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. 2025 Jun 16;20(1):588.
doi: 10.1186/s13018-025-06016-3.

Predictive value of Hounsfield units and vertebral bone quality on cage subsidence in oblique lateral interbody fusion with bilateral posterior fixation

Chaoshuo Liu #  1 , Zixi Zhang #  2 , Wenzhao Li  1 , Jialin Zhang  1 , Bing Wang  3 , Xinzhan Mao  1 , Shun Yang  4 , Tao Tu  2 , Yichao Xiao  2 , Cancan Wang  5 , Zhenbin Wang  6   7
Affiliations

Predictive value of Hounsfield units and vertebral bone quality on cage subsidence in oblique lateral interbody fusion with bilateral posterior fixation

Chaoshuo Liu et al. J Orthop Surg Res. .

Abstract

Background: Cage subsidence (CS) is a significant complication following oblique lateral interbody fusion combined with bilateral pedicle screw fixation (OLIF-BPSF) in patients with spinal degenerative diseases (SDDs). Identifying reliable predictors of CS is crucial for optimizing surgical outcomes.

Methods: This retrospective cohort study included 314 SDD patients who underwent OLIF-BPSF between July 2019 and July 2023. Preoperative Hounsfield unit (HU) values and vertebral bone quality (VBQ) scores were measured. Statistical analyses included correlation matrices, Kaplan-Meier survival analysis, Cox proportional hazards models, restricted cubic splines, and receiver operating characteristic (ROC) curve analysis. Sensitivity analyses were performed to ensure robustness.

Results: CS occurred in 13.38% of patients. Lower global (HR: 0.97, 95% CI: 0.97-0.99) and segmental (HR: 0.97, 95% CI: 0.95-0.98) HU values were significantly associated with higher CS incidence, whereas higher global (HR: 1.67, 95% CI: 1.29-2.16) and segmental (HR: 1.68, 95% CI: 1.30-2.17) VBQ scores were also significantly associated with increased CS risk. A nonlinear relationship was observed between the VBQ score and CS, with CS incidence significantly increasing when the global VBQ score was ≥ 2.67 or the segmental VBQ score was ≥ 2.49. ROC analysis demonstrated good predictive performance for HU values and VBQ scores, with segmental HU values showing superior incremental predictive value (AUC: 0.82). The findings remained consistent across various sensitivity analyses.

Conclusion: HU values and VBQ scores independently predict CS in SDD patients undergoing OLIF-BPSF. Incorporating these metrics into preoperative assessments may enhance risk stratification and guide personalized surgical planning.

Keywords: Cage subsidence (CS); Hounsfield unit (HU) value; Predictive value; Spinal degenerative disease; Vertebral bone quality (VBQ) score.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study involved the collection and analysis of patient case data and was conducted in accordance with ethical principles, adhering to the Declaration of Helsinki. The study protocol and data collection methods were reviewed and approved by the Medical Ethics Committee of the Fourth Clinical Medical School of Xinjiang Medical University (approval number: 2024XE-GS096). Consent to participate All the authors participated in the study and made significant intellectual contributions to the manuscript. Consent for publication: This manuscript is not under consideration for publication elsewhere, and the work reported will not be submitted elsewhere until a final decision has been made by the journal regarding its acceptability. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Preoperative measurement of HU values and VBQ scores. Created with BioRender.com. Abbreviations: HU, Hounsfield unit; VBQ, vertebral bone quality
Fig. 2
Fig. 2
Comparison of density curves and box plots for HU values and VBQ scores between the CS and non-CS groups. A P value < 0.05 indicated a significant difference. Abbreviations: CS, cage subsidence; HU, Hounsfield unit; VBQ, vertebral bone quality.
Fig. 3
Fig. 3
K–M analysis of CS incidence across HU values and VBQ scores. A P value < 0.05 indicated a significant difference. Abbreviations: CS, cage subsidence; HU, Hounsfield unit; K–M, Kaplan–Meier; VBQ, vertebral bone quality.
Fig. 4
Fig. 4
Associations between HU values, VBQ scores and CS in patients with SDDs. The solid line and red area represent the estimated values and their corresponding 95% CIs, respectively. A P value < 0.05 was considered statistically significant.Abbreviations: CI, confidence interval; CS, cage subsidence; HR, hazard ratio; HU, Hounsfield unit; SDD, spinal degenerative disease; VBQ, vertebral bone quality.
Fig.5
Fig.5
ROC curve analysis of HU values and VBQ scores for the prediction of CS incidence. Abbreviations: AUC, area under the curve; CI, confidence interval; CS, cage subsidence; HU, Hounsfield unit; ROC, receiver operating characteristic; SDD, spinal degenerative disease; VBQ, vertebral bone quality
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