Predicting cage subsidence after lumbar interbody fusion: a meta-analysis of opportunistic bone quality metrics.
Publication/Presentation Date
6-9-2026
Abstract
BACKGROUND CONTEXT: Cage subsidence (CS) is a frequent complication following lumbar interbody fusion and is closely linked to vertebral and endplate bone quality. Although CT- and MRI-derived bone metrics are increasingly used for preoperative risk stratification, their comparative discriminative performance for CS has not been systematically evaluated.
PURPOSE: To evaluate and compare the discriminative performance of CT- and MRI-derived bone quality metrics for CS following degenerative lumbar fusion.
STUDY DESIGN/SETTING: Systematic review and meta-analysis.
METHODS: PubMed, Embase, and CENTRAL were searched from inception to January 2026. Observational studies reporting preoperative imaging-based bone quality metrics in adult patients undergoing lumbar interbody fusion were included. Primary metrics included CT-based Hounsfield units, MRI-based vertebral bone quality (VBQ) and endplate bone quality (EBQ), and CT-derived bone mineral density (CT-BMD). Secondary outcomes included DEXA T-scores. Random-effects meta-analyses synthesized continuous inter-group differences and diagnostic accuracy parameters, summarized using pooled sensitivity, specificity, likelihood ratios, diagnostic odds ratios, and SROC curves. Risk of bias was assessed using QUADAS-2.
RESULTS: Thirty-six studies encompassing 5482 patients were included, of whom 1679 (30.6%) developed CS. Across all metrics, patients with subsidence demonstrated poorer preoperative bone quality, including lower Hounsfield units (MD -26.9; p< .01), lower CT-BMD (MD: -33.0; p< .01), and lower DEXA T-scores (MD: -0.77; p< .01), alongside higher VBQ (MD: 0.60; p< .01) and EBQ scores (MD: 0.68; p< .01). Diagnostic accuracy was moderate-to-good, with pooled AUCs ranging from 0.77 to 0.85. Differences in discriminative performance between metrics were modest and nonsignificant on meta-regression, with nomogram analyses demonstrating risk-shifting rather than definitive rule-in or rule-out performance.
CONCLUSIONS: Imaging-derived bone quality metrics demonstrate consistent associations and moderate-to-good discrimination for CS after degenerative lumbar fusion, reflecting shared vulnerability at the cage-endplate interface and supporting their use as pragmatic tools for preoperative risk stratification and surgical planning.
ISSN
1878-1632
Published In/Presented At
Patel, S., Nischal, S. A., Nallankuka, G. S., Kale, K. M., Sarikonda, A., Saad, H., Hines, K. J., Jallo, J., Harrop, J. S., & Prasad, S. K. (2026). Predicting cage subsidence after lumbar interbody fusion: a meta-analysis of opportunistic bone quality metrics. The spine journal : official journal of the North American Spine Society, S1529-9430(26)00173-7. Advance online publication. https://doi.org/10.1016/j.spinee.2026.06.004
Disciplines
Medicine and Health Sciences
PubMedID
42263858
Department(s)
Department of Surgery
Document Type
Article