Utilizing MRI and CT to identify risk factors associated with cage subsidence

Utilizing MRI and CT to identify risk factors associated with cage subsidence | 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 Utilizing MRI and CT to identify risk factors associated with cage subsidence Chaohui Ding, Changnan Xie, Jinwei Ying, Mengxian Jia, Ziwei Fan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6262321/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in European Journal of Medical Research → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: To identify risk factors associated with cage subsidence (CS) following single segment transforaminal lumbar interbody fusion (TLIF) and unilateral biportal endoscopic lumbar interbody fusion (ULIF) and to compare the predictive performance of various bone quality assessment methods using MRI and CT images. Methods: A total of 226 patients from 2021 to 2023 who underwent ULIF/TLIF because of lumbar disc herniation and lumbar spinal stenosis were enrolled. Subsidence of the cage into the vertebral body exceeding 2 mm was defined as CS and diagnosed using CT scans. Immediate endplate destruction (IED) was defined by CT and VBQ was measured through T1-weighted lumbar MRI. The independent sample t-test was employed to examine the risk factors associated with CS. Additionally, risk factors associated with CS were identified using logistic regression analysis. Lastly, the comparative predictive values were assessed through ROC curve analysis. Results: Logistic regression analysis revealed that increased postoperative posterior disc height (PPDH), higher segmental VBQ scores, higher mean VBQ (M-VBQ) scores, decreased segmental HU values, decreased mean HU (M-HU) values and immediate endplate destruction (IED) were associated with the occurrence of CS. The area under the curve (AUC) of the VBQ score was higher than that of the HU value, both in segment and in average. Conclusions : The incidence of CS was lower in ULIF compared to TLIF. High VBQ scores, low HU values, high PPDH and the presence of IED were associated with an increased risk of CS. Notably, the predictive value of both VBQ scores and HU values were high for CS, with the former potentially outperforming the latter. Unilateral biportal endoscopic lumbar interbody fusion immediate endplate destruction cage subsidence vertebral bone quality Hounsfield units Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Degenerative spinal diseases, which are among the most prevalent causes of disability, can result in back pain, radiculopathy, and spinal instability[ 1 ]. Ascribed to the aging population, their incidence is progressively rising[ 2 ]. Numerous therapeutic approaches are available for this condition, with transforaminal lumbar interbody fusion (TLIF) standing out as the preferred option and associated with favorable patient outcomes[ 2 ]. Considering that TLIF was initially characterized as an open surgical procedure, the growing utilization of minimally invasive techniques aims to mitigate injury to soft tissues[ 3 ]. ULIF represents an innovative approach to minimally invasive surgery, demonstrating efficacy in the treatment of degenerative spinal conditions[ 4 ]. Attributed to benefits such as its minimally invasive and traumatic nature and accelerated postoperative recovery, ULIF has garnered extensive attention and has been widely adopted by an increasing number of surgeons [ 4 , 5 ]. However, cage subsidence(CS) is a nonnegligible complication in lumbar fusion surgery that can prolong postoperative pain duration, loss of lumbar lordosis angle amd lead to pseudoarthrosis or revision surgery[ 6 , 7 ]. Its risk factors are multifactorial, encompassing age, body mass index (BMI), disc height, cage position and shape, modic change classification, and other factors[ 7 , 8 ]. Additionally, bone mineral density (BMD) and lumbar endplate destruction may be potential contributing factors in its development. At present, several quantitative indices are utilized to assess bone quality, including Dual-energy X-ray (DXA), Hounsfield units (HU), and vertebral quality (VBQ), with the former considered the current gold standard for the diagnosis of BMD[ 9 ]. However, previous compression fractures and aortic atherosclerosis can increase effective X-ray uptake, resulting in inaccuracies in diagnosis using DXA [ 10 ]. HU measured by computed tomography (CT) has been regarded as an effective means of assessing BMD[ 6 , 11 , 12 ].However, these two methods involve radiation exposure and impose a heavy financial burden on patients. Magnetic resonance imaging (MRI) based VBQ has recently been used to measure vertebral bone quality, with poor VBQ being one of the most accurate indicators of low BMD.[ 13 , 14 ]. Additionally, there is a paucity of research investigating immediate postoperative imaging and its correlation with the development of CS. Prior finite element analyses demonstrated that immediate endplate destruction (IED) can impact the biomechanics of the lumbar spine[ 15 ]. Nonetheless, studies exploring the clinical and imaging implications of IED and the incidence of CS are scarce. The objectives of this study were is to answer the following questions:1)Is there a disparity in the incidence of CS between ULIF and TILF? 2) What are the potential risk factors associated with CS after ULIF/TLIF? 3) Which specific method of bone mass imaging can effectively predict CS at one-year post-surgery? Materials and methods The study was approved by the institutional review board at our hospital, and informed consent was obtained from all participants (KY2024-R074). Patients This retrospective study of a single-institution database was performed on patients who underwent ULIF or TLIF from 2021 to 2023. The inclusion criteria were as follows : (1) patients older than 18 years old, (2) patients who underwent single-segment ULIF or single-segment TLIF for degenerative lumbar spinal disease (3) patients who underwent preoperative DXA, lumbar CT and lumbar MRI, (4) patients for whom conservative treatment was ineffective for over 6 months, (5) patients with a follow-up period exceeding 1 year, and (6) patients with immediate and one-year postoperative CT results. The exclusion criteria were as follows: (1) comorbidities such as lumbar malignancies, ankylosing spondylitis, severe spinal deformity and severe infection of the lumbar spine, (2) Relevant surgical history of the lumbar spine, including procedures such as fusion and percutaneous kyphoplasty, was taken into consideration, (3) Schmorl’s nodes, large bone sclerosis lead to measure difficult(Fig. 1 ). Patients in both cohorts underwent surgeries performed by physicians from the same medical team, who have substantial experience in spinal procedures. They were categorized into either the ULIF or TLIF groups based on the specific surgical approach. The surgeons involved in this study possess comparable expertise and extensive experience in both ULIF and TLIF surgeries. All patients underwent support screws and posterior instrumentation. Date collection Collected baseline data comprised age, gender, surgical technique, and history of BMI, diabetes, hypertension, smoking and alcohol abuse. Imaging data included superior endplate morphology, inferior endplate morphology, anterior disc height, posterior height, preoperative anterior disc height, preoperative posterior disc height, postoperative anterior disc height, postoperative posterior disc height (PPDH), immediate endplate destruction (IED) and bone quality assessment methods (DXA, HU and VBQ). [insert Fig. 1 .] CT measurements and HU value calculation The superior endplate morphology and inferior endplate morphology were evaluated in the sagittal plane on computed tomography (CT) images. The Farfan index, representing disc height, was measured by CT as the sum of anterior disc height[a] and posterior disc height by the sagittal width of the disc[c]; disc height =[(a + b)/c]*100%[ 16 ]. CS was defined as cage protrusion of more than 2 mm from the endplate of the vertebral body regardless of the upper or lower endplate[ 16 – 18 ] (Fig. 3 ). IED was defined as morphologic destruction of the endplate on immediate postoperative CT (Fig. 3 ). ROIs were delineated at the lower edge of the superior endplate, the center of the vertebral body and the upper edge of the inferior endplate on axial images, which were parallel to the endplate while avoiding the cortical bone and venous plexus[ 11 , 19 , 20 ]. The SI of the 3 ROIs were calculated to determine the average HU (Fig. 2 ). HU values of individual segments L4 and L5 were individually measured, while the mean HU values of the lumbar spine were determined from L1 to L4. [insert Fig. 2 .] [insert Fig. 3 .] MRI measurements and VBQ score calculation Based on the methods outlined in a previous study [ 21 ], the region of interest (ROI) was plotted in the center of the L1 to L4 vertebral body on the midsagittal plane of the non-contrast T1-weighted sequence and mapped by locating the cerebrospinal fluid posterior to the L3 vertebral body on the T2 sequence to determine the mean VBQ score (Fig. 2 ). Regarding the presence of hemangioma, Schmorl’s nodes or venous plexus in the mid-sagittal plane that impeded ROI measurements, the parasagittal plane was selected to assess vertebral bone quality[ 16 ]. When it was challenging to measure the CSF in L3, the ROI was shifted to the CSF space at the level of L2 or L4[ 18 , 22 ]. The single-segment VBQ score was defined as the ratio of the mean values of L4 and L5 to the SI of CSF. Statistical Analysis Continuous variables were expressed as mean ± standard deviation. The normality of continuous variables was assessed using the Shapiro-Wilk test, and group differences were compared using the independent sample t-test and Pearson χ2 test. Additionally, logistic regression analysis was employed to examine statistical differences in variables. Receiver operating characteristic (ROC) analysis was conducted to establish the discrimination criteria between CS and non-CS groups, including the calculation of the optimal cut-off value. Statistical analyses were performed using SPSS 26.0 (IBM). P < 0.05 was considered statistically significant. Results A total of 226 patients who underwent single-segment lumbar fusion at the L4/5 level (Table 1) were enrolled in the study. Their demographic and clinical data are detailed in Table 1. The study included 226 individuals who underwent ULIF/TLIF, of whom 102 experienced cage subsidence. Significant differences were observed in age, gender, superior endplate morphology, inferior endplate morphology, PPDH, M-HU, L4-HU, L5-HU, M-VBQ, L4-VBQ, L5-VBQ, and IED (Table 2). [insert Table 1 and Table 2).] Furthermore, the incidence of CS was lower in patients undergoing ULIF compared to those undergoing TLIF (40% versus 47.0%, p = 0.351). Interestingly, the female proportion (59.8% versus 36.3%, p < 0.001), age (62.36 ± 8.34 versus 59.11 ± 8.81, p < 0.001), and degree of postoperative endplate destruction (30.4% versus 4.8%, p < 0.001) were significantly higher in the subsidence group. Moreover, the subsidence group demonstrated significantly lower M-HU (105.01 ± 32.67 versus 146.84 ± 35.12, p < 0.001), L4-HU (101.82 ± 31.67 versus 144.71 ± 37.04, p < 0.001) and L5-HU values (114.13 ± 35.59 versus 154.00 ± 38.37, p = 0.010), as well as significantly higher M-VBQ (3.87 ± 1.07 versus 3.13 ± 0.45, p < 0.001), L4-VBQ (3.76 ± 0.51 versus 3.10 ± 0.49, p < 0.001), and L5-VBQ values (3.85 ± 0.52 versus 3.14 ± 0.51, p < 0,001). Additionally, the morphology of concave superior and inferior endplates promoted the occurrence of CS. The remaining variables were comparable between the two groups. Considering the presence of multicollinearity among M-VBQ, L4-VBQ, and L5-VBQ values, multivariate logistic regression analysis was performed using individual segments L4, L5, as well as the average of L1 to L4 (Fig. 4 ). Based on multivariable logistics analysis of L4, decreased L4-HU values (OR 0.982 [95% CI 0.968–0.996]; p = 0.001), increased L4-VBQ values (OR 15.075 [95% CL 5.186–43.826]; p < 0.001), increased postoperative posterior disc height (OR 1.492 [95% CL 1.138–1.955]; p = 0.006), and the presence of immediate endplate destruction (OR 17.636 [95% CL 4.739–65.636]; p < 0.001) were associated with an elevated CS rate. Likewise, based on the multivariate analysis of L5, decreased L5-HU values (OR 0.985 [95% CL 0.974–0.997]; p = 0.015), increased L5-VBQ values (OR 10.687 [95% CL 4.289–26.632]; p < 0.001), higher postoperative posterior disc height (OR 1.457 [95% CL 1.575–39.486]; p = 0.005), and the presence of immediate endplate destruction postoperatively (OR 11.493 [95% CL 3.302–40.007] ; p < 0.001) were associated with an increased risk of CS. Based on the multivariate analysis of lumbar spine mean bone mass, decreased M-HU values (OR 0.982 [95% CL 0.968–0.996]; p = 0.013), increased M-VBQ values (OR 15.075 [95% CL 5.186–43.826]; p < 0.001), increased postoperative posterior disc height (OR 1.492 [95% CL 1.138–1.955]; p = 0.005), and the presence of immediate postoperative endplate destruction (OR 17.636 [95% CL 4.739–65.636]; p < 0.001) were likewise significantly associated with a higher risk of CS. The ROC curve was constructed to predict the risk of CS (Fig. 4 ). The AUCs for the M-VBQ score, M-HU value, L4-VBQ score, L4-HU value, L5-VBQ score, and L5-HU value were 0.845, 0.827, 0.835, 0.827, 0.842, and 0.786, with optimal cutoff values of 3.53 (sensitivity: 76.5%, specificity: 86.3%), 125.72 (sensitivity: 85.3%, specificity: 72.6%), 3.55 (sensitivity: 73.5%, specificity: 85.5%), 124.36 (sensitivity: 86.3%, specificity: 72.6%), 3.47 (sensitivity: 80.4%, specificity: 74.2%), and 129.76 (sensitivity: 72.5%, specificity: 75.8%), respectively. [insert Fig. 4 .] Discussion To the best of our knowledge, this is the first study assessing the incidence of CS following ULIF or TLIF based on bone quality imaging. Additionally, risk factors associated with CS were examined. CS has been documented as a prevalent complication that should not be overlooked in lumbar spine fusion. Yu-Cheng Yao et al. described that CS was associated with prolonged postoperative pain duration, reduced lumbar lordosis angle, increased risk of pseudarthrosis, and a higher rate of revision surgery[ 7 ]. Therefore, there was a pressing need to identify risk factors associated with lumbar fusion to minimize the incidence of complications. Herein, CS was defined as the shifting of the cage to either the upper or lower endplate with a minimum distance of 2 mm[ 7 , 16 ]. Previous studies had demonstrated revealed that the geometry of the cage can influence the incidence of CS. Therefore, we selected a the same cage was used to investigate the evaluate risk factors associated with CS (IRENE). Notably, We observed the occurrence of CS was detected in 102 out of 228 patients who underwent single-segment ULIF/TLIF, reflecting a CS incidence rate of approximately 45.1%. Previous studies have reported an incidence rate of CS ranging from 14.1–45.9%[ 13 , 16 , 18 , 22 ], consistent with the results of this study. Earlier studies established an association between low bone mineral density and a higher incidence of CS, with age and gender also potentially serving as risk factors for this condition[ 16 ]. Furthermore, Huang Y et al. identified alterations in vertebral height and the morphology of upper and lower endplates as significant risk factors for CS [ 17 ]. At the same time, Hu YH et al. found that the renal-type cage shape may facilitate the development of CS[ 16 ]. Herein, a higher incidence of CS was noted among females. The age of the patient population was approximately 60 years, with females experiencing accelerated bone loss during menopause due to decreased ovarian function. The decline in estrogen levels post-menopause limits bone deposition, particularly in weight-bearing bones, and concurrently increases bone resorption, potentially predisposing individuals to CS[ 23 ]. Multivariate analysis exposed that higher vertebral bone quality (VBQ) scores and lower Hounsfield unit (HU) values were significantly associated with an increased rate of cage subsidence at 1 year postoperatively. Furthermore, immediate endplate destruction elevated the risk of CS. Noteworthily, VBQ values reflect the signal intensity observed on T1-weighted MRI sequences, thereby acting as an indicator of the adipose content within the vertebral body[ 21 ]. Osteoporosis results in the loss of bone trabecular components, leading to adipose tissue accumulation within porous structures, which in turn reduces mechanical stress on the vertebral body[ 24 ]. Additionally, the accumulation of fat in the vertebral body led to drives the release of cytokines and adipokines in the bone marrow, thereby inhibiting osteoblast differentiation and reducing inhibiting bone formation[ 25 ]. This process may contribute to the development of CS following lumbar fusion. Therefore, a higher VBQ score is indicative of increased fat content and potentially lower bone mass in the vertebral body, which is associated with an elevated incidence of ASD, in line with our study findings. Furthermore, irrespective of the lumbar vertebral level, the VBQ score demonstrated favorable predictive efficacy for the risk of CS following lumbar fusion surgery, in agreement with the result of a previous research conducted by Xingxiao Pu et al. [ 22 ]. Several studies have consistently demonstrated that the CT-based HU value is a robust and validated approach for quantifying BMD, enabling accurate assessment of the risk of fractures or compression fractures[ 20 , 26 , 27 ]. Through literature review and analysis, Xingxiao Pu et al. concluded that the HU value outperformed DXA in predicting the risk of CS in various surgical modalities[ 6 ]. Indeed, a significant association was noted between the occurrence of CS following lumbar fusion surgery and both single-segment HU measurements at L4 and L5, as well as the low HU value across the entire lumbar spine. Notably, patients without CS had significantly higher HU values compared to those with CS. These findings collectively indicated that both the M-HU value of the entire lumbar spine and the HU value at the surgical segment were predictive factors for the risk of CS after lumbar fusion surgery. Our study corroborated the findings of previous research and established similar cutoff values[ 11 , 22 , 27 ]. In addition, a significant association was detected between postoperative posterior intervertebral disc height (PPIDH) and CS, with changes in posterior vertebral height leading to alterations in sagittal stress load. Additionally, the presence of immediate endplate destruction (IED) at the operative segment following lumbar fusion was associated with CS, suggesting that IED is a potential risk factor for this complication. The endplate, situated between the intervertebral disc and vertebral body, comprises both cartilage and bone components. Disruption of its structural integrity impacts lumbar spine stability, potentially contributing to the development of CS[ 28 ]. Furthermore, the vertebral endplate plays a pivotal role in facilitating load transmission. Post-lumbar surgery, deteriorations in the endplate disrupt stress distribution within the upper or lower vertebral body, subsequently facilitating the development of CS within the vertebral body [ 29 ]. Previous studies have demonstrated that intact endplates exhibit significantly higher surface failure load and stiffness compared to damaged endplates[ 30 ]. As anticipated, finite element analysis identified the contact stress between the interbody cage and the endplate as a primary contributor to CS. IED resulted in reduced support area on the endplate, leading to increased force transmission onto the remaining endplate, which may substantially conduce to the development of CS[ 15 ]. Additionally, a lower incidence of CS was noted in patients undergoing ULIF, possibly attributable to the reduced risk of intraoperative endplate damage, necessitating further data for comprehensive analysis. Nevertheless, there are several limitations in this study that merit acknowledgment. To begin, the comparability of bone mass measurements on CT and MRI images might have been compromised by their inability to be compared on the same plane. Secondly, this study exclusively included patients who underwent the same type of cage operation in the same segment for comparison. Future research can consider increasing the sample size to explore additional potential risk factors, such as cage matching with superior and inferior endplates. In conclusion, the incidence of CS was lower in the ULIF group and the presence of IED increases the risk of CS. High PPDH and VBQ scores, as well as low HU values, were associated with a higher incidence of CS. Overall, both segmental and mean MRI and CT measurements were identified as accurate predictors of CS. However, MRI-based VBQ measurements appear to have superior predictive power. Declarations Ethics approval This study was supported by the Review of Ethics Committee in Clinical Research (ECCR) of the First Affiliated Hospital of Wenzhou Medical University (KY2024-R074)) .According to the Regulations and Rules of "Ethical Reviews for Biomedical Research Involving Human Subjects" (2023) the National Health Commission of PRC, "Declaration of Helsinki" of WMA, and "International Ethical Guidelines for Human Biomedical Research" of CIOMS, the project was approved by ECCR. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution Ding ,Xie and Teng design of the work; Jia and Fan analysis, Ding ,Ying ,Fang and Wang interpretation of data; Xie and Teng substantively revised it. All authors reviewed the manuscript. References Ravindra, V.M., et al., Degenerative Lumbar Spine Disease: Estimating Global Incidence and Worldwide Volume. Global Spine J, 2018. 8 (8): p. 784-794. Heemskerk, J.L., et al., Long-term clinical outcome of minimally invasive versus open single-level transforaminal lumbar interbody fusion for degenerative lumbar diseases: a meta-analysis. Spine J, 2021. 21 (12): p. 2049-2065. Vazan, M., et al., Minimally invasive transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion: a technical description and review of the literature. Acta Neurochir (Wien), 2017. 159 (6): p. 1137-1146. Peng, Y.J., et al., Comparison of the total and hidden blood loss in patients undergoing single-level open and unilateral biportal endoscopic transforaminal lumbar interbody fusion: a retrospective case control study. BMC Musculoskelet Disord, 2023. 24 (1): p. 295. Liu, G., et al., Clinical outcomes of unilateral biportal endoscopic lumbar interbody fusion (ULIF) compared with conventional posterior lumbar interbody fusion (PLIF). Spine J, 2023. 23 (2): p. 271-280. Pu, X., D. Wang, and S. Gu, Advances in Hounsfield units value for predicting cage subsidence on spinal interbody fusion surgery. Eur Spine J, 2023. 32 (9): p. 3149-3157. Yao, Y.C., et al., Risk Factors of Cage Subsidence in Patients Received Minimally Invasive Transforaminal Lumbar Interbody Fusion. Spine (Phila Pa 1976), 2020. 45 (19): p. E1279-e1285. Wu, H., et al., Poor Bone Quality, Multilevel Surgery, and Narrow and Tall Cages Are Associated with Intraoperative Endplate Injuries and Late-onset Cage Subsidence in Lateral Lumbar Interbody Fusion: A Systematic Review. Clin Orthop Relat Res, 2022. 480 (1): p. 163-188. Link, T.M., Osteoporosis imaging: state of the art and advanced imaging. Radiology, 2012. 263 (1): p. 3-17. Chen, A., et al., A meta-analysis of the value of MRI-based VBQ scores for evaluating osteoporosis. Bone Rep, 2023. 19 : p. 101711. Zaidi, Q., O.A. Danisa, and W. Cheng, Measurement Techniques and Utility of Hounsfield Unit Values for Assessment of Bone Quality Prior to Spinal Instrumentation: A Review of Current Literature. Spine (Phila Pa 1976), 2019. 44 (4): p. E239-e244. Pinto, E.M., et al., Efficacy of Hounsfield Units Measured by Lumbar Computer Tomography on Bone Density Assessment: A Systematic Review. Spine (Phila Pa 1976), 2022. 47 (9): p. 702-710. Özmen, E., et al., Vertebral bone quality score for opportunistic osteoporosis screening: a correlation and optimal threshold analysis. Eur Spine J, 2023. 32 (11): p. 3906-3911. Li, W., et al., Combinations of two imaging parameters to improve bone mineral density (BMD) assessment in patients with lumbar degenerative diseases. BMC Musculoskelet Disord, 2023. 24 (1): p. 747. Wang, J., et al., Biomechanical properties of lumbar vertebral ring apophysis cage under endplate injury: a finite element analysis. BMC Musculoskelet Disord, 2023. 24 (1): p. 695. Hu, Y.H., et al., Novel MRI-based vertebral bone quality score as a predictor of cage subsidence following transforaminal lumbar interbody fusion. J Neurosurg Spine, 2022: p. 1-9. Huang, Y., et al., Vertebral bone quality score to predict cage subsidence following oblique lumbar interbody fusion. J Orthop Surg Res, 2023. 18 (1): p. 258. Ai, Y., et al., MRI-based vertebral bone quality score for predicting cage subsidence by assessing bone mineral density following transforaminal lumbar interbody fusion: a retrospective analysis. Eur Spine J, 2023. 32 (9): p. 3167-3175. Schreiber, J.J., P.A. Anderson, and W.K. Hsu, Use of computed tomography for assessing bone mineral density. Neurosurg Focus, 2014. 37 (1): p. E4. Schreiber, J.J., et al., Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am, 2011. 93 (11): p. 1057-63. Kadri, A., et al., Opportunistic Use of Lumbar Magnetic Resonance Imaging for Osteoporosis Screening. Osteoporos Int, 2022. 33 (4): p. 861-869. Pu, X., et al., Comparison of predictive performance for cage subsidence between CT-based Hounsfield units and MRI-based vertebral bone quality score following oblique lumbar interbody fusion. Eur Radiol, 2023. 33 (12): p. 8637-8644. Long, G., et al., Predictors of osteoporotic fracture in postmenopausal women: a meta-analysis. J Orthop Surg Res, 2023. 18 (1): p. 574. Osterhoff, G., et al., Bone mechanical properties and changes with osteoporosis. Injury, 2016. 47 Suppl 2 (Suppl 2): p. S11-20. Kawai, M., F.J. de Paula, and C.J. Rosen, New insights into osteoporosis: the bone-fat connection. J Intern Med, 2012. 272 (4): p. 317-29. Pisano, A.J., et al., Lumbar disc height and vertebral Hounsfield units: association with interbody cage subsidence. Neurosurg Focus, 2020. 49 (2): p. E9. Pickhardt, P.J., et al., Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med, 2013. 158 (8): p. 588-95. Li, R., et al., The Relationship Between Endplate Defect Scores and Lumbar Sagittal Translation Stability in Lumbar Spondylolisthesis Patients. World Neurosurg, 2024. 181 : p. e938-e946. Zehr, J.D., J. Quadrilatero, and J.P. Callaghan, Incidence of Compression-Induced Microinjuries in the Cartilage Endplate of the Spine. Spine (Phila Pa 1976), 2023. 48 (9): p. E122-e129. Oxland, T.R., et al., Effects of endplate removal on the structural properties of the lower lumbar vertebral bodies. Spine (Phila Pa 1976), 2003. 28 (8): p. 771-7. Tables Tables 1 to 2 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Table1.jpg Table 1 Clinical factors of patients with and without cage subsidence Table2.jpg Table 2 Radiographic parameters of patients with and without cage subsidence Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in European Journal of Medical Research → Version 1 posted Editorial decision: Revision requested 13 May, 2025 Reviews received at journal 29 Apr, 2025 Reviewers agreed at journal 19 Apr, 2025 Reviews received at journal 18 Apr, 2025 Reviewers agreed at journal 18 Apr, 2025 Reviewers agreed at journal 26 Mar, 2025 Reviewers invited by journal 23 Mar, 2025 Editor assigned by journal 21 Mar, 2025 Submission checks completed at journal 21 Mar, 2025 First submitted to journal 19 Mar, 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-6262321","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":435977533,"identity":"59a89ce8-275c-407e-8804-07f96d333bd7","order_by":0,"name":"Chaohui Ding","email":"","orcid":"","institution":"The First Affiliated Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chaohui","middleName":"","lastName":"Ding","suffix":""},{"id":435977534,"identity":"db9f6f32-ca11-4707-b538-eccc871ac968","order_by":1,"name":"Changnan Xie","email":"","orcid":"","institution":"The First Affiliated Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Changnan","middleName":"","lastName":"Xie","suffix":""},{"id":435977535,"identity":"5e06b297-c7d5-49c3-a05b-a90e905bca7d","order_by":2,"name":"Jinwei Ying","email":"","orcid":"","institution":"The First Affiliated Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jinwei","middleName":"","lastName":"Ying","suffix":""},{"id":435977536,"identity":"42d7455c-f357-46ba-913f-0ca8b0b81a1d","order_by":3,"name":"Mengxian Jia","email":"","orcid":"","institution":"The First Affiliated Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mengxian","middleName":"","lastName":"Jia","suffix":""},{"id":435977537,"identity":"7db5c360-dc18-49fd-938a-a3256f288c01","order_by":4,"name":"Ziwei Fan","email":"","orcid":"","institution":"The First Affiliated Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ziwei","middleName":"","lastName":"Fan","suffix":""},{"id":435977539,"identity":"9842e536-7167-48a0-a845-30aa19a59f2e","order_by":5,"name":"Xiang Fang","email":"","orcid":"","institution":"The First Affiliated Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiang","middleName":"","lastName":"Fang","suffix":""},{"id":435977541,"identity":"a0bfff4e-3abf-45c7-8fed-a6607a99482a","order_by":6,"name":"Xianghe Wang","email":"","orcid":"","institution":"The First Affiliated Hospital of Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xianghe","middleName":"","lastName":"Wang","suffix":""},{"id":435977542,"identity":"20d16cf5-b31c-4a7b-81d4-c01eca60ffbb","order_by":7,"name":"Honglin Teng","email":"data:image/png;base64,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","orcid":"","institution":"The First Affiliated Hospital of Wenzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Honglin","middleName":"","lastName":"Teng","suffix":""}],"badges":[],"createdAt":"2025-03-19 14:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6262321/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6262321/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40001-025-02797-9","type":"published","date":"2025-07-01T15:58:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79750033,"identity":"6386c342-5507-4c1b-aa71-726cc3594676","added_by":"auto","created_at":"2025-04-02 09:16:03","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":779826,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of study population.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6262321/v1/b276c3a7126291333e902e44.jpg"},{"id":79750038,"identity":"194833e4-2236-457b-ac83-471ac1757552","added_by":"auto","created_at":"2025-04-02 09:16:03","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":986558,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative imaging measurement of bone quality. \u003c/strong\u003eA. The mean signal intensity (SI) was measured on T1-weighted MRI.B-E. Preoperative CT HU values were measured on the median sagittal plane (B), below the upper endplate (C), the middle of the vertebral body (D), and above the lower endplate (E).\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6262321/v1/0652c035686138ffc31211b0.jpg"},{"id":79751656,"identity":"cbf355e0-3c4e-479b-8940-673cb15a64e4","added_by":"auto","created_at":"2025-04-02 09:24:03","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":102180,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCT imaging related to cage subsidence (CS）\u003c/strong\u003eA. The patient, a 59-year-old female, presented with CS one year after undergoing ULIF. B. Sagittal CT images of a 71-year-old female subject acquired prior to undergoing ULIF. C. Sagittal CT images of a 71-year-old female patient immediately following ULIF.CS, cage subsidence. The blue line represents the pre-operative morphological position of the superior border of the inferior lumbar vertebrae, and the red line represents the post-operative morphological position of the superior border of the inferior lumbar vertebrae after the operation.\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6262321/v1/73c74bfbd43912a92e9873ad.jpg"},{"id":79750040,"identity":"6f69292a-dbb5-42e3-b847-a1e6259c2f2c","added_by":"auto","created_at":"2025-04-02 09:16:03","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1212397,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLogistic regression analysis and ROC curve \u003c/strong\u003eA. Logistic regression analysis at L4. B. The ROC curves for HU and VBQ at L4.C. Logistic regression analysis at L5. D. The ROC curves for HU and VBQ at L5. E. Logistic regression analysis at L1 to L4. F. The ROC curves for HU and VBQ at L1 to L4,\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6262321/v1/95c8bd4964d3f4ae83d2aaf6.jpg"},{"id":86179162,"identity":"f1707db9-2144-44ff-93fa-afe5f6aa5516","added_by":"auto","created_at":"2025-07-07 16:16:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5804354,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6262321/v1/e3dc9f87-e41d-40f4-b9e3-dcf523b6bb53.pdf"},{"id":79750032,"identity":"bcb0622d-5f47-4ee7-a95c-b06da22b8e55","added_by":"auto","created_at":"2025-04-02 09:16:03","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":753908,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable 1 Clinical factors of patients with and without cage subsidence\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Table1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6262321/v1/79b918db70e8ae63992f2933.jpg"},{"id":79751655,"identity":"8c6724a9-2692-488b-88ad-1756a0ca2145","added_by":"auto","created_at":"2025-04-02 09:24:03","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":952320,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable 2 Radiographic parameters of patients with and without cage subsidence\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Table2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6262321/v1/5fc3e4519d5d16883b6b5c5f.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Utilizing MRI and CT to identify risk factors associated with cage subsidence","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDegenerative spinal diseases, which are among the most prevalent causes of disability, can result in back pain, radiculopathy, and spinal instability[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Ascribed to the aging population, their incidence is progressively rising[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Numerous therapeutic approaches are available for this condition, with transforaminal lumbar interbody fusion (TLIF) standing out as the preferred option and associated with favorable patient outcomes[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Considering that TLIF was initially characterized as an open surgical procedure, the growing utilization of minimally invasive techniques aims to mitigate injury to soft tissues[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. ULIF represents an innovative approach to minimally invasive surgery, demonstrating efficacy in the treatment of degenerative spinal conditions[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Attributed to benefits such as its minimally invasive and traumatic nature and accelerated postoperative recovery, ULIF has garnered extensive attention and has been widely adopted by an increasing number of surgeons [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, cage subsidence(CS) is a nonnegligible complication in lumbar fusion surgery that can prolong postoperative pain duration, loss of lumbar lordosis angle amd lead to pseudoarthrosis or revision surgery[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Its risk factors are multifactorial, encompassing age, body mass index (BMI), disc height, cage position and shape, modic change classification, and other factors[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally, bone mineral density (BMD) and lumbar endplate destruction may be potential contributing factors in its development. At present, several quantitative indices are utilized to assess bone quality, including Dual-energy X-ray (DXA), Hounsfield units (HU), and vertebral quality (VBQ), with the former considered the current gold standard for the diagnosis of BMD[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, previous compression fractures and aortic atherosclerosis can increase effective X-ray uptake, resulting in inaccuracies in diagnosis using DXA [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. HU measured by computed tomography (CT) has been regarded as an effective means of assessing BMD[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].However, these two methods involve radiation exposure and impose a heavy financial burden on patients. Magnetic resonance imaging (MRI) based VBQ has recently been used to measure vertebral bone quality, with poor VBQ being one of the most accurate indicators of low BMD.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, there is a paucity of research investigating immediate postoperative imaging and its correlation with the development of CS. Prior finite element analyses demonstrated that immediate endplate destruction (IED) can impact the biomechanics of the lumbar spine[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Nonetheless, studies exploring the clinical and imaging implications of IED and the incidence of CS are scarce.\u003c/p\u003e \u003cp\u003eThe objectives of this study were is to answer the following questions:1)Is there a disparity in the incidence of CS between ULIF and TILF? 2) What are the potential risk factors associated with CS after ULIF/TLIF? 3) Which specific method of bone mass imaging can effectively predict CS at one-year post-surgery?\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e The study was approved by the institutional review board at our hospital, and informed consent was obtained from all participants (KY2024-R074).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis retrospective study of a single-institution database was performed on patients who underwent ULIF or TLIF from 2021 to 2023. The inclusion criteria were as follows : (1) patients older than 18 years old, (2) patients who underwent single-segment ULIF or single-segment TLIF for degenerative lumbar spinal disease (3) patients who underwent preoperative DXA, lumbar CT and lumbar MRI, (4) patients for whom conservative treatment was ineffective for over 6 months, (5) patients with a follow-up period exceeding 1 year, and (6) patients with immediate and one-year postoperative CT results. The exclusion criteria were as follows: (1) comorbidities such as lumbar malignancies, ankylosing spondylitis, severe spinal deformity and severe infection of the lumbar spine, (2) Relevant surgical history of the lumbar spine, including procedures such as fusion and percutaneous kyphoplasty, was taken into consideration, (3) Schmorl\u0026rsquo;s nodes, large bone sclerosis lead to measure difficult(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients in both cohorts underwent surgeries performed by physicians from the same medical team, who have substantial experience in spinal procedures. They were categorized into either the ULIF or TLIF groups based on the specific surgical approach. The surgeons involved in this study possess comparable expertise and extensive experience in both ULIF and TLIF surgeries. All patients underwent support screws and posterior instrumentation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDate collection\u003c/h3\u003e\n\u003cp\u003eCollected baseline data comprised age, gender, surgical technique, and history of BMI, diabetes, hypertension, smoking and alcohol abuse. Imaging data included superior endplate morphology, inferior endplate morphology, anterior disc height, posterior height, preoperative anterior disc height, preoperative posterior disc height, postoperative anterior disc height, postoperative posterior disc height (PPDH), immediate endplate destruction (IED) and bone quality assessment methods (DXA, HU and VBQ). [insert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.]\u003c/p\u003e\n\u003ch3\u003eCT measurements and HU value calculation\u003c/h3\u003e\n\u003cp\u003eThe superior endplate morphology and inferior endplate morphology were evaluated in the sagittal plane on computed tomography (CT) images. The Farfan index, representing disc height, was measured by CT as the sum of anterior disc height[a] and posterior disc height by the sagittal width of the disc[c]; disc height =[(a\u0026thinsp;+\u0026thinsp;b)/c]*100%[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. CS was defined as cage protrusion of more than 2 mm from the endplate of the vertebral body regardless of the upper or lower endplate[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). IED was defined as morphologic destruction of the endplate on immediate postoperative CT (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). ROIs were delineated at the lower edge of the superior endplate, the center of the vertebral body and the upper edge of the inferior endplate on axial images, which were parallel to the endplate while avoiding the cortical bone and venous plexus[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The SI of the 3 ROIs were calculated to determine the average HU (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). HU values of individual segments L4 and L5 were individually measured, while the mean HU values of the lumbar spine were determined from L1 to L4. [insert Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.] [insert Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.]\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eMRI measurements and VBQ score calculation\u003c/h3\u003e\n\u003cp\u003eBased on the methods outlined in a previous study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], the region of interest (ROI) was plotted in the center of the L1 to L4 vertebral body on the midsagittal plane of the non-contrast T1-weighted sequence and mapped by locating the cerebrospinal fluid posterior to the L3 vertebral body on the T2 sequence to determine the mean VBQ score (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Regarding the presence of hemangioma, Schmorl\u0026rsquo;s nodes or venous plexus in the mid-sagittal plane that impeded ROI measurements, the parasagittal plane was selected to assess vertebral bone quality[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. When it was challenging to measure the CSF in L3, the ROI was shifted to the CSF space at the level of L2 or L4[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The single-segment VBQ score was defined as the ratio of the mean values of L4 and L5 to the SI of CSF.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. The normality of continuous variables was assessed using the Shapiro-Wilk test, and group differences were compared using the independent sample t-test and Pearson χ2 test. Additionally, logistic regression analysis was employed to examine statistical differences in variables. Receiver operating characteristic (ROC) analysis was conducted to establish the discrimination criteria between CS and non-CS groups, including the calculation of the optimal cut-off value. Statistical analyses were performed using SPSS 26.0 (IBM). P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 226 patients who underwent single-segment lumbar fusion at the L4/5 level (Table\u0026nbsp;1) were enrolled in the study. Their demographic and clinical data are detailed in Table\u0026nbsp;1. The study included 226 individuals who underwent ULIF/TLIF, of whom 102 experienced cage subsidence. Significant differences were observed in age, gender, superior endplate morphology, inferior endplate morphology, PPDH, M-HU, L4-HU, L5-HU, M-VBQ, L4-VBQ, L5-VBQ, and IED (Table\u0026nbsp;2). [insert Table\u0026nbsp;1 and Table\u0026nbsp;2).]\u003c/p\u003e \u003cp\u003eFurthermore, the incidence of CS was lower in patients undergoing ULIF compared to those undergoing TLIF (40% versus 47.0%, p\u0026thinsp;=\u0026thinsp;0.351). Interestingly, the female proportion (59.8% versus 36.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), age (62.36\u0026thinsp;\u0026plusmn;\u0026thinsp;8.34 versus 59.11\u0026thinsp;\u0026plusmn;\u0026thinsp;8.81, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and degree of postoperative endplate destruction (30.4% versus 4.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly higher in the subsidence group. Moreover, the subsidence group demonstrated significantly lower M-HU (105.01\u0026thinsp;\u0026plusmn;\u0026thinsp;32.67 versus 146.84\u0026thinsp;\u0026plusmn;\u0026thinsp;35.12, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), L4-HU (101.82\u0026thinsp;\u0026plusmn;\u0026thinsp;31.67 versus 144.71\u0026thinsp;\u0026plusmn;\u0026thinsp;37.04, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and L5-HU values (114.13\u0026thinsp;\u0026plusmn;\u0026thinsp;35.59 versus 154.00\u0026thinsp;\u0026plusmn;\u0026thinsp;38.37, p\u0026thinsp;=\u0026thinsp;0.010), as well as significantly higher M-VBQ (3.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07 versus 3.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), L4-VBQ (3.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51 versus 3.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and L5-VBQ values (3.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52 versus 3.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51, p\u0026thinsp;\u0026lt;\u0026thinsp;0,001). Additionally, the morphology of concave superior and inferior endplates promoted the occurrence of CS. The remaining variables were comparable between the two groups.\u003c/p\u003e \u003cp\u003eConsidering the presence of multicollinearity among M-VBQ, L4-VBQ, and L5-VBQ values, multivariate logistic regression analysis was performed using individual segments L4, L5, as well as the average of L1 to L4 (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Based on multivariable logistics analysis of L4, decreased L4-HU values (OR 0.982 [95% CI 0.968\u0026ndash;0.996]; p\u0026thinsp;=\u0026thinsp;0.001), increased L4-VBQ values (OR 15.075 [95% CL 5.186\u0026ndash;43.826]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), increased postoperative posterior disc height (OR 1.492 [95% CL 1.138\u0026ndash;1.955]; p\u0026thinsp;=\u0026thinsp;0.006), and the presence of immediate endplate destruction (OR 17.636 [95% CL 4.739\u0026ndash;65.636]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were associated with an elevated CS rate. Likewise, based on the multivariate analysis of L5, decreased L5-HU values (OR 0.985 [95% CL 0.974\u0026ndash;0.997]; p\u0026thinsp;=\u0026thinsp;0.015), increased L5-VBQ values (OR 10.687 [95% CL 4.289\u0026ndash;26.632]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), higher postoperative posterior disc height (OR 1.457 [95% CL 1.575\u0026ndash;39.486]; p\u0026thinsp;=\u0026thinsp;0.005), and the presence of immediate endplate destruction postoperatively (OR 11.493 [95% CL 3.302\u0026ndash;40.007] ; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were associated with an increased risk of CS. Based on the multivariate analysis of lumbar spine mean bone mass, decreased M-HU values (OR 0.982 [95% CL 0.968\u0026ndash;0.996]; p\u0026thinsp;=\u0026thinsp;0.013), increased M-VBQ values (OR 15.075 [95% CL 5.186\u0026ndash;43.826]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), increased postoperative posterior disc height (OR 1.492 [95% CL 1.138\u0026ndash;1.955]; p\u0026thinsp;=\u0026thinsp;0.005), and the presence of immediate postoperative endplate destruction (OR 17.636 [95% CL 4.739\u0026ndash;65.636]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were likewise significantly associated with a higher risk of CS.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe ROC curve was constructed to predict the risk of CS (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The AUCs for the M-VBQ score, M-HU value, L4-VBQ score, L4-HU value, L5-VBQ score, and L5-HU value were 0.845, 0.827, 0.835, 0.827, 0.842, and 0.786, with optimal cutoff values of 3.53 (sensitivity: 76.5%, specificity: 86.3%), 125.72 (sensitivity: 85.3%, specificity: 72.6%), 3.55 (sensitivity: 73.5%, specificity: 85.5%), 124.36 (sensitivity: 86.3%, specificity: 72.6%), 3.47 (sensitivity: 80.4%, specificity: 74.2%), and 129.76 (sensitivity: 72.5%, specificity: 75.8%), respectively. [insert Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.]\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first study assessing the incidence of CS following ULIF or TLIF based on bone quality imaging. Additionally, risk factors associated with CS were examined. CS has been documented as a prevalent complication that should not be overlooked in lumbar spine fusion. Yu-Cheng Yao et al. described that CS was associated with prolonged postoperative pain duration, reduced lumbar lordosis angle, increased risk of pseudarthrosis, and a higher rate of revision surgery[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, there was a pressing need to identify risk factors associated with lumbar fusion to minimize the incidence of complications. Herein, CS was defined as the shifting of the cage to either the upper or lower endplate with a minimum distance of 2 mm[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Previous studies had demonstrated revealed that the geometry of the cage can influence the incidence of CS. Therefore, we selected a the same cage was used to investigate the evaluate risk factors associated with CS (IRENE). Notably, We observed the occurrence of CS was detected in 102 out of 228 patients who underwent single-segment ULIF/TLIF, reflecting a CS incidence rate of approximately 45.1%. Previous studies have reported an incidence rate of CS ranging from 14.1\u0026ndash;45.9%[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], consistent with the results of this study.\u003c/p\u003e \u003cp\u003eEarlier studies established an association between low bone mineral density and a higher incidence of CS, with age and gender also potentially serving as risk factors for this condition[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, Huang Y et al. identified alterations in vertebral height and the morphology of upper and lower endplates as significant risk factors for CS [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. At the same time, Hu YH et al. found that the renal-type cage shape may facilitate the development of CS[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Herein, a higher incidence of CS was noted among females. The age of the patient population was approximately 60 years, with females experiencing accelerated bone loss during menopause due to decreased ovarian function. The decline in estrogen levels post-menopause limits bone deposition, particularly in weight-bearing bones, and concurrently increases bone resorption, potentially predisposing individuals to CS[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Multivariate analysis exposed that higher vertebral bone quality (VBQ) scores and lower Hounsfield unit (HU) values were significantly associated with an increased rate of cage subsidence at 1 year postoperatively. Furthermore, immediate endplate destruction elevated the risk of CS. Noteworthily, VBQ values reflect the signal intensity observed on T1-weighted MRI sequences, thereby acting as an indicator of the adipose content within the vertebral body[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Osteoporosis results in the loss of bone trabecular components, leading to adipose tissue accumulation within porous structures, which in turn reduces mechanical stress on the vertebral body[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, the accumulation of fat in the vertebral body led to drives the release of cytokines and adipokines in the bone marrow, thereby inhibiting osteoblast differentiation and reducing inhibiting bone formation[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This process may contribute to the development of CS following lumbar fusion. Therefore, a higher VBQ score is indicative of increased fat content and potentially lower bone mass in the vertebral body, which is associated with an elevated incidence of ASD, in line with our study findings. Furthermore, irrespective of the lumbar vertebral level, the VBQ score demonstrated favorable predictive efficacy for the risk of CS following lumbar fusion surgery, in agreement with the result of a previous research conducted by Xingxiao Pu et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Several studies have consistently demonstrated that the CT-based HU value is a robust and validated approach for quantifying BMD, enabling accurate assessment of the risk of fractures or compression fractures[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Through literature review and analysis, Xingxiao Pu et al. concluded that the HU value outperformed DXA in predicting the risk of CS in various surgical modalities[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Indeed, a significant association was noted between the occurrence of CS following lumbar fusion surgery and both single-segment HU measurements at L4 and L5, as well as the low HU value across the entire lumbar spine. Notably, patients without CS had significantly higher HU values compared to those with CS. These findings collectively indicated that both the M-HU value of the entire lumbar spine and the HU value at the surgical segment were predictive factors for the risk of CS after lumbar fusion surgery. Our study corroborated the findings of previous research and established similar cutoff values[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In addition, a significant association was detected between postoperative posterior intervertebral disc height (PPIDH) and CS, with changes in posterior vertebral height leading to alterations in sagittal stress load. Additionally, the presence of immediate endplate destruction (IED) at the operative segment following lumbar fusion was associated with CS, suggesting that IED is a potential risk factor for this complication. The endplate, situated between the intervertebral disc and vertebral body, comprises both cartilage and bone components. Disruption of its structural integrity impacts lumbar spine stability, potentially contributing to the development of CS[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Furthermore, the vertebral endplate plays a pivotal role in facilitating load transmission. Post-lumbar surgery, deteriorations in the endplate disrupt stress distribution within the upper or lower vertebral body, subsequently facilitating the development of CS within the vertebral body [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Previous studies have demonstrated that intact endplates exhibit significantly higher surface failure load and stiffness compared to damaged endplates[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. As anticipated, finite element analysis identified the contact stress between the interbody cage and the endplate as a primary contributor to CS. IED resulted in reduced support area on the endplate, leading to increased force transmission onto the remaining endplate, which may substantially conduce to the development of CS[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Additionally, a lower incidence of CS was noted in patients undergoing ULIF, possibly attributable to the reduced risk of intraoperative endplate damage, necessitating further data for comprehensive analysis.\u003c/p\u003e \u003cp\u003eNevertheless, there are several limitations in this study that merit acknowledgment. To begin, the comparability of bone mass measurements on CT and MRI images might have been compromised by their inability to be compared on the same plane. Secondly, this study exclusively included patients who underwent the same type of cage operation in the same segment for comparison. Future research can consider increasing the sample size to explore additional potential risk factors, such as cage matching with superior and inferior endplates.\u003c/p\u003e \u003cp\u003eIn conclusion, the incidence of CS was lower in the ULIF group and the presence of IED increases the risk of CS. High PPDH and VBQ scores, as well as low HU values, were associated with a higher incidence of CS. Overall, both segmental and mean MRI and CT measurements were identified as accurate predictors of CS. However, MRI-based VBQ measurements appear to have superior predictive power.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Review of Ethics Committee in Clinical Research (ECCR) of the First Affiliated Hospital of Wenzhou Medical University (KY2024-R074)) .According to the Regulations and Rules of \u0026quot;Ethical Reviews for Biomedical Research Involving Human Subjects\u0026quot; (2023) the National Health Commission of PRC, \u0026quot;Declaration of Helsinki\u0026quot; of WMA, and \u0026quot;International Ethical Guidelines for Human Biomedical Research\u0026quot; of CIOMS, the project was approved by ECCR.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDing ,Xie and Teng design of the work; Jia and Fan analysis, Ding ,Ying ,Fang and Wang interpretation of data; Xie and Teng substantively revised it. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRavindra, V.M., et al., \u003cem\u003eDegenerative Lumbar Spine Disease: Estimating Global Incidence and Worldwide Volume.\u003c/em\u003e Global Spine J, 2018. \u003cstrong\u003e8\u003c/strong\u003e(8): p. 784-794.\u003c/li\u003e\n \u003cli\u003eHeemskerk, J.L., et al., \u003cem\u003eLong-term clinical outcome of minimally invasive versus open single-level transforaminal lumbar interbody fusion for degenerative lumbar diseases: a meta-analysis.\u003c/em\u003e Spine J, 2021. \u003cstrong\u003e21\u003c/strong\u003e(12): p. 2049-2065.\u003c/li\u003e\n \u003cli\u003eVazan, M., et al., \u003cem\u003eMinimally invasive transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion: a technical description and review of the literature.\u003c/em\u003e Acta Neurochir (Wien), 2017. \u003cstrong\u003e159\u003c/strong\u003e(6): p. 1137-1146.\u003c/li\u003e\n \u003cli\u003ePeng, Y.J., et al., \u003cem\u003eComparison of the total and hidden blood loss in patients undergoing single-level open and unilateral biportal endoscopic transforaminal lumbar interbody fusion: a retrospective case control study.\u003c/em\u003e BMC Musculoskelet Disord, 2023. \u003cstrong\u003e24\u003c/strong\u003e(1): p. 295.\u003c/li\u003e\n \u003cli\u003eLiu, G., et al., \u003cem\u003eClinical outcomes of unilateral biportal endoscopic lumbar interbody fusion (ULIF) compared with conventional posterior lumbar interbody fusion (PLIF).\u003c/em\u003e Spine J, 2023. \u003cstrong\u003e23\u003c/strong\u003e(2): p. 271-280.\u003c/li\u003e\n \u003cli\u003ePu, X., D. Wang, and S. Gu, \u003cem\u003eAdvances in Hounsfield units value for predicting cage subsidence on spinal interbody fusion surgery.\u003c/em\u003e Eur Spine J, 2023. \u003cstrong\u003e32\u003c/strong\u003e(9): p. 3149-3157.\u003c/li\u003e\n \u003cli\u003eYao, Y.C., et al., \u003cem\u003eRisk Factors of Cage Subsidence in Patients Received Minimally Invasive Transforaminal Lumbar Interbody Fusion.\u003c/em\u003e Spine (Phila Pa 1976), 2020. \u003cstrong\u003e45\u003c/strong\u003e(19): p. E1279-e1285.\u003c/li\u003e\n \u003cli\u003eWu, H., et al., \u003cem\u003ePoor Bone Quality, Multilevel Surgery, and Narrow and Tall Cages Are Associated with Intraoperative Endplate Injuries and Late-onset Cage Subsidence in Lateral Lumbar Interbody Fusion: A Systematic Review.\u003c/em\u003e Clin Orthop Relat Res, 2022. \u003cstrong\u003e480\u003c/strong\u003e(1): p. 163-188.\u003c/li\u003e\n \u003cli\u003eLink, T.M., \u003cem\u003eOsteoporosis imaging: state of the art and advanced imaging.\u003c/em\u003e Radiology, 2012. \u003cstrong\u003e263\u003c/strong\u003e(1): p. 3-17.\u003c/li\u003e\n \u003cli\u003eChen, A., et al., \u003cem\u003eA meta-analysis of the value of MRI-based VBQ scores for evaluating osteoporosis.\u003c/em\u003e Bone Rep, 2023. \u003cstrong\u003e19\u003c/strong\u003e: p. 101711.\u003c/li\u003e\n \u003cli\u003eZaidi, Q., O.A. Danisa, and W. Cheng, \u003cem\u003eMeasurement Techniques and Utility of Hounsfield Unit Values for Assessment of Bone Quality Prior to Spinal Instrumentation: A Review of Current Literature.\u003c/em\u003e Spine (Phila Pa 1976), 2019. \u003cstrong\u003e44\u003c/strong\u003e(4): p. E239-e244.\u003c/li\u003e\n \u003cli\u003ePinto, E.M., et al., \u003cem\u003eEfficacy of Hounsfield Units Measured by Lumbar Computer Tomography on Bone Density Assessment: A Systematic Review.\u003c/em\u003e Spine (Phila Pa 1976), 2022. \u003cstrong\u003e47\u003c/strong\u003e(9): p. 702-710.\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;zmen, E., et al., \u003cem\u003eVertebral bone quality score for opportunistic osteoporosis screening: a correlation and optimal threshold analysis.\u003c/em\u003e Eur Spine J, 2023. \u003cstrong\u003e32\u003c/strong\u003e(11): p. 3906-3911.\u003c/li\u003e\n \u003cli\u003eLi, W., et al., \u003cem\u003eCombinations of two imaging parameters to improve bone mineral density (BMD) assessment in patients with lumbar degenerative diseases.\u003c/em\u003e BMC Musculoskelet Disord, 2023. \u003cstrong\u003e24\u003c/strong\u003e(1): p. 747.\u003c/li\u003e\n \u003cli\u003eWang, J., et al., \u003cem\u003eBiomechanical properties of lumbar vertebral ring apophysis cage under endplate injury: a finite element analysis.\u003c/em\u003e BMC Musculoskelet Disord, 2023. \u003cstrong\u003e24\u003c/strong\u003e(1): p. 695.\u003c/li\u003e\n \u003cli\u003eHu, Y.H., et al., \u003cem\u003eNovel MRI-based vertebral bone quality score as a predictor of cage subsidence following transforaminal lumbar interbody fusion.\u003c/em\u003e J Neurosurg Spine, 2022: p. 1-9.\u003c/li\u003e\n \u003cli\u003eHuang, Y., et al., \u003cem\u003eVertebral bone quality score to predict cage subsidence following oblique lumbar interbody fusion.\u003c/em\u003e J Orthop Surg Res, 2023. \u003cstrong\u003e18\u003c/strong\u003e(1): p. 258.\u003c/li\u003e\n \u003cli\u003eAi, Y., et al., \u003cem\u003eMRI-based vertebral bone quality score for predicting cage subsidence by assessing bone mineral density following transforaminal lumbar interbody fusion: a retrospective analysis.\u003c/em\u003e Eur Spine J, 2023. \u003cstrong\u003e32\u003c/strong\u003e(9): p. 3167-3175.\u003c/li\u003e\n \u003cli\u003eSchreiber, J.J., P.A. Anderson, and W.K. Hsu, \u003cem\u003eUse of computed tomography for assessing bone mineral density.\u003c/em\u003e Neurosurg Focus, 2014. \u003cstrong\u003e37\u003c/strong\u003e(1): p. E4.\u003c/li\u003e\n \u003cli\u003eSchreiber, J.J., et al., \u003cem\u003eHounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management.\u003c/em\u003e J Bone Joint Surg Am, 2011. \u003cstrong\u003e93\u003c/strong\u003e(11): p. 1057-63.\u003c/li\u003e\n \u003cli\u003eKadri, A., et al., \u003cem\u003eOpportunistic Use of Lumbar Magnetic Resonance Imaging for Osteoporosis Screening.\u003c/em\u003e Osteoporos Int, 2022. \u003cstrong\u003e33\u003c/strong\u003e(4): p. 861-869.\u003c/li\u003e\n \u003cli\u003ePu, X., et al., \u003cem\u003eComparison of predictive performance for cage subsidence between CT-based Hounsfield units and MRI-based vertebral bone quality score following oblique lumbar interbody fusion.\u003c/em\u003e Eur Radiol, 2023. \u003cstrong\u003e33\u003c/strong\u003e(12): p. 8637-8644.\u003c/li\u003e\n \u003cli\u003eLong, G., et al., \u003cem\u003ePredictors of osteoporotic fracture in postmenopausal women: a meta-analysis.\u003c/em\u003e J Orthop Surg Res, 2023. \u003cstrong\u003e18\u003c/strong\u003e(1): p. 574.\u003c/li\u003e\n \u003cli\u003eOsterhoff, G., et al., \u003cem\u003eBone mechanical properties and changes with osteoporosis.\u003c/em\u003e Injury, 2016. \u003cstrong\u003e47 Suppl 2\u003c/strong\u003e(Suppl 2): p. S11-20.\u003c/li\u003e\n \u003cli\u003eKawai, M., F.J. de Paula, and C.J. Rosen, \u003cem\u003eNew insights into osteoporosis: the bone-fat connection.\u003c/em\u003e J Intern Med, 2012. \u003cstrong\u003e272\u003c/strong\u003e(4): p. 317-29.\u003c/li\u003e\n \u003cli\u003ePisano, A.J., et al., \u003cem\u003eLumbar disc height and vertebral Hounsfield units: association with interbody cage subsidence.\u003c/em\u003e Neurosurg Focus, 2020. \u003cstrong\u003e49\u003c/strong\u003e(2): p. E9.\u003c/li\u003e\n \u003cli\u003ePickhardt, P.J., et al., \u003cem\u003eOpportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications.\u003c/em\u003e Ann Intern Med, 2013. \u003cstrong\u003e158\u003c/strong\u003e(8): p. 588-95.\u003c/li\u003e\n \u003cli\u003eLi, R., et al., \u003cem\u003eThe Relationship Between Endplate Defect Scores and Lumbar Sagittal Translation Stability in Lumbar Spondylolisthesis Patients.\u003c/em\u003e World Neurosurg, 2024. \u003cstrong\u003e181\u003c/strong\u003e: p. e938-e946.\u003c/li\u003e\n \u003cli\u003eZehr, J.D., J. Quadrilatero, and J.P. Callaghan, \u003cem\u003eIncidence of Compression-Induced Microinjuries in the Cartilage Endplate of the Spine.\u003c/em\u003e Spine (Phila Pa 1976), 2023. \u003cstrong\u003e48\u003c/strong\u003e(9): p. E122-e129.\u003c/li\u003e\n \u003cli\u003eOxland, T.R., et al., \u003cem\u003eEffects of endplate removal on the structural properties of the lower lumbar vertebral bodies.\u003c/em\u003e Spine (Phila Pa 1976), 2003. \u003cstrong\u003e28\u003c/strong\u003e(8): p. 771-7.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 2 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Unilateral biportal endoscopic lumbar interbody fusion, immediate endplate destruction, cage subsidence, vertebral bone quality, Hounsfield units","lastPublishedDoi":"10.21203/rs.3.rs-6262321/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6262321/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eTo identify risk factors associated with cage subsidence (CS) following single segment transforaminal lumbar interbody fusion (TLIF) and unilateral biportal endoscopic lumbar interbody fusion (ULIF) and to compare the predictive performance of various bone quality assessment methods using MRI and CT images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA total of 226 patients from 2021 to 2023 who underwent ULIF/TLIF because of lumbar disc herniation and lumbar spinal stenosis were enrolled. Subsidence of the cage into the vertebral body exceeding 2 mm was defined as CS and diagnosed using CT scans. Immediate endplate destruction (IED) was defined by CT and VBQ was measured through T1-weighted lumbar MRI. The independent sample t-test was employed to examine the risk factors associated with CS. Additionally, risk factors associated with CS were identified using logistic regression analysis. Lastly, the comparative predictive values were assessed through ROC curve analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eLogistic regression analysis revealed that increased postoperative posterior disc height (PPDH), higher segmental VBQ scores, higher mean VBQ (M-VBQ) scores, decreased segmental HU values, decreased mean HU (M-HU) values and immediate endplate destruction (IED) were associated with the occurrence of CS. The area under the curve (AUC) of the VBQ score was higher than that of the HU value, both in segment and in average.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The incidence of CS was lower in ULIF compared to TLIF. High VBQ scores, low HU values, high PPDH and the presence of IED were associated with an increased risk of CS. Notably, the predictive value of both VBQ scores and HU values were high for CS, with the former potentially outperforming the latter.\u003c/p\u003e","manuscriptTitle":"Utilizing MRI and CT to identify risk factors associated with cage subsidence","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-02 09:15:58","doi":"10.21203/rs.3.rs-6262321/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-13T07:27:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-29T21:27:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325163886193260699581975081938187838784","date":"2025-04-19T12:57:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-18T14:16:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67680575554540216293743819609401503831","date":"2025-04-18T13:17:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219091915636887884995858757290390091999","date":"2025-03-26T12:37:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-24T03:04:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-21T08:43:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-21T06:16:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Medical Research","date":"2025-03-19T13:53:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"01f2f91a-69f4-43f4-be07-cdc01f705bd0","owner":[],"postedDate":"April 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:06:35+00:00","versionOfRecord":{"articleIdentity":"rs-6262321","link":"https://doi.org/10.1186/s40001-025-02797-9","journal":{"identity":"european-journal-of-medical-research","isVorOnly":false,"title":"European Journal of Medical Research"},"publishedOn":"2025-07-01 15:58:27","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-04-02 09:15:58","video":"","vorDoi":"10.1186/s40001-025-02797-9","vorDoiUrl":"https://doi.org/10.1186/s40001-025-02797-9","workflowStages":[]},"version":"v1","identity":"rs-6262321","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6262321","identity":"rs-6262321","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}