Advances in MRI-based bone quality scoring systems and their clinical applications_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Jianzhi ,  WANG Lei , SONG Yueming

Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;

Corresponding author：

WANG Lei, Email: wanglei_cd@126.com

Keywords：

MRI; bone quality scoring; osteoporosis; bone density

DOI：

10.7507/1002-1892.202410072

Video：

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Objective To summarize the advances in MRI-based bone quality scoring systems and their clinical applications. Methods A comprehensive literature review was conducted on recent studies related to the MRI-based bone quality scoring system, focusing on measurement methods, influencing factors, and clinical significance. Results Osteoporosis has a high incidence in China, significantly impacting patients’ quality of life and the postoperative outcomes of related orthopedic surgeries. Early identification of osteoporosis holds important clinical significance. In recent years, both domestic and international research has enriched the MRI-based bone quality scoring systems, which includes vertebral bone quality scoring, endplate bone quality scoring, and pedicle bone quality scoring. Compared to the “gold standard” of bone density measurement, dual-energy X-ray absorptiometry, the bone quality scoring systems demonstrate good efficacy in identifying abnormal bone mass and predicting postoperative complications, while being less influenced by degenerative changes in the lumbar spine, indicating its important clinical application value.Conclusion The MRI-based bone quality scoring systems have good value in clinical applications. However, current studies are mostly retrospective cohort and case-control studies, which carry a risk of bias. The clinical application value needs further clarification through meta-analysis and large-scale prospective studies.

1.	Seeman E, Delmas PD. Bone quality—the material and structural basis of bone strength and fragility. N Engl J Med, 2006, 354(21): 2250-2261.
2.	Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ, 1996, 312(7041): 1254-1259.
3.	Curry SJ, Krist AH, Owens DK, et al. Screening for osteoporosis to prevent fractures: US preventive services task force recommendation statement. JAMA, 2018, 319(24): 2521-2531.
4.	Masud T, Langley S, Wiltshire P, et al. Effect of spinal osteophytosis on bone mineral density measurements in vertebral osteoporosis. BMJ, 1993, 307(6897): 172-173.
5.	Brownbill RA, Ilich JZ. Measuring body composition in overweight individuals by dual energy x-ray absorptiometry. BMC Med Imaging, 2005, 5(1): 1. doi: 10.1186/1471-2342-5-1.
6.	Ramos O, Razzouk J, Chung JH, et al. Opportunistic assessment of bone density in patients with adolescent idiopathic scoliosis using MRI-based vertebral bone quality. J Clin Neurosci, 2022, 103: 41-43.
7.	Ehresman J, Pennington Z, Schilling A, et al. Novel MRI-based score for assessment of bone density in operative spine patients. Spine J, 2020, 20(4): 556-562.
8.	Courtois EC, Davidson IU, Ohnmeiss DD, et al. Evaluating alternatives to dual-energy X-ray absorptiometry for assessing bone quality in patients undergoing spine surgery. J Neurosurg Spine, 2023, 40(1): 84-91.
9.	Aynaszyan S, Devia LG, Udoeyo IF, et al. Patient physiology influences the MRI-based vertebral bone quality score. Spine J, 2022, 22(11): 1866-1874.
10.	Li R, Yin Y, Ji W, et al. MRI-based vertebral bone quality score effectively reflects bone quality in patients with osteoporotic vertebral compressive fractures. Eur Spine J, 2022, 31(5): 1131-1137.
11.	Lin W, He C, Xie F, et al. Assessment of bone density using the 1.5 T or 3.0 T MRI-based vertebral bone quality score in older patients undergoing spine surgery: does field strength matter? Spine J, 2023, 23(8): 1172-1181.
12.	Pu M, Zhong W, Heng H, et al. Vertebral bone quality score provides preoperative bone density assessment for patients undergoing lumbar spine surgery: a retrospective study. J Neurosurg Spine, 2023. doi: 10.3171/2023.1.SPINE221187.
13.	Mierke A, Ramos O, Macneille R, et al. Intra- and inter-observer reliability of the novel vertebral bone quality score. Eur Spine J, 2022, 31(4): 843-850.
14.	Hu F, Li X, Zhao D, et al. The diagnostic value of MRI-based vertebral bone quality score for osteoporosis or osteopenia in patients undergoing lumbar surgery: a meta-analysis. Osteoporos Int, 2024, 35(11): 1881-1895.
15.	Oezel L, Okano I, Jones C, et al. MRI-based vertebral bone quality score compared to quantitative computed tomography bone mineral density in patients undergoing cervical spinal surgery. Eur Spine J, 2023, 32(5): 1636-1643.
16.	Kuo CC, Soliman MAR, Aguirre AO, et al. Strong correlation between the vertebral bone quality score and the cervical-vertebral bone quality score in spine surgery patients. World Neurosurg, 2023. doi: 10.1016/j.wneu.2023.02.112.
17.	Yu F, Xia W. The epidemiology of osteoporosis, associated fragility fractures, and management gap in China. Arch Osteoporos, 2019, 14(1): 32. doi: 10.1007/s11657-018-0549-y.
18.	Ehresman J, Schilling A, Pennington Z, et al. A novel MRI-based score assessing trabecular bone quality to predict vertebral compression fractures in patients with spinal metastasis. J Neurosurg Spine, 2019, 32(4): 499-506.
19.	Li W, Zhu H, Liu J, et al. Characteristics of MRI-based vertebral bone quality scores in elderly patients with vertebral fragility fractures. Eur Spine J, 2023, 32(7): 2588-2593.
20.	Li W, Zhu H, Hua Z, et al. Vertebral bone quality score as a predictor of pedicle screw loosening following surgery for degenerative lumbar disease. Spine (Phila Pa 1976), 2023, 48(23): 1635-1641.
21.	Hu YH, Yeh YC, Niu CC, et al. Novel MRI-based vertebral bone quality score as a predictor of cage subsidence following transforaminal lumbar interbody fusion. J Neurosurg Spine, 2022, 37(5): 654-662.
22.	Huang Y, Chen Q, Liu L, et al. Vertebral bone quality score to predict cage subsidence following oblique lumbar interbody fusion. J Orthop Surg Res, 2023, 18(1): 258. doi: 10.1186/s13018-023-03729-1.
23.	Soliman MAR, Aguirre AO, Kuo CC, et al. Vertebral bone quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion. Spine J, 2022, 22(12): 2017-2023.
24.	Kuo CC, Soliman MAR, Aguirre AO, et al. Vertebral bone quality score independently predicts proximal junctional kyphosis and/or failure after adult spinal deformity surgery. Neurosurgery, 2023, 92(5): 945-954.
25.	Jones C, Okano I, Arzani A, et al. The predictive value of a novel site-specific MRI-based bone quality assessment, endplate bone quality (EBQ), for severe cage subsidence among patients undergoing standalone lateral lumbar interbody fusion. Spine J, 2022, 22(11): 1875-1883.
26.	Chen Q, Ai Y, Huang Y, et al. MRI-based endplate bone quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion. Spine J, 2023, 23(11): 1652-1658.
27.	Li J, Wang L, Li Q, et al. A novel MRI-based cervical-endplate bone quality score independently predicts cage subsidence after anterior cervical discectomy and fusion. Eur Spine J, 2024, 33(6): 2277-2286.
28.	Ran L, Xie T, Zhao L, et al. MRI-based endplate bone quality score predicts cage subsidence following oblique lumbar interbody fusion. Spine J, 2024, 24(10): 1922-1928.
29.	Li C, Gao W, Yao X, et al. The magnetic resonance imaging-based vertebral bone quality scoring system: A novel method to evaluate endplate changes in patients with primary single-level disk herniation and Modic changes. Jt Dis Relat Surg, 2024, 35(2): 257-266.
30.	Li Q, Hu B, Yang H, et al. MRI-based pedicle bone quality score: correlation to quantitative computed tomography bone mineral density and its role in quantitative assessment of osteoporosis. Spine J, 2024, 24(10): 1825-1832.
31.	Huang W, Gong Z, Wang H, et al. Use of MRI-based vertebral bone quality score (VBQ) of S₁ body in bone mineral density assessment for patients with lumbar degenerative diseases. Eur Spine J, 2023, 32(5): 1553-1560.
32.	Du SY, Dai J, Zhou ZT, et al. Size selection and placement of pedicle screws using robot-assisted versus fluoroscopy-guided techniques for thoracolumbar fractures: possible implications for the screw loosening rate. BMC Surg, 2022, 22(1): 365. doi: 10.1186/s12893-022-01814-6.
33.	Mikula AL, Lakomkin N, Pennington Z, et al. Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine. J Neurosurg Spine, 2022, 37(5): 694-702.
34.	Xu F, Zou D, Li W, et al. Hounsfield units of the vertebral body and pedicle as predictors of pedicle screw loosening after degenerative lumbar spine surgery. Neurosurg Focus, 2020, 49(2): E10. doi: 10.3171/2020.5.FOCUS20249.
35.	Weinstein JN, Rydevik BL, Rauschning W. Anatomic and technical considerations of pedicle screw fixation. Clin Orthop Relat Res, 1992(284): 34-46.
36.	Defino HL, Vendrame JR. Role of cortical and cancellous bone of the vertebral pedicle in implant fixation. Eur Spine J, 2001, 10(4): 325-333.

1. Seeman E, Delmas PD. Bone quality—the material and structural basis of bone strength and fragility. N Engl J Med, 2006, 354(21): 2250-2261.
2. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ, 1996, 312(7041): 1254-1259.
3. Curry SJ, Krist AH, Owens DK, et al. Screening for osteoporosis to prevent fractures: US preventive services task force recommendation statement. JAMA, 2018, 319(24): 2521-2531.
4. Masud T, Langley S, Wiltshire P, et al. Effect of spinal osteophytosis on bone mineral density measurements in vertebral osteoporosis. BMJ, 1993, 307(6897): 172-173.
5. Brownbill RA, Ilich JZ. Measuring body composition in overweight individuals by dual energy x-ray absorptiometry. BMC Med Imaging, 2005, 5(1): 1. doi: 10.1186/1471-2342-5-1.
6. Ramos O, Razzouk J, Chung JH, et al. Opportunistic assessment of bone density in patients with adolescent idiopathic scoliosis using MRI-based vertebral bone quality. J Clin Neurosci, 2022, 103: 41-43.
7. Ehresman J, Pennington Z, Schilling A, et al. Novel MRI-based score for assessment of bone density in operative spine patients. Spine J, 2020, 20(4): 556-562.
8. Courtois EC, Davidson IU, Ohnmeiss DD, et al. Evaluating alternatives to dual-energy X-ray absorptiometry for assessing bone quality in patients undergoing spine surgery. J Neurosurg Spine, 2023, 40(1): 84-91.
9. Aynaszyan S, Devia LG, Udoeyo IF, et al. Patient physiology influences the MRI-based vertebral bone quality score. Spine J, 2022, 22(11): 1866-1874.
10. Li R, Yin Y, Ji W, et al. MRI-based vertebral bone quality score effectively reflects bone quality in patients with osteoporotic vertebral compressive fractures. Eur Spine J, 2022, 31(5): 1131-1137.
11. Lin W, He C, Xie F, et al. Assessment of bone density using the 1.5 T or 3.0 T MRI-based vertebral bone quality score in older patients undergoing spine surgery: does field strength matter? Spine J, 2023, 23(8): 1172-1181.
12. Pu M, Zhong W, Heng H, et al. Vertebral bone quality score provides preoperative bone density assessment for patients undergoing lumbar spine surgery: a retrospective study. J Neurosurg Spine, 2023. doi: 10.3171/2023.1.SPINE221187.
13. Mierke A, Ramos O, Macneille R, et al. Intra- and inter-observer reliability of the novel vertebral bone quality score. Eur Spine J, 2022, 31(4): 843-850.
14. Hu F, Li X, Zhao D, et al. The diagnostic value of MRI-based vertebral bone quality score for osteoporosis or osteopenia in patients undergoing lumbar surgery: a meta-analysis. Osteoporos Int, 2024, 35(11): 1881-1895.
15. Oezel L, Okano I, Jones C, et al. MRI-based vertebral bone quality score compared to quantitative computed tomography bone mineral density in patients undergoing cervical spinal surgery. Eur Spine J, 2023, 32(5): 1636-1643.
16. Kuo CC, Soliman MAR, Aguirre AO, et al. Strong correlation between the vertebral bone quality score and the cervical-vertebral bone quality score in spine surgery patients. World Neurosurg, 2023. doi: 10.1016/j.wneu.2023.02.112.
17. Yu F, Xia W. The epidemiology of osteoporosis, associated fragility fractures, and management gap in China. Arch Osteoporos, 2019, 14(1): 32. doi: 10.1007/s11657-018-0549-y.
18. Ehresman J, Schilling A, Pennington Z, et al. A novel MRI-based score assessing trabecular bone quality to predict vertebral compression fractures in patients with spinal metastasis. J Neurosurg Spine, 2019, 32(4): 499-506.
19. Li W, Zhu H, Liu J, et al. Characteristics of MRI-based vertebral bone quality scores in elderly patients with vertebral fragility fractures. Eur Spine J, 2023, 32(7): 2588-2593.
20. Li W, Zhu H, Hua Z, et al. Vertebral bone quality score as a predictor of pedicle screw loosening following surgery for degenerative lumbar disease. Spine (Phila Pa 1976), 2023, 48(23): 1635-1641.
21. Hu YH, Yeh YC, Niu CC, et al. Novel MRI-based vertebral bone quality score as a predictor of cage subsidence following transforaminal lumbar interbody fusion. J Neurosurg Spine, 2022, 37(5): 654-662.
22. Huang Y, Chen Q, Liu L, et al. Vertebral bone quality score to predict cage subsidence following oblique lumbar interbody fusion. J Orthop Surg Res, 2023, 18(1): 258. doi: 10.1186/s13018-023-03729-1.
23. Soliman MAR, Aguirre AO, Kuo CC, et al. Vertebral bone quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion. Spine J, 2022, 22(12): 2017-2023.
24. Kuo CC, Soliman MAR, Aguirre AO, et al. Vertebral bone quality score independently predicts proximal junctional kyphosis and/or failure after adult spinal deformity surgery. Neurosurgery, 2023, 92(5): 945-954.
25. Jones C, Okano I, Arzani A, et al. The predictive value of a novel site-specific MRI-based bone quality assessment, endplate bone quality (EBQ), for severe cage subsidence among patients undergoing standalone lateral lumbar interbody fusion. Spine J, 2022, 22(11): 1875-1883.
26. Chen Q, Ai Y, Huang Y, et al. MRI-based endplate bone quality score independently predicts cage subsidence following transforaminal lumbar interbody fusion. Spine J, 2023, 23(11): 1652-1658.
27. Li J, Wang L, Li Q, et al. A novel MRI-based cervical-endplate bone quality score independently predicts cage subsidence after anterior cervical discectomy and fusion. Eur Spine J, 2024, 33(6): 2277-2286.
28. Ran L, Xie T, Zhao L, et al. MRI-based endplate bone quality score predicts cage subsidence following oblique lumbar interbody fusion. Spine J, 2024, 24(10): 1922-1928.
29. Li C, Gao W, Yao X, et al. The magnetic resonance imaging-based vertebral bone quality scoring system: A novel method to evaluate endplate changes in patients with primary single-level disk herniation and Modic changes. Jt Dis Relat Surg, 2024, 35(2): 257-266.
30. Li Q, Hu B, Yang H, et al. MRI-based pedicle bone quality score: correlation to quantitative computed tomography bone mineral density and its role in quantitative assessment of osteoporosis. Spine J, 2024, 24(10): 1825-1832.
31. Huang W, Gong Z, Wang H, et al. Use of MRI-based vertebral bone quality score (VBQ) of S₁ body in bone mineral density assessment for patients with lumbar degenerative diseases. Eur Spine J, 2023, 32(5): 1553-1560.
32. Du SY, Dai J, Zhou ZT, et al. Size selection and placement of pedicle screws using robot-assisted versus fluoroscopy-guided techniques for thoracolumbar fractures: possible implications for the screw loosening rate. BMC Surg, 2022, 22(1): 365. doi: 10.1186/s12893-022-01814-6.
33. Mikula AL, Lakomkin N, Pennington Z, et al. Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine. J Neurosurg Spine, 2022, 37(5): 694-702.
34. Xu F, Zou D, Li W, et al. Hounsfield units of the vertebral body and pedicle as predictors of pedicle screw loosening after degenerative lumbar spine surgery. Neurosurg Focus, 2020, 49(2): E10. doi: 10.3171/2020.5.FOCUS20249.
35. Weinstein JN, Rydevik BL, Rauschning W. Anatomic and technical considerations of pedicle screw fixation. Clin Orthop Relat Res, 1992(284): 34-46.
36. Defino HL, Vendrame JR. Role of cortical and cancellous bone of the vertebral pedicle in implant fixation. Eur Spine J, 2001, 10(4): 325-333.

Chinese Journal of Reparative and Reconstructive Surgery

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