Predictive Value of MRI-Based Vertebral Bone and Endplate Bone Quality Assessments for Screw Loosening and Cage Subsidence in Degenerative Thoracolumbar Spine Surgery: A Systematic Review and Meta-Analysis

  • International Journal of Spine Surgery
  • October 2025,
  • 19
  • (5)
  • 532-545;
  • DOI: https://doi.org/10.14444/8801

Abstract

Background Thoracolumbar spine surgical interventions are often complicated by cage subsidence and screw loosening. The main risk factor for such conditions is poor bone mineral density. Vertebral bone quality (VBQ) and endplate bone quality (EBQ) scores are novel radiation-free magnetic resonance imaging (MRI)-based tools that have shown promise in predicting such conditions. This meta-analysis sought to assess the predictive value of VBQ and EBQ scores in identifying the risk of screw loosening and cage subsidence following thoracolumbar spine surgery.

Methods PubMed, Scopus, Cochrane Library, and Web of Science databases were searched systematically to retrieve articles assessing the predictive potential of VBQ and EBQ scores for evaluating screw loosening and cage subsidence following thoracolumbar spine surgery. The quality assessment of diagnostic accuracy studies 2 (QUADAS-2) tool was utilized to assess the quality of diagnostic accuracy studies. Data were synthesized using a random-effects model, assessing for potential heterogeneity among the included studies.

Results 19 studies involving 2768 participants met the inclusion criteria. The cage subsidence and screw loosening groups showed significantly higher VBQ scores than the control group. The cage subsidence group showed significantly higher EBQ scores than the control group.

Conclusions MRI-based VBQ and EBQ scores demonstrate efficacy as predictive indicators of screw loosening and cage subsidence following surgical procedures for thoracolumbar degenerative disease. Consequently, preoperative assessment of bone quality is imperative for optimizing surgical outcomes.

Level of Evidence 1.

Introduction

Degenerative lumbar spine disease affects approximately 266 million individuals worldwide, accounting for 3.63% of the global population.1,2 Various spinal fusion techniques are employed. Among these, oblique lumbar interbody fusion (OLIF), lateral lumbar interbody fusion (LLIF), anterior lumbar interbody fusion (ALIF), transforaminal lumbar interbody fusion (TLIF), and posterior lumbar interbody fusion (PLIF) are widely accepted standard treatments for these conditions.3,4

These procedures carry significant risks impacting their success, notably cage subsidence and screw loosening.5,6 Cage subsidence is a common, debilitating complication. It can lead to pseudarthrosis, neighboring segment degeneration, and progressive spinal deformity, and it may require revision surgery.7,8 Similarly, screw loosening contributes to pseudarthrosis, instrumentation failure, progressive spinal deformity, and may require additional surgery.9,10

Low bone mineral density (BMD) is the main contributing factor for such complications.11 Dual-energy x-ray absorptiometry (DEXA), despite being a standard tool, is affected by vascular calcifications, obesity, and degenerative spinal changes.12 Quantitative computed tomography (QCT), though more precise in measuring trabecular bone density, exposes patients to higher radiation doses.13,14

Two novel, radiation-free magnetic resonance imaging (MRI)-based methods—vertebral bone quality (VBQ) and endplate bone quality (EBQ) scores—have emerged as promising noninvasive solutions for BMD assessment.15–17 The VBQ score evaluates the extent of fat infiltration in the trabecular bone of the osteoporotic vertebral body.15 The EBQ score evaluates BMD at the bone-implant interface.16 Despite their radiation-free nature and high reliability, there are no comprehensive studies assessing their potential in predicting screw loosening and cage subsidence. Therefore, this study aims to address this gap following degenerative thoracolumbar spine surgery.

Materials and Methods

Search Strategy

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42024603990). We performed an extensive search across the PubMed, Cochrane Library, Scopus, and Web of Science databases through November 2024.

Study Selection

After duplicate entries were removed through Rayyan software,18 2 reviewers independently screened the relevant papers’ titles and abstracts, followed by a full-text review to determine final eligibility. Any disagreements were resolved through discussion.

Eligibility Criteria

We included retrospective studies investigating the utility of VBQ and EBQ scores in predicting postoperative outcomes of thoracolumbar spine surgery in adult degenerative thoracolumbar spine disorders. Nonoriginal research, such as reviews, case reports, conference abstracts, or editorials, was excluded.

VBQ and EBQ Scores Calculation

VBQ was calculated by dividing the median signal intensity (SI) of L1 to L4 vertebral bodies by the median SI of cerebrospinal fluid (CSF) at the L3 level using midsagittal T1-weighted MRI ( Figure 1 )15,16:

Vertebral bone quality and endplate bone quality regions of interest selection method using a T1-weighted sagittal section of the lumbar spine. CSF, cerebral spinal fluid.
Figure 1

Vertebral bone quality and endplate bone quality regions of interest selection method using a T1-weighted sagittal section of the lumbar spine. CSF, cerebral spinal fluid.

Formula

The EBQ was calculated by dividing the median SI of L1 to L4 superior and inferior endplates by the median SI of CSF at the L3 level using axial T1-weighted MRI ( Figure 1 )16,19:

Formula

Higher VBQ or EBQ values indicate greater marrow fat infiltration within the endplates, suggesting weaker bone structure and a higher likelihood of endplate failure. Elevated VBQ and/or EBQ scores have been associated with higher risks of cage subsidence following thoracolumbar spine surgery, as well as potential complications related to hardware fixation.20 Cage subsidence was defined as a reduction in cage height ≥2 mm, and screw loosening was diagnosed based on the observed radiolucent zone of 1 mm or more surrounding the pedicle screw, periscrew osteolysis, on follow-up computed tomography (CT).20,21

Data Extraction, Quality Assessment, and Statistical Analysis

Four independent reviewers extracted study characteristics (eg, first author’s name, publication year), participant demographics (eg, age, gender, detailed pathology information), and surgical details (eg, type of procedure, instrumentation used, reported complications, VBQ or EBQ scores). Discrepancies in data extraction were resolved through discussion among the reviewers.

The quality assessment of diagnostic accuracy studies 2 (QUADAS-2) tool22 was utilized to assess the quality of diagnostic accuracy studies, focusing on 4 key domains: patient selection, index test, reference standard, and flow and timing. Any disagreements among reviewers were resolved through discussion.

Pooled estimates were calculated using a random-effects model meta-analysis to account for potential heterogeneity among studies. Effect sizes were reported as mean differences (MDs) for continuous variables and ORs for categorical variables, along with 95% CIs. Heterogeneity was assessed using I 2 statistics. Subgroup and sensitivity analyses using the leave-one-out method were conducted to explore the heterogeneity source. Deeks’ funnel plot was used to assess publication bias. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and the area under the curve of the pooled summary receiver operating characteristic (SROC) curve were calculated. The Youden index was used to determine the optimal cut-off values. Statistical significance was determined using P values, with a threshold of <0.05 considered significant. All statistical analyses were conducted using Review Manager (RevMan) and STATA software.23,24

Results

Study Characteristics

This review included 19 retrospective studies with a total of 2768 patients (Figure 2). Of these, 13 studies investigated cage subsidence,16,25–36 while 6 studies focused on screw loosening.11,21,37–40 VBQ score was assessed in 15 studies,11,16,21,25–27,29–40 while EBQ score was examined in 5 studies.16,25,27,28,31,35 Six different surgical procedures were investigated: OLIF (2769),26,28,31 TLIF (1385),16,21,27,29,30,32,33,39 PLIF (579),11,35,36,40 lumbar pedicle screw fixation (116),21 dynamic pedicle screw fixation (117),38 and standalone lateral lumbar interbody fusion (205; Tables 1 and 2).25

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of the identification of the studies.
Figure 2

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of the identification of the studies.

View this table:
Table 1

Characteristics of included studies.

View this table:
Table 2

Characteristics of patients in included studies.

Quality Assessment

Most of the included studies had a low risk of bias and applicability concerns. High risk of bias was reported in the patient selection domain for 1 study11 and in the reference standard domain for another study.25 An unclear concern was reported in the reference standard domain for 1 study11 (Figure 3).

Risk of bias assessment through the quality assessment of diagnostic accuracy studies 2 tool: (A) overall assessment and (B) individualized assessment. Regarding the cited studies, see the author note at the end of this article.
Figure 3

Risk of bias assessment through the quality assessment of diagnostic accuracy studies 2 tool: (A) overall assessment and (B) individualized assessment. Regarding the cited studies, see the author note at the end of this article.

Higher VBQ Score Associated With Increased Incidence of Postoperative Complications After Degenerative Thoracolumbar Spine Surgery

The total incidence of complications was 31.54% (757 of 2400). A significantly higher VBQ score was associated with the cage subsidence (MD, 0.59; 95% CI, 0.39–0.79; P < 0.0001; I 2 = 76.1%), and screw loosening (MD, 0.62; 95% CI, 0.38–0.85; P = 0.0011; I 2 = 83.7%; Figure 4).

Forest plot of vertebral bone quality scores for postoperative complications subgrouped by cage subsidence and screw loosening. Regarding the cited studies, see the author note at the end of this article.
Figure 4

Forest plot of vertebral bone quality scores for postoperative complications subgrouped by cage subsidence and screw loosening. Regarding the cited studies, see the author note at the end of this article.

A significantly higher VBQ score was observed in the complication group for the TLIF/PLIF subgroup (MD, 0.59; 95% CI, 0.43–0.75; P < 0.0001; I 2 = 80.7%), whereas no statistically significant difference was observed in the OLIF/LLIF subgroup (MD, 0.73; 95% CI, -0.32–1.79; P = 0.1128; I 2 = 84.7%; Figure 5).

Forest plot of vertebral bone quality scores for postoperative complications subgrouped by surgery type. Regarding the cited studies, see the author note at the end of this article.
Figure 5

Forest plot of vertebral bone quality scores for postoperative complications subgrouped by surgery type. Regarding the cited studies, see the author note at the end of this article.

Risk Factor Analysis for Postoperative Complications Associated With a High VBQ Score

A significantly higher VBQ was associated with a greater chance of cage subsidence (OR, 3.84; 95% CI, 2.03–7.25; P < 0.0001; I 2 = 84 %) and screw loosening (OR, 3.59; 95% CI, 1.62–7.92; P = 0.00116; I 2 = 95.1%; Figure 6 ).

Forest plot of the risk factor analysis of vertebral bone quality values for cage subsidence and screw loosening. Regarding the cited studies, see the author note at the end of this article.
Figure 6

Forest plot of the risk factor analysis of vertebral bone quality values for cage subsidence and screw loosening. Regarding the cited studies, see the author note at the end of this article.

High VBQ Score Diagnostic Value in Postoperative Complication Group After Degenerative Thoracolumbar Spine Surgery

The VBQ score cut-off values ranged from 2.7 to 4.1, with a mean of 3.12 ± 0.41. The optimal cut-off value was 3.15, corresponding to the highest Youden index of 0.636. The pooled sensitivity and specificity were 77.25% (95% CI, 70.42–84.08; I 2 = 100%) and 68.19% (95% CI, 56.75–79.64; I 2 = 100%), respectively (Figure 7).

Forest plot of the sensitivity (upper) and specificity (lower) of vertebral bone quality scores among patients of both screw loosening and cage subsidence. Regarding the cited studies, see the author note at the end of this article.
Figure 7

Forest plot of the sensitivity (upper) and specificity (lower) of vertebral bone quality scores among patients of both screw loosening and cage subsidence. Regarding the cited studies, see the author note at the end of this article.

Higher EBQ Score Associated With Increased Incidence of Postoperative Complications After Degenerative Thoracolumbar Spine Surgery

The total incidence of cage subsidence was 26.9% (260 of 966). A significantly higher EBQ score was associated with cage subsidence (MD, 0.67; 95% CI, 0.35–0.99; P = 0.0029; I 2 = 76.9%; Figure 8).

Forest plot of endplate bone quality scores for postoperative cage subsidence. Regarding the cited studies, see the author note at the end of this article.
Figure 8

Forest plot of endplate bone quality scores for postoperative cage subsidence. Regarding the cited studies, see the author note at the end of this article.

A significantly higher EBQ score was observed in the complication group for the TLIF/PLIF subgroup (SMD, 0.86; 95% CI, 0.63–1.08; P = 0.0037; I 2 = 0%), whereas no statistically significant difference was observed in the OLIF/LLIF subgroup (SMD, 0.47; 95% CI, −0.50–1.45; P = 0.1024; I 2 = 0%; (Figure 9).

Forest plot of endplate bone quality scores for cage subsidence subgrouped by surgery type. Regarding the cited studies, see the author note at the end of this article.
Figure 9

Forest plot of endplate bone quality scores for cage subsidence subgrouped by surgery type. Regarding the cited studies, see the author note at the end of this article.

Risk Factor Analysis for Postoperative Complications Associated With a High EBQ Score

A significantly higher EBQ was associated with a greater chance of cage subsidence (OR, 2.27; 95% CI, 1.29–4.01; P = 0.0046; I 2 = 62.8%; Figure 10 ).

Forest plot of the risk factor analysis of vertebral bone quality values for cage subsidence. Regarding the cited studies, see the author note at the end of this article.
Figure 10

Forest plot of the risk factor analysis of vertebral bone quality values for cage subsidence. Regarding the cited studies, see the author note at the end of this article.

High EBQ Score Diagnostic Value in Postoperative Complication Group After Degenerative Thoracolumbar Spine Surgery

The EBQ score cut-off values ranged from 2.3 to 5.1 with a mean of 3.89 ± 1.32. The optimal cut-off value was 4.7, corresponding to the highest Youden index of 0.596. The pooled sensitivity and specificity were 70.68% (95% CI, 56.74–84.63; I 2 = 100%) and 74.27% (95% CI, 65.47–83.06; I 2 = 100%), respectively ( Figure 11 ).

Forest plot of the sensitivity (upper) and specificity (lower) of endplate bone quality scores among patients with cage subsidence. Regarding the cited studies, see the author note at the end of this article.
Figure 11

Forest plot of the sensitivity (upper) and specificity (lower) of endplate bone quality scores among patients with cage subsidence. Regarding the cited studies, see the author note at the end of this article.

Sensitivity Analysis

After outlier removal, VBQ and EBQ scores showed stable effect estimates for postoperative complications, surgical intervention subgroups, and risk factor analysis ( Figures S1–S5 - 5 ). No significant heterogeneity reduction was observed for VBQ/EBQ sensitivity and specificity assessments ( Figures S6 and S7 and 7 ).

SROC Analysis

The SROC analysis of sensitivity and specificity of VBQ for the complication group indicated moderate to good discriminative ability, the curve being clearly above the diagonal reference line ( Figure S8 ). Calculations of area under the curve provided quantitative measures of diagnostic performance, with CI indicating sufficient precision of the estimates. The SROC analysis of EBQ score performance alone for the prediction of cage subsidence showed identical diagnostic qualities, with curve position suggesting clinically useful predictive ability ( Figure S9 ).

Publication Bias Assessment

Publication bias was investigated using funnel plots. Funnel plots showed asymmetrical patterns of distribution for VBQ scores ( Figures S10–S13 - 13 ), with the most evident bias in screw loosening and cage subsidence analyses ( Figures S14 and S15 and 15 ). Similar patterns were observed for EBQ scores, particularly in cage subsidence and risk factor analyses ( Figures S16 and S17 and 17 ).

Discussion

Summary of the Main Findings

This meta-analysis evaluated the ability of MRI-based VBQ and EBQ scores to predict postoperative complications such as cage subsidence and screw loosening in thoracolumbar spine surgery. In this meta-analysis, patients with cage subsidence and screw loosening showed significantly higher VBQ scores. Similarly, EBQ scores were elevated in cage subsidence cases. The overall sensitivity and specificity of VBQ scores in predicting these complications were 77.25% and 68.19%, respectively. For the EBQ score, the sensitivity was 70.68%, and the specificity was 74.27%, indicating that both scores provide reasonably accurate diagnostic value. Our findings underscore the clinical significance of using MRI-based bone quality assessments to guide preoperative planning, as they allow for more precise risk stratification, ultimately leading to improved surgical outcomes and reduced complications for patients undergoing thoracolumbar spine surgery.

Degenerative Thoracolumbar Spine Disorders and Potential Mechanisms Underlying VBQ and EBQ Scores’ Predictive Potential

With the increasing prevalence of thoracolumbar degenerative diseases in an aging population, the demand for surgical interventions such as PLIF and TLIF continues to rise. However, cage subsidence remains a significant postoperative complication, occurring in 23.9% to 54% of cases. Multiple factors, including age and endplate integrity, contribute to cage subsidence risk, with BMD being a critical determinant.35

Preoperative BMD screening allows surgeons to tailor surgical strategies and fixation methods based on individual bone quality. Given the rising life expectancy and the increasing number of elderly patients requiring thoracolumbar spine surgery, comprehensive BMD assessments are essential to reduce complications such as construct failure, pseudarthrosis, and revision surgery.41 Spine surgeons vary widely in selecting patients for spinal fusion in chronic low back pain management. Their decisions are based on prognostic patient factors (including age, body mass index, and number of fusion levels) and predictive tests (including MRI and provocative discography).42

DEXA does not account for microarchitectural or endplate changes, which are essential in understanding the mechanical strength of vertebral structures.41 Similarly, QCT and CT-derived Hounsfield units, though useful in assessing bone alignment and density, expose patients to radiation and may lack sensitivity in detecting subtle degenerative changes, especially at the bone-screw or cage interface.43 Recent studies have highlighted the utility of MRI-based VBQ and EBQ scores as promising alternatives. These scores allow for noninvasive, radiation-free evaluation of bone microstructure and integrity, making them particularly valuable in preoperative planning.16 By offering better assessment of endplate integrity and trabecular architecture, VBQ and EBQ scores have shown potential in predicting the risk of cage subsidence and screw loosening more accurately than conventional imaging techniques.35,44,45

VBQ score has a significant accuracy of up to 82.5%, making it a strong marker of bone fragility and postoperative complications.29 The sensitivity and specificity of the EBQ score have been reported to be up to 76%, indicating its reliability in assessing endplate deterioration and surgical risk prediction.20 In comparison, CT-derived Hounsfield units demonstrated much lower sensitivity and specificity (≈67%) for predicting such complications.46 The endplate is responsible for distributing axial loads across the vertebral column. Therefore, endplate integrity plays a crucial role in implant stability. A reduction in endplate quality compromises the ability of interbody cages to maintain height and fusion stability, increasing the risk of cage subsidence, particularly at L4 to L5 and L5 to S1, where mechanical stress is greatest.29 Notably, prolonged disc degeneration may paradoxically reduce VBQ scores due to decreased bone marrow fat content, which may suggest improved bone strength.45 Therefore, the EBQ score may be more suitable for assessing the cage implantation site, particularly in patients with weaker endplates.

Comparison With Existing Literature

Recently, the VBQ score has been well studied as a diagnostic tool for osteoporosis and/or osteopenia. Hu et al (2024)47 demonstrated a sensitivity of 76% and specificity of 74%. Chen et al (2023)48 showed a sensitivity of 80% and specificity of 64%. Although the VBQ score has been well studied in osteoporosis and/or osteopenia evaluation, its diagnostic potential in thoracolumbar spinal surgery remains insufficiently explored. To date, only Hu et al (2024)49 have reported the promising role of the VBQ score in predicting such conditions. Unlike Hu’s analysis, which looked only at VBQ score diagnostic potential, our study provides the first precise estimates of sensitivity and specificity for both VBQ and EBQ scores. Furthermore, the incorporation of a greater number of patients and a diverse range of surgical procedures significantly enhances the generalizability and reliability of our findings.

Limitations

To the best of our knowledge, this is the first meta-analysis to jointly assess the predictive value of VBQ and EBQ scores in diagnosing postoperative complications following degenerative thoracolumbar spine surgery. However, multiple limitations must be taken into consideration. First, the inclusion of retrospective analyses, which are susceptible to selection bias, may have contributed to an overestimation of the diagnostic advantage ratio. Second, the majority of included studies were conducted in China, which might affect the generalizability of our findings to other demographic groups. Third, EBQ scores were not reported in any of the studies that evaluated screw loosening, further limiting the generalizability of these findings. Fourth, further analysis is required to assess the predictive value of VBQ and EBQ scores in predicting other bone quality-associated conditions, such as proximal junctional kyphosis, reoperation, and adjacent segment degeneration. Furthermore, assessing the predictive potential of VBQ and EBQ scores in minimally invasive surgeries is paramount. While our results showed statistically significant predictive values, differences in surgical techniques (fusion techniques vs screw fixation alone), measurement methodologies, and other confounding factors such as cage material, surgical levels, and associated comorbidities may influence the generalizability of our findings. Lastly, the included patients’ age distribution is significantly skewed, with a disproportionately higher number of elderly patients compared with younger patients, potentially limiting the reliability of the drawn conclusion in the younger population. Therefore, our findings should be interpreted in light of the aforementioned limitations.

Future Directions for Research

Future research should focus on standardizing MRI protocols (including the usage of other MRI sequences such as T2-weighted or short tau inversion recovery imaging) and bone quality scoring systems thresholds to ensure consistency in future studies, which would improve the reliability and generalizability of results. Additionally, exploring the potential diagnostic potential of the combined VBQ and EBQ scoring system could provide a more comprehensive picture of a patient’s bone health and surgical risk. Longitudinal studies are also crucial to assess how MRI-based bone quality scores predict long-term surgical outcomes, including implant failure, degeneration, and patient functionality. Expanding research in these areas will refine clinical practice, improve presurgical assessments, and contribute to better outcomes in thoracolumbar spine surgery.

Conclusion

The MRI-based VBQ and EBQ scoring system showed promise in predicting screw loosening and cage subsidence. Our findings demonstrate the importance of preoperative bone quality assessment for optimizing surgical outcomes. Therefore, integrating VBQ and EBQ scores into routine evaluations could enhance patient selection, improve recovery, and reduce complications. Future studies should focus on standardizing these methods and directly comparing their performance with the standard methods, such as DEXA and CT, to determine their efficacy and clinical value.

Supplementary material

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Footnotes

  • Funding The authors received no financial support for the research, authorship, and/or publication of this article.

  • Declaration of Conflicting Interests The authors report no conflicts of interest in this work.

  • Author Note Some articles were identifed as preprints before publication, while others were recorded with earlier received or issue dates. Thus, for some studies, there may be a discrepancy between the citation year listed in the tables and figures and the publication date of the final article as listed in the reference list.

  • Data Availability Statement All data generated or analyzed during this study are included in this published article (and its supplementary information files).

References

  1. 1.
    ↵
    Ravindra VM , Senglaub SS , Rattani A , et al . Degenerative lumbar spine disease: estimating global incidence and worldwide volume. Global Spine J. 2018;8(8):784–794. 10.1177/2192568218770769
    Google ScholarCrossRefPubMed
  2. 2.
    ↵
    Fehlings MG , Tetreault L , Nater A , et al . The aging of the global population. Neurosurgery. 2015;77(Supplement 1):S1–S5. 10.1227/NEU.0000000000000953
    Google ScholarCrossRef
  3. 3.
    ↵
    Mobbs RJ , Phan K , Malham G , Seex K , Rao PJ . Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. J Spine Surg. 2015;1(1):2–18. 10.3978/j.issn.2414-469X.2015.10.05
    Google ScholarCrossRef
  4. 4.
    ↵
    Lowe TG , Tahernia AD . Unilateral transforaminal posterior lumbar interbody fusion. Clin Orthop Relat Res. 2002;394(394):64–72. 10.1097/00003086-200201000-00008
    Google ScholarCrossRef
  5. 5.
    ↵
    Johnson AT , Kumar G , Mohapatra B , Mahajan R . Perioperative complications of oblique lumbar interbody fusion (OLIF): 5 years of experience with OLIF. Asian J Neurosurg. 2024;19(4):721–727. 10.1055/s-0044-1790515
    Google ScholarCrossRef
  6. 6.
    ↵
    Marie-Hardy L , Pascal-Moussellard H , Barnaba A , Bonaccorsi R , Scemama C . Screw loosening in posterior spine fusion: prevalence and risk factors. Global Spine J. 2020;10(5):598–602. 10.1177/2192568219864341
    Google ScholarCrossRefPubMed
  7. 7.
    ↵
    Masuda S , Fujibayashi S , Kimura H , et al . Salvage oblique lateral interbody fusion for pseudarthrosis after posterior/transforaminal lumbar interbody fusion: a technical note. World Neurosurg. 2021;152:107–112. 10.1016/j.wneu.2021.06.020
    Google ScholarCrossRef
  8. 8.
    ↵
    Kim H , Chang BS , Chang SY . Pearls and pitfalls of oblique lateral interbody fusion: a comprehensive narrative review. Neurospine. 2022;19(1):163–176. 10.14245/ns.2143236.618
    Google ScholarCrossRef
  9. 9.
    ↵
    Yuan L , Zhang X , Zeng Y , Chen Z , Li W . Incidence, risk, and outcome of pedicle screw loosening in degenerative lumbar scoliosis patients undergoing long-segment fusion. Global Spine J. 2023;13(4):1064–1071. 10.1177/21925682211017477
    Google ScholarCrossRefPubMed
  10. 10.
    ↵
    Chen Z , Lv G , Zhang O , et al . Risk factors of instrumentation failure after laminectomy and posterior cervical fusions (PCF). BMC Musculoskelet Disord. 2024;25(1):1–9. 10.1186/S12891-023-07116-Z/TABLES/2
    Google ScholarCrossRef
  11. 11.
    ↵
    Chen Z , Lei F , Ye F , Chen H , Gao Y , Li Y . Preoperative MRI-based vertebral bone quality (VBQ) score in lumbar degenerative disease: a predictor of pedicle screw loosening. World Neurosurg. 2023;171:e760–e767.
    Google ScholarCrossRef
  12. 12.
    ↵
    Salzmann SN , Okano I , Jones C , et al . Preoperative MRI-based vertebral bone quality (VBQ) score assessment in patients undergoing lumbar spinal fusion. Spine J. 2022;22(8):1301–1308. 10.1016/j.spinee.2022.03.006
    Google ScholarCrossRef
  13. 13.
    ↵
    Haffer H . MRI-derived vertebral bone quality correlates with micro-CT trabecular structure. Spine J. 2022;22(10):1642–1650. 10.1016/j.spinee.2022.05.008
    Google ScholarCrossRef
  14. 14.
    ↵
    Engelke K , Adams JE , Armbrecht G , et al . Clinical use of quantitative computed tomography and peripheral quantitative computed tomography in the management of osteoporosis in adults: the 2007 ISCD official positions. J Clin Densitom. 2008;11(1):123–162. 10.1016/j.jocd.2007.12.010
    Google ScholarCrossRefPubMedWeb of Science
  15. 15.
    ↵
    Ehresman J , Schilling A , Yang X , et al . Vertebral bone quality score predicts fragility fractures independently of bone mineral density. Spine J. 2021;21(1):20–27. 10.1016/j.spinee.2020.05.540
    Google ScholarCrossRef
  16. 16.
    ↵
    Ai Y , Zhu C , Chen Q , et al . Comparison of predictive value for cage subsidence between MRI-based endplate bone quality and vertebral bone quality scores following transforaminal lumbar interbody fusion: a retrospective propensity-matched study. Spine J. 2024;24(6):1046–1055. 10.1016/j.spinee.2024.01.014
    Google ScholarCrossRef
  17. 17.
    ↵
    Kim AYE , Lyons K , Sarmiento M , Lafage V , Iyer S . MRI-based score for assessment of bone mineral density in operative spine patients. Spine (Phila Pa 1986). 2023;48(2):107–112. 10.1097/BRS.0000000000004509
    Google ScholarCrossRef
  18. 18.
    ↵
    Ouzzani M , Hammady H , Fedorowicz Z , Elmagarmid A . Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):1–10. 10.1186/S13643-016-0384-4/FIGURES/6
    Google ScholarCrossRefPubMed
  19. 19.
    ↵
    Li X , Zhang Y , Wang Y , Chen H , Sun X , Liu W . MRI-based vertebral bone quality scores for assessing bone mineral density: implications for endplate bone quality evaluation. Spine J. 2023;23(8):1452–1461.
    Google Scholar
  20. 20.
    ↵
    Chen Q , Yu W , Sun Z , Xie L , Xu J , Qiu Y . MRI-based endplate bone quality score independently predicts cage subsidence following TLIF: using QCT as a reference. Spine J. 2023;23(11):1652–1658.
    Google ScholarCrossRef
  21. 21.
    ↵
    Gao Y , Ye W , Ge X , et al . Assessing the utility of MRI-based vertebral bone quality (VBQ) for predicting lumbar pedicle screw loosening. Eur Spine J. 2024;33(1):289–297. 10.1007/s00586-023-08034-3
    Google ScholarCrossRef
  22. 22.
    ↵
    Whiting PF , Rutjes AWS , Westwood ME , et al . QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155(8):529–536. 10.7326/0003-4819-155-8-201110180-00009
    Google ScholarCrossRefPubMedWeb of Science
  23. 23.
    ↵
    RevMan: Systematic review and meta-analysis tool for researchers worldwide | Cochrane RevMan. https://revman.cochrane.org/info. 31 March 2025.
    Google Scholar
  24. 24.
    ↵
    New in Stata 18 | Stata. https://www.stata.com/new-in-stata. 31 March 2025.
    Google Scholar
  25. 25.
    ↵
    Jones C , Okano I , Arzani A , Buser Z , Oro D , Wang A . MRI-based endplate bone quality (EBQ) score independently predicts severe cage subsidence following lateral lumbar interbody fusion. Spine J. 2022;22(11):1875–1883. 10.1016/j.spinee.2022.07.085
    Google ScholarCrossRef
  26. 26.
    ↵
    Pu X , Wang X , Ran L , et al . Comparison of predictive performance for cage subsidence between CT-based hounsfield units and MRI-based vertebral bone quality score following oblique lumbar interbody fusion. Eur Radiol. 2023;33(12):8637–8644. 10.1007/s00330-023-09929-x
    Google ScholarCrossRef
  27. 27.
    ↵
    Chen Q , Ai Y , Huang Y , et al . MRI-based endplate bone quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion. Spine J. 2023;23(11):1652–1658. 10.1016/j.spinee.2023.07.002
    Google ScholarCrossRef
  28. 28.
    ↵
    Ran L , Xie T , Zhao L , et al . MRI-based endplate bone quality score predicts cage subsidence following oblique lumbar interbody fusion. Spine J. 2024;24(10):1922–1928. 10.1016/j.spinee.2024.05.002
    Google ScholarCrossRef
  29. 29.
    ↵
    Ai Y , Zhang Y , Huang X , Du J , Wang X . MRI-based VBQ score for predicting cage subsidence after TLIF. Eur Spine J. 2023;32(9):3167–3175. 10.1007/s00586-023-07854-7
    Google ScholarCrossRef
  30. 30.
    ↵
    Hu Y-H , Yeh Y-C , Niu C-C , et al . Novel MRI-based vertebral bone quality score as a predictor of cage subsidence following transforaminal lumbar interbody fusion. J Neurosurg Spine. 2022;37(5):654–662. 10.3171/2022.3.SPINE211489
    Google ScholarCrossRef
  31. 31.
    ↵
    Zheng X , Tong T , Li W , et al . Predictive value of different site-specific MRI-based assessments of bone quality for cage subsidence among patients undergoing oblique lumbar interbody fusion. J Neurosurg Spine. 2024;41(2):246–253. 10.3171/2024.2.SPINE231107
    Google ScholarCrossRef
  32. 32.
    ↵
    Khoylyan A , Girgis MY , Tang A , Vazquez F , Chen T . The utility of magnetic resonance imaging-based vertebral bone quality scores as a predictor of cage subsidence following transforaminal and posterior lumbar interbody fusion. Clin Spine Surg. 2025;38(3):E145–E151. 10.1097/BSD.0000000000001682
    Google ScholarCrossRef
  33. 33.
    ↵
    Soliman MAR , Aguirre AO , Kuo CC , et al . Vertebral bone quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion. Spine J. 2022;22(12):2017–2023. 10.1016/j.spinee.2022.08.002
    Google ScholarCrossRef
  34. 34.
    ↵
    Huang Y , Chen Q , Liu L , Feng G . Vertebral bone quality score to predict cage subsidence following oblique lumbar interbody fusion. J Orthop Surg Res. 2023;18(1):258. 10.1186/s13018-023-03729-1
    Google ScholarCrossRef
  35. 35.
    ↵
    Zhang F , Lin H , Zhao Y , He Y , Wu H , Hu R . Comparative analysis of VBQ and EBQ scores for cage subsidence in PLIF. J Orthop Surg Res. 2024;19. 10.1186/s13018-024-05332-4
    Google ScholarCrossRef
  36. 36.
    ↵
    Wang Y , Zhang J , Tong T , Miao D , Wang F , Wang L . Comparison of hounsfield unit, vertebral bone quality, and dual-energy x-ray absorptiometry t-score for predicting cage subsidence after posterior lumbar interbody fusion. Global Spine J. 2025;15(4):2226–2235. 10.1177/21925682241293038
    Google ScholarCrossRef
  37. 37.
    ↵
    Ye W , Wang J , Wang X , Tang P . Comparison of predictive performance for pedicle screw loosening between computed tomography-based hounsfield units and magnetic resonance imaging-based vertebral bone quality score after lumbar surgery. World Neurosurg. 2024;190:e191–e198. 10.1016/j.wneu.2024.07.088
    Google ScholarCrossRef
  38. 38.
    ↵
    Jiang G , Xu L , Ma Y , et al . Prediction of screw loosening after dynamic pedicle screw fixation with lumbar polyetheretherketone rods using magnetic resonance imaging-based vertebral bone quality score. Neurospine. 2024;21(2):712–720. 10.14245/ns.2448184.092
    Google ScholarCrossRef
  39. 39.
    ↵
    Hu Y-H , Chou J-H , Yeh Y-C , et al . The MRI-based vertebral bone quality score is a predictor of pedicle screw loosening following instrumented posterior lumbar fusion. Sci Rep. 2025;15(1):1696. 10.1038/s41598-025-85625-8
    Google ScholarCrossRef
  40. 40.
    ↵
    Li W , Zhu H , Hua Z , et al . Vertebral bone quality score as a predictor of pedicle screw loosening following surgery for degenerative lumbar disease. Spine (Phila Pa 1986). 2023;48(23):1635–1641. 10.1097/BRS.0000000000004577
    Google ScholarCrossRef
  41. 41.
    ↵
    Deshpande N , Kim D , Smith T , Wagner S , Kim J . MRI-based bone quality: predictive value for spine surgery. J Neurosurgry Spine. 2023;38(3):436–445.
    Google Scholar
  42. 42.
    ↵
    Willems P , de Bie R , Oner C , Castelein R , de Kleuver M . Clinical decision making in spinal fusion for chronic low back pain. results of a nationwide survey among spine surgeons. BMJ Open. 2011;1(2):e000391. 10.1136/bmjopen-2011-000391
    Google ScholarCrossRefAbstract/Full TextPubMed
  43. 43.
    ↵
    Schreiber J , Anderson P , Rosas H , Buchholz A , Au A . Hounsfield unit measurement for bone mineral density assessment: a review. J Am Acad Orthop Surg. 2022;30(1):e90–98.
    Google Scholar
  44. 44.
    ↵
    Halvorson TL , Kelley LA , Thomas KA , Whitecloud TS , Cook SD . Effects of bone mineral density on pedicle screw fixation. Spine (Phila Pa 1986). 1976;19(21):2415–2420. 10.1097/00007632-199411000-00008
    Google ScholarCrossRef
  45. 45.
    ↵
    Moser M , Adl Amini D , Albertini Sanchez L , et al . The reciprocal relationship between lumbar intervertebral disk degeneration and the MRI-based vertebral bone quality score. Spine (Phila Pa 1986). 1976;49(17):1227–1234. 10.1097/BRS.0000000000004937
    Google ScholarCrossRef
  46. 46.
    ↵
    Yao Y-C , Chao H , Kao K-Y , et al . CT hounsfield unit is a reliable parameter for screws loosening or cages subsidence in minimally invasive transforaminal lumbar interbody fusion. Sci Rep. 2023;13(1):1620. 10.1038/s41598-023-28555-7
    Google ScholarCrossRef
  47. 47.
    ↵
    Hu F , Wu X , Liu Y , Xu D , Li Y , Huang Y . MRI-based VBQ score for diagnosing osteoporosis: a meta-analysis. Osteoporos Int. 2024;35(2):345–352. 10.1007/s00198-024-07190-6
    Google ScholarCrossRef
  48. 48.
    ↵
    Chen A , Feng S , Lai L , Yan C . A meta-analysis of the value of MRI-based VBQ scores for evaluating osteoporosis. Bone Rep. 2023;19:101711. 10.1016/j.bonr.2023.101711
    Google ScholarCrossRef
  49. 49.
    ↵
    Hu F , Xue L , Zhao D , Chen C , Jing F , Yang Q . Magnetic resonance imaging-based vertebral bone quality score for prediction of cage subsidence and screw loosening in patients undergoing degenerative lumbar surgery: a meta-analysis. Neurospine. 2024;21(3):913–924. 10.14245/ns.2448496.248
    Google ScholarCrossRef
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In this Issue
International Journal of Spine Surgery

Vol. 19, Issue 5

1 Oct 2025

Table of Contents Index by author

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Keywords

vertebral bone quality, endplate bone quality, screw loosening, cage subsidence, thoracolumbar spine, postoperative complication