MRI-based pedicle bone quality score: correlation to quantitative computed tomography bone mineral density and its role in quantitative assessment of osteoporosis.

BACKGROUND CONTEXT: Bone quality in the pedicle region generally determines screw pullout strength, insertion torque, and vertebral body loading characteristics. Dual-energy X-ray absorptiometry (DEXA), as the gold standard for evaluating bone mineral density (BMD), cannot measure the BMD of specific parts, such as pedicle, and DEXA is limited in many ways. Recent studies have shown a correlation between the magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score and BMD measured using DEXA or quantitative computed tomography (QCT). However, no studies have been reported on the MRI-based pedicle bone quality (PBQ) score. Moreover, few studies have investigated the relationship between MRI-based PBQ and osteoporosis. PURPOSE: To create a new site-specific MRI-based PBQ assessment method and assess its diagnostic capacity in patients with normal BMD and osteopenia/osteoporosis. STUDY DESIGN/SETTING: A retrospective study. PATIENT SAMPLE: A total of 156 patients underwent lumbar fusion surgery for chronic low back pain at our hospital between 2021 and 2022, with lumbar QCT and T1-weighted MRI performed before surgery. OUTCOME MEASURES: Correlation of the PBQ score with QCT BMD, and the association between the PBQ score and presence of osteopenia/osteoporosis. METHODS: BMD of the lumbar was calculated as the mean BMD of the L1 and L2 vertebral bodies on the basis of asynchronous QCT measurements. The PBQ score, which is the average of the bone quality values of both pedicles on the basis of site-specific T1-weighted sagittal MRI images, was calculated by dividing the median signal intensity of the L1-L4 pedicles by the signal intensity of the cerebrospinal fluid at the L3 level. The interobserver reliability of the PBQ score was assessed using the intraclass correlation coefficient (ICC). A receiver operating characteristic curve was drawn, and the area under the curve (AUC) was calculated to assess the predictive performance of PBQ for osteoporosis. The PBQ score was compared with QCT BMD, as the gold standard, using Pearson correlation analysis. RESULTS: In total, 156 patients participated in this study, including 51 in the Normal BMD group and 105 in the osteopenia/osteoporosis group. The PBQ score in the osteopenia/osteoporosis group was significantly higher than that in the normal BMD group (3.19±0.55 vs. 2.84±0.51, p<.001). The VBQ and PBQ scores were calculated by 2 authors and were in good agreement (intraclass correlation coefficient=0.949 and 0.929, respectively). Pearson's test showed a significant negative correlation between PBQ and QCT BMD (r=-0.4887, p<.001). The optimal cutoff PBQ score to differentiate patients with osteopenia/osteoporosis from those with normal BMD was 3.160, with a sensitivity of 66.7%, specificity of 72.5%, and AUC of 0.776. The PBQ score correlated more strongly with QCT BMD (r=-0.4887) than VBQ (r=-0.4078). CONCLUSIONS: In this study, we propose a novel, MRI-based pedicle-specific bone quality score. This is the first study to investigate the relationship between the PBQ score and QCT BMD. The PBQ score showed diagnostic utility, differentiating between patients with osteopenia/osteoporosis and those with normal BMD (AUC=0.776), and the PBQ score correlated more strongly with QCT BMD than VBQ.

Correlations among MRI-based cervical and thoracic vertebral bone quality score, CT-based Hounsfield Unit score, and DEXA t-score in assessment of bone mineral density.

BACKGROUND: Further optimization of the validated vertebral bone quality (VBQ) score using magnetic resonance imaging (MRI) may expand its clinical utility for bone mineral density (BMD) assessment. This study evaluated the correlations among cervical and thoracic VBQ scores, the validated Hounsfield Unit (HU) measured on computed tomography (CT), and dual-energy x-ray absorptiometry (DEXA) values. METHODS: We retrieved the medical and radiographic records of 165 patients who underwent synchronous MRI of the cervical and thoracic spine, as well as DEXA and CT imaging of the spine obtained within 1 year of each other between 2015 and 2022. Radiographic data consisted of the MRI-based cervical and thoracic VBQ scores, CT-based HU, and DEXA T-scores of the spine and hip. Patient age, sex, body mass index (BMI), and ethnicity were also obtained. RESULTS: Mean cervical and thoracic VBQ scores were 3.99 ± 1.68 and 3.82 ± 2.11, respectively. Mean HU and DEXA T-scores of the spine and hip were 135.75 ± 60.36, -1.01 ± 1.15, and -0.47 ± 2.27. All correlations among VBQ, HU, and DEXA were insignificant except for weak correlations between cervical and thoracic VBQ, and cervical VBQ and HU. No correlations were observed between radiographic scores and patient age or BMI. No differences based on ethnicity or sex were observed with respect to cervical or thoracic VBQ, HU, or DEXA. CONCLUSION: Cervical and thoracic VBQ scores are distinct from Hounsfield Unit and DEXA values. VBQ scoring in the cervical and thoracic spine is not influenced by patient age, ethnicity, sex, or BMI.

S1 vertebral bone quality score independently predicts pedicle screw loosening following surgery in patients with adult degenerative scoliosis.

BACKGROUND CONTEXT: MRI-based vertebral bone quality (VBQ) score is an effective predictor of pedicle screw loosening after lumbar fusion surgery and has been recognized as a valuable tool for assessing preoperative bone quality. Due to the lateral curvature of lumbar spine of degenerative scoliosis, accurate measurement of VBQ score by conventional measurement methods that capture MRI signal intensity at L1-4 may be limited under certain conditions. To this end, a new simplified S1 VBQ score method has been proposed, which is comparable to the previous L1-4 VBQ score or S1 Hounsfield unit (HU) value, and has high accuracy and reliability. PURPOSE: To evaluate the predictive value of MRI-based S1 VBQ score for pedicle screw loosening following surgery for adult degenerative scoliosis (ADS). STUDY DESIGN/SETTING: Retrospective single-center cohort. PATIENT SAMPLE: We reviewed 92 patients who underwent posterior lumbar interbody fusion (PLIF) with pedicle screw fixation for ADS between January 2017 and January 2020. OUTCOME MEASURES: Association between S1 VBQ score and pedicle screw loosening following surgery for ADS. METHODS: We retrospectively reviewed the records of all patients who performed PLIF between January 2017 and January 2020. The clear zone around pedicle screws≥1 mm can be identified as screw loosening. The S1 VBQ score is calculated from the S1 central-based noncontrast T1-weighted magnetic resonance imaging (MRI). The signal intensity (SI) of the cerebrospinal fluid (CSF) was then measured using ROI placed at the L3 level to normalize the results. Multivariate logistic regression analysis was performed to identify independent risk factors for screw loosening. Then, constructed a receiver operating characteristic (ROC) curve and determined the threshold (cut-off) of VBQ score with high sensitivity and specificity based on Youden Index. RESULTS: A total of 92 patients were included, including 34 males and 58 females. The mean age of the patients was 61.23±1.23 years old. At 1-year follow-up, the screw loosening rate was 56.5% (52/92). The age and levels of fixation were higher in the loosening group than in the nonloosening group (p=.036, p=.025). Patients in the loosening group had a greater VBQ score compared to patients in the nonloosening group (3.31±0.41 vs 3.01±0.28, p=.001). Multivariate logistic regression analysis showed that advanced age (OR, 1.090; 95% CI 1.005-1.183; p=.039) and higher VBQ score (OR, 5.778; 95% CI 2.889-16.177; p=.001) were independent risk factors for screw loosening. In addition, the ROC curve were created to assess the role of VBQ score as predictors of screw loosening with a diagnostic accuracy of 74.6% (95% CI 64.2%-85.1%).The most suitable threshold for the VBQ score as determined by the Youden Index was 3.175 (sensitivity: 76.0%, specificity: 83.3%). CONCLUSIONS: Higher S1 VBQ score was significantly associated with pedicle screw loosening following surgery for ADS. The S1 VBQ score can be used as an effective preoperative predictor, which has the potential clinical application.

MRI-based vertebral bone quality score in cervical ossification of the posterior longitudinal ligament: a comparison with cervical spondylotic myelopathy using propensity score matching.

BACKGROUND: Bone mineral density plays a key role in the assessment of operative instrumentation complications and clinical outcomes. The MRI-based vertebral bone quality (VBQ) score has been introduced as a novel marker of bone quality. However, few studies have investigated the relationship between VBQ score and patients associated with cervical ossification of the posterior longitudinal ligament (OPLL). PURPOSE: The aims of the study were (1) to reveal bone mineral density between cervical OPLL and cervical spondylotic myelopathy (CSM) group by VBQ score, (2) to compare the VBQ score of cervical OPLL between male and female group, (3) to explore the relationship between segmental VBQ scores associated with OPLL. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Consecutive series of 425 patients at a single academic institution. OUTCOME MEASURES: MRI based measurements of C2-C7 VBQ scores. METHODS: Preoperative noncontrast T1-weighted MRIs of the cervical spine was used to measure the VBQ score. The VBQ score was defined as the mean value of the signal intensity of the vertebrae divided by that of the cerebrospinal fluid (CSF) space at the cisterna magna. Patients with cervical OPLL and CSM were matched based on age, sex, body mass index (BMI), comorbidity, medication history, diet habit, smoking, alcohol consumption via propensity score matching (PSM). Normality of each VBQ score was tested by the Shapiro-Wilk test. Wilcoxon's rank-sum test was used to compare matched cohorts. Kruskal-Wallis test was performed to compare the VBQ scores between segments. Multivariate logistic regression analysis was used to evaluate factors associated with the development of cervical OPLL. RESULTS: A total of 425 patients were assessed. For final analysis, 135 paired patients were compared between the cervical OPLL and CSM groups, and 22 paired patients were compared between male and female group associated with cervical OPLL. There were no statistically significant differences in age, sex, BMI, comorbidity, medication history, diet habit, smoking, alcohol between the matched cohorts. OPLL group was associated with lower VBQ score compared with CSM group at C3, while there were no differences in VBQ score for the other levels between the two groups. There were no differences between male and female group associated with OPLL in C2-C7 VBQ scores. VBQ scores of cervical OPLL are variable between segments, with significantly lower scores at C6, C7 compared with C1-C5. Multivariate logistic regression analysis showed that BMI was correlated with the development of OPLL (regression coefficient, 0.162; 95% confidence interval, 0.010-0.037). Additional risk factors included hypertension, calcium supple history and smoking. CONCLUSIONS: This study demonstrates that cervical OPLL is associated with lower VBQ score at C3, with no differences for the other levels when compared with CSM derived from measurements on MRI. No differences were found between male and female group associated with OPLL in C2-C7 VBQ scores. Cervical OPLL were found to have smaller VBQ score at C6, C7 compared with C1-C5. Our findings provide new insight for bone density assessment in cervical OPLL patient.

Simplified S1 Vertebral Bone Quality Score in the Assessment of Patients with Vertebral Fragility Fractures.

OBJECTIVE: To evaluate the effectiveness of the S1 vertebral bone quality (VBQ) score in assessing bone quality among patients with vertebral fragility fractures (VFF). Additionally, whether the combination of S1 VBQ and Hounsfield unit (HU) values improves the predictive accuracy of VFF. METHODS: Using lumbar noncontrast computed tomography and T1-weighted magnetic resonance imaging, we measured L1 HU values, S1 VBQ, and L1-L4 VBQ. To assess their predictive performance for VFF, we constructed receiver operating characteristic curves. We also compared the diagnostic efficacy of HU values with that of S1 VBQ and L1--L4 VBQ values for the joint diagnosis of VFF. The Delong test was used to compare the value of individual or combined predictions of VFF. RESULTS: In comparison to the nonfracture group, all patients exhibited markedly elevated S1 VBQ and L1--L4 VBQ and notably reduced HU values (P < 0.001). Multivariate analysis revealed that elevated S1 VBQ, increased L1--L4 VBQ, and decreased HU values independently correlated with VFF development. The areas under the curve for VFF prediction were 0.806 for S1 VBQ, 0.799 for L1--L4 VBQ, and 0.820 for HU values. According to the Delong test, the combination of HU values with S1 VBQ/L1--L4 VBQ significantly improved the diagnostic accuracy. CONCLUSIONS: The simplified S1 VBQ is a valuable tool for predicting the occurrence of VFF and can be used as an alternative to the L1--L4 VBQ. In addition, the combination of S1 VBQ and HU values can significantly improve the predictive value of VFF.

Association Between Vertebral Bone Quality Score and Dual-Energy X-ray Absorptiometry for the Assessment of Bone Mineral Density in Adolescent Patients.

BACKGROUND: The MRI-based vertebral bone quality (VBQ) score is an assessment tool for bone mineral density (BMD) that has been validated in adults against the clinical standard of dual-energy X-ray absorptiometry (DEXA). However, VBQ has yet to be validated against DEXA for use in adolescents. This study evaluated the associations between adolescent VBQ scores, DEXA Z-scores, and BMD values. METHODS: The radiographic records of 63 consecutive patients between the ages of 11 and 21 who underwent MRI of the abdomen and pelvis and DEXA of the spine and hip were retrieved. The collected radiographic data consisted of the MRI-based VBQ score, DEXA Z-score, and BMD values of the femoral neck, L1-4 vertebrae, and total body. The VBQ score was calculated by taking the median signal intensity (MSI) from L1-L4 and the SI of the L3 cerebrospinal fluid (CSF). The VBQ score was derived as the quotient of MSIL1-L4 divided by SICSF. RESULTS: A mean VBQ score of 2.41 ± 0.29 was observed. Strong correlations of -0.749 (p<0.0001) and -0.780 (p<0.0001) were detected between the VBQ score and DEXA femoral neck and spine Z-scores, respectively. Correlations between VBQ score and DEXA femoral neck, spine, and total body BMD scores were -0.559 (p<0.0001), -0.611 (p<0.0001), and -0.516 (p<.0001), respectively. No significant correlations were found between the VBQ score and age, BMI, weight, or height. A mean difference in VBQ score of -0.155 (p=0.035) was observed between sexes. VBQ demonstrated moderate predictive ability for DEXA-derived Z-scores and BMD scores. CONCLUSIONS: VBQ scores were strongly correlated with DEXA Z-scores and moderately correlated with BMD values. The VBQ score can also be used by adolescent patients as an accessory tool to assess bone health.

Using advanced imaging to measure bone density, compression fracture risk, and risk for construct failure after spine surgery.

Low bone mineral density (BMD) can predispose to vertebral body compression fractures and postoperative instrumentation failure. DEXA is considered the gold standard for measurement of BMD, however it is not obtained for all spine surgery patients preoperatively. There is a growing body of evidence suggesting that more routinely acquired spine imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) can be opportunistically used to measure BMD. Here we review available studies that assess the validity of opportunistic screening with CT-derived Hounsfield Units (HU) and MRI-derived vertebral vone quality (VBQ) to measure BMD of the spine as well the utility of these measures in predicting postoperative outcomes. Additionally, we provide screening thresholds based on HU and VBQ for prediction of osteopenia/ osteoporosis and postoperative outcomes such as cage subsidence, screw loosening, proximal junctional kyphosis, and implant failure.

Comparison of Hounsfield units and vertebral bone quality score for the prediction of time to pathologic fracture in mobile spine metastases treated with radiotherapy.

OBJECTIVE: Spine metastases are commonly treated with radiotherapy for local tumor control; pathologic fracture is a potential complication of spinal radiotherapy. Both Hounsfield units (HUs) on CT and vertebral bone quality (VBQ) on MRI have been argued to predict stability as measured by odds of pathologic fracture, although it is unclear if there is a difference in the predictive power between the two methodologies. The objective of the present study was to examine whether one methodology is a better predictor of pathologic fracture following radiotherapy for mobile spine metastases. METHODS: Patients who underwent radiotherapy (conventional external-beam radiation therapy, stereotactic body radiation therapy, or intensity-modulated radiation therapy) for mobile spine (C1-L5) metastases at a tertiary care center were retrospectively identified. Details regarding underlying pathology, patient demographics, and tumor morphology were collected. Vertebral involvement was assessed using the Weinstein-Boriani-Biagini (WBB) system. Bone quality of the non-tumor-involved bone was assessed on both pretreatment CT and MRI. Univariable analyses were conducted to identify independent predictors of fracture, and Kaplan-Meier analyses were used to identify significant predictors of time to pathologic fracture. Stepwise Cox regression analysis was used to determine independent predictors of time to fracture. RESULTS: One hundred patients were included (mean age 62.7 ± 11.9 years; 61% male), of whom 35 experienced postradiotherapy pathologic fractures. The most common histologies were lung (22%), prostate (21%), breast (14%), and renal cell (13%). On univariable analysis, the mean HUs of the vertebrae adjacent to the fractured vertebra were significantly lower among those experiencing fracture; VBQ was not significantly associated with fracture odds. Survival analysis showed that average HUs ≤ 132, nonprostate pathology, involvement of ≥ 3 vertebral body segments on the WBB system, Spine Instability Neoplastic Score (SINS) ≥ 7, and the presence of axial pain all predicted increased odds of fracture (all p < 0.001). Cox regression found that HUs ≤ 132 (OR 2.533, 95% CI 1.257-5.103; p = 0.009), ≥ 3 WBB vertebral body segments involved (OR 2.376, 95% CI 1.132-4.987; p = 0.022), and axial pain (OR 2.036, 95% CI 0.916-4.526; p = 0.081) predicted increased fracture odds, while prostate pathology predicted decreased odds (OR 0.076, 95% CI 0.009-0.613; p = 0.016). Sensitivity analysis suggested that an HU threshold of ≤ 132 and a SINS of ≥ 7 identified patients at increased risk of fracture. CONCLUSIONS: The present results suggest that bone density surrogates as measured on CT, but not MRI, can be used to predict the risk of pathologic fracture following radiotherapy for mobile spine metastases. More extensive vertebral body involvement and the presence of mechanical axial pain additionally predict increased fracture odds.

Assessing the utility of MRI-based vertebral bone quality (VBQ) for predicting lumbar pedicle screw loosening.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The purpose of this study is to assess the potential of utilizing the MRI-based vertebral bone quality (VBQ) score as a predictive tool for pedicle screw loosening (PSL) in patients who have undergone pedicle screw fixation and to identify risk factors associated with VBQ scores. METHODS: One hundred and sixteen patients who had undergone pedicle screw fixation between December 2019 and January 2021 and had more than a year of follow-up were divided into two groups of PSL and non-PSL. The radiological and clinical parameters investigated were age, gender, body mass index, the VBQ score, length of fusion and the DXA T-score. RESULTS: Of the 116 patients included in the study, 22 patients developed pedicle screw loosening after surgery (18.97%). VBQ score of PSL group was higher than the non-PSL group (3.61 ± 0.63 vs. 2. 86 ± 0.43, p < 0.001). According to logistic regression, PSL was independently linked with a higher VBQ score (OR = 3.555, 95% confidence interval [1.620-7.802], p < 0.005). The AUC of predicting screw loosening was 0.774 (p < 0.001) for VBQ score, and the best threshold was 3.055 (sensitivity, 81.8%; specificity, 71.3%). High VBQ score was associated with age (r (114) = 0.29, p = 0.002), while it was not negatively correlated with T-scores of each part. CONCLUSION: VBQ score is an independent predictor of pedicle screw loosening, with higher scores indicating a greater risk. Our results showed that older patients and women had higher VBQ scores.

The Significance of Combined OSTA, HU Value and VBQ Score in Osteoporosis Screening Before Spinal Surgery.

OBJECTIVE: This study aimed to assess the utility of a combined assessment using the Osteoporosis Self-Assessment Tool for Asians (OSTA), Hounsfield unit (HU) value, and vertebral bone quality (VBQ) score for preoperative osteoporosis (OP) screening in patients scheduled for spinal surgery. METHODS: This study encompassed 288 participants, including 128 males and 160 females. Patients were stratified into 2 groups: the OP group (T-score ≤ -2.5) and the non-OP group (T-score > -2.5), determined by dual-energy X-ray absorptiometry (DEXA). Binary logistic regression was used to construct a combined diagnostic model, and the receiver operating characteristic (ROC) curve evaluated the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of these metrics individually or in combination to screen for OP. RESULTS: Osteoporosis patients exhibited significantly lower OSTA and HU values in comparison to non-OP patients, while their VBQ scores were significantly higher (P < 0.001). The ROC curve analysis results indicated that within the male group, the combined diagnosis had a sensitivity of 93.8%, specificity of 82.3%, accuracy of 85.2%, PPV of 63.8%, and NPV of 97.5%. In the female group, the combined diagnosis had a sensitivity of 93.9%, specificity of 87.4%, accuracy of 90.0%, PPV of 83.6%, and NPV of 95.4%. CONCLUSIONS: The combined use of OSTA, HU values, and VBQ scores in preoperative OP screening for spinal surgery demonstrates significantly higher accuracy and superior screening value compared to individual assessments. These results establish a robust scientific foundation for conducting preoperative OP screening in patients undergoing spinal surgery.

Comparative Analysis of the 3 Cervical Vertebral Bone Quality (C-VBQ) Score Methodologies and Their Correlations to the Lumbar Vertebral Bone Quality (VBQ) Score.

OBJECTIVE: Common complications after spinal fusion, such as pseudoarthrosis, cage subsidence, or instrumentation failure, are affected by patients' bone quality. The cervical-vertebral bone quality (C-VBQ) score, a magnetic resonance imaging (MRI)-based adaption of the lumbar vertebral bone quality (VBQ) score, was developed by 3 separate research groups simultaneously to evaluate bone quality in cervical spinal fusion patients. We present the first analysis comparing these scoring methods to the well-validated VBQ score. METHODS: A retrospective analysis of data for consecutive patients who underwent spine surgery at a single institution was completed. The VBQ score was calculated using the Ehresman et al. METHOD: The C-VBQ scores, named according to placement of the region of interest within the cerebral spinal fluid, were calculated separately using the methods of Soliman et al. (C2-VBQ), Razzouk et al. (C5-VBQ), and Huang et al. (T1-VBQ). Linear regression models were utilized to evaluate correlations to the VBQ score. RESULTS: A total of 105 patients were identified (mean age, 57.0 ± 11.9 years; women, 50.5%). Mean scores were C2-VBQ, 2.37 ± 0.55; C5-VBQ, 2.36 ± 0.61; and T1-VBQ, 2.64 ± 0.68. The C-VBQ scores for the C2 level were significantly higher than those for the C3-C6 levels (3.18 ± 0.96 vs. 2.63 ± 0.77, P < 0.001), whereas the C7 level was found to have significantly lower C-VBQ scores (2.42 ± 0.78 vs. 2.63 ± 0.77, P = 0.04). The C2-VBQ (r = 0.63) score had the strongest correlation to the VBQ score, compared to C5-VBQ (r = 0.41) and T1-VBQ (r = 0.43) (P < 0.001). CONCLUSIONS: This study demonstrates that the C2-VBQ had the strongest correlation to the lumbar VBQ score among all C-VBQ scores.

Correlation between MRI-based spinal muscle parameters and the vertebral bone quality score in lumbar fusion patients.

Introduction: The vertebral bone quality (VBQ) score that is based on non-contrast enhanced T1-weighted MRI was recently introduced as a novel measure of bone quality in the lumbar spine and shown to be a significant predictor of healthy versus osteopenic/osteoporotic bone. Research question: This study aimed to assess possible correlations between the VBQ score and the functional cross-sectional area (FCSA) of psoas and lumbar spine extensor muscles. Material and methods: Patients who underwent fusion surgery between 2014 and 2017 and had lumbar MRI and CT scans within 6 months prior to surgery were included. The FCSA was assessed at L3-L5 using a pixel intensity threshold method. The VBQ score was calculated by dividing the signal intensity (SI) of the vertebrae L1-L4 through the SI of the cerebrospinal fluid at L3. Volumetric bone mineral density (vBMD) was assessed by quantitative CT. Results: 80 patients (58.8% female, median age 68.8 years) were included. Overall prevalence of osteopenia/osteoporosis was 66.3%, with no significant differences between men and women. The mean (SD) VBQ score was significantly smaller in men, at 2.26 (0.45) versus women at 2.59 (0.39) (p = 0.001). After adjusting for age and BMI, a significant negative correlation was seen between the VBQ score and psoas FCSA at L3 (ß = -0.373; p = 0.022), but only in men. Conclusion: Our results highlight sex differences in the VBQ score that were not demonstrated by vBMD and suggest a potential role of this novel measure to assess not only bone quality, but also spinal muscle quantity.

Vertebral bone quality different in magnetic resonance imaging parameters.

OBJECTIVE: This was a single-center retrospective study that aimed to measure the vertebral bone quality (VBQ) in people of all ages and compare changes in VBQ across ages. Differences in VBQ under various MRI parameters were compared. METHODS: We first screened patients without underlying disease and no history of fractures who underwent lumbar MRI in our center in the past four years. Over the span of 10 years, 200 patients (100 males and 100 females) were randomly recruited into each cohort to undergo 1.5 T and 3.0 T MRI scans. Subsequently, we tabulated the number of patients admitted to our hospital with OVCF over the past four years. There were 30 healthy adults under 4 times of MRI scans in different parameters to determine the differentiation of VBQ. The 30 healthy adults were recruited to validate the differentiation of VBQ under various parameters. RESULTS: A total of 2400 patients without OVCF and 405 patients with OVCF were enrolled. The VBQ value of 1.5 T was significantly higher compared with that of 3.0 T (2.769 ± 0.494 > 2.199 ± 0.432, P < 0.0001). VBQ of 43.31 kHz in 1.5 T was significantly lower than that of 35.36 kHz (2.447 ± 0.350 < 2.632 ± 0.280, P < 0.05). The differentiation of VBQ in 1.5 T and 3.0 T was validated using results of healthy adults. CONCLUSIONS: VBQ is an effective tool for differentiating patients with OVCF and can be used as a primary screening tool for osteoporosis. However, VBQ is significantly affected by magnetic field intensity and bandwidth and cannot achieve its universality as it originally proposed.

A meta-analysis of the value of MRI-based VBQ scores for evaluating osteoporosis.

Objective: Osteoporosis is the most common skeletal disease in humans. Early onset of osteoporosis is usually asymptomatic, so early diagnosis is critical. The purpose of this study was to analyze the value of MRI-based VBQ scores for evaluating osteoporosis. Methods: We searched PubMed, Embase, the Cochrane Library databases, Web of Science, and some Chinese electronic databases for published articles and the ClinicalTrials.gov site for completed but unpublished studies on evaluating the value of MRI-based VBQ scores for evaluating osteoporosis. We calculated the summarized sensitivity, specificity, the ROC curve (AUC) values and their 95% confidence intervals (CIs) using MetaDiSc 1.4 software and STATA. Results: Our study included 8 studies involving 999 patients of which 660 patients were diagnosed with osteopenia/osteoporosis, and 339 patients were identified as having normal BMD. The pooled sensitivity was 0.809 (95% CI, 0.777-0.838, I2 = 78.8%), the pooled specificity was 0.640 (95% CI, 0.587-0.691, I2 = 85.9%), and the pooled AUC was 0.8375. Conclusion: MRI-based VBQ scores provided high sensitivity and moderate specificity in detecting osteoporosis. Opportunistic use of VBQ scores could be considered, e.g. before lumbar spine surgery. Prospero registration number: CRD42022377024.

MRI-based Endplate Bone Quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion.

BACKGROUND CONTEXT: Cage subsidence following transforaminal lumbar interbody fusion (TLIF) has closely correlated with poor vertebral bone quality. Studies have shown better predictive value for cage subsidence by measuring bone density at specific site. However, few studies have been performed to examine the relationship between site-specific MRI bone assessment and cage subsidence in patients who have undergone lumbar interbody fusion. The association between MRI-based assessment of endplate bone quality and cage subsidence after TLIF remains unclear. PURPOSE: To study the predictive value of MRI-based endplate bone quality (EBQ) score for cage subsidence following TLIF, using QCT bone densitometry as a reference standard. STUDY DESIGN/SETTING: A retrospective study. PATIENT SAMPLE: A total of 280 adult patients undergoing single-segment TLIF for degenerative lumbar spine disease from 2010 to 2020 at our institution who had preoperative T1-weighted MRIs. OUTCOME MEASURES: Cage subsidence, disc height, endplate bone quality (EBQ) score, bone mineral density, fusion rate. METHODS: The retrospective study reviewed patients who underwent TLIF at one institution between March 2010 and October 2020. Cage subsidence was measured with postoperative lumbar X-rays based on the cage protrusion through into the superior or inferior end plate or both by more than 2 mm. The EBQ score was measured from preoperative T1-weighted MRI in accordance with the previously reported method. RESULTS: Cage subsidence was observed in 42 of the 280 patients. Bone densitometry with quantitative computed tomography was visibly reduced in the subsidence group. The mean EBQ scores of the lumbar endplate bone was 4.3±0.9 in nonsubsidence and 5.0±0.6 in subsidence. On multivariate logistic regression, the difference between the two groups was remarkable. Risk of cage subsidence increases significantly with higher EBQ scores (odds ratio [OR]=2.063, 95% confidence interval [CI] 1.365-3.120, p=.001) and was an independent factor in predicting subsidence after TLIF. On receiver operating characteristic curve, the AUC for the EBQ score was 0.820 (95% confidence interval [CI]: 0.755-0.844) and the most suitable threshold for the EBQ score was 4.730 (sensitivity: 76.2%, specificity: 83.2%). CONCLUSIONS: Higher EBQ scores measured on preoperative MRI correlated significantly with cage subsidence following TLIF. Performing EBQ assessment prior to TLIF may be a valid method of predicting the risk of postoperative subsidence.

MRI-based vertebral bone quality score compared to quantitative computed tomography bone mineral density in patients undergoing cervical spinal surgery.

PURPOSE: The vertebral bone quality (VBQ) score based on magnetic resonance imaging (MRI) was introduced as a bone quality marker in the lumbar spine. Prior studies showed that it could be utilized as a predictor of osteoporotic fracture or complications after instrumented spine surgery. The objective of this study was to evaluate the correlation between VBQ scores and bone mineral density (BMD) measured by quantitative computer tomography (QCT) in the cervical spine. METHODS: Preoperative cervical CT and sagittal T1-weighted MRIs from patients undergoing ACDF were retrospectively reviewed and included. The VBQ score in each cervical level was calculated by dividing the signal intensity of the vertebral body by the signal intensity of the cerebrospinal fluid on midsagittal T1-weighted MRI images and correlated with QCT measurements of the C2-T1 vertebral bodies. A total of 102 patients (37.3% female) were included. RESULTS: VBQ values of C2-T1 vertebrae strongly correlated with each other. C2 showed the highest VBQ value [Median (range) 2.33 (1.33, 4.23)] and T1 showed the lowest VBQ value [Median (range) 1.64 (0.81, 3.88)]. There was significant weak to moderate negative correlations between and VBQ Scores for all levels [C2: p < 0.001; C3: p < 0.001; C4: p < 0.001; C5: p < 0.004; C6: p < 0.001; C7: p < 0.025; T1: p < 0.001]. CONCLUSION: Our results indicate that cervical VBQ scores may be insufficient in the estimation of BMDs, which might limit their clinical application. Additional studies are recommended to determine the utility of VBQ and QCT BMD to evaluate their potential use as bone status markers.

Comparison of cervical, thoracic, and lumbar vertebral bone quality scores for increased utility of bone mineral density screening.

PURPOSE: To evaluate the associations among the validated lumbar vertebral bone quality (VBQ) score, and cervical and thoracic VBQ scores. METHODS: Radiographic records of 100 patients who underwent synchronous MRI of the cervical, thoracic, and lumbar spine were retrieved. DEXA-validated lumbar VBQ was calculated using median signal intensity (MSI) of the L1-L4 vertebrae and L3 CSF. VBQ was derived as the quotient of MSIL1-L4 divided by MSICSF. Cervical and thoracic VBQ were similarly obtained using C3-C6 and C5 CSF, and T5-T8 and T7 CSF, respectively. Paired sample t-tests were used to evaluate differences among regional VBQ scores. Independent sample t-tests were used to identify sex differences in VBQ. Regression models with one-way analysis of variance (ANOVA) were constructed to identify associations among all permutations of anthropometric and regional VBQ measures. RESULTS: Mean cervical, thoracic, and lumbar VBQ scores were 3.06 ± 0.89, 2.60 ± 0.77, and 2.47 ± 0.61, respectively. Mean differences of .127 (p = 0.045) and - 0.595 (p < 0.001) were observed between thoracic and lumbar, and cervical and lumbar VBQ scores. Correlations of 0.324, 0.356, and 0.600 (p < 0.001) were found between cervical and lumbar, cervical and thoracic, and thoracic and lumbar VBQ scores. Regression with ANOVA predicting lumbar VBQ in relation to cervical and thoracic VBQ demonstrated R Square values of 0.105 and 0.360 (p < 0.001), and ß coefficient values of 0.471 and 0.217 (p < 0.001), respectively. CONCLUSION: Thoracic VBQ provides values representative of the validated lumbar VBQ score. Cervical VBQ scores are distinct from lumbar VBQ scores and do not provide adequate surrogate values of lumbar VBQ.

Vertebral bone quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion.

BACKGROUND CONTEXT: Cage subsidence following transforaminal lumbar interbody fusion (TLIF) has been associated with poor bone quality. Current evidence suggests that the magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score correlates with poor bone quality. PURPOSE: To our knowledge, this is the first study to assess whether the VBQ score can predict the occurrence of postoperative cage subsidence after TLIF surgery. DESIGN/SETTING: Retrospective single-center cohort. PATIENT SAMPLE: Patients undergoing single-level TLIF for degenerative spine disease between February 2014 and October 2021. OUTCOME MEASURES: Extent of subsidence. METHODS: Demographic, procedure-related, and radiographic data were collected for study patients. VBQ scores were determined from preoperative T1-weighted MRI. Subsidence was defined as ≥2 mm of migration of the cage into the superior or inferior end plate or both. Univariate and multivariate logistic regression were used to determine the correlation between potential risk factors for subsidence and actual subsidence rates. RESULTS: Subsidence was observed among 42 of the 74 study patients. The mean VBQ scores were 2.9±0.5 for patients with subsidence and 2.5±0.5 for patients without subsidence. The difference among groups was significant (p=.003). On multivariate logistic regression, a higher VBQ score was significantly associated with an increased risk of subsidence (OR=1.5, 95% CI=1.160-1.973, p=.004) and was the only significant independent predictor of subsidence after TLIF. CONCLUSION: We found that a higher VBQ score was significantly associated with cage subsidence following TLIF. The MRI-VBQ score may be a valuable tool for assisting in identifying patients at risk of cage subsidence following TLIF.

The predictive value of a novel site-specific MRI-based bone quality assessment, endplate bone quality (EBQ), for severe cage subsidence among patients undergoing standalone lateral lumbar interbody fusion.

BACKGROUND CONTEXT: Studies have shown that site-specific bone density measurements had more predictive value for complications than standard whole-region measurements. Recently, MRI-based assessments of vertebral bone quality (VBQ) were introduced. However, there have been few studies that investigate the association between site-specific MRI bone assessment and osteoporosis-related complications in patients undergoing lumbar interbody fusion. In this work, we created a novel site-specific MRI-based assessment of the endplate bone quality (EBQ) and assessed its predictive value for severe cage subsidence following standalone lateral lumbar interbody fusion (SA-LLIF). PURPOSE: To investigate the predictive value of a novel MRI-based bone assessment for severe cage subsidence after SA-LLIF. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients who underwent SA-LLIF from 2008 to 2019 at a single, academic institution with available preoperative lumbar CT and T1-weighted MRIs. OUTCOME MEASURES: Association between EBQ and severe subsidence after SA-LLIF. METHODS: We retrospectively reviewed the records of SA-LLIF patients treated between 2008 and 2019. EBQ was measured using preoperative non-contrast T1-weighted MRIs of the lumbar spine. EBQ was defined as the average value of signal intensity of both endplates divided by that of the cerebrospinal fluid space at the level of L3. Bivariate and multivariable analyses with generalized linear mixed models were performed and set binary severe subsidence as the outcome. RESULTS: Two hundred five levels in 89 patients were included. Fifty levels (24.4%) demonstrated severe subsidence. Bone mineral density measured by quantitative computed tomography was significantly lower in the subsidence group. Both VBQ and EBQ were significantly higher in the subsidence group. The EBQ plus Modic change (MC) model demonstrated that the effect of EBQ was independent of MC. In multivariate analyses adjusted with QCT-vBMD, EBQ showed a significant association with cage subsidence whereas VBQ only showed a marginal trend. The EBQ-based prediction model for severe subsidence showed better goodness of fit compared to the VBQ-based model. CONCLUSIONS: High EBQ was an independent factor for severe cage subsidence after SA-LLIF and the EBQ-based model showed better goodness of fit compared to VBQ- or MC-based models. EBQ assessment before SA-LLIF may provide insight into a patient's risk for severe subsidence.

Patient physiology influences the MRI-based vertebral bone quality score.

BACKGROUND CONTEXT: Osteoporosis is a critical issue affecting postmenopausal women and the aging population. A novel magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score has been proposed as a method to identify poor bone quality and predict fragility fractures. The diagnostic accuracy of this tool is not well understood. PURPOSE: To examine the ability of VBQ to predict osteoporosis and osteopenia, its correlation with dual-energy x-ray absorptiometry (DEXA), and the influence of patient-specific factors upon the score. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Patients over the age of 18 with a DEXA scan and noncontrast, T1-weighted MRI of the lumbar spine completed within a 2-year period. OUTCOME MEASURES: Area-under-curve (AUC) values of the VBQ score predicting osteopenia and osteoporosis when controlling for patient characteristics. METHODS: Patients with noncontrast, T1-weighted MRIs of the lumbar spine and DEXA scans completed within a 2-year time frame were retrospectively reviewed. Patient demographics and medical risk factors for osteoporosis were identified and compared. VBQ scores were measured by two trained researchers and interrater reliability was calculated. Patients were separated into three groups defined by lowest DEXA T-score: Healthy Bone, Osteopenia, and Osteoporosis. analysis of variance, Kruskal-Wallis test, chi-square, t tests, Mann-Whitney U tests, and multivariate linear regression were performed to examine the relationship between patient characteristics, DEXA t-scores, and VBQ scores. Receiver operating characteristic analysis and AUC values were generated for the prediction of osteopenia and osteoporosis. RESULTS: A total of 156 patients were included for analysis. Sufficient inter-rater reliability was determined for VBQ measures (intraclass correlation coefficient: 0.81). Most patients were female (83%), postmenopausal (81%), and had hyperlipidemia (64%). Patients with hyperlipidemia and healthy bone density by DEXA had elevated baseline VBQ scores (p<.001) reflective of values seen in osteopenia and osteoporosis. The AUC of the VBQ score predicting osteopenia and osteoporosis changed to be more concordant with DEXA results after controlling for hyperlipidemia (AUC=0.72, 0.70 vs. AUC=0.88, 0.89; p<.001). Sub-analysis of hyperlipidemia subtypes revealed that elevated high-density lipoprotein is associated with elevated VBQ scores. CONCLUSIONS: Hyperlipidemia increased the MRI-based VBQ score in our healthy bone population. The high signal intensities resembled values seen in osteopenia and osteoporosis, suggesting that physiologic variables which impact bone composition may influence the VBQ score. Specifically, elevated high-density lipoprotein may contribute to this. The microarchitectural changes and the clinical implications of these factors need further exploration.