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. 2025 Jul 1;30(1):529.
doi: 10.1186/s40001-025-02797-9.

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

Chaohui Ding #  1 , Changnan Xie #  1 , Jinwei Ying  1 , Mengxian Jia  1 , Ziwei Fan  1 , Xiang Fang  1 , Xianghe Wang  1 , Honglin Teng  2
Affiliations

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

Chaohui Ding et al. Eur J Med Res. .

Abstract

Objectives: 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. The 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.

Keywords: Cage subsidence; Hounsfield units; Unilateral biportal endoscopic lumbar interbody fusion immediate endplate destruction; Vertebral bone quality.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: 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. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of study population
Fig. 2
Fig. 2
Preoperative imaging measurement of bone quality. A 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)
Fig. 3
Fig. 3
CT imaging related to cage subsidence (CS) A 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
Fig. 4
Fig. 4
Logistic regression analysis and ROC curve A 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
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