Hounsfield units-based grading of osteoporosis (HUGO) and its association with risk of osteoporotic vertebral compression fractures

Abstract

Background: There is a lack of a rapid and convenient quantitative method for assessing the severity of osteoporosis. Thus this study explored the association between Hounsfield unit (HU)-based grading of osteoporosis and the risk of suffering from different levels of osteoporotic vertebral compression fractures (OVCF).

Materials and methods: A total of 1463 patients aged ≥ 60 years undergoing percutaneous kyphoplasty for OVCF in 4 spine centers were reviewed. We recorded general information including age, gender, height, weight, and the vertebral level of acute and chronic OVCF. The HU value of L1 (L1-HU) was measured with preoperative computed tomography scans. The number of fractured vertebral levels was classified into 3 categories: single level, two level, and multilevel (≥ 3). The general risk factors of multilevel OVCF were analyzed.

Results: A total of 2358 levels of OVCF were recorded, including 1867 acute OVCF and 491 chronic OVCF. T12 and L1 were the 2 most common fractured vertebral levels. The average L1-HU value was 71.7 ± 31.8 HU. It was significantly different among 3 groups (p < 0.05): 78.8 ± 30.4 HU (95% confidence interval [CI]: 76.9–80.8) for single-level group, 65.0 ± 31.2 HU (95% CI: 61.6–68.5) for two-level group, and 49.6 ± 25.7 (95% CI: 46.0–53.1) for multilevel group. The L1-HU of each group showed no significant difference among the 4 spine centers (p > 0.05). The numbers of multiples of ten within the 95% CI of average L1-HU values were chosen as cutoffs: cutoff of 80 HU representing the risk of at least single-level OVCF, and the cutoff of 50 HU representing the risk of multilevel OVCF. L1-HU < 50 HU was the independent risk factor of multilevel OVCF, its odds ratio was 4.4 (95% CI: 3.2–6.0, p < 0.001).

Conclusions: The HUGO method can be used to classify the severity of osteoporosis. Especially patients with LI-HU of < 50 have extremely severe osteoporosis with risk of multilevel OVCF.

Keywords

Hounsfield units / osteoporosis / osteoporotic vertebral compression fracture

References

[1] Deshpande N, Hadi MS, Lillard JC, et al. Alternatives to DEXA for the assessment of bone density: a systematic review of the literature and future recommendations. J Neurosurg Spine. 2023;38:436–45.

[2] Anderson PA, Polly DW, Binkley NC, Pickhardt PJ. Clinical use of opportunistic computed tomography screening for osteoporosis. J Bone Joint Surg Am. 2018;100:2073–81.

[3] Zaidi Q, Danisa OA, Cheng W. Measurement techniques and utility of hounsfield unit values for assessment of bone quality prior to spinal instrumentation: a review of current literature. Spine. 2019;44:E239–44.

[4] Jang S, Graffy PM, Ziemlewicz TJ, Lee SJ, Summers RM, Pickhardt PJ. Opportunistic osteoporosis screening at routine abdominal and thoracic CT: normative L1 trabecular attenuation values in more than 20 000 adults. Radiology. 2019;291:360–7.

[5] Pickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ, Binkley N. Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med. 2013;158:588–95.

[6] Zou D, Li W, Deng C, Du G, Xu N. The use of CT hounsfield unit values to identify the undiagnosed spinal osteoporosis in patients with lumbar degenerative diseases. Eur Spine J. 2019;28:1758–66.

[7] Zou D, Jiang S, Zhou S, et al. Prevalence of osteoporosis in patients undergoing lumbar fusion for lumbar degenerative diseases: a combination of DXA and hounsfield units. Spine. 2020;45:E406–10.

[8] Mo GY, Guo HZ, Guo DQ, et al. Augmented pedicle trajectory applied on the osteoporotic spine with lumbar degenerative disease: mid-term outcome. J Orthop Surg Res. 2019;14:170.

[9] Formby PM, Kang DG, Helgeson MD, Wagner SC. Clinical and radiographic outcomes of transforaminal lumbar interbody fusion in patients with osteoporosis. Global Spine J. 2016;6:660–4.

[10] Lee BG, Choi JH, Kim DY, Choi WR, Lee SG, Kang CN. Risk factors for newly developed osteoporotic vertebral compression fractures following treatment for osteoporotic vertebral compression fractures. Spine J. 2019;19:301–5.

[11] Ji C, Rong Y, Wang J, et al. Risk factors for refracture following primary osteoporotic vertebral compression fractures. Pain Physician. 2021;24:E335–40.

[12] Akesson K, Marsh D, Mitchell PJ, et al; IOF Fracture Working Group. Capture the fracture: a best practice framework and global campaign to break the fragility fracture cycle. Osteoporos Int. 2013;24:2135–52.

[13] Mao YF, Zhang Y, Li K, et al. Discrimination of vertebral fragility fracture with lumbar spine bone mineral density measured by quantitative computed tomography. J Orthop Translat. 2019;16:33–9.

[14] Shen Y, Shen H, Zhang W. Comparison of single versus and multi-level vertebral compression fractures in elders. Zhonghua Yi Xue Za Zhi. 2015;95:1158–61.

[15] Zou D, Ye K, Tian Y, et al. Characteristics of vertebral CT Hounsfield units in elderly patients with acute vertebral fragility fractures. Eur Spine J. 2020;29:1092–7.

[16] Zou D, Muheremu A, Sun Z, Zhong W, Jiang S, Li W. Computed tomography Hounsfield unit-based prediction of pedicle screw loosening after surgery for degenerative lumbar spine disease. J Neurosurg Spine. 2020;32:716–21.

[17] Emohare O, Cagan A, Morgan R, et al. The use of computed tomography attenuation to evaluate osteoporosis following acute fractures of the thoracic and lumbar vertebra. Geriatr Orthop Surg Rehabil. 2014;5:50–5.

[18] Mi J, Li K, Zhao X, Zhao CQ, Li H, Zhao J. Vertebral body compressive strength evaluated by dual-energy X-ray absorptiometry and hounsfield units in vitro. J Clin Densitom. 2018;21:148–53.

[19] Johannesdottir F, Allaire B, Bouxsein ML. Fracture prediction by computed tomography and finite element analysis: current and future perspectives. Curr Osteoporos Rep. 2018;16:411–22.

[20] Lee SJ, Graffy PM, Zea RD, Ziemlewicz TJ, Pickhardt PJ. Future osteoporotic fracture risk related to lumbar vertebral trabecular attenuation measured at routine body CT. J Bone Miner Res. 2018;33:860–7.

[21] Fang J, Franconeri A, Boos J, et al. Opportunistic bone density measurement on abdomen and pelvis computed tomography to predict fracture risk in women aged 50 to 64 years without osteoporosis risk factors. J Comput Assist Tomogr. 2018;42:798–806.

[22] Ye K, Zou D, Zhou F, Li W, Tian Y. Low vertebral CT hounsfield units: a risk factor for new osteoporotic vertebral fractures after the treatment of percutaneous kyphoplasty. Arch Osteoporos. 2022;17:137.

[23] Wang F, Sun R, Zhang SD, Wu XT. Comparison of acute single versus multiple osteoporotic vertebral compression fractures in radiographic characteristic and bone fragility. J Orthop Surg Res. 2023;18:387.

RIGHTS & PERMISSIONS

2025 the Author(s). published by Wolters Kluwer Health, Inc. on behalf of Higher Education Press.