Evaluation of MRI-Based Region-specific Vertebral Bone Quality Score for Bone Mineral Density in Lumbar Fusion Surgery

Abstract

Study Design

Retrospective study.

Objectives

To compare region-specific VBQ scores and to evaluate their effectiveness in assessing bone quality in patients with lumbar degenerative diseases.

Methods

This study retrospectively included patients who underwent lumbar fusion surgery for lumbar degenerative diseases between April 2021 and January 2025. Region-specific VBQ scores (VBQ-anterior, VBQ-classic and VBQ-posterior), assessed using preoperative MRI. Hounsfield Unit (HU) values were also recorded. Receiver operating characteristic (ROC) curves were generated to assess the diagnostic accuracy. Pearson correlation analysis was performed to evaluate the associations between region-specific VBQ scores, HU values, and lumbar T-scores.

Results

A total of 329 eligible patients was included. VBQ-anterior demonstrated the highest scores, whereas VBQ-posterior exhibited significantly lower values. Furthermore, we evaluated the diagnostic accuracy of the three VBQ measurement approaches, as well as HU values, in identifying osteoporotic patients. The results revealed that HU values showed the highest area under the curve (AUC = 0.857), followed by VBQ-posterior (AUC = 0.825). In contrast, VBQ-anterior exhibited the lowest diagnostic accuracy (AUC = 0.735). Correlation analysis demonstrated that HU values had the strongest correlation with lumbar T-scores (r = 0.57, P < 0.001), followed by VBQ-posterior (r = 0.49, P < 0.001) and VBQ-classic (r = 0.37, P < 0.001). VBQ-anterior showed the weakest correlation with T-scores (r = 0.24, P < 0.001).

Conclusions

VBQ scoring provides a simple and relatively accurate method for assessing bone quality in patients with lumbar degenerative diseases. However, region-specific variations exist and VBQ-posterior may demonstrate superior diagnostic accuracy.

Keywords

osteoporosis region-specific vertebral bone quality lumbar fusion surgery

Introduction

With the accelerating aging of the population, the incidence of lumbar degenerative diseases has been increasing steadily, leading to chronic low back pain, nerve compression, and functional impairments, which have become major health concerns affecting the quality of life in elderly populations.¹ When conservative treatments are ineffective, lumbar fusion surgery represents a viable and effective therapeutic option.² However, surgical success depends not only on the selection and technical execution of the procedure, but also critically on the patient’s own bone quality, which directly influence the stability of internal fixation and the overall success rate of fusion.^3,4 Therefore, accurate preoperative assessment of bone quality is critical for preventing postoperative screw loosening.

Dual-energy X-ray absorptiometry (DEXA) is currently the gold standard for clinical assessment of bone mineral density (BMD).^5,6 However, a survey of 114 spine surgeons revealed that, despite the fact that the majority of patients scheduled for surgery are elderly, only 44% of respondents routinely perform preoperative DEXA scans.⁷ Furthermore, the presence of lumbar degeneration, vascular calcification, and obesity can artificially elevate BMD measurements, leading to false-positive results.^8,9 This may result in an underestimation of compromised bone quality and consequently increase the risk of complications related to internal fixation failure.^3,10

In recent years, the vertebral bone quality (VBQ) score has emerged as a novel imaging biomarker and has been extensively validated in clinical studies for its diagnostic efficacy.^10-13 In principle, VBQ indirectly reflects the bone quality by quantifying the fat content within the vertebral cancellous bone.¹¹ However, in previous studies, VBQ measurement has predominantly relied on signal intensity within the mid-portion of the vertebral body on MRI T1-weighted images, thereby overlooking the biomechanical alterations associated with spinal degeneration and the spatial heterogeneity of fat distribution within the vertebral body.^11,14-16 With the progressive degenerative changes, the load transmission pathway along the spine shifts from the anterior vertebral bodies toward the posterior facet joints, leading to altered stress distribution patterns across the vertebral body.^17,18 This shift in mechanical loading is consistent with Wolff’s Law, which posits that bone adapts its microstructure in response to prevailing stress patterns. As intervertebral discs degenerate and lose height, the anterior column experiences reduced compressive forces, leading to disuse-related trabecular thinning and increased marrow adipogenesis in the anterior vertebral body. Conversely, the posterior vertebral rim, which bears greater mechanical demand due to increased loading through the facet joints, maintains denser trabecular architecture and lower fat content. Therefore, relying solely on mid-vertebral measurements may underestimate the true severity of osteoporosis in degenerative spines.

To date, few studies have explored the diagnostic utility of region-specific VBQ measurements in determining bone quality. Therefore, this study aims to investigate (i) whether there are significant differences in VBQ scores obtained from different vertebral regions (including the anterior, classic, and posterior); and (ii) to evaluate the diagnostic accuracy of region-specific VBQ and HU value in assessing vertebral bone quality. Through systematic analysis, we aim to provide a more precise bone quality evaluation strategy for clinical practice and to optimize the preoperative assessment system for patients undergoing lumbar fusion surgery.

Methods

Study Population

In this single-center cohort study, we retrospectively included patients who underwent lumbar fusion surgery for lumbar degenerative diseases between April 2021 and January 2025. The study was conducted after obtaining approval of institutional review board (IRB#2024-010-002), and all included patients provided written informed consent. All surgical procedures were performed by two experienced spine surgeons with over 10 years of clinical expertise. The inclusion criteria were as follows: (1) age ≥65 years; (2) availability of complete preoperative lumbar MRI, CT, and DEXA data; and (3) no prior history of spinal surgery. Exclusion criteria included: (1) presence of bone tumors, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, or rheumatoid arthritis, which may affect bone metabolism; (2) secondary osteoporosis; and (3) presence of spinal deformities or fractures that obscures vertebral boundaries, thereby precluding accurate measurement of VBQ. Demographic data included age, gender, body mass index (BMI), smoking status, alcohol consumption, history of hypertension, and diabetes mellitus. Radiological information encompassed preoperative DEXA-derived T-scores, average Hounsfield Unit (HU) values at L1–L4 levels, and region-specific VBQ scores measured on T1-weighted MRI scans. Laboratory data included serum levels of thyroid-stimulating hormone (TSH), total cholesterol, vitamin D, calcium, and phosphate.

Region-specific VBQ Score and HU Value

T1-weighted non-contrast lumbar MRI studies were obtained using 3.0 Tesla Trio Tim scanners (Siemens, Erlangen, Germany). The standard scanning protocol included a field of view (FOV) of 310 * 310 mm, a matrix size of 320 * 320, a repetition time (TR)/echo time (TE) of 550 ms/9.6 ms, 11 slices per slab, a slice thickness of 4.0 mm, and 2 excitations (NEX) for sagittal T1-weighted scans. Previous studies have reported on the measurement of the classic VBQ score (mid-vertebral). In general, signal intensity (SI) assessment involves defining regions of interest (ROIs) within the trabecular compartments of the vertebral bodies from L1 to L4 on mid-sagittal imaging planes. ROIs are placed within the medullary cavity of the L1–L4 vertebral bodies as well as in the cerebrospinal fluid (CSF) space posterior to the L3 vertebral body level. In cases where the mid-vertebral slice is not clearly visible, measurements may be obtained from para-sagittal slices containing visible trabecular structures. Any vertebral segments exhibiting compression fractures or severe deformities are excluded from further analysis. The VBQ-classic score is calculated by dividing the median signal intensity of the L1–L4 vertebral bodies by the SI of the CSF at the posterior margin of the L3 vertebral body. For the anterior (VBQ-anterior) and posterior (VBQ-posterior) VBQ scores, the ROIs are placed in the anterior half and posterior half of the trabecular compartments of the L1–L4 vertebral bodies, respectively, while following the consistent measurement methodology as the classic VBQ approach. Detailed measurement procedures are illustrated in Figure 1A–C. Regarding HU value assessment, as previously described in the literature,^19,20 HU values are measured using the PACS system. Briefly, elliptical ROIs are placed within the axial CT slices at the L1 to L4 levels. These ROIs are carefully positioned to encompass as much trabecular bone as possible while avoiding cortical bone and heterogeneous regions such as the posterior venous plexus, bone islands, or compressed areas. The average HU value across the L1–L4 levels is used as a representative measure of overall vertebral bone mineral density (Figure 1D–E).

Figure 1.

Representative Images of ROI Used to Calculate (A) VBQ-Anterior, (B) VBQ-Classic, (C) VBQ-Posterior and (D-E) HU Value Measurement

Statistical Analysis

The Shapiro-Wilk test and histogram analysis were employed to assess the normality of data distribution. For continuous variables that followed a normal distribution, results were expressed as mean ± standard deviation. Categorical variables were summarized using frequencies and percentages. Inter-group comparisons were conducted using Fisher’s exact test or one-way ANOVA, as appropriate. Receiver operating characteristic (ROC) curves and the corresponding area under the curve (AUC) were generated to evaluate the diagnostic accuracy of VBQ-anterior, VBQ-classic, VBQ-posterior, and HU values in predicting osteoporosis. Pearson correlation analysis was performed to evaluate the relationships among the various scoring metrics. Intra- and inter-observer reliability between two independent raters was calculated using intraclass correlation coefficients (ICCs) with 95% confidence intervals (CI). All statistical analyses were performed using GraphPad Prism version 9.0.0. A P-value <0.05 was considered statistically significant.

Results

Patient Demographic

A total of 329 eligible patients were included in the study, comprising 91 individuals with normal bone density, 174 with osteopenia, and 64 with osteoporosis (Table 1). Among the 329 patients included, 33 (36.3%) had hypertension, and 37 (40.7%) had diabetes mellitus. A total of 17 patients (18.7%) were smokers, and 15 (16.5%) reported regular alcohol consumption. Laboratory assessments revealed a mean serum vitamin D level of 37.4 ± 12.3 ng/mL. The average serum calcium was 2.4 ± 0.2 mmol/L, phosphate was 1.1 ± 0.2 mmol/L, and TSH was 2.2 ± 1.3 mIU/L. These parameters were within normal ranges for the majority of participants. The detailed information was summarized in Table 1.

Table 1.

Demographics and Laboratory Indicators Among Three Bone Groups

Variables	Normal (n = 91)	Osteopenia (n = 174)	Osteoporosis (n = 64)	P value
Demographics
Age	67.2 ± 5.5	67.9 ± 4.9	69.7 ± 5.1	0.011
Female	49 (53.8%)	86 (49.4%)	35 (54.7 %)	0.685
BMI	25.6 ± 3.6	26.1 ± 3.3	25.7 ± 3.5	0.597
Smoking	17 (18.7%)	34 (19.5%)	13 (20.3%)	0.968
Drinking	15 (16.5%)	27 (15.5%)	11(17.2%)	0.947
Hypertension	33 (36.3%)	69 (39.7%)	27 (42.2%)	0.747
Diabetes	37 (40.7%)	81 (46.6%)	30 (46.9%)	0.621
Chronic anemia	22 (24.2%)	43 (24.7%)	19 (29.7%)	0.694
Lumbar T-score	1.0 ± 1.1	−0.6 ± 1.2	−2.5 ± 1.1	<0.001
Mean HU of L1-L4	167.8 ± 38.4	124.1 ± 40.6	94.5 ± 37.6	<0.001
Laboratory index
TSH (mIU/L)	2.2 ± 1.3	2.3 ± 2.1	2.4 ± 1.8	0.354
Total cholesterol(mmol/L)	4.7 ± 1.3	4.9 ± 1.0	4.8 ± 1.2	0.513
Vitamin D(ng/L)	37.4 ± 12.3	37.5 ± 11.6	36.5 ± 13.4	0.883
Calcium(mmol/L)	2.4 ± 0.2	2.3 ± 0.2	2.2 ± 0.2	0.112
Phosphate(mmol/L)	1.1 ± 0.2	1.1 ± 0.1	1.2 ± 0.2	0.423

Diagnosis Accuracy of the Region-specific VBQ Scores

The intra-observer and inter-observer reliabilities for VBQ-anterior, VBQ-classic, VBQ-posterior and HU values were summarized in Table 2, and all ICC >0.85, demonstrated favorable reproducibility. As expected, osteoporotic patients were significantly older and exhibited lower HU values. The VBQ scores across the three vertebral regions are presented in Figure 2. Consistent with our hypothesis, VBQ-anterior demonstrated the highest values, while VBQ-posterior showed the lowest scores. This trend was further confirmed after stratifying the patients into three groups based on bone mass (normal, osteopenia, and osteoporosis) as illustrated in Figure 3. With progressive deterioration in bone quality, VBQ scores increased across all regions. However, regardless of the BMD group, VBQ-posterior scores remained significantly lower than those of VBQ-anterior and VBQ-classic. Furthermore, we evaluated the diagnostic accuracy of the three VBQ measurements, along with HU values, in identifying osteoporotic patients. The results demonstrated that HU values exhibited the highest area under the curve (AUC = 0.857), followed by VBQ-posterior (AUC = 0.825). In contrast, VBQ-anterior showed the lowest diagnostic accuracy (AUC = 0.735). The cut-off value was 3.21 with sensitivity of 77.1% and specificity of 51.7% for VBQ-anterior; 3.02 with sensitivity of 81.7% and specificity of 64.6% for VBQ-classic and 2.77 with sensitivity of 87.3% and specificity of 78.4% for VBQ-posterior. The detailed characteristics were summarized in Figure 4 and Table 3.

Table 2.

Reliability Analysis of VBQ-Anterior, VBQ-Classic, VBQ-Posterior and HU Value

Characteristic	Inter-observer	Intra-observer	Interpretation
VBQ-anterior	0.87 (0.79-0.91)	0.89 (0.80-0.94)	Good
VBQ-classic	0.90 (0.82-0.95)	0.95 (0.86-0.97)	Excellent
VBQ-posterior	0.93 (0.83-0.95)	0.90 (0.77-0.94)	Excellent
HU value	0.94 (0.82-0.97)	0.94 (0.86-0.98)	Excellent

Figure 2.

Results of Comparison of Region-specific VBQ Scores for the Total Population

Figure 3.

The Region-specific VBQ Scores Were Compared in Patients With Different Bone Conditions

Figure 4.

Diagnostic Efficacy of Region-specific VBQ Score and HU Assessment Methods

Table 3.

Accuracy of VBQ at Different Region in Determining Osteoporosis Based on BMI Cut-Off Adjusted for Other Covariates

	Cut-off	Sensitivity	Specificity	AUC	P value
VBQ-anterior	3.21	77.1	51.7	0.735	<0.001
VBQ-classic	3.02	81.7	64.6	0.792	<0.001
VBQ-posterior	2.77	87.3	78.4	0.825	<0.001

Correlation Between Lumbar T Score, L1 L4 HU, and Region-specific VBQ

Associations of the VBQ-anterior, VBQ-classic, VBQ-posterior, HU value and BMD T score was shown in Figure 5. Results demonstrated that all bone quality measurement methods showed statistically significant correlations with the lumbar T-score (P < 0.001). Among these, the L1–L4 HU values exhibited the strongest correlation with the DEXA T-score (r = 0.57, P < 0.001), followed by VBQ-posterior (r = 0.49, P < 0.001) and VBQ-classic (r = 0.37, P < 0.001). In contrast, VBQ-anterior showed the weakest correlation with the T-score (r = 0.24, P < 0.001).

Figure 5.

The Correlation Between Lumbar T-Score, Region-specific VBQ Scores and CT HU Value

Discussion

To our knowledge, this is the first study to systematically evaluate the diagnostic performance of VBQ scores measured in different vertebral regions (anterior, mid, and posterior) in predicting osteoporosis. The results demonstrated that VBQ-posterior exhibited superior accuracy in identifying osteoporotic patients (AUC = 0.825), significantly outperforming both the conventional VBQ-classic (AUC = 0.783) and VBQ-anterior (AUC = 0.735).

Osteoporosis is a systemic metabolic bone disease characterized by reduced bone mass and microarchitectural deterioration of bone tissue, ultimately leading to increased bone fragility and susceptibility to fractures.²¹ It has been reported that the number of individuals aged 60 years and older with osteoporosis in China has reached up to 112 million.²² Studies have shown that osteoporotic patients exhibit significantly decreased vertebral bone density and diminished screw fixation strength, which markedly increases the risk of postoperative mechanical complications such as internal fixation loosening, nonunion of bone grafts, and cage subsidence—ultimately compromising quality of life.^23-26 Therefore, accurate preoperative assessment of bone quality is of critical importance for formulating appropriate surgical strategies and optimizing the selection of internal fixation devices.

Although dual-energy X-ray absorptiometry (DEXA) is widely regarded as the “gold standard” for assessing bone mineral density (BMD), its application in preoperative evaluation within spinal surgery remains limited by several challenges.⁵ First, a survey of 114 spine surgeons revealed that only 44% routinely ordered preoperative DEXA scans for patients scheduled to undergo lumbar fusion surgery.⁷ This low utilization rate may be attributed to unclear clinical indications for DEXA, uneven distribution of healthcare resources, and insufficient awareness among surgeons regarding the importance of bone quality assessment. Second, DEXA measurements are susceptible to artifacts caused by lumbar degeneration, vascular calcification, and obesity, which can lead to falsely elevated BMD readings.^8,9 This phenomenon may result in underestimation of osteoporosis risk. For instance, osteophyte formation at the vertebral margins or aortic calcification can increase local bone density measurements, potentially leading to missed diagnoses of osteoporosis and consequently increasing the risk of postoperative implant failure. Therefore, there is a pressing need in clinical practice for a more accurate and readily accessible method of bone quality assessment to address the limitations of DEXA in spinal surgical applications.

Against this background, the VBQ score has emerged as a novel imaging biomarker and has garnered increasing attention.^27,28 VBQ assesses the fat content within the trabecular bone of the vertebral body using MRI T1-weighted images, thereby indirectly reflecting the integrity of the trabecular microarchitecture and overall bone quality. Emerging evidence has demonstrated that VBQ is not only strongly correlated with BMD, but also effectively predicts the risk of mechanical complications following lumbar fusion surgery.^28-30 In a retrospective cohort study, Ehresman et al.¹¹ Showed that VBQ can independently predict the occurrence of fragility fractures, irrespective of BMD. In another retrospective cohort study, Soliman et al.¹⁰ Demonstrated that VBQ independently predicts cage subsidence after transforaminal lumbar interbody fusion. Similarly, Gao et al.³¹ Identified VBQ as an independent risk factor for screw loosening after lumbar fusion surgery. Furthermore, VBQ measurement does not rely on cortical bone integrity, thereby circumventing the misinterpretation issues associated with DEXA caused by osteophytes or vascular calcifications. This makes VBQ particularly advantageous in assessing bone quality in degenerative lumbar spines. However, conventional VBQ measurement has primarily focused on the mid-vertebral region, overlooking the spatial heterogeneity of fat distribution within the vertebral body during spinal degeneration, which may compromise its diagnostic accuracy.

Previous studies have demonstrated that with advancing age and progression of lumbar degeneration, the biomechanical load distribution along the spine undergoes significant alterations.^17,18 As intervertebral disc spaces gradually narrow, the load transmission pathway shifts from the anterior vertebral bodies toward the posterior facet joints.^17,18 According to Wolff’s Law, bone remodeling is closely associated with mechanical stimulation; prolonged redistribution of biomechanical forces promotes the realignment of trabecular architecture along new stress trajectories. During this process, the anterior vertebral margin, subjected to reduced mechanical stress, experiences increased adipocyte deposition and progressive trabecular rarefaction. In contrast, the posterior vertebral margin, which bears greater biomechanical loads, maintains a denser trabecular structure and relatively lower fat content. This phenomenon largely explains the clinical observation that osteoporotic vertebral compression fractures predominantly occur in the anterior portion of the vertebral body. Therefore, conventional VBQ measurement methods, which primarily target the mid-vertebral region, may fail to accurately reflect the overall bone quality of the entire vertebral body.

In a retrospective cohort study, Li et al³² evaluated the performance of a modified VBQ (defined as the VBQ score measured in the anterior half of the vertebral body), and the VBQ-classic in assessing bone quality in patients with lumbar degenerative disease. They found that the modified-VBQ scores were significantly lower than those of the VBQ-classic and demonstrated a stronger correlation with lumbar T-scores. The authors hypothesized that this may be attributed to the posterior half of the vertebral body containing a higher density of vascular and neural structure, which could introduce measurement artifacts and lead to overestimation of VBQ scores in that region. However, in our study, we systematically compared the diagnostic performance of VBQ scores measured in the anterior, mid, and posterior regions of the vertebral body in identifying osteoporotic patients. The results demonstrated that VBQ-anterior values were generally higher, whereas VBQ-posterior values were significantly lower. Notably, regardless of the underlying bone quality, the VBQ-posterior region consistently exhibited lower fat content and superior bone quality characteristics. This finding is in line with the well-documented clinical observation that vertebral compression fractures predominantly occur in the anterior portion of the vertebral body, further supporting the notion that bone quality in the posterior vertebral region is superior to that in the anterior region. More importantly, VBQ-posterior demonstrated higher sensitivity and specificity (87.3% sensitivity and 78.4% specificity) in predicting osteoporosis, indicating its substantial diagnostic value in clinical practice.

Although this study demonstrates certain innovations and clinical applicability in methodology, several limitations must be acknowledged. First, as a single-center retrospective study, the sample size remains relatively limited, and therefore, multi-center prospective studies are warranted to further validate the generalizability of our findings. Additionally, while this study focused on the diagnostic accuracy of region-specific VBQ scores for osteoporosis, we did not evaluate their association with postoperative mechanical complications. Future studies should explore whether VBQ-posterior, due to its higher sensitivity and specificity, can better predict mechanical failure after lumbar fusion. Additionally, spinal alignment parameters, which may influence regional biomechanical stress and thus fat distribution, were not assessed in this study. These factors represent potential confounders and should be considered in subsequent investigations. Finally, although the scientific basis of the VBQ method is well-established and its efficacy has been supported by numerous studies from multiple institutions, it is important to note that, due to its simplicity and cost-effectiveness, VBQ may serve as a potential opportunistic screening tool or complementary assessment method. However, at present, it is not intended to replace DEXA as the gold standard for bone density evaluation.

Conclusion

In conclusion, this study systematically compared the diagnostic performance of VBQ scores measured in different vertebral regions in identifying osteoporotic patients. We found that VBQ-posterior demonstrated superior sensitivity and specificity among all evaluated parameters, significantly outperforming the traditional VBQ-classic and VBQ-anterior.

Footnotes

Acknowledgements

We thank the Department of Orthopedics, Xuanwu Hospital Capital Medical University staff and all the patients who participated in the study.

ORCID iD

Xuan Zhao

Ethical Considerations

The study protocol was validated by the institutional review board in Xuanwu Hospital Capital Medical University (IRB#2024-010-002). And all patients had provided informed consent.

Author Contributions

S.B.L., X.L.C., and W.W. were responsible for the concept and experimental design. X.Z. performed the data analysis and statistical analysis. S.B.L., X.Z., and X.L.C. were involved in drafting and revision of the manuscript. S.B.L. and W.W. supervised this study. All authors discussed the results and commented on the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Post-subsidy funds for National Clinical Research Center, Ministry of Science and Technology of China (No. 303-01-001-0272-05), Beijing Natural Science Foundation (L254007), R&D Program of Beijing Municipal Education Commission (No. KZ20231002537), Chinese Institutes for Medical Research, Beijing (Grant No. CX24PY10), and the Capital’s Funds for Health Improvement and Research (No. 2024-1-2012).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.*

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