Comparative Diagnostic Performance of Hounsfield Units, Vertebral Bone Quality, and Endplate Bone Quality for Predicting Cage Subsidence After Lumbar Fusion Surgery: A Systematic Review and Meta-Analysis

Study DesignSystematic Review and Meta-analysis.ObjectivePoor preoperative bone quality is a key risk factor for postoperative cage subsidence (CS) following degenerative lumbar fusion surgery. Computed tomography (CT)-based Hounsfield unit (HU) values, and magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) and endplate bone quality (EBQ) scores, are reliable tools for assessing bone quality. This study is the first meta-analysis comparing the predictive value of HU, VBQ, and EBQ for postoperative CS.MethodsA comprehensive literature search was conducted through databases such as PubMed up to April 5, 2025. The QUADAS-2 was used to evaluate the quality of included studies. Calculate the pooled sensitivity, specificity and hierarchical summary receiver operating characteristic (HSROC) curve, and perform subgroup analyses and meta-regression to identify sources of heterogeneity.Results20 studies involving a total of 2648 patients were included. The quality of these studies was relatively low. The areas under the HSROC curves for HU value, VBQ, and EBQ were 0.78 (95% CI, 0.74-0.81), 0.86 (95% CI, 0.83-0.89), and 0.83 (95% CI, 0.79-0.86), respectively. The pooled sensitivities were 0.84, 0.82, and 0.80, while the pooled specificities were all 0.76. The corresponding diagnostic odds ratios (DORs) were 16.34 (95% CI, 7.43-35.93), 14.67 (95% CI, 10.51-20.48), and 12.24 (95% CI, 5.63-26.61), respectively.ConclusionThe HU value, VBQ, and EBQ all demonstrate relatively high efficacy in predicting CS, with the VBQ showing a modest advantage. Collectively, these indicators can provide valuable information for preoperative risk stratification and individualized surgical decision-making.