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Chen B, Cui J, Li C, Xu P, Xu G, Jiang J, Xue P, Sun Y, Cui Z. Application of radiomics model based on lumbar computed tomography in diagnosis of elderly osteoporosis. J Orthop Res 2024; 42:1356-1368. [PMID: 38245854 DOI: 10.1002/jor.25789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 12/31/2023] [Accepted: 01/04/2024] [Indexed: 01/22/2024]
Abstract
A metabolic bone disease characterized by decreased bone formation and increased bone resorption is osteoporosis. It can cause pain and fracture of patients. The elderly are prone to osteoporosis and are more vulnerable to osteoporosis. In this study, radiomics are extracted from computed tomography (CT) images to screen osteoporosis in the elderly. Collect the plain scan CT images of lumbar spine, cut the region of interest of the image and extract radiomics features, use Lasso regression to screen variables and adjust complexity, use python language to model random forests, support vector machines, K nearest neighbor, and finally use receiver operating characteristic curve to evaluate the performance of the model, including precision, recall, accuracy and area under the curve (AUC). For the model, 14 radiolomics features were selected. The diagnosis performance of random forest model and support vector machine is good, all around 0.9. The AUC of K nearest neighbor model in training set and test set is 0.828 and 0.796, respectively. We selected the plain scan CT images of the elderly lumbar spine to build radiomics features model, which has good diagnostic performance and can be used as a tool to assist the diagnosis of osteoporosis in the elderly.
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Affiliation(s)
- Baisen Chen
- Department of Orthopedics, Nantong City No. 1 People's Hospital and Second Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
- Nantong University, Nantong, Jiangsu Province, China
| | - Jiaming Cui
- Department of Orthopedics, Nantong City No. 1 People's Hospital and Second Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Chaochen Li
- Department of Orthopedics, Nantong City No. 1 People's Hospital and Second Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
- Nantong University, Nantong, Jiangsu Province, China
- Key Laboratory for Restoration Mechanism and Clinical Translation of Spinal Cord Injury, Nantong, China
- Research Institute for Spine and Spinal Cord Disease of Nantong University, Nantong, China
| | - Pengjun Xu
- Department of Orthopedics, Nantong University Affiliated Hospital, Nantong, Jiangsu, China
| | - Guanhua Xu
- Department of Orthopedics, Nantong City No. 1 People's Hospital and Second Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Jiawei Jiang
- Department of Orthopedics, Nantong City No. 1 People's Hospital and Second Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Pengfei Xue
- Department of Orthopedics, Nantong City No. 1 People's Hospital and Second Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Yuyu Sun
- Department of Orthopedic, Nantong Third People's Hospital, Nantong, Jiangsu Province, China
| | - Zhiming Cui
- Department of Orthopedics, Nantong City No. 1 People's Hospital and Second Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
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Praveen AD, Sollmann N, Baum T, Ferguson SJ, Benedikt H. CT image-based biomarkers for opportunistic screening of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 2024; 35:971-996. [PMID: 38353706 PMCID: PMC11136833 DOI: 10.1007/s00198-024-07029-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 01/19/2024] [Indexed: 05/30/2024]
Abstract
The use of opportunistic computed tomography (CT) image-based biomarkers may be a low-cost strategy for screening older individuals at high risk for osteoporotic fractures and populations that are not sufficiently targeted. This review aimed to assess the discriminative ability of image-based biomarkers derived from existing clinical routine CT scans for hip, vertebral, and major osteoporotic fracture prediction. A systematic search in PubMed MEDLINE, Embase, Cochrane, and Web of Science was conducted from the earliest indexing date until July 2023. The evaluation of study quality was carried out using a modified Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) checklist. The primary outcome of interest was the area under the curve (AUC) and its corresponding 95% confidence intervals (CIs) obtained for four main categories of biomarkers: areal bone mineral density (BMD), image attenuation, volumetric BMD, and finite element (FE)-derived biomarkers. The meta-analyses were performed using random effects models. Sixty-one studies were included in this review, among which 35 were synthesized in a meta-analysis and the remaining articles were qualitatively synthesized. In comparison to the pooled AUC of areal BMD (0.73 [95% CI 0.71-0.75]), the pooled AUC values for predicting osteoporotic fractures for FE-derived parameters (0.77 [95% CI 0.72-0.81]; p < 0.01) and volumetric BMD (0.76 [95% CI 0.71-0.81]; p < 0.01) were significantly higher, but there was no significant difference with the pooled AUC for image attenuation (0.73 [95% CI 0.66-0.79]; p = 0.93). Compared to areal BMD, volumetric BMD and FE-derived parameters may provide a significant improvement in the discrimination of osteoporotic fractures using opportunistic CT assessments.
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Affiliation(s)
- Anitha D Praveen
- Early Detection of Health Risks and Prevention, Future Health Technologies, Singapore-ETH Centre (SEC), Campus for Research Excellence and Technological Enterprise (CREATE), 1 Create Way, CREATE Tower, #06-01, Singapore, 138602, Singapore.
| | - Nico Sollmann
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stephen J Ferguson
- Early Detection of Health Risks and Prevention, Future Health Technologies, Singapore-ETH Centre (SEC), Campus for Research Excellence and Technological Enterprise (CREATE), 1 Create Way, CREATE Tower, #06-01, Singapore, 138602, Singapore
- Institute for Biomechanics, ETH-Zurich, Zurich, Switzerland
| | - Helgason Benedikt
- Early Detection of Health Risks and Prevention, Future Health Technologies, Singapore-ETH Centre (SEC), Campus for Research Excellence and Technological Enterprise (CREATE), 1 Create Way, CREATE Tower, #06-01, Singapore, 138602, Singapore
- Institute for Biomechanics, ETH-Zurich, Zurich, Switzerland
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Aydin Ozturk P, Arac E, Ozturk U, Arac S. Estimation of bone mineral density with hounsfield unit measurement. Br J Neurosurg 2024; 38:464-467. [PMID: 33629886 DOI: 10.1080/02688697.2021.1888877] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Although dual-energy x-ray absorptiometry (DXA) remains the gold standard for the measurement of bone mineral density (BMD), degenerative spine and spinal instrumentation yields inaccurate results, warranting the need for optional methods. METHODS Surgical options depend on the BMD of the patients, and to accommodate this need, we compared Hounsfield unit (HU) measurements obtained from computed tomography (CT) scans with the T-scores obtained from DXA scans to inquire whether HU measurements can screen for BMD. In this study, we also evaluated the relationship between body mass index and spontaneous fractures. RESULTS Based on the findings described in this study, we provide evidence that HU measurements obtained from CT scans can predict BMD. CONCLUSIONS This, therefore, allows HU measurements to be used as an effective diagnostic method in lieu of DXA scans when deciding on appropriate management of therapy for patients with spinal instrumentation or degenerative spines.
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Affiliation(s)
- Pınar Aydin Ozturk
- Department of Neurosurgery, University of Health Sciences, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Esref Arac
- Department of Internal Medicine, University of Health Sciences, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Unal Ozturk
- Department of Neurology, University of Health Sciences, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Songul Arac
- Department of Emergency Medicine and First Aid, University of Health Sciences, Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
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Goller SS, Rischewski JF, Liebig T, Ricke J, Siller S, Schmidt VF, Stahl R, Kulozik J, Baum T, Kirschke JS, Foreman SC, Gersing AS. Automated Opportunistic Trabecular Volumetric Bone Mineral Density Extraction Outperforms Manual Measurements for the Prediction of Vertebral Fractures in Routine CT. Diagnostics (Basel) 2023; 13:2119. [PMID: 37371014 DOI: 10.3390/diagnostics13122119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/16/2023] [Accepted: 06/18/2023] [Indexed: 06/29/2023] Open
Abstract
Opportunistic osteoporosis screening using multidetector CT-scans (MDCT) and convolutional neural network (CNN)-derived segmentations of the spine to generate volumetric bone mineral density (vBMD) bears the potential to improve incidental osteoporotic vertebral fracture (VF) prediction. However, the performance compared to the established manual opportunistic vBMD measures remains unclear. Hence, we investigated patients with a routine MDCT of the spine who had developed a new osteoporotic incidental VF and frequency matched to patients without incidental VFs as assessed on follow-up MDCT images after 1.5 years. Automated vBMD was generated using CNN-generated segmentation masks and asynchronous calibration. Additionally, manual vBMD was sampled by two radiologists. Automated vBMD measurements in patients with incidental VFs at 1.5-years follow-up (n = 53) were significantly lower compared to patients without incidental VFs (n = 104) (83.6 ± 29.4 mg/cm3 vs. 102.1 ± 27.7 mg/cm3, p < 0.001). This comparison was not significant for manually assessed vBMD (99.2 ± 37.6 mg/cm3 vs. 107.9 ± 33.9 mg/cm3, p = 0.30). When adjusting for age and sex, both automated and manual vBMD measurements were significantly associated with incidental VFs at 1.5-year follow-up, however, the associations were stronger for automated measurements (β = -0.32; 95% confidence interval (CI): -20.10, 4.35; p < 0.001) compared to manual measurements (β = -0.15; 95% CI: -11.16, 5.16; p < 0.03). In conclusion, automated opportunistic measurements are feasible and can be useful for bone mineral density assessment in clinical routine.
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Affiliation(s)
- Sophia S Goller
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Jon F Rischewski
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Thomas Liebig
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Sebastian Siller
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Vanessa F Schmidt
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Robert Stahl
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Julian Kulozik
- Institute of Micro Technology and Medical Device Technology (MIMED), Technical University of Munich, Boltzmannstr. 15, 85748 Garching, Germany
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Jan S Kirschke
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Sarah C Foreman
- Department of Diagnostic and Interventional Radiology, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Alexandra S Gersing
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
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Cai P, Xi Z, Deng C, Li J, Zhang X, Zhou Y. Fixation-induced surgical segment's high stiffness and the damage of posterior structures together trigger a higher risk of adjacent segment disease in patients with lumbar interbody fusion operations. J Orthop Surg Res 2023; 18:371. [PMID: 37208705 DOI: 10.1186/s13018-023-03838-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/06/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Adjacent segment disease (ASD) is a commonly reported complication after lumbar interbody fusion (LIF); changes in the mechanical environment play an essential role in the generation of ASD. Traditionally, fixation-induced high stiffness in the surgical segment was the main reason for ASD. However, with more attention paid to the biomechanical significance of posterior bony and soft structures, surgeons hypothesize that this factor may also play an important role in ASD. METHODS Oblique and posterior LIF operations have been simulated in this study. The stand-alone OLIF and OLIF fixed by bilateral pedicle screw (BPS) system have been simulated. The spinal process (the attachment point of cranial ligamentum complex) was excised in the PLIF model; the BPS system has also been used in the PLIF model. Stress values related to ASD have been computed under physiological body positions, including flexion, extension, bending, and axial rotations. RESULTS Compared to the stand-alone OLIF model, the OLIF model with BPS fixation suffers higher stress values under extension body position. However, there are no apparent differences under other loading conditions. Moreover, significant increases in stress values can be recorded in flexion and extension loading conditions in the PLIF model with posterior structures damage. CONCLUSIONS Fixation-induced surgical segment's high stiffness and the damage of posterior soft tissues together trigger a higher risk of ASD in patients with LIF operations. Optimizing BPS fixation methods and pedicle screw designs and reducing the range of posterior structures excision may be an effective method to reduce the risk of ASD.
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Affiliation(s)
- Ping Cai
- Department of Orthopedics, Lianyungang Hospital of Traditional Chinese Medicine, Lianyungang, Jiangsu, People's Republic of China
- Department of Orthopedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Zhieng Xi
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Chao Deng
- Department of Orthopedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Jingchi Li
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Xiaoyu Zhang
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People's Republic of China
| | - Yingguang Zhou
- Department of Orthopedics, Lianyungang Hospital of Traditional Chinese Medicine, Lianyungang, Jiangsu, People's Republic of China.
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Heilbronner AK, Dash A, Straight BE, Snyder LJ, Ganesan S, Adu KB, Jae A, Clare S, Billings E, Kim HJ, Cunningham M, Lebl DR, Donnelly E, Stein EM. Peripheral cortical bone density predicts vertebral bone mineral properties in spine fusion surgery patients. Bone 2023; 169:116678. [PMID: 36646265 PMCID: PMC10081687 DOI: 10.1016/j.bone.2023.116678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/22/2022] [Accepted: 01/10/2023] [Indexed: 01/15/2023]
Abstract
Spine fusion surgery is one of the most common orthopedic procedures, with over 400,000 performed annually to correct deformities and pain. However, complications occur in approximately one third of cases. While many of these complications may be related to poor bone quality, it is difficult to detect bone abnormalities prior to surgery. Areal BMD (aBMD) assessed by DXA may be artifactually high in patients with spine pathology, leading to missed diagnosis of deficits. In this study, we related preoperative imaging characteristics of both central and peripheral sites to direct measurements of bone quality in vertebral biopsies. We hypothesized that pre-operative imaging outcomes would relate to vertebral bone mineralization and collagen properties. Pre-operative assessments included DXA measurements of aBMD of the spine, hip, and forearm, central quantitative computed tomography (QCT) of volumetric BMD (vBMD) at the lumbar spine, and high resolution peripheral quantitative computed tomography (HRpQCT; Xtreme CT2) measurements of vBMD and microarchitecture at the distal radius and tibia. Bone samples were collected intraoperatively from the lumbar vertebrae and analyzed using Fourier-transform Infrared (FTIR) spectroscopy. Bone samples were obtained from 23 postmenopausal women (mean age 67 ± 7 years, BMI 28 ± 8 kg/m2). We found that patients with more mature bone by FTIR, measured as lower acid phosphate content and carbonate to phosphate ratio, and greater collagen maturity and mineral maturity/crystallinity (MMC), had greater cortical vBMD at the tibia and greater aBMD at the lumbar spine and one-third radius. Our data suggests that bone quality at peripheral sites may predict bone quality at the spine. As bone quality at the spine is challenging to assess prior to surgery, there is a great need for additional screening tools. Pre-operative peripheral bone imaging may provide important insight into vertebral bone quality and may foster identification of patients with bone quality deficits.
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Affiliation(s)
- Alison K Heilbronner
- Division of Endocrinology, Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Alexander Dash
- Division of Endocrinology, Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Beth E Straight
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, United States of America
| | - Leah J Snyder
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, United States of America
| | - Sandhya Ganesan
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, United States of America
| | - Kobby B Adu
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, United States of America
| | - Andy Jae
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, United States of America
| | - Shannon Clare
- Division of Endocrinology, Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Emma Billings
- Division of Endocrinology, Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Matthew Cunningham
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Darren R Lebl
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Eve Donnelly
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, United States of America; Research Institute, Hospital for Special Surgery, New York, NY, United States of America
| | - Emily M Stein
- Division of Endocrinology, Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America.
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Zhao H, Wang YJ, Wang RG, Liu D, Duan YQ, Liu YJ, Zeng YH, Zhao QP, Zhang ZP. Three-Dimensional Hounsfield Units Measurement of Pedicle Screw Trajectory for Predicating Screw Loosening in Lumbar Fusion Surgery. Clin Interv Aging 2023; 18:485-493. [PMID: 37008803 PMCID: PMC10065021 DOI: 10.2147/cia.s389059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Purpose Dual-energy X-ray absorptiometry (DXA) is commonly used for evaluation of bone mineral density before spinal surgery, but frequently leads to overestimation in degenerative spinal diseases due to osteoproliferation factors. We introduce a novel method to compare the predictive ability of Hounsfield Units (HU) and DXA methods to predict screw loosening after lumbar interbody fusion surgery in degenerative spinal diseases by measuring HU of pedicle screw trajectory on computed tomography (CT) images preoperatively. Patients and Methods This retrospective study was conducted on patients who underwent posterior lumbar fusion surgery for degenerative diseases. CT HUs measurement was performed using medical imaging software, including the cancellous region on cross-sections of the vertebral body and three-dimensional pedicle screw trajectory. Receiver operating characteristic (ROC) curve analyses were performed for the risk of pedicle screw loosening in association with the Hounsfield scale and preoperative BMD, and the area under the curve (AUC) and the cutoff values were calculated. Results A total of 90 patients were enrolled and were divided into loosening (n = 33, 36.7%) and non-loosening groups (n = 57, 63.3%). No significant differences in age, gender, length of fixation and preoperative BMD were found between both groups. The loosening group showed lower CT HU values in the vertebral body and screw trajectory than the non-loosening group. Screw trajectory HU (ST-HU) exhibited a higher AUC value than vertebral body HU (B-HU). The cutoff values of B-HU and ST-HU were 160 and 110 HUs, respectively. Conclusion Three-dimensional pedicle screw trajectory HU values yields a stronger predictive value than vertebral body HU values and BMD and may provide more guidance for surgery. The risk of screw loosening is significantly increased at ST-HU <110 or B-HU <160 at L5 segment.
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Affiliation(s)
- He Zhao
- Department of Emergency Medicine, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Yan-jun Wang
- Department of Emergency Medicine, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Rui-guo Wang
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Da Liu
- Department of Orthopaedics, General Hospital of Western Theatre Command of PLA, Chengdu, Sichuan, 610083, People’s Republic of China
| | - Ya-qing Duan
- Department of Imaging, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Yang-jin Liu
- Department of Emergency Medicine, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Yu-hong Zeng
- Department of Osteoporosis, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Qin-peng Zhao
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
| | - Zheng-ping Zhang
- Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710054, People’s Republic of China
- Correspondence: Zheng-ping Zhang, Department of Spine Surgery, Honghui Hospital, Xi’an Jiaotong University, No. 76 Nanguo Road, Xi’an, Shaanxi, 710054, People’s Republic of China, Tel +86 17791674069, Email
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Keaveny TM, Adams AL, Fischer H, Brara HS, Burch S, Guppy KH, Kopperdahl DL. Increased risks of vertebral fracture and reoperation in primary spinal fusion patients who test positive for osteoporosis by Biomechanical Computed Tomography analysis. Spine J 2023; 23:412-424. [PMID: 36372353 DOI: 10.1016/j.spinee.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND CONTEXT While osteoporosis is a risk factor for adverse outcomes in spinal fusion patients, diagnosing osteoporosis reliably in this population has been challenging due to degenerative changes and spinal deformities. Addressing that challenge, biomechanical computed tomography analysis (BCT) is a CT-based diagnostic test for osteoporosis that measures both bone mineral density and bone strength (using finite element analysis) at the spine; CT scans taken for spinal evaluation or previous care can be repurposed for the analysis. PURPOSE Assess the effectiveness of BCT for preoperatively identifying spinal fusion patients with osteoporosis who are at high risk of reoperation or vertebral fracture. STUDY DESIGN Observational cohort study in a multi-center integrated managed care system using existing data from patient medical records and imaging archives. PATIENT SAMPLE We studied a randomly sampled subset of all adult patients who had any type of primary thoracic (T4 or below) or lumbar fusion between 2005 and 2018. For inclusion, patients with accessible study data needed a preop CT scan without intravenous contrast that contained images (before any instrumentation) of the upper instrumented vertebral level. OUTCOME MEASURES Reoperation for any reason (primary outcome) or a newly documented vertebral fracture (secondary outcome) occurring up to 5 years after the primary surgery. METHODS All study data were extracted using available coded information and CT scans from the medical records. BCT was performed at a centralized lab blinded to the clinical outcomes; patients could test positive for osteoporosis based on either low values of bone strength (vertebral strength ≤ 4,500 N women or 6,500 N men) and/or bone mineral density (vertebral trabecular bone mineral density ≤ 80 mg/cm3 both sexes). Cox proportional hazard ratios were adjusted by age, presence of obesity, and whether the fusion was long (four or more levels fused) or short (3 or fewer levels fused); Kaplan-Meier survival was compared by the log rank test. This project was funded by NIH (R44AR064613) and all physician co-authors and author 1 received salary support from their respective departments. Author 6 is employed by, and author 1 has equity in and consults for, the company that provides the BCT test; the other authors declare no conflicts of interest. RESULTS For the 469 patients analyzed (298 women, 171 men), median follow-up time was 44.4 months, 11.1% had a reoperation (median time 14.5 months), and 7.7% had a vertebral fracture (median time 2.0 months). Overall, 25.8% of patients tested positive for osteoporosis and no patients under age 50 tested positive. Compared to patients without osteoporosis, those testing positive were at almost five-fold higher risk for vertebral fracture (adjusted hazard ratio 4.7, 95% confidence interval = 2.2-9.7; p<.0001 Kaplan-Meier survival). Of those positive-testing patients, those who tested positive concurrently for low values of both bone strength and bone mineral density (12.6% of patients overall) were at almost four-fold higher risk for reoperation (3.7, 1.9-7.2; Kaplan-Meier survival p<.0001); the remaining positive-testing patients (those who tested positive for low values of either bone strength or bone mineral density but not both) were not at significantly higher risk for reoperation (1.6, 0.7-3.7) but were for vertebral fracture (4.3, 1.9-10.2). For both clinical outcomes, risk remained high for patients who underwent short or long fusion. CONCLUSION In a real-world clinical setting, BCT was effective in identifying primary spinal fusion patients aged 50 or older with osteoporosis who were at elevated risks of reoperation and vertebral fracture.
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Affiliation(s)
- Tony M Keaveny
- Departments of Mechanical Engineering and Bioengineering, University of California, Berkeley, CA, USA.
| | - Annette L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Heidi Fischer
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Harsimran S Brara
- Department of Neurosurgery, Southern California Permanente Medical Group, Los Angeles, CA, USA
| | - Shane Burch
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Kern H Guppy
- Department of Neurosurgery, Kaiser Permanente Medical Group, Sacramento, CA, USA
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Yao YC, Chao H, Kao KY, Lin HH, Wang ST, Chang MC, Liu CL, Chou PH. CT Hounsfield unit is a reliable parameter for screws loosening or cages subsidence in minimally invasive transforaminal lumbar interbody fusion. Sci Rep 2023; 13:1620. [PMID: 36709341 PMCID: PMC9884280 DOI: 10.1038/s41598-023-28555-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/20/2023] [Indexed: 01/30/2023] Open
Abstract
Retrospective cohort study. To validate computed tomography (CT) radiodensity in Hounsfield units (HU) as a prognostic marker for pedicle screw loosening or cage subsidence in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). The retrospective study involved 198 patients treated with MI-TLIF. Screw loosening (SL), cage subsidence (CS), and fusion status were assessed by plain radiographs. The risk factors of SL and CS were identified using logistic regression. A total of 258 levels and 930 screws were analyzed. During a 2-year follow-up, 16.2% and 24.7% of patients had CS and SL respectively. The cut-off value of L1 HU for predicting SL or CS was 117. The L1 HU < 117 and BMI ≥ 25 were two independent risk factors. The risk of SL or CS was 4.1 fold in patients L1 HU < 117 and 2.6 fold in patients with BMI ≥ 25. For patients concurrently having BMI ≥ 25 and pre-op L1 HU < 117, the risk was 4.3 fold. Fusion rate and clinical outcome were comparable in patients with SL or CS. L1 HU < 117 and BMI > 25 were two independent risk factors that can be screened preoperatively for preventing SL or CS and lead to better management of patients undergoing MI-TLIF.
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Affiliation(s)
- Yu-Cheng Yao
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsien Chao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Medical Education, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kun-Yu Kao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Medical Education, Chi Mei Hospital, Tainan, Taiwan
| | - Hsi-Hsien Lin
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Tien Wang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan
| | - Ming-Chau Chang
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Lin Liu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Hsin Chou
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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10
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Li J, Zhang Z, Xie T, Song Z, Song Y, Zeng J. The preoperative Hounsfield unit value at the position of the future screw insertion is a better predictor of screw loosening than other methods. Eur Radiol 2023; 33:1526-1536. [PMID: 36241918 PMCID: PMC9935714 DOI: 10.1007/s00330-022-09157-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/11/2022] [Accepted: 09/09/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Screw loosening is a widely reported issue after spinal screw fixation and triggers several complications after lumbar interbody fusion. Osteoporosis is an essential risk factor for screw loosening. Hounsfield units (HU) value is a credible indicator during bone mineral density (BMD) evaluation. As compared with the general evaluation of BMD, we hypothesized that specific measurements of HU at the precise location of the future screw insertion may be a better predictor of screw loosening. METHODS Clinical data of 56 patients treated by oblique lumbar interbody fusion (OLIF) of the L4-L5 segments with an anterior lateral single rod (ALSR) screw fixation were reviewed in this study. Vertebral bodies with ≥ 1 mm width radiolucent zones around the screw were defined as screw loosening. HU in the insertional screw positions, the central transverse plane, and the average values of three and four planes were measured. Regression analyses identified independent risk factors for screw loosening separately. The area under the receiver operating characteristic curve (AUC) was computed to evaluate predictive performance. RESULTS The local HU values were significantly lower in the loosening group, regardless of the selected measuring methods. The AUC of screw loosening prediction was higher in the insertional screw positions' HU than other frequently used methods. CONCLUSIONS The HU value measured in the insertional screw position is a better predictor of ALSR screw loosening than other methods. The risk of screw loosening should be reduced by optimizing the trajectory of the screw based on the measurement of HU in preoperative CT. KEY POINTS • Osteoporosis is an essential risk factor for screw loosening, and Hounsfield units (HU) are a credible predictor during bone mineral density (BMD) evaluation. • The HU value measured in the insertional screw position is a better predictor of screw loosening than other frequently used HU measurement methods. • The risk of screw loosening might potentially be reduced by optimizing the trajectory of the screw based on the measurement of HU in preoperative CT.
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Affiliation(s)
- Jingchi Li
- grid.412901.f0000 0004 1770 1022Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Zhuang Zhang
- grid.412901.f0000 0004 1770 1022Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Tianhang Xie
- grid.412901.f0000 0004 1770 1022Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Zhetao Song
- grid.13291.380000 0001 0807 1581Department of Imaging, Sichuan University, Chengdu, Sichuan People’s Republic of China
| | - Yueming Song
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China.
| | - Jiancheng Zeng
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China.
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11
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Cho J, Ryu S, Jang HJ, Park JY, Ha Y, Kuh SU, Chin DK, Kim KS, Cho YE, Kim KH. Clinical Effect of Transverse Process Hook with K-Means Clustering-Based Stratification of Computed Tomography Hounsfield Unit at Upper Instrumented Vertebra Level in Adult Spinal Deformity Patients. J Korean Neurosurg Soc 2023; 66:44-52. [PMID: 36050868 PMCID: PMC9837488 DOI: 10.3340/jkns.2022.0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the efficacy of transverse process (TP) hook system at the upper instrumented vertebra (UIV) for preventing screw pullout in adult spinal deformity surgery using the pedicle Hounsfield unit (HU) stratification based on K-means clustering. METHODS We retrospectively reviewed 74 patients who underwent deformity correction surgery between 2011 and 2020 and were followed up for >12 months. Pre- and post-operative data were used to determine the incidence of screw pullout, UIV TP hook implementation, vertebral body HU, pedicle HU, and patient outcomes. Data was then statistically analyzed for assessment of efficacy and risk prediction using stratified HU at UIV level alongside the effect of the TP hook system. RESULTS The screw pullout rate was 36.4% (27/74). Perioperative radiographic parameters were not significantly different between the pullout and non-pullout groups. The vertebral body HU and pedicle HU were significantly lower in the pullout group. K-means clustering stratified the vertebral body HU ≥205.3, <137.2, and pedicle HU ≥243.43, <156.03. The pullout rate significantly decreases in patients receiving the hook system when the pedicle HU was from ≥156.03 to < 243.43 (p<0.05), but the difference was not statistically significant in the vertebra HU stratified groups and when pedicle HU was ≥243.43 or <156.03. The postoperative clinical outcomes improved significantly with the implementation of the hook system. CONCLUSION The UIV hook provides better clinical outcomes and can be considered a preventative strategy for screw-pullout in the certain pedicle HU range.
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Affiliation(s)
- Jongwon Cho
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungjun Ryu
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurosurgery, National Health Insurance Service Hospital, Goyang, Korea
| | - Hyun-Jun Jang
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Yoon Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ha
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Uk Kuh
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Kyu Chin
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keun-Su Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Eun Cho
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Hyun Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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12
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Osteoporosis as a Risk Factor for Intraoperative Complications and Long-term Instrumentation Failure in Patients With Scoliotic Spinal Deformity. Spine (Phila Pa 1976) 2022; 47:1435-1442. [PMID: 36174132 DOI: 10.1097/brs.0000000000004418] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/23/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective review study. OBJECTIVE This study aims to determine the effect of osteoporosis on spine instrumentation. SUMMARY OF BACKGROUND DATA Osteoporosis is a common skeletal pathology that affects systemic cortical bone maintenance and remodeling. This disease accelerates the degeneration of the spine, often necessitating spinal surgery for progressive vertebral deformity, pathologic fracture, bony canal stenosis, and/or neural element decompression. There is a paucity of literature describing the role of osteoporosis as it relates to both perioperative complications and outcomes after spine fusion surgery. MATERIALS AND METHODS A retrospective review was conducted of a prospectively maintained database for patients undergoing spine surgery between January 1, 2006 and October 3, 2017. Inclusion criteria included age 18 years and above and surgery performed for the correction of thoracolumbar scoliosis. Data collected included various demographic, clinical, and operative variables. RESULTS A total of 532 patients met inclusion criteria, including 144 (27%) patients with a diagnosis of osteoporosis. Osteoporosis was significantly associated with increased blood volume loss (P=0.003). Postoperatively, osteoporosis was associated with increased rates of instrumentation failure (19% vs. 10%; P=0.008) and the need for revision surgery (33% vs. 16%; P<0.001). Multivariate analysis confirmed osteoporosis to be an independent risk factor for increased mean number of spinal segments fused (P<0.05), mean blood volume loss (P<0.05), rate of postoperative deep venous thrombosis/pulmonary embolism (P<0.05), rate of instrumentation failure (P<0.05), and need for revision surgery (P<0.05). CONCLUSION Osteoporosis is a significant risk factor for instrumentation failure and need for revision surgery following arthrodesis for scoliosis correction. Furthermore, patients with osteoporosis have a significantly higher risk of intraoperative blood volume loss and postoperative thromboembolic events.
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13
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Mooney J, Morgan S, Brockington D, Rehder D, Rothenberg S, Omar N, MacLennan P, Chambers MR. Inter-Rater Reliability and Correlation of L1 Hounsfield Unit Measurements with DXA Scores. J Clin Densitom 2022; 25:668-673. [PMID: 36180332 DOI: 10.1016/j.jocd.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/02/2022] [Accepted: 09/12/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION While prior studies have generally reported rigorous protocols using prespecified CT scanner settings for HU measurements, the present study sought to report on the correlation between DXA and HUs recorded using several CT scanners with varying sequences, simulating measurements performed in "real-world" hospital and Emergency Department (ED) settings. METHODOLOGY Six raters performed HU measurements of trabecular bone at the L1 vertebral body for forty consecutive patients on Phillips and General Electric (GE) abdominal CT scans obtained between 2017 and 2021. Inter-rater reliability of the HU measurements and their correlations with recorded DXA-based bone assessments were determined. Correlation coefficients were calculated for the HU measurements between scanner vendors as well as for the CT HUs with each DXA measurement. RESULTS The ICC for L1 HUs read on the Phillips and GE scanners were 0.85 and 0.82, respectively, indicating excellent agreement. The correlation coefficient for the mean HUs on the Phillips and GE scanners was 0.92, also indicating excellent correlation. For both scanner vendors, the HU values most closely correlated with the total femur and femoral neck T-scores. CONCLUSIONS HU values recorded on a Phillips and GE scanner both demonstrated excellent inter-rater reliability. Correlations were strongest between L1 HU values and total femur DXA T-scores. Readily available abdominal CT image data across multiple hospital settings can be utilized by providers of varying level of imaging interpretation expertise to determine vertebral body Hounsfield units that may help identify osteoporosis risk without additional radiation exposure or cost.
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Affiliation(s)
- James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, 1802 6th Avenue South, FOT 1001, AL 35233, USA.
| | - Sarah Morgan
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | | | - Dirk Rehder
- Department of Radiology, University of Alabama at Birmingham, AL, USA
| | | | - Nidal Omar
- Department of Neurosurgery, University of Alabama at Birmingham, 1802 6th Avenue South, FOT 1001, AL 35233, USA
| | - Paul MacLennan
- Department of Surgery, University of Alabama at Birmingham, AL, USA
| | - M R Chambers
- Department of Neurosurgery, University of Alabama at Birmingham, 1802 6th Avenue South, FOT 1001, AL 35233, USA
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14
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Schlaeger S, Kirschke JS. Postoperative Bildgebung der Wirbelsäule. DIE RADIOLOGIE 2022; 62:851-861. [PMID: 35789426 PMCID: PMC9519694 DOI: 10.1007/s00117-022-01034-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
Die Bildgebung der postoperativen Wirbelsäule hat im Wesentlichen zwei Aufgaben: Sie dient der Kontrolle des operativen Erfolgs und der Identifikation von Komplikationen. Dafür stehen die konventionelle Röntgenaufnahme, Computertomographie (CT), Myelographie und Magnetresonanztomographie (MRT) zur Verfügung. Unter Berücksichtigung der präoperativen Situation, der durchgeführten Operation und der postoperativen Beschwerdekonstellation ist es Aufgabe der Radiologinnen und Radiologen, die passende Modalität für eine suffiziente Diagnostik zu wählen. Insbesondere der Zustand nach Implantation von Fremdmaterial bedeutet eine technische Herausforderung im Rahmen der Bildakquisition. In der Befundung sehen sich die Radiologinnen und Radiologen mit der Aufgabe konfrontiert, zwischen natürlichen, zu erwartenden postoperativen Veränderungen und relevanten Komplikationen zu differenzieren. Ein reger Austausch mit Patientinnen und Patienten und zuweisenden Klinikerinnen und Klinikern ist dabei unerlässlich. Insbesondere klinische Hinweise auf einen Infekt, neue oder deutliche progrediente neurologische Ausfallserscheinungen und das Konus-Kauda-Syndrom erfordern eine zeitnahe Diagnosestellung, um eine rasche Therapieeinleitung zu gewährleisten.
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Affiliation(s)
- S Schlaeger
- Abteilung für Diagnostische und Interventionelle Neuroradiologie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland.
| | - J S Kirschke
- Abteilung für Diagnostische und Interventionelle Neuroradiologie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland.
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15
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Aparisi Gómez MP, Isaac A, Dalili D, Fotiadou A, Kariki EP, Kirschke JS, Krestan CR, Messina C, Oei EHG, Phan CM, Prakash M, Sabir N, Tagliafico A, Aparisi F, Baum T, Link TM, Guglielmi G, Bazzocchi A. Imaging of Metabolic Bone Diseases: The Spine View, Part II. Semin Musculoskelet Radiol 2022; 26:491-500. [PMID: 36103890 DOI: 10.1055/s-0042-1754341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Metabolic bone diseases comprise a wide spectrum. Osteoporosis, the most frequent, characteristically involves the spine, with a high impact on health care systems and on the morbidity of patients due to the occurrence of vertebral fractures (VFs).Part II of this review completes an overview of state-of-the-art techniques on the imaging of metabolic bone diseases of the spine, focusing on specific populations and future perspectives. We address the relevance of diagnosis and current status on VF assessment and quantification. We also analyze the diagnostic techniques in the pediatric population and then review the assessment of body composition around the spine and its potential application. We conclude with a discussion of the future of osteoporosis screening, through opportunistic diagnosis and the application of artificial intelligence.
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Affiliation(s)
- Maria Pilar Aparisi Gómez
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand.,Department of Radiology, IMSKE, Valencia, Spain
| | - Amanda Isaac
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Danoob Dalili
- Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), Epsom, London, United Kingdom.,Department of Diagnostic and Interventional Radiology, Epsom and St. Helier University Hospitals NHS Trust, London, United Kingdom
| | - Anastasia Fotiadou
- Consultant Radiologist, Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Eleni P Kariki
- Manchester University NHS Foundation Trust, Manchester, United Kingdom.,Division of Informatics, Imaging & Data Sciences, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Jan S Kirschke
- Interventional und Diagnostic Neuroradiology, School of Medicine, Technical University Munich, Munich, Germany
| | | | | | - Edwin H G Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Catherine M Phan
- Service de Radiologie Ostéo-Articulaire, APHP, Nord-Université de Paris, Hôpital Lariboisière, Paris, France
| | - Mahesh Prakash
- Department of Radiodiagnosis & Imaging, PGIMER, Chandigarh, India
| | - Nuran Sabir
- Department of Radiology, Pamukkale University School of Medicine, Denizli, Turkey
| | - Alberto Tagliafico
- DISSAL, University of Genova, Genova, Italy.,Ospedale Policlinico San Martino, Genova, Italy
| | - Francisco Aparisi
- Department of Radiology, Hospital Vithas Nueve de Octubre, Valencia, Spain
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Thomas M Link
- Department of Radiology and Biomedical Imaging, University of California at San Francisco, San Francisco, California
| | | | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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16
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Insuffizienzfrakturen der Wirbelsäule in Abhängigkeit von der spongiösen Knochendichte. DIE ORTHOPÄDIE 2022; 51:547-555. [PMID: 35776151 PMCID: PMC9249701 DOI: 10.1007/s00132-022-04261-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/27/2022] [Indexed: 11/12/2022]
Abstract
Hintergrund Das Risiko für osteoporotische Insuffizienzfrakturen (Fx) am Achsenskelett steigt mit zunehmender Abnahme der Knochendichte, wobei sich thorakal und thorakolumbal eine Häufung findet. Um die unterschiedliche Verteilung von Fx entlang der Wirbelsäule (WS) besser zu verstehen, wurden morphologische und osteodensitometrische Untersuchungen mittels Computertomographie (CT) in den verschiedenen WS-Abschnitten durchgeführt. Zudem war zu klären, ob die bei CT-Untersuchungen aus anderen Indikationen gefunden Hounsfield-Einheiten (HE) mit der Knochendichte korrelieren und Anlass für eine osteologische Diagnostik sein könnten. Material und Methoden Von 26 Körperspenden wurden die gesamten WS in einem Plexiglas-Wasser-Phantom fixiert und mittels hochauflösende Spiral-CT analysiert. Zusätzlich erfolgte die Messung der CT-morphologischen Spongiosadichte in HE von C3 bis S2 (624 Wirbelkörper). Der Knochenmineralgehalt (KMG, mg/ml) wurde ermittelt und zur Abschätzung einer Osteoporose (OPO) herangezogen. Ergebnisse Bei allen WS lag eine OPO vor. Bei einem KMG unterhalb von 60 mg/ml fanden sich signifikant vermehrte Sinterungsfrakturen im thorakalen und thorakolumbalen Bereich. Osteoporotische Insuffizienzfrakturen im HWS-Bereich fanden sich insgesamt nicht. Die Spongiosadichte war signifikant höher in den zervikalen (Median 188,6 HE) als in den lumbalen (Median 63,6 HE) und sakralen (Median 25,5 HE) Wirbelkörpern aller untersuchten WS. Schlussfolgerung Ein KMG-Verlust der Wirbelkörperspongiosa führt zu einem erhöhten Fx-Risiko, welches sich auch bei den verwendeten WS findet. Jedoch wird im zervikalen Bereich ein scheinbarer Schwellenwert für das Auftreten von Sinterungsfrakturen nicht unterschritten. Einen Schwellenwert für HE zu finden, wäre für die klinische Praxis relevant.
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17
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Wanderman N, Glassman SD, Mkorombindo T, Dimar JR, Gum JL, Carreon LY. Evaluation of bone mineral density after instrumented lumbar fusion with computed tomography. Spine J 2022; 22:951-956. [PMID: 35189347 DOI: 10.1016/j.spinee.2022.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 01/07/2022] [Accepted: 02/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Computed tomography (CT) measurement of Hounsfield Units (HU) has been described as a tool for assessing BMD. For surgeons considering a revision lumbar fusion, knowledge of the BMD of the UIV is of value for surgical planning. However, the presence of metal artifact from instrumentation presents a potential confounder, and prior studies have not validated measurements of HU in this setting. PURPOSE To determine if HU can be measured reliably at the supra-adjacent and upper instrumented levels of a lumbar fusion. STUDY DESIGN Retrospective observational cohort PATIENT SAMPLE: Consecutive series of patients who had lumbar CT scans after an instrumented posterior lumbar fusion. OUTCOME MEASURES Hounsfield Units at the upper instrumented vertebra and levels proximal. METHODS We analysed pre- and postoperative CT scans of 50 patients who underwent L2 and distal instrumented lumbar fusion whose scans were no greater than 1 year apart, obtaining HU measurements of analogous axial cuts at the upper instrumented level (immediately caudal to the halo of the pedicle screw), as well as additional control levels above the construct. RESULTS The HU at the pre-and postoperative UIV exhibited a strong correlation (r=0.917, p<.001), as did one (r=0.887, p<.001) and two (r=0.853, p<.001) levels above the UIV. There were significant but predictable reductions in the postoperative HU compared to preoperative at one (-9.0±26.2) and two (-12.2±30.2) levels above the UIV, as well as T12 (-13.9±42.2). There was no significant difference in HU at the UIV (4.6±34.1). CONCLUSIONS Postoperative HU at the UIV was strongly correlated with and not significantly different from the preoperative HU. Although the HU in the vertebrae proximal to the UIV were slightly lower postoperatively, this change was predictable using a correction factor.
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Affiliation(s)
- Nathan Wanderman
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; University of Louisville School of Medicine, 500 South Preston Street. Instructional Building, Room 305, Louisville, KY 40202, USA
| | - Tino Mkorombindo
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - John R Dimar
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, Kentucky 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA.
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18
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Prediction of Sacral Screw Loosening after Lumbosacral Surgeries Involving Rigid Fixation of Sacral Bone Using Preoperative Computed Tomography Scans. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7123139. [PMID: 35655477 PMCID: PMC9152424 DOI: 10.1155/2022/7123139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 04/04/2022] [Accepted: 04/30/2022] [Indexed: 11/21/2022]
Abstract
Objective To find a preoperative computed tomography-based method to predict the incidence of sacral screw loosening and assist surgical planning. Methods Surgically treated patients for degenerative lumbosacral disorders with rigid pedicle screw fixation of patients with L5-S1 vertebra in our center from January 2016 to January 2021 were retrospectively included in the current study. CT scan attenuation of the horizontal plane of the sacrum was measured with Hounsfield units (HU). Postoperative X-ray tests were used to diagnose screw loosening. The data was analyzed by independent sample t-tests, X2 analysis, Pearson correlation analysis, and ROC curve analysis. Results A total of 162 (114 male, 48 female, average age 63.7 ± 7.3 years) patients were included in the final analysis. Significant differences were found between the screw loosening group and nonloosening group concerning the HU value of the sacrum at the horizontal plane (P < 0.01). In ROC curve analysis, AUC was 0.674 (95% CI: 0.592-0.756). A cutoff of 200 HU provided 64.8% sensitivity and 62.4% specificity, and a cutoff of 150 HU provided 90.2% sensitivity. Conclusions Analyzing 162 patients with at least 12 months of follow-up, we propose cutoff CT attenuation values of 200 HU and 150 HU to take moderate and radical measures of screw augmentation to prevent screw loosening in the sacral bone.
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Bokov A, Kalinina S, Leontev A, Mlyavykh S. Circumferential Fusion Employing Transforaminal vs. Direct Lateral Lumbar Interbody Fusion—A Potential Impact on Implants Stability. Front Surg 2022; 9:827999. [PMID: 35651676 PMCID: PMC9150499 DOI: 10.3389/fsurg.2022.827999] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDifferent fusion techniques were introduced in clinical practice in patients with lumbar degenerative disc disease, however, no evidence has been provided on the advantages of one technique over another.The Objective of This StudyIs to assess the potential impact of circumferential fusion employing transforaminal lumbar interbody fusion (TLIF) vs. direct lateral interbody fusion (DLIF) on pedicle screw stability.Materials and MethodsThis is a single-center prospective evaluation of consecutive 138 patients with degenerative instability of lumbar spinal segments. Either conventional transforaminal lumbar interbody fusion (TLIF) with posterior fusion or direct lateral interbody fusion (DLIF) using cages of standard dimensions, were applied. The conventional open technique was used to supplement TLIF with pedicle screws while percutaneous screw placement was used in patients treated with DLIF. The duration of the follow-up accounted for 24 months. Signs of pedicle screws loosening (PSL) and bone union after fusion were assessed by the results of CT imaging. Fisher‘s exact test was used to assess the differences in the rate of CT loosening and revision surgery because of implant instability. Logistic regression was used to assess the association between potential factors and complication rate.ResultsThe rate of PSL detected by CT and relevant revision surgery in groups treated with TLIF and DLIF accounted for 25 (32.9%) vs. 2 (3.2%), respectively, for the former and 9 (12.0%) vs. 0 (0%) for the latter (p < 0.0001 and p = 0.0043) respectively. According to the results of logistic regression, a decrease in radiodensity values and a greater number of levels fused were associated with a rise in PSL rate. DLIF application in patients with radiodensity below 140 HU was associated with a considerable decrease in complication rate. Unipolar or bipolar pseudoarthrosis in patients operated on with TLIF was associated with a rise in PSL rate while patients treated with DLIF tolerate delayed interbody fusion formation. In patients treated with TLIF supplementary total or partial posterior fusion resulted in a decline in PSL rate.ConclusionEven though the supplementary posterior fusion may considerably reduce the rate of PSL in patients treated with TLIF, the application of DLIF provide greater stability resulting in a substantial decline in PSL rate and relevant revision surgery.
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Affiliation(s)
- Andrey Bokov
- Department of Oncology and Neurosurgery, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Svetlana Kalinina
- Department of Traumatology, Orthopedics and Neurosurgery, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Andrei Leontev
- Department of Oncology and Neurosurgery, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Sergey Mlyavykh
- Department of Traumatology, Orthopedics and Neurosurgery, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
- *Correspondence: Sergey Mlyavykh
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The Usefulness of Trabecular CT Attenuation Measurement at L4 Level to Predict Screw Loosening After Degenerative Lumbar Fusion Surgery: Consider Number of Fused Levels and Postoperative Sagittal Balance. Spine (Phila Pa 1976) 2022; 47:745-753. [PMID: 35102120 DOI: 10.1097/brs.0000000000004330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To evaluate the absolute value of L4 trabecular region-of-interest (t-ROI) computed tomography (CT) attenuation, which can predict pedicle screw loosening, and determine the changes in value according to number of fused levels and sagittal balance in patients undergoing lumbar fusion surgery. SUMMARY OF BACKGROUND DATA Although osteoporosis was not diagnosed in spinal dual x-ray absorptiometry preoperatively, we encountered several cases of screw loosening within 1 year of lumbar fusion surgery. METHODS We enrolled 478 patients and analyzed factors related to screw loosening. We evaluated the association between L4 t-ROI CT attenuation and screw loosening and determined the best cutoff value of t L4 t-ROI CT attenuation for predicting screw loosening. RESULTS The number of fused levels, postoperative C7-S1 sagittal vertical axis (SVA), and L4 t-ROI CT attenuation were independently correlated with screw loosening. According to number of fused level and postoperative C7-T1 SVA (≥36.9 mm or <36.9 mm), in patients with one-level fusion and C7-S1 SVA less than 36.9 mm, the optimal cutoff point of the L4 t-ROI CT attenuation predicting screw loosening was 106.5 Hounsfield unit (HU). L4 t-ROI attenuation did not change until two-level fusions. In patients with three-level fusions and C7-S1 SVA less than 36.9 mm, the optimal cutoff point of the L4 t-ROI CT attenuation predicting screw loosening was 159.0 HU. The optimal cutoff point of L4 t-ROI CT attenuation in patients with three-level fusions and C7-S1 SVA more than or equal to 36.9 mm was 191.0 HU. CONCLUSION L4 t-ROI CT attenuation value considering number of fused levels and sagittal balance is an accurate measurement method to predict screw loosening. Spine surgeons should be aware of the L4 t-ROI attenuation before surgery to improve the fusion rate and reduce instrument-related complications of lumbar spine surgery in osteoporotic patients. LEVEL OF EVIDENCE 3.
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Ma C, Zou D, Qi H, Li C, Zhang C, Yang K, Zhu F, Li W, Lu WW. A novel surgical planning system using an AI model to optimize planning of pedicle screw trajectories with highest bone mineral density and strongest pull-out force. Neurosurg Focus 2022; 52:E10. [DOI: 10.3171/2022.1.focus21721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The purpose of this study was to evaluate the ability of a novel artificial intelligence (AI) model in identifying optimized transpedicular screw trajectories with higher bone mineral density (BMD) as well as higher pull-out force (POF) in osteoporotic patients.
METHODS
An innovative pedicle screw trajectory planning system called Bone’s Trajectory was developed using a 3D graphic search and an AI-based finite element analysis model. The preoperative CT scans of 21 elderly osteoporotic patients were analyzed retrospectively. The AI model automatically calculated the number of alternative transpedicular trajectories, the trajectory BMD, and the estimated POF of L3–5. The highest BMD and highest POF of optimized trajectories were recorded and compared with AO standard trajectories.
RESULTS
The average patient age and average BMD of the vertebral bodies were 69.6 ± 7.8 years and 55.9 ± 17.1 mg/ml, respectively. On both sides of L3–5, the optimized trajectories showed significantly higher BMD and POF than the AO standard trajectories (p < 0.05). On average, the POF of optimized trajectory screws showed at least a 2.0-fold increase compared with AO trajectory screws.
CONCLUSIONS
The novel AI model performs well in enabling the selection of optimized transpedicular trajectories with higher BMD and POF than the AO standard trajectories.
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Affiliation(s)
- Chi Ma
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Da Zou
- Orthopaedic Department and
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing
| | - Huan Qi
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Chentian Li
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou; and
| | - Cheng Zhang
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Kedi Yang
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Feng Zhu
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
- Department of Orthopaedics, The University of Hong Kong–Shenzhen Hospital, Shenzhen, China
| | - Weishi Li
- Orthopaedic Department and
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing
| | - William W. Lu
- Department of Orthopaedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
- Department of Orthopaedics, The University of Hong Kong–Shenzhen Hospital, Shenzhen, China
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Löffler MT, Kallweit M, Niederreiter E, Baum T, Makowski MR, Zimmer C, Kirschke JS. Epidemiology and reporting of osteoporotic vertebral fractures in patients with long-term hospital records based on routine clinical CT imaging. Osteoporos Int 2022; 33:685-694. [PMID: 34648040 PMCID: PMC8844161 DOI: 10.1007/s00198-021-06169-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022]
Abstract
UNLABELLED Osteoporotic vertebral fractures signify an increased risk of future fractures and mortality and can manifest the diagnosis of osteoporosis. We investigated the prevalence of vertebral fractures in routine CT of patients with long-term hospital records. Three out of ten patients showed osteoporotic vertebral fractures (VFs) corresponding to the highest rates reported in European population-based studies. INTRODUCTION VFs are a common manifestation of osteoporosis, which influences future fracture risk. Their epidemiology has been investigated in population-based studies. However, few studies report the prevalence of osteoporotic VF in patients seen in clinical routine and include all common fracture levels of the thoracolumbar spine. The purpose of this study was to investigate the prevalence of osteoporotic VF in patients with CT scans and long-term hospital records and identify clinical factors associated with prevalent VFs. METHODS All patients aged 45 years and older with a CT scan and prior hospital record of at least 5 years that were seen in the study period between September 2008 and May 2017 were reviewed. Imaging requirements were a CT scan with sagittal reformations including at least T6-L4. Patients with multiple myeloma were excluded. Fracture reading was performed using the Genant semi-quantitative method. Medical notes were reviewed for established diagnoses of osteoporosis and clinical information. Clinical factors (e.g. drug intake, chemotherapy, and mobility level) associated with prevalent VF were identified in logistic regression. RESULTS The study population consisted of 718 patients (228 women and 490 men; mean age 69.3 ± 10.1 years) with mainly cancer staging and angiography CT imaging. The overall prevalence of VFs was 30.5%, with non-significantly more men showing a fracture (32.5%) compared to women (26.3%; p > 0.05). Intake of metamizole for ≥ 3 months was significantly associated with a prevalent VF. Medical records did not include information about bone health in 90% of all patients. CT reports did mention a VF in only 24.7% of patients with a prevalent VF on CT review. CONCLUSION Approximately 30% of elderly patients with CT imaging and long-term hospital records showed VFs. Only one-quarter of these patients had VFs mentioned in CT reports. Osteoporosis management could be improved by consequent reporting of VFs in CT, opportunistic bone density measurements, and early involvement of fracture liaison services.
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Affiliation(s)
- M T Löffler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany.
- Department of Diagnostic and Interventional Radiology, University Medical Center Freiburg, Freiburg im Breisgau, Germany.
| | - M Kallweit
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - E Niederreiter
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - T Baum
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - M R Makowski
- Department of Diagnostic and Interventional Radiology, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - C Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - J S Kirschke
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
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Woisetschläger M, Klintström E, Spångeus A. The impact of imaging time and contrast agent dose on screening for osteoporosis with contrast-enhanced CT. Eur Radiol Exp 2022; 6:8. [PMID: 35141833 PMCID: PMC8828831 DOI: 10.1186/s41747-021-00259-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/22/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Screening for osteoporosis with contrast-enhanced computed tomography (CT) is promising for identifying high-risk osteoporotic patients. Our aims were (1) to investigate the estimated volume bone mineral density (vBMD) change over time after contrast injection (CT perfusion imaging, CTPI); and (2) to examine the influence of contrast dose on vBMD. METHODS Fifteen patients, aged 71 ± 9 years (mean ± standard deviation, range 55-86) underwent a CTPI examination (28 scans within 63 s) of the upper body followed (after a waiting time of 10 min) by a full 4-phase CT examination (4 scans within 4 min). The contrast dose for CTPI was 0.38-0.83 mL/kg, and for 4-phase CT was 0.87-1.29 mL/kg. Vertebrae L1-L3 were analysed totalling 43 vertebrae, using Mindways qCT Pro. RESULTS After contrast injection, vBMD showed a near-horizontal line until 17.5 s (non-contrast phase), followed by a steep increase 17.5-41.5 s after contrast injection, i.e., in the arterial phase, which plateaued 41.5 s after, i.e., in the early venous phase. A higher contrast dose per kg yielded significantly higher vBMD increase in both the arterial and venous phase (p < 0.003). CONCLUSIONS Both time from contrast administration and contrast dose per kg affected vBMD results. In arterial phase, the steepness of the curve makes vBMD estimation unsure. However, as values plateaued in the venous phase it might be possible to predict the correct vBMD values. Furthermore, contrast dose is a factor that needs to be adjusted for when using such a formula.
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Affiliation(s)
- Mischa Woisetschläger
- Department of Radiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, 58185, Linköping, Sweden. .,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.
| | - Eva Klintström
- Department of Radiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, 58185, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Anna Spångeus
- Department of Acute Internal Medicine and Geriatrics, Department of Endocrinology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Guha D, Mushlin HM, Muthiah N, Vodovotz LL, Agarwal N, Alan N, Hamilton DK, Okonkwo DO, Kanter AS. CT Hounsfield Units as a predictor of reoperation and graft subsidence following standalone and multi-level lateral lumbar interbody fusion. World Neurosurg 2022; 161:e417-e426. [PMID: 35149250 DOI: 10.1016/j.wneu.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Standalone single and multi-level lateral lumbar interbody fusion (LLIF) are increasingly being applied to treat degenerative spinal conditions in a less invasive fashion. Graft subsidence following LLIF is a known complication and has been associated with poor bone mineral density (BMD). Previous research has demonstrated the utility of CT Hounsfield Units (HU) as a surrogate for BMD. This study aims to investigate the relationship between CT HU and subsidence and reoperation after standalone and multi-level LLIF. METHODS A prospectively-maintained single-institution database was retrospectively reviewed for LLIF patients from 2017-2020 including single and multi-level standalone cases with or without supplemental posterior fixation. Data on demographics, graft parameters, BMD on DEXA, preoperative mean segmental CT HU, and postoperative subsidence and reoperation, were collected. Three-foot standing radiographs were used to measure preoperative global sagittal alignment and disc height, and subsidence at last follow-up. Subsidence was classified using the Marchi grading system corresponding to disc height loss: Grade 0: 0-24%; I: 25-49%; II: 50-74%; III: 75-100%. RESULTS Eighty-nine LLIF patients met study criteria, with mean follow-up 19.9 ± 13.9 months. Among the 54 patients who underwent single-level LLIF, mean segmental HU was 152.0 ± 8.7 in 39 patients with Grade 0 subsidence, 136.7 ± 10.4 in nine with Grade I subsidence, 133.9 ± 23.1 in three with Grade II subsidence, and 119.9 ± 30.9 in three with Grade III subsidence (p=0.032). In the 96 instrumented levels in 35 patients who underwent multi-level LLIF, 85 had Grade 0 subsidence, 9 Grade I, 1 Grade II, and 1 Grade III, with no differences in HU. In multivariate logistic regression, increased CT HU was independently associated with a decreased risk of reoperation in both single-level and multi-level LLIF (OR:0.98, 95%CI:0.97-0.99, p=0.044; and OR:0.97, 95%CI: 0.94-0.99, p=0.017, respectively). Overall BMD on DEXA was not associated with graft subsidence nor reoperation. Using a receiver-operating-characteristic curve to establish separation between patients requiring reoperation and those that did not, the determined threshold HU for single-level LLIF was 131.4 (sensitivity 0.62, specificity 0.65), and for multi-level was 131.0 (sensitivity 0.67, specificity 0.63). CONCLUSIONS Lower CT HU are independently associated with an increased risk of graft subsidence following single-level LLIF. In addition, lower CT HU significantly increased the risk of reoperation in both single and multi-level LLIF with a critical threshold of 131 HU. Preoperative CT HU may provide a more robust gauge of local bone quality and the likelihood of graft subsidence requiring reoperation following LLIF, than overall BMD.
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Affiliation(s)
- Daipayan Guha
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Harry M Mushlin
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nallammai Muthiah
- Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lena L Vodovotz
- Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nima Alan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Faculty of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Li D, Sun C, Jiang J, Lu F, Xia X, Wang H, Zou F, Ma X. A study of screw placement to obtain the optimal pull-out resistance of lumbar pedicle screws-analysis of Hounsfield units measurements based on computed tomography. BMC Musculoskelet Disord 2022; 23:124. [PMID: 35130888 PMCID: PMC8819881 DOI: 10.1186/s12891-022-05074-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/25/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The screw path of lumbar pedicle screws in the vertebral body has certain variability. It is not clear whether the screw paths in different directions can obtain the same pull-out resistance. This study intends to use CT (Computed Tomography) to measure the Hounsfield unit (HU value) around the screw paths in different parts of the lumbar vertebral body to obtain the bone mineral density value of the corresponding parts which will provide some reference for the direction of lumbar pedicle screw placement. METHODS This retrospective study included 200 patients with lumbar degenerative diseases selected randomly from the case base and the patient's basic information was recorded. L1-L5 vertebral body was divided equally into the upper, middle and lower 1/3, which was consistent with the three sagittal entry directions of the pedicle screw head tilt, parallel endplate and caudal tilt, and the HU values were measured by CT cross-sectional scanning to indirectly reflect the local bone density values. The paired t-test (randomized block experiment) was used to compare the HU values of the upper, middle and lower 1 / 3 parts, with P < 0.05 being considered statistically significant. RESULTS Comparison of HU values in different parts of each vertebral body revealed that HU values in the middle 1/3 of the L1,L2 (163.88 ± 58.44 and 152.94 ± 59.45) and in the lower 1/3 of the L4 (149.86 ± 60.18) were higher than in the other two parts of the vertebral body of the same segment(P < 0.0001,P = 0.0069 and P = 0.0024, respectively); According to the results of each stratification, patients with younger age and better bone condition had higher HU values in the middle 1/3 of L1 and L2, and higher HU values in the lower 1/3 of L3, L4 and L5; With the increase of age, the decrease of bone condition and the difference of HU value in each vertebral body gradually decreased. CONCLUSION Although further follow-up studies are needed, based on the analysis of the statistical results, we speculate that from the perspective of obtaining the best pull-out resistance of the lumbar pedicle screws, the placement direction of L1 and L2 in the sagittal position may be as parallel to the endplate as possible; L3, L4, and L5 may be as appropriate as possible to the tail tilt theoretically.
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Affiliation(s)
- Dachuan Li
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Chi Sun
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Jianyuan Jiang
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Feizhou Lu
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Xinlei Xia
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Hongli Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China
| | - Fei Zou
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China.
| | - Xiaosheng Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, No.12, middle Urumqi Road, Jing'an District, Shanghai, 200040, China.
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Buenger F, Sakr Y, Eckardt N, Senft C, Schwarz F. Correlation of quantitative computed tomography derived bone density values with Hounsfield units of a contrast medium computed tomography in 98 thoraco-lumbar vertebral bodies. Arch Orthop Trauma Surg 2022; 142:3335-3340. [PMID: 34562119 PMCID: PMC9522714 DOI: 10.1007/s00402-021-04184-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/15/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Vertebral fractures in patients with bone density reduction are often a major challenge for the surgeon, as reduced bone density can lead to screw loosening. Several options are available to determine bone density preoperatively. In our study, we investigated the correlation of Hounsfield units (HU) of a contrast medium computed tomography (CT) to the bone density values of a quantitative computed tomography (QCT) and computed a formula to estimate bone density values using HU. MATERIALS AND METHODS In our retrospective data analysis, we examine 98 vertebral bodies from 35 patients who received a contrast medium CT of the spine and a QCT, performed no longer than 1 month apart. The determined HU from the contrast medium CT were compared with the bone density values of the QCT and examined for correlations. Linear logistic regression was used to estimate bone density values base on HU. RESULTS A strong correlation was found between the HU measured in the CT and the bone density values (r = 0.894, p < 0.001), irrespective of patients' gender. We also found no correlation differences when the HU were measured at different levels. Bland-Altman plot demonstrated good agreement between the two measurements. The following formula was developed to estimate bone density values using HU: QCT-value = 0.71 × HU + 13.82. CONCLUSIONS Bone density values correlate well to HU measured in contrast medium CT. Using simple formula, the bone density of a contrast medium CT of vertebral bodies can be estimated based on HU without additional examinations and unnecessary costs.
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Affiliation(s)
- Fabian Buenger
- grid.9613.d0000 0001 1939 2794Department of Neurosurgery, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany
| | - Yasser Sakr
- grid.9613.d0000 0001 1939 2794Department for Anaesthesiology and Intensive Care, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany
| | - Niklas Eckardt
- grid.9613.d0000 0001 1939 2794Department for Radiology, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany
| | - Christian Senft
- grid.9613.d0000 0001 1939 2794Department of Neurosurgery, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany
| | - Falko Schwarz
- grid.9613.d0000 0001 1939 2794Department of Neurosurgery, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany
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Dieckmeyer M, Löffler MT, El Husseini M, Sekuboyina A, Menze B, Sollmann N, Wostrack M, Zimmer C, Baum T, Kirschke JS. Level-Specific Volumetric BMD Threshold Values for the Prediction of Incident Vertebral Fractures Using Opportunistic QCT: A Case-Control Study. Front Endocrinol (Lausanne) 2022; 13:882163. [PMID: 35669688 PMCID: PMC9165054 DOI: 10.3389/fendo.2022.882163] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To establish and evaluate the diagnostic accuracy of volumetric bone mineral density (vBMD) threshold values at different spinal levels, derived from opportunistic quantitative computed tomography (QCT), for the prediction of incident vertebral fractures (VF). MATERIALS AND METHODS In this case-control study, 35 incident VF cases (23 women, 12 men; mean age: 67 years) and 70 sex- and age-matched controls were included, based on routine multi detector CT (MDCT) scans of the thoracolumbar spine. Trabecular vBMD was measured from routine baseline CT scans of the thoracolumbar spine using an automated pipeline including vertebral segmentation, asynchronous calibration for HU-to-vBMD conversion, and correction of intravenous contrast medium (https://anduin.bonescreen.de). Threshold values at T1-L5 were calculated for the optimal operating point according to the Youden index and for fixed sensitivities (60 - 85%) in receiver operating characteristic (ROC) curves. RESULTS vBMD at each single level of the thoracolumbar spine was significantly associated with incident VFs (odds ratio per SD decrease [OR], 95% confidence interval [CI] at T1-T4: 3.28, 1.66-6.49; at T5-T8: 3.28, 1.72-6.26; at T9-T12: 3.37, 1.78-6.36; and at L1-L4: 3.98, 1.97-8.06), independent of adjustment for age, sex, and prevalent VF. AUC showed no significant difference between vertebral levels and was highest at the thoracolumbar junction (AUC = 0.75, 95%-CI = 0.63 - 0.85 for T11-L2). Optimal threshold values increased from lumbar (L1-L4: 52.0 mg/cm³) to upper thoracic spine (T1-T4: 69.3 mg/cm³). At T11-L2, T12-L3 and L1-L4, a threshold of 80.0 mg/cm³ showed sensitivities of 85 - 88%, and specificities of 41 - 49%. To achieve comparable sensitivity (85%) at more superior spinal levels, resulting thresholds were higher: 114.1 mg/cm³ (T1-T4), 92.0 mg/cm³ (T5-T8), 88.2 mg/cm³ (T9-T12). CONCLUSIONS At all levels of the thoracolumbar spine, lower vBMD was associated with incident VFs in an elderly, predominantly oncologic patient population. Automated opportunistic osteoporosis screening of vBMD along the entire thoracolumbar spine allows for risk assessment of imminent VFs. We propose level-specific vBMD threshold at the thoracolumbar spine to identify individuals at high fracture risk.
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Affiliation(s)
- Michael Dieckmeyer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- *Correspondence: Michael Dieckmeyer,
| | - Maximilian Thomas Löffler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Radiology, University Medical Center, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Malek El Husseini
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Anjany Sekuboyina
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bjoern Menze
- Image-Based Biomedical Modeling, Department of Computer Science, Technical University of Munich, Munich, Germany
- Department of Quantitative Biomedicine, Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Maria Wostrack
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jan Stefan Kirschke
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Li Y, Jiang Y, Liu H, Yu X, Chen S, Ma D, Gao J, Wu Y. A phantom study comparing low-dose CT physical image quality from five different CT scanners. Quant Imaging Med Surg 2022; 12:766-780. [PMID: 34993117 DOI: 10.21037/qims-21-245] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 07/29/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND To systematically evaluate the physical image quality of low-dose computed tomography (LDCT) on CT scanners from 5 different manufacturers using a phantom model. METHODS CT images derived from a Catphan 500 phantom were acquired using manufacturer-specific iterative reconstruction (IR) algorithms and deep learning image reconstruction (DLIR) on CT scanners from 5 different manufacturers and compared using filtered back projection with 2 radiation doses of 0.25 and 0.75 mGy. Image high-contrast spatial resolution and image noise were objectively characterized by modulation transfer function (MTF) and noise power spectrum (NPS). Image high-contrast spatial resolution and image low-contrast detectability were compared directly by visual evaluation. CT number linearity and image uniformity were compared with intergroup differences using one-way analysis of variance (ANOVA). RESULTS The CT number linearity of 4 insert materials were as follows: acrylic (95% CI: 120.35 to 121.27; P=0.134), low-density polyethylene (95% CI: -98.43 to -97.43; P=0.070), air (95% CI: -996.16 to -994.51; P=0.018), and Teflon (95% CI: 984.40 to 986.87; P=0.883). The image uniformity values of GE Healthcare (95% CI: 3.24 to 3.83; P=0.138), Philips (95% CI: 2.62 to 3.70; P=0.299), Siemens (95% CI: 2.10 to 3.59; P=0.054), Minfound (95% CI: 2.35 to 3.65; P=0.589), and Neusoft (95% CI: 2.63 to 3.37; P=0.900) were evaluated and found to be within ±4 Hounsfield units (HU), with a range of 0.99-2.76 HU for standard deviations. There was no statistically significant difference in CT number linearity and image uniformity across the 5 CT scanners under different radiation doses with IR and DLIR algorithms (P>0.05). The resolution level at 10% MTF was 6.98 line-pairs-per-centimeter (lp/cm) on average, which was similar to the subjective evaluation results (mostly up to 7 lp/cm). DLIR at all 3 levels had the highest 50% MTF values among all reconstruction algorithms. For image low-contrast detectability, the minimum diameter of distinguishable contrast holes reached 4 mm at a 0.5% resolution. Increasing the radiation dose and IR strength reduced the image noise and NPS curve peak frequency while improving image low-contrast detectability. CONCLUSIONS This study demonstrated that the image quality of CT scanners from 5 different manufacturers in LDCT is comparable and that the CT number linearity is unbiased and can contribute to accurate bone mineral density quantification.
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Affiliation(s)
- Yali Li
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yaojun Jiang
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huilong Liu
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xi Yu
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Sihui Chen
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Duoshan Ma
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jianbo Gao
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Wu
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Bokov A, Pavlova S, Bulkin A, Aleynik A, Mlyavykh S. Potential contribution of pedicle screw design to loosening rate in patients with degenerative diseases of the lumbar spine: An observational study. World J Orthop 2021; 12:310-319. [PMID: 34055588 PMCID: PMC8152435 DOI: 10.5312/wjo.v12.i5.310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/15/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The majority of published data report the results of biomechanical tests of various design pedicle screw performance. The clinical relevance and relative contribution of screw design to instrumentation stability have been insufficiently studied.
AIM To estimate the contribution of screw design to rate of pedicle screw loosening in patients with degenerative diseases of the lumbar spine.
METHODS This study is a prospective evaluation of 175 patients with degenerative diseases and instability of the lumbar spine segments. Participants underwent spinal instrumentation employing pedicle screws with posterior only or transforaminal interbody fusion. Follow-up was for 18 mo. Patients with signs of pedicle screw loosening on computed tomography were registered; logistic regression analysis was used to identify the factors that influenced the rate of loosening.
RESULTS Parameters included in the analysis were screw geometry, type of thread, external and internal screw diameter and helical pitch, bone density in Hounsfield units, number of levels fused, instrumentation without anterior support, laminectomy, and unilateral and bilateral total facet joint resection. The rate of screw loosening decreased with the increment in outer diameter, decrease in core diameter and helical pitch. The rate of screw loosening correlated positively with the number of fused levels and decreasing bone density. Bilateral facet joint removal significantly favored pedicle screw loosening. The influence of other factors was insignificant.
CONCLUSION Screw parameters had a significant impact on the loosening rate along with bone quality characteristics, the number of levels fused and the extensiveness of decompression. The significance of the influence of screw parameters was comparable to those of patient- and surgery-related factors. Pedicle screw loosening was influenced by helical pitch, inner and outer diameter, but screw geometry and thread type were insignificant factors.
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Affiliation(s)
- Andrey Bokov
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Svetlana Pavlova
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Anatoliy Bulkin
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Alexandr Aleynik
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Sergey Mlyavykh
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
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30
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Buenger F, Eckardt N, Sakr Y, Senft C, Schwarz F. Correlation of Bone Density Values of Quantitative Computed Tomography and Hounsfield Units Measured in Native Computed Tomography in 902 Vertebral Bodies. World Neurosurg 2021; 151:e599-e606. [PMID: 33933695 DOI: 10.1016/j.wneu.2021.04.093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Due to the increasing age of patients, the evaluation of bone density is crucial, especially in preparation for spinal surgery. The aim of this study was to determine bone density using a computed tomography (CT) and to correlate Hounsfield units (HU) with bone density values of a quantitative computed tomography (QCT). METHODS The study is a monocentric, retrospective data analysis. We examined 902 vertebral bodies from a total of 369 patients who received a CT of the thoracolumbar spine in the period from 2015 to 2019 and compared the HU with values of a QCT. A general equation for calculation the QCT values was established. RESULTS We found a significant correlation between the Hounsfield units and the corresponding QCT-values (r = 0.944, P < 0.001). We also demonstrated that the calculated QCT values are independent of patient sex (P < 0.942). Furthermore, we could not demonstrate differences in the correlation of the 3 measured levels (axial, sagittal, and coronary) to the QCT values. The QCT-values can be calculated on the basis of a native CT of the lumbar spine using the equation: QCT = 17.8 + 0.7 × HU. CONCLUSIONS The equation allows calculating bone density values without the need for an additional QCT and without further radiation exposure or costs. With this measuring method it is possible to obtain additional information from a computed tomography.
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Affiliation(s)
- Fabian Buenger
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University, Jena, Germany
| | - Niklas Eckardt
- Department of Radiology, Jena University Hospital - Friedrich Schiller University, Jena, Germany
| | - Yasser Sakr
- Department of Anaesthesiology and Intensive Care, Jena University Hospital - Friedrich Schiller University, Jena, Germany
| | - Christian Senft
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University, Jena, Germany
| | - Falko Schwarz
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University, Jena, Germany.
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31
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Kim HJ, Dash A, Cunningham M, Schwab F, Dowdell J, Harrison J, Zaworski C, Krez A, Lafage V, Agarwal S, Carlson B, McMahon DJ, Stein EM. Patients with abnormal microarchitecture have an increased risk of early complications after spinal fusion surgery. Bone 2021; 143:115731. [PMID: 33157283 PMCID: PMC9518007 DOI: 10.1016/j.bone.2020.115731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/12/2022]
Abstract
Spine fusion is one of the most common orthopedic surgeries, with more than 400,000 cases performed annually. While these procedures correct debilitating pain and deformities, complications occur in up to 45%. As successful fusion rests upon early stability of hardware in bone, patients with structural skeletal deficits may be at particular risk for complications. Few studies have investigated this relationship, and none have used higher order imaging to evaluate microstructural mechanisms for complications. Standard DXA measurements are subject to artifact in patients with spinal disease and therefore provide limited information. The goal of this prospective study was to investigate pre-operative bone quality as a risk factor for early post-operative complications using high resolution peripheral QCT (HR-pQCT) measurements of volumetric BMD (vBMD) and microarchitecture. We hypothesized that patients with low vBMD and abnormal microarchitecture at baseline would have more skeletal complications post-operatively. Conversely, we hypothesized that pre-operative DXA measurements would not be predictive of complications. Fifty-four subjects (mean age 63 years, BMI 27 kg/m2) were enrolled pre-operatively and followed for 6 months after multi-level lumbar spine fusion. Skeletal complications occurred in 14 patients. Patients who developed complications were of similar age and BMI to those who did not. Baseline areal BMD and Trabecular Bone Score by DXA did not differ. In contrast, HR-pQCT revealed that patients who developed complications had lower trabecular vBMD, fewer and thinner trabeculae at both the radius and tibia, and thinner tibial cortices. In summary, abnormalities of both trabecular and cortical microarchitecture were associated the development of complications within the first six months following spine fusion surgery. Our results suggest a mechanism for early skeletal complications after fusion. Given the burgeoning number of fusion surgeries, further studies are necessary to investigate strategies that may improve bone quality and lower the risk of post-operative complications.
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Affiliation(s)
- Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Alexander Dash
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Matthew Cunningham
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Frank Schwab
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - James Dowdell
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Jonathan Harrison
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Caroline Zaworski
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Alexandra Krez
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Sanchita Agarwal
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States of America
| | - Brandon Carlson
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Donald J McMahon
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Emily M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America.
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Löffler MT, Sollmann N, Burian E, Bayat A, Aftahy K, Baum T, Meyer B, Ryang YM, Kirschke JS. Opportunistic Osteoporosis Screening Reveals Low Bone Density in Patients With Screw Loosening After Lumbar Semi-Rigid Instrumentation: A Case-Control Study. Front Endocrinol (Lausanne) 2021; 11:552719. [PMID: 33505353 PMCID: PMC7832475 DOI: 10.3389/fendo.2020.552719] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 11/24/2020] [Indexed: 12/17/2022] Open
Abstract
Objective Decreased bone mineral density (BMD) impairs screw purchase in trabecular bone and can cause screw loosening following spinal instrumentation. Existing computed tomography (CT) scans could be used for opportunistic osteoporosis screening for decreased BMD. Purpose of this case-control study was to investigate the association of opportunistically assessed BMD with the outcome after spinal surgery with semi-rigid instrumentation for lumbar degenerative instability. Methods We reviewed consecutive patients that had primary surgery with semi-rigid instrumentation in our hospital. Patients that showed screw loosening in follow-up imaging qualified as cases. Patients that did not show screw loosening or-if no follow-up imaging was available (n = 8)-reported benefit from surgery ≥ 6 months after primary surgery qualified as controls. Matching criteria were sex, age, and surgical construct. Opportunistic BMD screening was performed at L1 to L4 in perioperative CT scans by automatic spine segmentation and using asynchronous calibration. Processing steps of this deep learning-driven approach can be reproduced using the freely available online-tool Anduin (https://anduin.bonescreen.de). Area under the curve (AUC) was calculated for BMD as a predictor of screw loosening. Results Forty-six elderly patients (69.9 ± 9.1 years)-23 cases and 23 controls-were included. The majority of surgeries involved three spinal motion segments (n = 34). Twenty patients had low bone mass and 13 had osteoporotic BMD. Cases had significantly lower mean BMD (86.5 ± 29.5 mg/cm³) compared to controls (118.2 ± 32.9 mg/cm³, p = 0.001), i.e. patients with screw loosening showed reduced BMD. Screw loosening was best predicted by a BMD < 81.8 mg/cm³ (sensitivity = 91.3%, specificity = 56.5%, AUC = 0.769, p = 0.002). Conclusion Prevalence of osteoporosis or low bone mass (BMD ≤ 120 mg/cm³) was relatively high in this group of elderly patients undergoing spinal surgery. Screw loosening was associated with BMD close to the threshold for osteoporosis (< 80 mg/cm³). Opportunistic BMD screening is feasible using the presented approach and can guide the surgeon to take measures to prevent screw loosening and to increase favorable outcomes.
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Affiliation(s)
- Maximilian T. Löffler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Medical Center Freiburg, Freiburg im Breisgau, Germany
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Egon Burian
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Amirhossein Bayat
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kaywan Aftahy
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Neurosurgery, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Jan S. Kirschke
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Bokov AE, Bulkin AA, Bratsev IS, Kalinina SY, Mlyavykh SG, Anderson DG. Augmentation of Pedicle Screws Using Bone Grafting in Patients with Spinal Osteoporosis. Sovrem Tekhnologii Med 2021; 13:6-10. [PMID: 35265344 PMCID: PMC8858411 DOI: 10.17691/stm2021.13.5.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 11/14/2022] Open
Abstract
The aim of the study was to develop a new method of vertebral augmentation based on autologous and allogeneic bone chips to be used in pedicle screw fixation and to compare this method with the technique based on polymethyl methacrylate (PMMA).
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Affiliation(s)
- A E Bokov
- Head of the Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - A A Bulkin
- Staff Neurosurgeon, Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - I S Bratsev
- Staff Neurosurgeon, Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - S Ya Kalinina
- Staff Neurosurgeon, Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - S G Mlyavykh
- Director of the Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - D G Anderson
- Professor, Departments of Orthopaedic and Neurological Surgery; Clinical Director of the Spine Section, Orthopaedic Research Laboratory Thomas Jefferson University, 130 S., 9 St., Philadelphia, PA, 19107, USA
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Chang HK, Huang WC, Wu JC. Commentary: Low-Grade Infection and Implant Failure Following Spinal Instrumentation: A Prospective Comparative Study. Neurosurgery 2020; 87:E541-E542. [PMID: 32409829 DOI: 10.1093/neuros/nyaa160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/17/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Hsuan-Kan Chang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Cheng Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jau-Ching Wu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
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Kurrumeli D, Oechsner M, Weidenbächer B, Brambs C, Löffler M, Combs SE, Borm K, Duma MN. An easy way to determine bone mineral density and predict pelvic insufficiency fractures in patients treated with radiotherapy for cervical cancer. Strahlenther Onkol 2020; 197:487-493. [PMID: 33025097 PMCID: PMC8154790 DOI: 10.1007/s00066-020-01690-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/07/2020] [Indexed: 12/04/2022]
Abstract
Purpose The aim of this study was to investigate whether bone mineral density (BMD) as measured in planning computed tomographies (CTs) by a new method is a risk factor for pelvic insufficiency fractures (PIF) after radio(chemo)therapy (R(C)T) for cervical cancer. Methods 62 patients with cervical cancer who received definitive or adjuvant radio(chemo)therapy between 2013 and 2017 were reviewed. The PIF were detected on follow-up magntic resonance imaging (MRI). The MRI of the PIF patients was registered to the planning CT and the PIF contoured. On the contralateral side of the fracture, a mirrored structure of the fracture was generated (mPIF). For the whole sacral bone, three lumbar vertebrae, the first and second sacral vertebrae, and the PIF, we analyzed the BMD (mg/cm3), V50Gy, Dmean, and Dmax. Results Out of 62 patients, 6 (9.7%) had a fracture. Two out of the 6 patients had a bilateral fracture with only one of them being symptomatic. PIF patients showed a significantly lower BMD in the sacral and the lumbar vertebrae (p < 0.05). The BMD of the contoured PIF, however, when comparing to the mPIF, did not reach significance (p < 0.49). The difference of the V50Gy of the sacrum in the PIF group compared to the other (OTH) patients, i.e. those without PIF, did not reach significance. Conclusion The dose does not seem to have a relevant impact on the incidence of PIF in our patients. One of the predisposing factors for developing PIF after radiotherapy seems to be the low BMD. We presented an easy method to assess the BMD in planning CTs.
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Affiliation(s)
- Drilon Kurrumeli
- Department of Radiation Oncology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
- School of Medicine, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Bianca Weidenbächer
- Department of Radiation Oncology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Christine Brambs
- Department of Gynaecology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Maximilian Löffler
- Department of Neuroradiology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
- Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München (HMGU), Munich, Germany
- German Cancer Consortium (DKTK)-Partner Site Munich, Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Marciana Nona Duma
- School of Medicine, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany.
- Department of Radiotherapy and Radiation Oncology, University Hospital Jena, Bachstr. 18, 07743, Jena, Germany.
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Shirley M, Wanderman N, Keaveny T, Anderson P, Freedman BA. Opportunistic Computed Tomography and Spine Surgery: A Narrative Review. Global Spine J 2020; 10:919-928. [PMID: 32905730 PMCID: PMC7485075 DOI: 10.1177/2192568219889362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE This article seeks to provide a narrative review regarding the ability of opportunistic information available from computed tomography (CT) scans to guide decisions in spine surgery related to patient bone quality. METHODS A review of the literature (limited to human and English language) was performed via PubMed and Google Scholar using the search terms; "osteoporosis" AND "opportunistic" AND "computed tomography" AND "spine surgery." The titles and then abstracts of all identified citations were reviewed for inclusion by 2 of the authors (MS, BAF). Relevant articles were then studied in full text. RESULTS A review of the literature found 25 articles that were selected for inclusion in this narrative review. These articles were broadly divided into 4 subcategories: (1) opportunistic CT (oCT) and osteoporosis detection, (2) oCT data and the quality of screw fixation, (3) utilization of Hounsfield units to assess clinical and/or radiographic outcomes following spine fusion, and (4) virtual stress testing in spine surgery. CONCLUSION The literature on oCT, as well as associated virtual stress-testing techniques, demonstrate the potential to enhance spine surgery outcomes by preoperatively identifying at-risk patients in need of bone health optimization and informing best techniques for performing spinal fusion surgery on patients with diminished bone quality. While our narrative summary of the limited literature to date suggests a promising future for oCT data, significant additional research and/or radiographic workflow standardization is needed to validate these methods for clinical use.
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Affiliation(s)
| | | | - Tony Keaveny
- University of California at Berkeley, Berkeley, CA, USA
| | | | - Brett A. Freedman
- Mayo Clinic, Rochester, MN, USA,Brett A. Freedman, Department of Orthopedics, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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Revision by S2-alar-iliac instrumentation reduces caudal screw loosening while improving sacroiliac joint pain-a group comparison study. Neurosurg Rev 2020; 44:2145-2151. [PMID: 32914234 PMCID: PMC8338829 DOI: 10.1007/s10143-020-01377-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/10/2020] [Accepted: 08/20/2020] [Indexed: 11/25/2022]
Abstract
Lumbosacral instrumentation continues to be challenging due to complex biomechanical force distributions and poor sacral bone quality. Various techniques have therefore been established. The aim of this study was to investigate the outcome of patients treated with S2-alar-iliac (S2AI), S2-alar (S2A), and iliac (I) instrumentation as the most caudal level. Sixty patients underwent one of the 3 techniques between January 2012 and June 2017 (S2AI 18 patients, S2A 20 patients, I 22 patients). Mean age was 70.4 ± 8.5 years. Screw loosening (SL) and sacroiliac joint (SIJ) pain were evaluated during the course at 3-month and maximum follow-up (FU). All patients completed 3-month FU, the mean FU period was 2.5 ± 1.5 years (p = 0.38), and a median of 5 segments was operated on (p = 0.26), respectively. Bone mineral density (BMD), derived opportunistically from computed tomography (CT), did not significantly differ between the groups (p = 0.66), but cages were more frequently implanted in patients of the S2A group (p = 0.04). SL of sacral or iliac screws was more common in patients of the S2A and I groups compared with the S2AI group (S2AI 16.7%, S2A 55.0%, I 27.3% of patients; p = 0.03). SIJ pain was more often improved in the S2AI group not only after 3 months but also at maximum FU (S2AI 61.1%, S2A 25.0%, I 22.7% of patients showing improvement; p = 0.02). Even in shorter or mid-length lumbar or thoracolumbar constructs, S2AI might be considered superior to S2A and I instrumentation due to showing lower incidences of caudal SL and SIJ pain.
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Laugerette A, Baum T, Gersing AS, Schwaiger BJ, Brown K, Frerking LC, Shapira N, Pfeiffer D, Rummeny EJ, Proksa R, Pfeiffer F, Noël PB. Spectral-detector based x-ray absorptiometry (SDXA): in-vivo bone mineral density measurements in patients with and without osteoporotic fractures. Biomed Phys Eng Express 2020; 6:055021. [DOI: 10.1088/2057-1976/abab6b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Value-Added Opportunistic CT: Insights Into Osteoporosis and Sarcopenia. AJR Am J Roentgenol 2020; 215:582-594. [DOI: 10.2214/ajr.20.22874] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Duan PG, Mummaneni PV, Rivera J, Guinn JMV, Wang M, Xi Z, Li B, Wu HH, Ames CP, Burch S, Berven SH, Chou D. The association between lower Hounsfield units of the upper instrumented vertebra and proximal junctional kyphosis in adult spinal deformity surgery with a minimum 2-year follow-up. Neurosurg Focus 2020; 49:E7. [DOI: 10.3171/2020.5.focus20192] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPatients undergoing long-segment fusions from the lower thoracic (LT) spine to the sacrum for adult spinal deformity (ASD) correction are at risk for proximal junctional kyphosis (PJK). One mechanism of PJK is fracture of the upper instrumented vertebra (UIV) or higher (UIV+1), which may be related to bone mineral density (BMD). Because Hounsfield units (HUs) on CT correlate with BMD, the authors evaluated whether HU values were correlated with PJK after long fusions for ASD.METHODSThe authors performed a retrospective study of patients older than 50 years who had undergone ASD correction from the LT spine to the sacrum in the period from October 2007 to January 2018 and had a minimum 2-year follow-up. Demographic and spinopelvic parameters were measured. HU values were measured on preoperative CT at the UIV, UIV+1, and UIV+2 (2 levels above the UIV) levels and were assessed for correlations with PJK.RESULTSThe records of 127 patients were reviewed. Fifty-four patients (19 males and 35 females) with a mean age of 64.91 years and mean follow-up of 3.19 years met the study inclusion criteria; there were 29 patients with PJK and 25 patients without. There was no statistically significant difference in demographics or follow-up between these two groups. Neither was there a difference between the groups with regard to postoperative pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), PI minus LL (PI-LL), thoracic kyphosis (TK), or sagittal vertical axis (SVA; all p > 0.05). Postoperative pelvic tilt (p = 0.003) and T1 pelvic angle (p = 0.014) were significantly higher in patients with PJK than in those without. Preoperative HUs at UIV, UIV+1, and UIV+2 were 120.41, 124.52, and 129.28 in the patients with PJK, respectively, and 152.80, 155.96, and 160.00 in the patients without PJK, respectively (p = 0.011, 0.02, and 0.018). Three receiver operating characteristic (ROC) curves for preoperative HU values at the UIV, UIV+1, and UIV+2 as a predictor for PJK were established, with areas under the ROC curve of 0.710 (95% CI 0.574–0.847), 0.679 (95% CI 0.536–0.821), and 0.681 (95% CI 0.539–0.824), respectively. The optimal HU value by Youden index was 104 HU at the UIV (sensitivity 0.840, specificity 0.517), 113 HU at the UIV+1 (sensitivity 0.720, specificity 0.517), and 110 HU at the UIV+2 (sensitivity 0.880, specificity 0.448).CONCLUSIONSIn patients undergoing long-segment fusions from the LT spine to the sacrum for ASD, PJK was associated with lower HU values on CT at the UIV, UIV+1, and UIV+2. The measurement of HU values on preoperative CTs may be a useful adjunct for ASD surgery planning.
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Affiliation(s)
- Ping-Guo Duan
- Departments of 1Neurological Surgery and
- 3Department of Orthopaedic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | | | | | | | | | - Zhuo Xi
- Departments of 1Neurological Surgery and
| | - Bo Li
- Departments of 1Neurological Surgery and
| | - Hao-Hua Wu
- 2Orthopaedic Surgery, University of California, San Francisco, California; and
| | | | - Shane Burch
- 2Orthopaedic Surgery, University of California, San Francisco, California; and
| | - Sigurd H. Berven
- 2Orthopaedic Surgery, University of California, San Francisco, California; and
| | - Dean Chou
- Departments of 1Neurological Surgery and
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Liu Y, Dash A, Krez A, Kim HJ, Cunningham M, Schwab F, Hughes A, Carlson B, Samuel A, Marty E, Moore H, McMahon DJ, Carrino JA, Bockman RS, Stein EM. Low volumetric bone density is a risk factor for early complications after spine fusion surgery. Osteoporos Int 2020; 31:647-654. [PMID: 31919536 DOI: 10.1007/s00198-019-05245-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 11/20/2019] [Indexed: 12/17/2022]
Abstract
UNLABELLED This study aims to investigate lumbar spine (LS) volumetric bone density (vBMD) as a risk factor for complications (pseudoarthrosis, instrumentation failure, adjacent fractures), re-operation, and time to complication after fusion. INTRODUCTION Lumbar spine (LS) fusion surgery is increasingly performed worldwide. Complications after fusion result in significant morbidity and healthcare costs. Multiple factors, including osteoporosis, have been suggested to contribute to risk of complications and re-operation. However, most studies have used DXA, which is subject to artifact in patients with spine pathology, and none have investigated the relationship between BMD and timing of post-operative complications. This study aims to investigate LS volumetric bone density (vBMD) as a risk factor for complications (pseudoarthrosis, instrumentation failure, adjacent fractures), re-operation, and time to complication after fusion. METHODS We evaluated a cohort of 359 patients who had initial LS fusion surgery at our institution, had pre-operative LS CTs and post-operative imaging available for review. Demographic factors, smoking status, vBMD, and details of surgical procedure were related to likelihood and timing of post-operative complications. RESULTS Mean age was 60 ± 14 years, vBMD 122 ± 37 g/cm3. Median follow-up was 11 months. Skeletal complications occurred in 47 patients (13%); 34 patients (10%) required re-operation. Low vBMD (directly measured and estimated using HU) and smoking were associated with increased risk of skeletal complications. Each increase in baseline vBMD of 10 g/cm3 decreased the complication hazard and increased the complication-free duration in time-to-event analysis (hazard ratio 0.91, 95% CI 0.83-0.98, p < 0.02). CONCLUSIONS Low vBMD was a significant risk factor for early post-operative complications in patients undergoing LS fusion. Prospective studies are needed to confirm these findings and to elucidate the optimal timing for follow-up and strategies for prevention of post-operative complications in this population.
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Affiliation(s)
- Y Liu
- Division of Endocrinology and Metabolic Bone Disease, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
- Department of Medicine, Lahey Clinic, Burlington, MA, USA
| | - A Dash
- Division of Endocrinology and Metabolic Bone Disease, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - A Krez
- Division of Endocrinology and Metabolic Bone Disease, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - H J Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - M Cunningham
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - F Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - A Hughes
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - B Carlson
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- Department of Orthopedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - A Samuel
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - E Marty
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - H Moore
- Weill Cornell Medical College, New York, NY, USA
| | - D J McMahon
- Division of Endocrinology and Metabolic Bone Disease, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - J A Carrino
- Department of Radiology, Hospital for Special Surgery, New York, NY, USA
| | - R S Bockman
- Division of Endocrinology and Metabolic Bone Disease, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - E M Stein
- Division of Endocrinology and Metabolic Bone Disease, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA.
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Zou D, Sun Z, Zhou S, Zhong W, Li W. Hounsfield units value is a better predictor of pedicle screw loosening than the T-score of DXA in patients with lumbar degenerative diseases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1105-1111. [PMID: 32211997 DOI: 10.1007/s00586-020-06386-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 03/18/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the performance of using Hounsfield units (HU) value derived from computed tomography and T-score of dual-energy X-ray absorptiometry (DXA) to predict pedicle screw loosening. METHODS We reviewed 253 patients aged ≥ 50 years undergoing pedicle screw fixation for lumbar degenerative diseases (LDD). The evaluation of screw loosening: radiolucent zones of ≥ 1 mm thick in X-ray. The criterion for osteoporosis: the lowest T-score ≤ - 2.5. The average HU value of L1-L4 was used to represent lumbar bone mineral density (BMD). The area under receiver operating characteristics curve (AUC) was used to evaluate the performance of predicting screw loosening. RESULTS One patient underwent reoperation for screw loosening at 9 months follow-up. At 12 months follow-up, the loosening rate was 30.6% (77/252) in the remaining 252 patients. Osteoporotic patients had higher loosening rate than non-osteoporotic patients (39.3% vs. 25.8%, P = 0.026). The T-score showed no significant difference between loosening group and non-loosening group (- 2.1 ± 1.5 vs. - 1.7 ± 1.6, P = 0.074), and so is the lowest lumbar BMD of DXA (0.83 ± 0.16 g/cm2 vs. 0.88 ± 0.19 g/cm2, P = 0.054). The HU value was lower in the loosening group (106.8 ± 34.4 vs. 129.8 ± 45.7, P < 0.001). The HU value (OR, 0.980; 95%CI 0.968-0.993; P = 0.002) was the independent influencing factor of screw loosening. The AUC of predicting screw loosening was 0.666 (P < 0.001) for HU value and 0.574 (P = 0.062) for T-score. CONCLUSIONS HU value is a better predictor of pedicle screw loosening than T-score of DXA in patients aged ≥ 50 years with LDD. We should not only focus on the DXA measurements when making surgical plans concerning lumbar fixation. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Da Zou
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Zhuoran Sun
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Siyu Zhou
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Woquan Zhong
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China
| | - Weishi Li
- Orthopaedic Department, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, China.
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Huang Z, Sun N, Ren J, Li R, Liu X, Li Y, Bi J, Sun Z. [Application of three-dimensional reconstruction simulation to define the starting point of lumbar cortical bone trajectory]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:162-167. [PMID: 32030945 DOI: 10.7507/1002-1892.201908087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective CT three-dimensional reconstruction technology was used to simulate the placement of the lumbar cortical bone trajectory (CBT), to determine the starting point and direction of the screw trajectory. Methods Between February 2017 and April 2018, 24 patients with lumbar CT were selected as the study object. There were 7 males and 17 females, with an average age of 50.4 years (range, 37-68 years). The CT DICOM data of patients were imported into Mimics 16.0 software, and the three-dimensional model of lumbar spine was established. A 5 mm diameter cylinder was set up to simulate the CBT by using Mimics 16.0 software. According to the different implant schemes, the study was divided into groups A, B, and C, the track of the screw respectively passed through the upper edge, the medial edge, and the lower edge of the isthmus of the pedicle. The intersection of simulated screw and lumbar spine was marked as region of interest (ROI) and a mask was generated. The average CT value [Hounsfield unit (HU)] and the screw length of ROI were automatically measured by Mimics 16.0 software. In addition, the head inclination angle and head camber angle of the screw were measured respectively. Point F was the intersection of the level of the lowest edge of the transverse process and the lumbar isthmus periphery. The horizontal and vertical distance between point F and the starting point were measured, and the relationship between the three schemes and the position of the zygapophysial joint and spinous process was observed. Results Plan A has the highest ROI average HU, with the maximum value appearing in L 4; plan B has the longest screw length, with the maximum value appearing in L 5; plan C has the largest nail track head inclination angle, with the maximum value appearing in L 4; plan B has the largest nail track head camber angle, with the maximum value appearing in L 3. The screw length and head camber angle of the nail in group B were significantly greater than those in groups A and C ( P<0.05); the head inclination angle in groups A, B, and C was gradually increased, showing significant differences ( P<0.05); there was no significant difference in the average HU value of ROI between the 3 groups ( P>0.05). In plan A, 74.48% (143/192) screws had a horizontal distance of -2 to 4 mm from point F, a vertical distance of 6-14 mm from point F, a head inclination angle of (14.64±2.77)°, and a head camber angle of (6.55±2.09)°, respectively; in plan B, 84.58% (203/240) screws had a horizontal distance of 1-6 mm from point F, a vertical distance of 1-5 mm from point F, a head inclination angle of (26.93±2.21)°, and a head camber angle of (10.29±2.46)°, respectively; in plan C, 85.94% (165/192) screws had a horizontal distance of -2 to 3 mm from point F, a vertical distance of -2 to 4 mm from point F, a head inclination angle of (33.50±3.69)°, and a head camber angle of (6.47±2.48)°, respectively. Conclusion Plan B should be selected as the starting point of the L 1-L 5 CBT implant. It is located at the intersection of the lowest horizontal line of the transverse process root and the lateral edge of the lumbar isthmus, which is 1-6 mm horizontally inward, 1-5 mm vertically upward, with a head inclination angle of (26.93±2.21)°, and a head camber angle of (10.29±2.46)°, respectively.
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Affiliation(s)
- Zhen Huang
- Department of Spine Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou Shandong, 256600, P.R.China
| | - Ning Sun
- Department of Spine Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou Shandong, 256600, P.R.China
| | - Jiabin Ren
- Department of Spine Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou Shandong, 256600, P.R.China
| | - Rui Li
- Department of Spine Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou Shandong, 256600, P.R.China
| | - Xin Liu
- Department of Spine Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou Shandong, 256600, P.R.China
| | - Yuefei Li
- Department of Spine Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou Shandong, 256600, P.R.China
| | - Jingwei Bi
- Department of Spine Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou Shandong, 256600, P.R.China
| | - Zhaozhong Sun
- Department of Spine Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou Shandong, 256600, P.R.China
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Cataño Jimenez S, Saldarriaga S, Chaput CD, Giambini H. Dual-energy estimates of volumetric bone mineral densities in the lumbar spine using quantitative computed tomography better correlate with fracture properties when compared to single-energy BMD outcomes. Bone 2020; 130:115100. [PMID: 31678491 DOI: 10.1016/j.bone.2019.115100] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/02/2019] [Accepted: 10/02/2019] [Indexed: 11/23/2022]
Abstract
It is estimated that over 200 million people worldwide are affected by osteoporosis. Vertebral fracture risk prediction using dual energy x-ray absorptiometry (DXA) is confounded by limitations of the technology, such as 2D measurements of bone mineral density (BMD), inability to measure bone distribution and heterogeneity, and potential overestimations of BMD due to degenerative diseases. To overcome these shortcomings, single energy (SE) quantitative computed tomography (QCT) imaging estimates of Hounsfield units (HU) and volumetric BMD have been implemented as alternative methodologies for assessing fracture risk. However, marrow fat within the vertebrae can highly affect the vBMD and fracture properties estimations. To address this issue, 54 vertebrae were dissected from nine cadaveric spines and scanned using SE-QCT (120kVp) and dual energy (DE)-QCT (80/140 kVp), with the latter accounting for marrow fat within the vertebrae. The vertebrae were then scanned using DXA and subjected to mechanical testing to obtain fracture properties. aBMD outcomes from DXA showed a better correlation with DE-QCT vBMD versus SE outcomes [DE: aBMD vs. vBMD (R2: 0.61); SE: aBMD vs. vBMD (R2: 0.27)]. SE-QCT underestimated vertebral vBMD by -56% (p<0.0001) when compared to DE-QCT. vBMD estimates from SE-QCT could predict 45% and 37% of the vertebral failure loads and stiffness, respectively, compared to 67% and 46% from DE-QCT. DE-QCT vBMD outcomes highly correlated with fracture properties of vertebrae as compared to SE-QCT metrics. As DE scanning has the ability to correct for the effects of bone marrow fat, estimated vBMD from SE-QCT were significantly underestimated compared to DE-QCT. Dual energy CT scanning has the potential to more accurately predict vertebral failure and aid the clinician in the evaluation of appropriate interventions. Future studies should consider implementing DE-QCT in their fracture assessment.
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Affiliation(s)
- Simon Cataño Jimenez
- Department of Biomedical Engineering, The University of Texas at San Antonio, San Antonio, TX, USA
| | - Sebastian Saldarriaga
- Department of Biomedical Engineering, The University of Texas at San Antonio, San Antonio, TX, USA
| | - Christopher D Chaput
- Department of Orthopedics, The University of Texas Health Science Center, San Antonio, San Antonio, TX, USA
| | - Hugo Giambini
- Department of Biomedical Engineering, The University of Texas at San Antonio, San Antonio, TX, USA.
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Association between true non-contrast and virtual non-contrast vertebral bone CT attenuation values determined using dual-layer spectral detector CT. Eur J Radiol 2019; 121:108740. [DOI: 10.1016/j.ejrad.2019.108740] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 08/23/2019] [Accepted: 11/04/2019] [Indexed: 01/07/2023]
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Abstract
Despite today's good diagnostic and therapeutic options for osteoporosis, the number of unidentified cases is very high and therapy is therefore usually inadequate. Frequently, the diagnosis of osteoporosis is made only after the occurrence of a fracture. The reason for this, apart from the costs incurred as well as the additional radiation exposure of the diagnostics, is certainly the limited availability of dual energy X‑ray absorptiometry (DEXA) as well as quantitative computed tomography (q-CT). In search of an alternative technique, Hounsfield units (HU) of the clinical CT examination proved to be ground-breaking: the results of previous investigations demonstrated a reliable correlation between the T values of the DEXA measurement and the HU of the same vertebral body. Due to the widespread use of clinical CT scans of the thorax and the abdomen for a variety of indications, it is expected that the number of unidentified cases of osteoporosis can be significantly reduced-without additional costs and radiation exposure associated with osteoporosis screening. In addition to osteoporosis diagnostics, the calculated HU may also provide better preoperative planning as well as predicting the further course of the disease. Thus, the risk for vertebral body fractures, screw loosening and cage sintering after ventral fusion operations can be sufficiently predicted. In this way, preoperative modifications to the surgical procedure can be made to reduce the risk of implant failure.
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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:E239-E244. [PMID: 30063528 DOI: 10.1097/brs.0000000000002813] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A systematic review. OBJECTIVE The aim of this study was to evaluate the clinical utility of assessing bone quality using computed tomography (CT) attenuation in Hounsfield units (HU). SUMMARY OF BACKGROUND DATA Assessing bone quality before spine instrumentation is an essential step of preoperative planning. Dual energy x-ray absorptiometry (DEXA) has been the gold standard for assessing bone mineral density (BMD); however, DEXA can result in spuriously elevated BMD measurements in patients with degenerative disease, compression fractures, and/or vascular calcifications. Measuring vertebral HU values has been proposed as an alternate method of assessing BMD and bone quality. METHODS We searched MEDLINE, Cochrane Library, and EMBASE for studies correlating HU to BMD and to spine surgery outcomes. RESULTS HU measurements correlate with success of lumbar interbody fusion (133.7 vs. 107.3 HU) and posterolateral fusion (167 vs. 139.8 HU), cage subsidence (112.4 vs. 140.2 HU), adjacent segment fractures (145.6 vs. 199.4 HU), pedicle screw loosening (116.4 vs. 132.7 HU) and (99.1 vs. 141.2 HU), and risk of incidental durotomy (149.2 vs. 177.0 HU). Intra and inter-rater reliability coefficients are 0.964 and 0.975. The correlation between HU values and BMD in nondegenerative patients is r = 0.52 compared with HU versus BMD in degenerative patients r = 0.18. CONCLUSION HU value measurement is a simple and rapid technique to assess bone quality that should be performed in all patients with pre-existing CT scans. HU measurement has excellent inter and intra-rater reliability and can be performed on axial or sagittal images. L1 HU threshold values of 110 HU for detecting osteoporosis, and 135 HU for detecting osteopenia are 90% specific. In patients with significant degenerative disease, HU values should be given more credence. Additional high-quality prospective studies comparing HU and DEXA values to patient outcomes are necessary to validate the role of CT measurements in preoperative evaluation. LEVEL OF EVIDENCE 4.
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Bokov A, Bulkin A, Aleynik A, Kutlaeva M, Mlyavykh S. Pedicle Screws Loosening in Patients With Degenerative Diseases of the Lumbar Spine: Potential Risk Factors and Relative Contribution. Global Spine J 2019; 9:55-61. [PMID: 30775209 PMCID: PMC6362557 DOI: 10.1177/2192568218772302] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine risk factors that may affect the rate of pedicle screws loosening in patients with degenerative diseases of the lumbar spine. METHODS A total of 250 patients with a low-grade spondylolisthesis and lumbar instability associated with degenerative diseases were enrolled. Preoperatively patients underwent computed tomography (CT) and cancellous bone radiodensity of a vertebral body was measured in Hounsfield units (HU). Pedicle screw fixation was used to treat patients either with a posterior fusion only or in combination with transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and direct lateral interbody fusion (D-LIF). Minimal follow-up period accounted for 18 months. Cases with screw loosening were registered assessing association with risk factors using logistic regression. RESULTS The rate of screw loosening was in positive correlation with the number fused levels and decreasing bone radiodensity. Fusion with a greater load-bearing surface cage was associated with the decrease in rate of pedicle screws loosening. Incomplete reduction in case of spondylolisthesis, bilateral facet joints removal, and laminectomy performed without anterior support favored pedicle screws loosening development. The estimated model classifies correctly 79% of cases with the specificity and sensitivity accounting for 87% and 66% respectively. CONCLUSIONS The decreasing bone radiodensity in Hounsfield units has a considerable correlation with the rate of pedicle screws loosening. On the other hand, the length of fixation and applied surgical technique including fusion type also have a significant impact on complication rate. Spinal instrumentations should be planned by taking into account all potential risk factors and not characteristics relevant to bone quality assessment alone.
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Affiliation(s)
- Andrey Bokov
- Privolzhskiy Research Medical University, Nizhny Novgorod, Russia,Andrey Bokov, Privolzhskiy Research Medical University, Nizhny Novgorod, 603115, Russia.
| | - Anatoliy Bulkin
- Privolzhskiy Research Medical University, Nizhny Novgorod, Russia
| | | | - Marina Kutlaeva
- Privolzhskiy Research Medical University, Nizhny Novgorod, Russia
| | - Sergey Mlyavykh
- Privolzhskiy Research Medical University, Nizhny Novgorod, Russia
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Patient-Specific Phantomless Estimation of Bone Mineral Density and Its Effects on Finite Element Analysis Results: A Feasibility Study. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2019; 2019:4102410. [PMID: 30719069 PMCID: PMC6335860 DOI: 10.1155/2019/4102410] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/06/2018] [Accepted: 12/06/2018] [Indexed: 01/22/2023]
Abstract
Objectives This study proposes a regression model for the phantomless Hounsfield units (HU) to bone mineral density (BMD) conversion including patient physical factors and analyzes the accuracy of the estimated BMD values. Methods The HU values, BMDs, circumferences of the body, and cross-sectional areas of bone were measured from 39 quantitative computed tomography images of L2 vertebrae and hips. Then, the phantomless HU-to-BMD conversion was derived using a multiple linear regression model. For the statistical analysis, the correlation between the estimated BMD values and the reference BMD values was evaluated using Pearson's correlation test. Voxelwise BMD and finite element analysis (FEA) results were analyzed in terms of root-mean-square error (RMSE) and strain energy density, respectively. Results The HU values and circumferences were statistically significant (p < 0.05) for the lumbar spine, whereas only the HU values were statistically significant (p < 0.05) for the proximal femur. The BMD values estimated using the proposed HU-to-BMD conversion were significantly correlated with those measured using the reference phantom: Pearson's correlation coefficients of 0.998 and 0.984 for the lumbar spine and proximal femur, respectively. The RMSEs of the estimated BMD values for the lumbar spine and hip were 4.26 ± 0.60 (mg/cc) and 8.35 ± 0.57 (mg/cc), respectively. The errors of total strain energy were 1.06% and 0.91%, respectively. Conclusions The proposed phantomless HU-to-BMD conversion demonstrates the potential of precisely estimating BMD values from CT images without the reference phantom and being utilized as a viable tool for FEA-based quantitative assessment using routine CT images.
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QUANTITATIVE COMPUTED TOMOGRAPHY OF HEALTHY ADULT BOAS (BOA CONSTRICTOR). J Zoo Wildl Med 2018; 49:1012-1015. [DOI: 10.1638/2017-0224.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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