Objective Hounsfield units (HU), vertebral bone quality (VBQ), and bone mineral density (BMD) can all serve as predictive indicators for thoracolumbar fragility fractures. This study aims to explore which indicator provides better risk prediction for thoracolumbar fragility fractures.
Methods Patients who have received medical attention from The First Affiliated Hospital of Anhui Medical University for thoracolumbar fragility fractures were selected. A total of 78 patients with thoracolumbar fragility fractures were included in the study. To establish a control group, 78 patients with degenerative spinal diseases were matched to the fracture group on the basis of gender, age, and body mass index. The lumbar vertebral HU, the VBQ, and the BMD were obtained for all the 156 patients through computed tomography, magnetic resonance imaging, and dual-energy x-ray absorptiometry (DEXA). The correlations among these parameters were analyzed. The area under curve (AUC) analysis was employed to assess the predictive efficacy and thresholds of lumbar vertebral HU, VBQ, and BMD in relation to the risk of thoracolumbar fragility fractures.
Results Among the cohort of 156 patients, lumbar vertebral HU exhibited a positive correlation with BMD (p < 0.01). Conversely, VBQ showed a negative correlation with HU, BMD (p < 0.05). HU and BMD displayed a favorable predictive efficacy for thoracolumbar fragility fractures (p < 0.01), with HU (AUC = 0.863) showcasing the highest predictive efficacy, followed by the DEXA-measured BMD (AUC = 0.813). VBQ (AUC = 0.602) ranked lowest among the 3 indicators. The thresholds for predicting thoracolumbar fragility fractures were as follows: HU (88),VBQ (3.37), and BMD (0.81).
Conclusion All 3 of these indicators, HU, VBQ, and BMD, can predict thoracolumbar fragility fractures. Notably, lumbar vertebral HU exhibits the highest predictive efficacy, followed by the BMD obtained through DEXA scanning, with VBQ demonstrating the lowest predictive efficacy.
Citations
Citations to this article as recorded by
Evaluation of bone mineral density in patients with cervical ossification of the posterior longitudinal ligament utilizing vertebral bone quality and Hounsfield units Kangcheng Zhao, Tong Su, JuHan Li, WeiBo Huang, HuaBin Yin European Spine Journal.2026; 35(4): 1785. CrossRef
Comparison between Hounsfield unit value and vertebral bone quality score for adjacent vertebral fracture risk assessment after balloon kyphoplasty: a propensity score matching study Koji Matsumoto, Masahiro Hoshino, Hirokatsu Sawada, Sosuke Saito, Tomohiro Furuya, Hirohiko Tsujisawa, Ryo Ozaki, Kazuyoshi Nakanishi Asian Spine Journal.2026; 20(1): 52. CrossRef
Disuse Bone Loss in Fusion Constructs After Multilevel Lumbar Fusion: A Computed Tomography Hounsfield Unit Analysis Hyun-Jun Jang, Dongkyu Kim, Bong-Ju Moon, Kyung-Hyun Kim, Jeong-Yoon Park, Sung-Uk Kuh, Keun-Su Kim, Dong-Kyu Chin Neurospine.2026; 23(1): 176. CrossRef
Abdominal aortic calcification and functional recovery in patients undergoing posterior lumbar interbody fusion: a retrospective cohort study Shangshu Wei, Sizheng Zhan, Yanjun Huang, Danning Lu, Chenxu Liu, Haoning Ma, Ping Yi, Xiangsheng Tang European Spine Journal.2026;[Epub] CrossRef
S1 vertebral Hounsfield Unit value independently predicts pedicle screw loosening after posterior lumbar interbody fusion in patients with lumbar degenerative diseases Han Ke, Minghui Liang, Yu Xi, Ruiyuan Chen, Congying Zou, Tianyi Wang, Aobo Wang, Ziqian Ma, Ning Fan, Shuo Yuan, Lei Zang BMC Surgery.2026;[Epub] CrossRef
The Role of Hounsfield Units in Predicting Cage Subsidence After Lateral Lumbar Interbody Fusion: A Systematic Review and Meta-Analysis Chen Zhang, Zachary Chu, Jonathan Boey, Reuben Chee Cheong Soh World Neurosurgery.2026; 208: 124836. CrossRef
Diagnostic performance of lumbar computed tomography Hounsfield unit thresholds for osteoporosis and osteopenia: a systematic review and meta-analysis Omar Lubbad, Akram Hagos, Laila Lubbad, Yahya El-Tahlawy, Giuseppe Lambros Morassi, Nektarios K. Mazarakis Osteoporosis International.2026;[Epub] CrossRef
Morphological characteristics of lumbar vertebral bodies and regional distribution patterns of bone mineral density: a CT study Xiaoteng Li, Fengzi Lv, Xin Tang, Peng Jia, Yang Gao Frontiers in Physiology.2026;[Epub] CrossRef
Comparison of Hounsfield Unit, Vertebral Bone Quality, and Dual-Energy X-Ray Absorptiometry T-Score for Predicting Cage Subsidence After Posterior Lumbar Interbody Fusion Yunsheng Wang, Jiali Zhang, Tong Tong, Dechao Miao, Feng Wang, Linfeng Wang Global Spine Journal.2025; 15(4): 2226. CrossRef
Comprehensive Diagnostic Value of Vertebral Bone Quality Scores and Paravertebral Muscle Quality Parameters in Osteoporotic Vertebral Fractures Song Wang, Le Liu, Hao Liu, Xiang Zhang, Honglin Liao, Ping He, Hao Yang, Hongsheng Yang, Bo Qu World Neurosurgery.2025; 194: 123503. CrossRef
Does Baseline Hounsfield Unit Predict Patients’ Outcomes Following Surgical Management of Unstable Osteoporotic Thoracolumbar Fractures? Ahmed Qretam, Julien Ceuterick, Maher Ghandour, Ümit Mert, Christian Herren, Miguel Pishnamaz, Matthias Knobe, Frank Hildebrand, Rolf Sobottke, Mohamad Agha Mahmoud Medicina.2025; 61(2): 227. CrossRef
Prevalence and Predictors of Osteoporosis and Osteopenia in Lagos, Nigeria Taoreed Adegoke Azeez, Babajide Lawson, Aishat Usman Aminu, Deborah Oluwatoyin Ola, Hosanna Nnennaya Obasi SN Comprehensive Clinical Medicine.2025;[Epub] CrossRef
Analysis of the Predictive Efficiency of Lumbar Vertebral Body Quantification (VBQ) and CT Hounsfield Units (HUs) for Bone Density: Age and Gender Differences Xianghe Wang, Minghang Chen, Chenjie Shan, Xiang Fang, Chaohui Ding, Zongjie Yuan, Honglin Teng Global Spine Journal.2025; 15(8): 3869. CrossRef
Emerging MRI-based spine scoring techniques targeting bone quality to assess osteoporosis, vertebral fracture risk, other spinal degenerative diseases, and post-surgical outcomes Rahman Ud Din, Haisheng Yang La radiologia medica.2025; 130(9): 1442. CrossRef
Predicting osteoporosis-related complications in lumbar spine surgery using Hounsfield unit and vertebral bone quality scores: A 5-Year follow-up study with principal component analysis insights Yuki Kinoshita, Hiroshi Taniwaki, Takashi Namikawa, Akira Matsumura, Minori Kato, Yusuke Hori, Masatoshi Hoshino, Shinji Takahashi, Koji Tamai, Akinobu Suzuki, Hiromitsu Toyoda, Hiroaki Nakamura, Hidetomi Terai European Spine Journal.2025; 34(11): 5148. CrossRef
Regional variations and spatial heterogeneity of lumbar CT attenuation are associated with osteoporotic vertebral fracture Jinhui Cai, Ludan Chen, Long Liu, Jinsheng Yi, Jiaqi Wu, Tingqian Yang, Wensheng Huang, Qingyu Liu Frontiers in Endocrinology.2025;[Epub] CrossRef
Magnetic Resonance Imaging-Based Assessment of Bone Quality Using Vertebral Bone Quality (VBQ) Scores in Spine Surgery—A Critical Assessment and Narrative Review Adeesya Gausper, Wende N. Gibbs, Benjamin D. Elder, Justin K. Scheer, Tiffany G. Perry, Suhas K. Etigunta, Andy M. Liu, Alexander Tuchman, Corey T. Walker Journal of Clinical Medicine.2025; 14(18): 6477. CrossRef
Role of S1 vertebral Hounsfield units value and bone quality score in predicting new vertebral compression fracture after percutaneous kyphoplasty Minghui Liang, Ruiyuan Chen, Tianyi Wang, Ning Fan, Shuo Yuan, Peng Du, Aobo Wang, Yu Xi, Lei Zang European Spine Journal.2025;[Epub] CrossRef
Preoperative bone mineral density quantitatively assessed by Hounsfield units is associated with failed back surgery syndrome after lumbar fusion surgery: a retrospective study Longlong Qiu, Haocheng Xu, Liming Yu, Xiaojie Chen, Junwei Qu, Xinlei Xia, Chaojun Zheng, Qiwang Chen Asian Spine Journal.2025; 19(6): 939. CrossRef
Simplified S1 Vertebral Bone Quality Score in the Assessment of Patients with Vertebral Fragility Fractures Song Wang, Yongrong Hu, Hao Liu, Kunhai Yang, Xiang Zhang, Bo Qu, Hongsheng Yang World Neurosurgery.2024; 185: e1004. CrossRef
Best Bisphosphonate Threshold for 10-Year Vertebral and Non-vertebral Fracture Mitigation Samer M Alboun, Eman Khreisat, Zaid E Alawneh, Khaled M Bani Hani, Rania F Khreisat, Mohammed A Al-Mughrabi, Bara’ah E Alshagoor, Rabaa I Alfarajat, Madher A Doumi, Mino Cycline Cureus.2024;[Epub] CrossRef
The association between body mass index and bone mineral density in older adults: a cross-sectional study of community population in Beijing Peng Cui, Wei Wang, Zheng Wang, Xinli Hu, Xu Liu, Chao Kong, Shibao Lu BMC Musculoskeletal Disorders.2024;[Epub] CrossRef
Exploring the impact of body mass index on the accuracy of vertebral bone quality in determining bone mineral density in patients undergoing lumbar fusion surgery Xuan Zhao, Qijun Wang, Peng Wang, Chao Kong, Shibao Lu Journal of Orthopaedic Surgery and Research.2024;[Epub] CrossRef
Comparative effectiveness of four techniques for identifying vertebral fragility fractures among elderly patients Hui-Ya Ma, Ren-Jie Zhang, Lu-Ping Zhou, Yan-Xin Wang, Jia-Qi Wang, Cai-Liang Shen, Xiu-Jun Zhang European Radiology.2024; 35(6): 3673. CrossRef
L-Point Entry, Juxtapedicular, and Endplate-Parallel Trajectory (L-JET) Screw Fixation: A Novel Technique in Thoracic Spinal Tumor Surgery Seunghoon Lee, Young Rak Kim, Chang-Hyun Lee, Jungbo Sim, Woojin Kim, Ho Sung Myeong, Hangeul Park, Jun-Hoe Kim, Chi Heon Kim Journal of Minimally Invasive Spine Surgery and Technique.2026; 11(1): 6. CrossRef
5G-Enabled remote Robotic-Assisted percutaneous pedicle screw fixation in single thoracolumbar fractures: initial clinical feasibility and safety evaluation Lu-Ping Zhou, Xian-Liang Zhang, Hua-Qing Zhang, Yu Chen, Chong-Yu Jia, Peng Ge, Yong Zhang, Ao Liu, Ren-Jie Zhang, Cai-Liang Shen European Spine Journal.2026; 35(2): 944. CrossRef
Objective Robot-assisted (RA) techniques have been widely investigated in thoracolumbar spine surgery. However, the application of RA methods on cervical spine surgery is rare due to the complex morphology of cervical vertebrae and catastrophic complications. Thus, the feasibility and safety of RA cervical screw placement remain controversial. This study aims to evaluate the feasibility and safety of RA screw placement on cervical spine surgery.
Methods A comprehensive search on PubMed, Cochrane Library, Embase Database, Web of Science, Chinese National Knowledge Databases, and Wanfang Database was performed to select potential eligible studies. Randomized controlled trials (RCTs), comparative cohort studies, and case series reporting the accuracy of cervical screw placement were included. The Cochrane risk of bias criteria and Newcastle-Ottawa Scale criteria were utilized to rate the risk of bias of the included literatures. The primary outcome was the rate of cervical screw placement accuracy with robotic guidance; subgroup analyses based on the screw type and insertion segments were also performed.
Results One RCT, 3 comparative cohort studies, and 3 case series consisting of 160 patients and 719 cervical screws were included in this meta-analysis. The combined outcomes indicated that the rates of optimal and clinically acceptable cervical screw placement accuracy under robotic guidance were 88.0% (95% confidence interval [CI], 84.1%–91.4%; p = 0.073; I2 = 47.941%) and 98.4% (95% CI, 96.8%–99.5%; p = 0.167; I2 = 35.954%). The subgroup analyses showed that the rate of optimal pedicle screw placement accuracy was 88.2% (95% CI, 83.1%–92.6%; p = 0.057; I2 = 53.305%); the rates of optimal screw placement accuracy on C1, C2, and subaxial segments were 96.2% (95% CI, 80.5%–100.0%; p = 0.167; I2 = 44.134X%), 89.7% (95% CI, 80.6%–96.6%; p = 0.370; I2 = 0.000X%), and 82.6% (95% CI, 70.9%–91.9%; p = 0.057; I2 = 65.127X%;), respectively.
Conclusion RA techniques were associated with high rates of optimal and clinically acceptable screw positions. RA cervical screw placement is accurate, safe, and feasible in cervical spine surgery with promising clinical potential.
Citations
Citations to this article as recorded by
5G-Enabled remote Robotic-Assisted percutaneous pedicle screw fixation in single thoracolumbar fractures: initial clinical feasibility and safety evaluation Lu-Ping Zhou, Xian-Liang Zhang, Hua-Qing Zhang, Yu Chen, Chong-Yu Jia, Peng Ge, Yong Zhang, Ao Liu, Ren-Jie Zhang, Cai-Liang Shen European Spine Journal.2026; 35(2): 944. CrossRef
Surgical management of ossified posterior longitudinal ligament: a review Freddie Y. Rodriguez Beato, Jose Castillo, Muhammad Sulman, Omar Ortuno, Khadija Soufi, Kee Kim British Journal of Neurosurgery.2026; : 1. CrossRef
Robotics in Cervical Spine Surgery: The Current Scenario S. Vidyadhara, Abhishek Soni, T. Balamurugan, H. S. Chhabra Indian Spine Journal.2026; 9(1): 12. CrossRef
Extended uses of robots in spine surgery beyond thoracolumbar pedicle screws: A narrative review Vidyadhara Srinivasa, Abhishek Soni, Balamurugan Thirugnanam, Prabhu Krishnan Journal of Robotic Surgery.2026;[Epub] CrossRef
Accuracy of Cervical Pedicle Screw Placement Using a Patient-Specific Template Guide System in Revision Cervical Spine Surgery: A CT-Based Morphometric and Accuracy Analysis Kesavan Ramachandran, Akira Fukushima, Hiroyuki Hasebe, Hirohito Takeuchi, Shigeki Oshima, Masanori Fujiya, Itaru Oda Cureus.2026;[Epub] CrossRef
Evaluation of the precision and accuracy of augmented reality for pedicle screw placement in the cervical spine Lisa M. Tamburini, Anthony Viola, Rohan R. Patel, Tomer Korabelnikov, Raghunandan Nayak, Justin S King, Scott Mallozzi, Isaac L. Moss, Hardeep Singh North American Spine Society Journal (NASSJ).2025; 23: 100618. CrossRef
Robotisch assistierte und navigierte Pedikelschraubenplatzierung an der subaxialen Halswirbelsäule Dominik M. Haida, Mike Holl, Oybek Khakimov, Stefan Huber-Wagner Die Unfallchirurgie.2025; 128(9): 722. CrossRef
Minimally Invasive Techniques in Posterior Atlanto-Axial Fixation: State of the Art and Systematic Review Gianpaolo Jannelli, Luca Paun, Cédric Y. Barrey, Paola Borrelli, Karl Schaller, Enrico Tessitore, Ivan Cabrilo Journal of Clinical Medicine.2025; 14(13): 4657. CrossRef
Robot-assisted technique versus freehand technique for spine surgery: an umbrella review Ting Li, Jingxin Yan, Jin Li, Yuanting Shang, Xiaoyu Tang Annals of Medicine.2025;[Epub] CrossRef
Robot-assisted percutaneous pedicle screw fixation in thoracolumbar burst fractures: a comparative study Peng Liu, Jiang Hu, Wei Zhang, Shu Lin, Yang Yu, Liuyi Tang, Fei Wang Scientific Reports.2025;[Epub] CrossRef
Robotic-Assisted Correction of Cervicothoracic Deformity in Neurofibromatosis Type 1: A Case Report and Review of Literature Balamurugan Thirugnanam, Abhishek Soni, Dinesh Iyer, Srinivasa Vidyadhara Journal of Orthopaedic Association of South Indian States.2025; 22(1): 57. CrossRef
Robot-assisted cervical pedicle screw placement using a novel hybrid dilator technique: A clinical series of 565 screws Abhishek Soni, S Vidyadhara, Madhava Pai Kanhangad, T Balamurugan Journal of Craniovertebral Junction and Spine.2025; 16(3): 301. CrossRef
Application of Tianji Orthopedic Robot-Assisted Screw Placement versus Traditional Free-Hand Screw Placement in Upper Cervical Fractures Tong Zhao, Xianhai Zeng, Feng Chen, Minghao Bi, Tao Jiang, Qianhou Zhou, Junlei Tan, Wenye Ma, Mingfu Li, Chengkua Huang, Guosheng Su Advances in Bioscience and Biotechnology.2025; 16(10): 422. CrossRef
Safety and Accuracy of Robot-Assisted Cervical Screw Placement: A Systematic Review and Meta-Analysis Jing Peng, Qiang Li, Xuejun Zhang, Jiaheng Li, Song Wan, Shuangqi Yu, Wei Chen, Dong Chen, Fan Ding World Neurosurgery.2024; 181: e163. CrossRef
Letter to the Editor Regarding “A Comparison of Percutaneous Pedicle Screw Accuracy Between Robotic Navigation and Novel Fluoroscopy-Based Instrument Tracking for Patients Undergoing Instrumented Thoracolumbar Surgery” Zhi-Gang Zhang, Lu-Ping Zhou, Liang Kang, Cai-Liang Shen World Neurosurgery.2024; 181: 191. CrossRef
Accuracy and clinical characteristics of robot-assisted cervical spine surgery: a systematic review and meta-analysis Jiayuan Wu, Mingxing Fan, Da He, Yi Wei, Fangfang Duan, Xieyuan Jiang, Wei Tian International Orthopaedics.2024; 48(7): 1903. CrossRef
Feasibility and safety report on robotic assistance for cervical pedicle screw fixation: a cadaveric study Seungjun Ryu, Byeong-Jin Ha, Sunjin Yoon, Chang Kyu Lee, Dong Ah Shin, Keung-Nyun Kim, Seong Yi Scientific Reports.2024;[Epub] CrossRef
Hybrid-3D robotic suite in spine and trauma surgery - experiences in 210 patients Dominik M. Haida, Peter Mohr, Sae-Yeon Won, Thorsten Möhlig, Mike Holl, Thorsten Enk, Marc Hanschen, Stefan Huber-Wagner Journal of Orthopaedic Surgery and Research.2024;[Epub] CrossRef
To Be Trustworthy, the Robot Assisted Cervical Spine Surgery Needs More Than Accuracy Beyond Technological Limitations: Commentary on “Robotics in Cervical Spine Surgery: Feasibility and Safety of Posterior Screw Placement” Seong Yi Neurospine.2023; 20(2): 725. CrossRef
Advancing the Adoption of Robot-Assisted Surgery as the Routine Minimally Invasive Approach in Spinal Procedures: Commentary on “Floor-Mounted Robotic Pedicle Screw Placement in Lumbar Spine Surgery: An Analysis of 1,050 Screws” Lu-Ping Zhou, Ren-Jie Zhang, Cai-Liang Shen Neurospine.2023; 20(3): 1088. CrossRef
Spine Surgical Robotics: Current Status and Recent Clinical Applications Jiangtao Wang, Junxian Miao, Yi Zhan, Yongchao Duan, Yuanshun Wang, Dingjun Hao, Biao Wang Neurospine.2023; 20(4): 1256. CrossRef
Objective Patients with basilar invagination (BI) had high incidences of vertebral variations and high-riding vertebral artery (HRVA) that might restrict the use of pedicle or pars screw and increase the use of translaminar screw on axis. Here, we conducted a radiographic study to investigate the feasibility of translaminar screws and the bone quality of C2 laminae in patients with BI, which were compared with those without BI as control to provide guidelines for safe placement.
Methods In this study, a total of 410 patients (205 consecutive patients with BI and 205 matched patients without BI) and 820 unilateral laminae of the axis were included at a 1:1 ratio. Comparisons with regard to insertion parameters (laminar length, thickness, angle, and height) for C2 translaminar screw placement and Hounsfield unit (HU) values for the assessment of the appropriate bone mineral density of C2 laminae between BI and control groups were performed. Besides, the subgroup analyses based on the Goel A and B classification of BI, HRVA, atlas occipitalization, and C2/3 assimilation were also carried out. Furthermore, the factors that might affect the insertion parameters and HU values were explored through multiple linear regression analyses.
Results The BI group showed a significantly smaller laminar length, thickness, height, and HU value than the control group, whereas no significant difference was observed regarding the laminar angle. By contrast, the control group showed significantly higher rates of acceptability for unilateral and bilateral translaminar screw fixations than the BI group. Subgroup analyses showed that the classification of Goel A and B, HRVA, atlas occipitalization, and C2/3 assimilation affected the insertion parameters except the HU values. Multiple linear regression indicated that the laminar length was significantly associated with the male gender (B = 0.190, p < 0.001), diagnoses of HRVA (B = -0.109, p < 0.001), Goel A (B = -0.167, p < 0.001), and C2/3 assimilation (B = -0.079, p = 0.029); the laminar thickness was significantly associated with the male gender (B = 0.353, p < 0.001), diagnoses of HRVA (B = -0.430, p < 0.001), Goel B (B = -0.249, p = 0.026), and distance from the top of odontoid to the Chamberlain line (B = -0.025, p = 0.003); laminar HU values were significantly associated with age (B = -2.517, p < 0.001), Goel A (B = -44.205, p < 0.001), Goel B (B = -25.704, p = 0.014), and laminar thickness (B = -11.706, p = 0.001).
Conclusion Patients with BI had narrower and smaller laminae with lower HU values and lower unilateral and bilateral acceptability for translaminar screws than patients without BI. Preoperative 3-dimensional computed tomography (CT) and CT angiography were needed for BI patients.
Citations
Citations to this article as recorded by
High-Riding Vertebral Artery in Cervical Spine Surgery: A Review of Preoperative Identification and Surgical Implications Alexander Kucherina, Paul G Mastrokostas, Themistocles S Protopsaltis, Charla R Fischer Cureus.2026;[Epub] CrossRef
Letter to the Editor regarding “Types of high-riding vertebral artery: a classification system for preoperative planning of C2 instrumentation based on 908 potential screw insertion sites” by Klepinowski et al. Yuwang Du, Hua Jiang The Spine Journal.2025; 25(5): 1069. CrossRef
MORPHOMETRIC PARAMETERS OF THE AXIS RELATED TO INTRALAMINAR FIXATION VITOR ARAúJO GONçALVES, MATHEUS PIPPA DEFINO, GABRIEL MATTOS GOES, THIAGO DE OLIVEIRA DORIGãO, HELTON LUIZ APARECIDO DEFINO Coluna/Columna.2025;[Epub] CrossRef
Development and Evaluation of an Automated Computational Approach for the Precise Placement of Pedicle Screws in Spinal Surgery Leveraging Three-Dimensional Point Cloud Registration Methods Guoli Song, Andi Li, Yuhan Ying, Yiwen Zhao, Xingang Zhao, Lei Zhang IEEE Transactions on Automation Science and Engineering.2025; 22: 19606. CrossRef
First
Prev
