Vertebral Body Hounsfield Units are Associated With Cage Subsidence After Transforaminal Lumbar Interbody Fusion With Unilateral Pedicle Screw Fixation

Objective: To assess the association between Hounsfield units (HU) measurement and cage subsidence after lumbar interbody fusion. Background: Transforaminal lumbar interbody fusion (TLIF) with unilateral fixation becomes a popular treatment modality for lumbar degenerative disease. Cage subsidence is a potentially devastating complication after lumbar interbody fusion with unilateral fixation. Recently, a new technique for assessing bone mineral density using HU values from computed tomography has been proposed. Bone quality is believed to be one of the important factors that cause cage subsidence after TLIF. Materials and Methods: Cage subsidence after single- level (L4/5) TLIF with unilateral fixation was prospectively documented at a single institution between 2013 and 2014. Patients with cage subsidence were matched 1: 1 to a control cohort without cage subsidence on the basis of age and sex. HU values were measured from the preoperative computed tomography. All patients received computed tomographic scans at a minimum of 6 months postoperatively. Sagittal images were evaluated for evidence of cage subsidence. Results: Eighteen patients with cage subsidence were well matched 1: 1 to a cohort without cage subsidence and had complete imaging data. The global lumbar HU values were significantly lower in patients with cage subsidence than in the controls (112.4 +/- 10.08 vs. 140.2 +/- 10.17; P= 0.0015). Similarly, a regional assessment of HU across the fusion levels was significantly lower in patients with cage subsidence (113.4 +/- 10.47 vs. 127.9 +/- 8.13; P= 0.0075). The areas under the receiver operating characteristic cure were 0.715 and 0.636 for global and regional assessment, respectively. The best cut-offs for global and regional assessment were 132 (sensitivity: 83.3%; specificity: 61.1%) and 122 (sensitivity: 72.2%; specificity: 55.6%), respectively. Conclusions: Lower preoperative HU values is associated with cage subsidence after TLIF with unilateral fixation. HU measurement may be used as a predictor of cage subsidence after unilateral fixation, which also should be incorporated in preoperative planning.