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Hounsfield units value is a better predictor of pedicle screw loosening than the T-score of DXA in patients with lumbar degenerative diseases

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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.

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References

  1. Boos N, Webb JK (1997) Pedicle screw fixation in spinal disorders: a European view. Eur Spine J 6:2–18

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Chin DK, Park JY, Yoon YS, Kuh SU, Jin BH, Kim KS, Cho YE (2007) Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease. Osteoporos Int 18:1219–1224. https://doi.org/10.1007/s00198-007-0370-8

    Article  CAS  PubMed  Google Scholar 

  3. Hoppe S, Keel MJB (2017) Pedicle screw augmentation in osteoporotic spine: indications, limitations and technical aspects. Eur J Trauma Emerg Surg 43:3–8. https://doi.org/10.1007/s00068-016-0750-x

    Article  CAS  PubMed  Google Scholar 

  4. Galbusera F, Volkheimer D, Reitmaier S, Berger-Roscher N, Kienle A, Wilke H-J (2015) Pedicle screw loosening: a clinically relevant complication? Eur Spine J 24:1005–1016. https://doi.org/10.1007/s00586-015-3768-6

    Article  PubMed  Google Scholar 

  5. Alanay A, Vyas R, Shamie AN, Sciocia T, Randolph G, Wang JC (2007) Safety and efficacy of implant removal for patients with recurrent back pain after a failed degenerative lumbar spine surgery. J Spinal Disord Tech 20:271–277. https://doi.org/10.1097/01.bsd.0000211283.14143.ad

    Article  PubMed  Google Scholar 

  6. Berjano P, Bassani R, Casero G, Sinigaglia A, Cecchinato R, Lamartina C (2013) Failures and revisions in surgery for sagittal imbalance: analysis of factors influencing failure. Eur Spine J 22:853–858. https://doi.org/10.1007/s00586-013-3024-x

    Article  PubMed Central  Google Scholar 

  7. Bredow J, Boese CK, Werner CML, Siewe J, Löhrer L, Zarghooni K, Eysel P, Scheyerer MJ (2016) Predictive validity of preoperative CT scans and the risk of pedicle screw loosening in spinal surgery. Arch Orthop Trauma Surg 136:1–5. https://doi.org/10.1007/s00402-016-2487-8

    Article  Google Scholar 

  8. Röllinghoff M, Schlüter-Brust K, Groos D, Sobottke R, Michael JW-P, Eysel P, Delank KS (2010) Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine. Orthop Rev 2:3–4. https://doi.org/10.4081/or.2010.e3

    Article  Google Scholar 

  9. Okuyama K, Sato K, Abe E, Inaba H, Shimada Y, Murai H (1993) Stability of transpedicle screwing for the osteoporotic spine. An in vitro study of the mechanical stability. Spine 18:2240–2245

    Article  CAS  PubMed  Google Scholar 

  10. Shepherd JA, Schousboe JT, Broy SB, Engelke K, Leslie WD (2015) Executive summary of the 2015 ISCD position development conference on advanced measures from DXA and QCT: fracture prediction beyond BMD. J Clin Densitom 18:274–286. https://doi.org/10.1016/j.jocd.2015.06.013

    Article  PubMed  Google Scholar 

  11. Hamdy RC, Petak SM, Lenchik L (2002) Which central dual X-ray absorptiometry skeletal sites and regions of interest should be used to determine the diagnosis of osteoporosis? J Clin Densitome 5(Suppl):S11–S18

    Article  Google Scholar 

  12. Xie Y, Fu Q, Chen ZQ, Shi ZC, Zhu XD, Wang CF, Li M (2011) Comparison between two pedicle screw augmentation instrumentations in adult degenerative scoliosis with osteoporosis. BMC Musculoskelet Disord 12:286. https://doi.org/10.1186/1471-2474-12-286

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Pinera AR, Duran C, Lopez B, Saez I, Correia E, Alvarez L (2011) Instrumented lumbar arthrodesis in elderly patients: prospective study using cannulated cemented pedicle screw instrumentation. Eur Spine J 20:408–414. https://doi.org/10.1007/s00586-011-1907-2

    Article  PubMed  PubMed Central  Google Scholar 

  14. Dai F, Liu Y, Zhang F, Sun D, Luo F, Zhang Z, Xu J (2015) Surgical treatment of the osteoporotic spine with bone cement-injectable cannulated pedicle screw fixation: technical description and preliminary application in 43 patients. Clinics 70:114–119. https://doi.org/10.6061/clinics/2015(02)08

    Article  PubMed  PubMed Central  Google Scholar 

  15. Muraki S, Yamamoto S, Ishibashi H, Horiuchi T, Hosoi T, Orimo H, Nakamura K (2004) Impact of degenerative spinal diseases on bone mineral density of the lumbar spine in elderly women. Osteoporos Int 15:1–5. https://doi.org/10.1007/s00198-004-1600-y

    Article  Google Scholar 

  16. Zou D, Li W, Deng C, Du G, Xu N (2019) The use of CT Hounsfield unit values to identify the undiagnosed spinal osteoporosis in patients with lumbar degenerative diseases. Eur Spine J 28:1758–1766. https://doi.org/10.1007/s00586-018-5776-9

    Article  PubMed  Google Scholar 

  17. Pompe E, de Jong PA, de Jong WU, Takx RAP, Eikendal ALM, Willemink MJ, Oudkerk M, Budde RPJ, Lammers J-WJ, Hoesein FAAM (2016) Inter-observer and inter-examination variability of manual vertebral bone attenuation measurements on computed tomography. Eur Radiol. https://doi.org/10.1007/s00330-015-4145-x

    Article  PubMed  PubMed Central  Google Scholar 

  18. Pickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ, Binkley N (2013) Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med 158:588–522. https://doi.org/10.7326/0003-4819-158-8-201304160-00003

    Article  PubMed  PubMed Central  Google Scholar 

  19. Zaidi Q, Danisa OA, Cheng W (2019) Measurement techniques and utility of Hounsfield unit values for assessment of bone quality prior to spinal instrumentation: a review of current literature. Spine 44:E239–E244. https://doi.org/10.1097/BRS.0000000000002813

    Article  PubMed  Google Scholar 

  20. Anderson PA, Polly DW, Binkley NC, Pickhardt PJ (2018) clinical use of opportunistic computed tomography screening for osteoporosis. J Bone Joint Surg Am 100:2073–2081. https://doi.org/10.2106/JBJS.17.01376

    Article  PubMed  Google Scholar 

  21. Schwaiger BJ, Gersing AS, Baum T, Noel PB, Zimmer C, Bauer JS (2014) Bone mineral density values derived from routine lumbar spine multidetector row CT predict osteoporotic vertebral fractures and screw loosening. Am J Neuroradiol 35:1628–1633. https://doi.org/10.3174/ajnr.A3893

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Spirig JM, Sutter R, Götschi T, Farshad-Amacker NA, Farshad M (2018) Value of standard radiographs, CT and MRI of the lumbar spine in detection of intraoperatively confirmed pedicle screw loosening—a prospective clinical trial. Spine J. https://doi.org/10.1016/j.spinee.2018.06.345

    Article  PubMed  Google Scholar 

  23. Sanden B, Olerud C, Petren-Mallmin M, Johansson C, Larsson S (2004) The significance of radiolucent zones surrounding pedicle screws. Definition of screw loosening in spinal instrumentation. J Bone Jt Surg Ser B 86:461–457

    Google Scholar 

  24. Larsen JM, Rimoldi RL, Capen DA, Nelson RW, Nagelberg S, Thomas JC Jr (1996) Assessment of pseudarthrosis in pedicle screw fusion: a prospective study comparing plain radiographs, flexion/extension radiographs, CT scanning, and bone scintigraphy with operative findings. J Spinal Disord 9:117–120

    Article  CAS  PubMed  Google Scholar 

  25. Tokuhashi Y, Matsuzaki H, Oda H, Uei H (2008) Clinical course and significance of the clear zone around the pedicle screws in the lumbar degenerative disease. Spine 33:903–908

    Article  PubMed  Google Scholar 

  26. Ohtori S, Inoue G, Orita S, Yamauchi K, Eguchi Y, Ochiai N, Kishida S, Kuniyoshi K, Aoki Y, Nakamura J, Ishikawa T, Miyagi M, Kamoda H, Suzuki M, Kubota G, Sakuma Y, Oikawa Y, Inage K, Sainoh T, Takaso M, Toyone T, Takahashi K (2013) Comparison of teriparatide and bisphosphonate treatment to reduce pedicle screw loosening after lumbar spinal fusion surgery in postmenopausal women with osteoporosis from a bone quality perspective. Spine 38:E487–E492. https://doi.org/10.1097/BRS.0b013e31828826dd

    Article  PubMed  Google Scholar 

  27. Kim JW, Park S-W, Kim Y-B, Ko MJ (2018) The effect of postoperative use of teriparatide reducing screw loosening in osteoporotic patients. J Korean Neurosurg Soc 61:494–502. https://doi.org/10.3340/jkns.2017.0216

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Kim HJ, Kim SG, Lee HM, Kim HS, Moon ES, Park JO, Seol NH, Moon SH (2008) Risk factors associated with the halo phenomenon after lumbar fusion surgery and its clinical significance. Asian Spine J 2:22–26. https://doi.org/10.4184/asj.2008.2.1.22

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Okuyama K, Abe E, Suzuki T, Tamura Y, Chiba M, Sato K (2001) Influence of bone mineral density on pedicle screw fixation: a study of pedicle screw fixation augmenting posterior lumbar interbody fusion in elderly patients. Spine J 1:402–407

    Article  CAS  PubMed  Google Scholar 

  30. Orita S, Ohtori S, Eguchi Y, Kamoda H, Arai G, Ishikawa T, Miyagi M, Inoue G, Ochiai N, Kishida S, Takaso M, Aoki Y, Takahashi K (2010) Radiographic evaluation of monocortical versus tricortical purchase approaches in lumbosacral fixation with sacral pedicle screws: a prospective study of ninety consecutive patients. Spine 35:E1230–E1237

    Article  PubMed  Google Scholar 

  31. Kim J-B, Park S-W, Lee Y-S, Nam T-K, Park Y-S, Kim Y-B (2015) The effects of spinopelvic parameters and paraspinal muscle degeneration on S1 screw loosening. J Korean Neurosurg Soc 58:356–357. https://doi.org/10.3340/jkns.2015.58.4.357

    Article  CAS  Google Scholar 

  32. Bokov A, Bulkin A, Aleynik A, Kutlaeva M, Mlyavykh S (2018) Pedicle screws loosening in patients with degenerative diseases of the lumbar spine: potential risk factors and relative contribution. Global Spine J. https://doi.org/10.1177/2192568218772302

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

This study was funded by the Clinical Cohort Construction Program of Peking University Third Hospital (BYSYDL2019006).

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Correspondence to Weishi Li.

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All data collection and analysis conducted in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

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Zou, D., Sun, Z., Zhou, S. et al. Hounsfield units value is a better predictor of pedicle screw loosening than the T-score of DXA in patients with lumbar degenerative diseases. Eur Spine J 29, 1105–1111 (2020). https://doi.org/10.1007/s00586-020-06386-8

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  • DOI: https://doi.org/10.1007/s00586-020-06386-8

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