:57:41","publishedOnDateReadable":"July 26th, 2025"},"versionCreatedAt":"2025-04-21 08:37:13","video":"","vorDoi":"10.1007/s00586-025-09178-0","vorDoiUrl":"https://doi.org/10.1007/s00586-025-09178-0","workflowStages":[]},"version":"v1","identity":"rs-6320872","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6320872","identity":"rs-6320872","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}