Journal of spine surgery (Hong Kong) · 2026
Hounsfield units as a predictor of cage subsidence and clinical outcomes following anterior cervical discectomy and fusion.
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Salvato Jason, Vazquez Frank, Moglia Taylor, Khoylyan Ara, Pamula Arpitha, Tang Alex, Chen Tan
Аннотация
BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is a standard treatment for cervical degenerative disease, though cage subsidence remains a significant complication that can compromise recovery. While Hounsfield units (HU) from computed tomography (CT) scans serve as a surrogate for bone mineral density (BMD), their utility in predicting physical complications and patient-reported outcomes requires further investigation. This study aimed to evaluate the association between preoperative cervical HU measurements and both radiographic cage subsidence and long-term clinical outcomes following single-level ACDF.
METHODS: A retrospective review was conducted of 39 patients who underwent single-level ACDF between 2019 and 2023 with preoperative cervical CT within 6 months and 12-month radiographic and clinical follow-up. Operative-level HU was defined as the mean trabecular HU of the cephalad and caudal vertebral bodies adjacent to the index disc space using standardized regions of interest. Subsidence was graded on 12-month lateral radiographs as grade 0 (none), grade 1 (<1/3), grade 2 (≥1/3 and <2/3), and grade 3 (≥2/3). Radiographic subsidence was defined as grade 1-3, and clinically significant subsidence as grade 2-3. Outcomes included neck disability index (NDI) and Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) scores at baseline and 12 months; minimal clinically important difference (MCID) thresholds were predefined as ≥7.5 NDI and ≥4.5 PROMIS-PF. Receiver operating characteristic (ROC) analysis assessed discrimination for radiographic subsidence.
RESULTS: Radiographic subsidence occurred in 15 of 39 patients (38.5%), while clinically significant subsidence occurred in 6 of 39 (15.4%). Mean operative-level HU was significantly lower in patients with radiographic subsidence compared with those without (231.4±24.5 vs. 284.6±28.1; P<0.01). ROC analysis demonstrated an area under the curve (AUC) of 0.81, with a threshold of 255 HU providing 82% sensitivity and 75% specificity for radiographic subsidence. Patients with HU <255 demonstrated higher observed rates of MCID non-attainment for NDI and PROMIS-PF in descriptive analyses.
CONCLUSIONS: Lower preoperative operative-level HU was associated with radiographic subsidence and less favorable 12-month patient-reported outcomes following single-level ACDF. An HU threshold near 255 demonstrated moderate discrimination for radiographic subsidence. These findings should be considered hypothesis-generating and require validation in larger, standardized cohorts.
METHODS: A retrospective review was conducted of 39 patients who underwent single-level ACDF between 2019 and 2023 with preoperative cervical CT within 6 months and 12-month radiographic and clinical follow-up. Operative-level HU was defined as the mean trabecular HU of the cephalad and caudal vertebral bodies adjacent to the index disc space using standardized regions of interest. Subsidence was graded on 12-month lateral radiographs as grade 0 (none), grade 1 (<1/3), grade 2 (≥1/3 and <2/3), and grade 3 (≥2/3). Radiographic subsidence was defined as grade 1-3, and clinically significant subsidence as grade 2-3. Outcomes included neck disability index (NDI) and Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) scores at baseline and 12 months; minimal clinically important difference (MCID) thresholds were predefined as ≥7.5 NDI and ≥4.5 PROMIS-PF. Receiver operating characteristic (ROC) analysis assessed discrimination for radiographic subsidence.
RESULTS: Radiographic subsidence occurred in 15 of 39 patients (38.5%), while clinically significant subsidence occurred in 6 of 39 (15.4%). Mean operative-level HU was significantly lower in patients with radiographic subsidence compared with those without (231.4±24.5 vs. 284.6±28.1; P<0.01). ROC analysis demonstrated an area under the curve (AUC) of 0.81, with a threshold of 255 HU providing 82% sensitivity and 75% specificity for radiographic subsidence. Patients with HU <255 demonstrated higher observed rates of MCID non-attainment for NDI and PROMIS-PF in descriptive analyses.
CONCLUSIONS: Lower preoperative operative-level HU was associated with radiographic subsidence and less favorable 12-month patient-reported outcomes following single-level ACDF. An HU threshold near 255 demonstrated moderate discrimination for radiographic subsidence. These findings should be considered hypothesis-generating and require validation in larger, standardized cohorts.