Comparing the Prognostic Utility of Vertebral and Endplate Bone Quality Scores for Cage Subsidence Following Single-Level Anterior Cervical Discectomy and Fusion: A Retrospective Analysis

Omar Lubbad; Wajeeh Ullah Mahmood; Rafiq Sheikhali; Mohammad Abir Mamun; Akram Hagos; Laila Lubbad; Suzanne Murphy; Giuseppe Lambros Morassi; Nektarios K. Mazarakis

doi:10.1111/os.70260

Orthopaedic Surgery ›› 2026, Vol. 18 ›› Issue (3) :489 -499. DOI: 10.1111/os.70260

CLINICAL ARTICLE

Comparing the Prognostic Utility of Vertebral and Endplate Bone Quality Scores for Cage Subsidence Following Single-Level Anterior Cervical Discectomy and Fusion: A Retrospective Analysis

Author information +

History +

PDF (1691KB)

Abstract

Objective: Cage subsidence following anterior cervical discectomy and fusion (ACDF) is linked with poor bone quality. MRI-derived bone quality scores have been shown to provide valuable insights into postoperative complication risk; however, the optimal MRI-based metric for predicting cage subsidence remains unclear. This study aims to compare the predictive value of different MRI-derived bone quality measures for cage subsidence following ACDF.

Methods: Patients undergoing single-level ACDF between October 2012 and September 2022 at our institution with at least 6 months of radiographic follow-up were retrospectively evaluated. T1 preoperative MRI scans were used to measure mean, median, and segmental vertebral bone quality (VBQ) scores, and upper, lower, and average endplate bone quality (EBQ) scores. Postoperative and follow-up X-rays were used to identify cage subsidence.

Results: Fifty-six patients met the inclusion criteria; 26 developed cage subsidence and 30 did not. Age, sex, surgical indication, cage type, and clinical setting were similar between groups. Mean disc space loss was significantly greater in the subsidence group (3.99 mm vs. 0.37 mm; p < 0.001). All bone quality scores were significantly higher in the subsidence group across all metrics. Mean VBQ (OR = 14.22), segmental VBQ (OR = 8.23), and lower EBQ (OR = 5.54) were strong predictors of subsidence (p < 0.001). ROC analysis showed excellent discrimination for mean VBQ (AUC = 0.821), segmental VBQ (AUC = 0.817), and median VBQ (AUC = 0.817). Interobserver reliability was high for all bone quality metrics (ICC 0.836–0.925).

Conclusion: MRI-derived bone quality metrics, particularly VBQ and lower endplate EBQ scores, are strong predictors of cage subsidence following single-level ACDF. These findings reinforce the clinical utility of preoperative MRI as a non-invasive, radiation-free tool for assessing vertebral bone integrity. Incorporating VBQ and EBQ assessments into surgical planning may enhance risk stratification and optimize postoperative outcomes in patients undergoing cervical fusion.

Keywords

anterior cervical discectomy and fusion / bone quality / cage subsidence / magnetic resonance imaging

Cite this article

Download citation ▾

Omar Lubbad, Wajeeh Ullah Mahmood, Rafiq Sheikhali, Mohammad Abir Mamun, Akram Hagos, Laila Lubbad, Suzanne Murphy, Giuseppe Lambros Morassi, Nektarios K. Mazarakis. Comparing the Prognostic Utility of Vertebral and Endplate Bone Quality Scores for Cage Subsidence Following Single-Level Anterior Cervical Discectomy and Fusion: A Retrospective Analysis. Orthopaedic Surgery, 2026, 18 (3) : 489-499 DOI:10.1111/os.70260

登录浏览全文

4963

注册一个新账户忘记密码

References

Publishing order | Descend order by publishing year | Descend order by cited within

[1]	Y. H. Su, P. K. Wu, M. H. Wu, et al., “Subsidence of Spinal Fusion Cages: A Systematic Review,” International Journal of Spine Surgery 16, no. 6 (2022): 1103–1118, https://doi.org/10.14444/8311.

[2]	P. Barsa and P. Suchomel, “Factors Affecting Sagittal Malalignment due to Cage Subsidence in Standalone Cage Assisted Anterior Cervical Fusion,” European Spine Journal 16, no. 9 (2007): 1395–1400, https://doi.org/10.1007/s00586-006-0284-8.

[3]	J. W. Kwon, J. B. Park, J. H. Lee, et al., “Radiographic Measurements of Cervical Alignment, Fusion and Subsidence After ACDF Surgery and Their Impact on Clinical Outcome,” Journal of Clinical Neuroscience 70 (2019): 186–193, https://doi.org/10.1016/j.jocn.2019.09.008.

[4]	Y. Zhou, J. Wang, J. Li, et al., “Factors Influencing Cage Subsidence in Anterior Cervical Corpectomy and Discectomy: A Systematic Review,” European Spine Journal 32, no. 1 (2023): 1–12.

[5]

H. Wu, Z. Shan, F. Zhao, et al., “Poor Bone Quality, Multilevel Surgery, and Narrow and Tall Cages Are Associated With Intraoperative Endplate Injuries and Late-Onset Cage Subsidence in Lateral Lumbar Interbody Fusion: A Systematic Review,” Clinical Orthopaedics and Related Research 480, no. 1 (2022): 163–188, https://doi.org/10.1097/CORR.0000000000001915.

[6]

C. S. Bailey, J. C. Urquhart, M. F. Dvorak, et al., “The Extent of Diagnosis and Treatment of Osteoporosis in a Veterans Affairs Population Undergoing Vertebral Augmentation,” PM & R : The Journal of Injury, Function, and Rehabilitation 2, no. 11 (2010): 1007–1013, https://doi.org/10.1016/j.pmrj.2010.05.012.

[7]	Z. Chen, F. Lei, F. Ye, et al., “A Meta-Analysis of the Value of MRI-Based VBQ Scores for Evaluating Osteoporosis,” Journal of Orthopaedic Translation 38 (2023): 1–10, https://doi.org/10.1016/j.jot.2023.03.002.

[8]	S. N. Salzmann, I. Okano, J. Shue, et al., “Preoperative MRI-Based Vertebral Bone Quality (VBQ) Score Assessment in Patients Undergoing Lumbar Spinal Fusion,” Spine Journal 22, no. 5 (2022): 785–794, https://doi.org/10.1016/j.spinee.2022.01.017.

[9]	L. Ran, T. Xie, L. Zhao, et al., “MRI-Based Endplate Bone Quality Score Predicts Cage Subsidence Following Oblique Lumbar Interbody Fusion,” Spine Journal 24, no. 4 (2024): 567–575, https://doi.org/10.1016/j.spinee.2024.02.012.

[10]	Z. Wang, Y. Huang, Q. Chen, L. Liu, Y. Song, and G. Feng, “Cervical Vertebral Bone Quality Score Independently Predicts Zero-Profile Cage Subsidence After Single-Level Anterior Cervical Discectomy and Fusion,” World Neurosurgery 182 (2024): e377–e385, https://doi.org/10.1016/j.wneu.2023.11.111.

[11]	H. Zhao, Y. Xie, X. Yu, et al., “Anterior Cervical Discectomy and Fusion With a Zero-Profile VA Spacer Device: A Clinical and Radiological Study With Two-Year Follow-Up,” Journal of Orthopaedic Surgery and Research 19, no. 1 (2024): 18, https://doi.org/10.1186/s13018-024-04539-9.

[12]	J. Li, L. Wang, Q. Li, Z. Deng, L. Wang, and Y. Song, “A Novel MRI-Based Cervical-Endplate Bone Quality Score Independently Predicts Cage Subsidence After Anterior Cervical Discectomy and Fusion,” European Spine Journal 33, no. 6 (2024): 2277–2286, https://doi.org/10.1007/s00586-024-08250-5.

[13]	B. Kwon, D. H. Kim, S. H. Lee, et al., “Incidence and Clinical Relevance of Cage Subsidence in Anterior Cervical Discectomy and Fusion: A Systematic Review,” Journal of Korean Neurosurgical Society 61, no. 2 (2018): 1–10, https://doi.org/10.3340/jkns.2017.0404.

[14]	Y. Zhou, J. Wang, J. Li, et al., “A Biomechanical Investigation of Lumbar Interbody Fusion Techniques,” Journal of Orthopaedic Translation 30 (2021): 1–10, https://doi.org/10.1016/j.jot.2021.01.003.

[15]

X. Li, Y. Zhang, Y. Wang, et al., “Comparison of Predictive Value for Cage Subsidence Between MRI-Based Endplate Bone Quality and Vertebral Bone Quality Scores Following Transforaminal Lumbar Interbody Fusion: A Retrospective Propensity-Matched Study,” Spine Journal 24, no. 2 (2024): 123–131, https://doi.org/10.1016/j.spinee.2023.11.005.

[16]	Y. Zhang, X. Li, Y. Wang, et al., “MRI-Based Endplate Bone Quality Scores Outperform Vertebral Bone Quality Scores in Predicting Adjacent Segment Disease Following Transforaminal Lumbar Interbody Fusion,” Spine Journal 25, no. 4 (2025): 456–464, https://doi.org/10.1016/j.spinee.2025.01.010.

[17]	J. Liu, Y. Chen, H. Wang, et al., “Comparative Analysis of MRI-Based VBQ and EBQ Score for Predicting Cage Subsidence in PILF Surgery,” Journal of Orthopaedic Surgery and Research 20, no. 1 (2025): 1–9, https://doi.org/10.1186/s13018-024-05332-4.

[18]

Z. Daher, L. L. Jouppi, B. G. Anderson, et al., “The Association of Bone Mineral Density With Distal Junctional Kyphosis and Distal Junctional Failure After Multilevel Spine Fusions: A Systematic Review and Meta-Analysis,” World Neurosurgery 195 (2024): 123598, https://doi.org/10.1016/j.wneu.2024.123598.

[19]	C. C. Kuo, M. A. R. Soliman, A. O. Aguirre, et al., “Vertebral Bone Quality Score Independently Predicts Proximal Junctional Kyphosis and/or Failure After Adult Spinal Deformity Surgery,” Neurosurgery 92, no. 2 (2023): 307–315, https://doi.org/10.1227/neu.0000000000002291.

[20]	O. Ramos, J. Razzouk, E. Beauchamp, et al., “Adding Vertebral Bone Quality to the Fusion Risk Score: Does It Improve Predictions of Postoperative Complications?,” Spine (Phila Pa 1976) 49, no. 13 (2024): 916–922, https://doi.org/10.1097/BRS.0000000000004974.

[21]	J. Ehresman, A. K. Ahmed, D. Lubelski, et al., “Vertebral Bone Quality Score and Postoperative Lumbar Lordosis Associated With Need for Reoperation After Lumbar Fusion,” World Neurosurgery 140 (2020): e268–e275, https://doi.org/10.1016/j.wneu.2020.05.020.

[22]

W. J. Wu, L. S. Jiang, Y. Liang, and L. Y. Dai, “Cage Subsidence Does Not, but Cervical Lordosis Improvement Does Affect the Long-Term Results of Anterior Cervical Fusion With Stand-Alone Cage for Degenerative Cervical Disc Disease: A Retrospective Study,” European Spine Journal 21, no. 7 (2012): 1374–1382, https://doi.org/10.1007/s00586-011-2131-9.

[23]	A. H. Duey, C. Gonzalez, E. A. Geng, et al., “The Effect of Subsidence on Segmental and Global Lordosis at Long-Term Follow-Up After Anterior Cervical Discectomy and Fusion,” Spine (Phila Pa 1976) 49, no. 13 (2024): 923–930, https://doi.org/10.1097/BRS.0000000000004975.

[24]	U. K. Dhar, E. L. Menzer, M. Lin, et al., “Factors Influencing Cage Subsidence in Anterior Cervical Corpectomy and Discectomy: A Systematic Review,” European Spine Journal 32, no. 3 (2023): 957–968, https://doi.org/10.1007/s00586-023-07530-w.