Opportunistic osteoporosis screening reveals low bone density in patients with screw loosening after lumbar semi-rigid instrumentation: a case-control study
Creators: name: Löffler, Maximilian T.
name: Sollmann, Nico
name: Burian, Egon
name: Bayat, Amirhossein
name: Aftahy, Kaywan
name: Baum, Thomas
name: Meyer, Bernhard
name: Ryang, Yu-Mi
name: Kirschke, Jan S.
Publisher: name: Universität Ulm
Year: 2021
Subjects: subject: bone mineral density
subject: spinal fusion and instrumentation
subject: multidetector computed tomography
subject: computer-assisted image analysis
subject: computer neural networks
subject: degenerative spine surgery
subject: DDC 610 / Medicine &amp; health
subject: Bone density
subject: Osteoporosis
subject: Osteoporosis; Diagnostic imaging
subject: Neural networks, Computer
subject: Spine; Surgery
subject: Tomography, X-ray computed
subject: Osteoporose
subject: Knochendichte
subject: Computertomografie

description: Objective Decreased bone mineral density (BMD) impairs screw purchase in trabecular bone and can cause screw loosening following spinal instrumentation. Existing computed tomography (CT) scans could be used for opportunistic osteoporosis screening for decreased BMD. Purpose of this case-control study was to investigate the association of opportunistically assessed BMD with the outcome after spinal surgery with semi-rigid instrumentation for lumbar degenerative instability. Methods We reviewed consecutive patients that had primary surgery with semi-rigid instrumentation in our hospital. Patients that showed screw loosening in follow-up imaging qualified as cases. Patients that did not show screw loosening or—if no follow-up imaging was available (n = 8)—reported benefit from surgery ≥ 6 months after primary surgery qualified as controls. Matching criteria were sex, age, and surgical construct. Opportunistic BMD screening was performed at L1 to L4 in perioperative CT scans by automatic spine segmentation and using asynchronous calibration. Processing steps of this deep learning-driven approach can be reproduced using the freely available online-tool Anduin (https://anduin.bonescreen.de). Area under the curve (AUC) was calculated for BMD as a predictor of screw loosening. Results Forty-six elderly patients (69.9 ± 9.1 years)—23 cases and 23 controls—were included. The majority of surgeries involved three spinal motion segments (n = 34). Twenty patients had low bone mass and 13 had osteoporotic BMD. Cases had significantly lower mean BMD (86.5 ± 29.5 mg/cm³) compared to controls (118.2 ± 32.9 mg/cm³, p = 0.001), i.e. patients with screw loosening showed reduced BMD. Screw loosening was best predicted by a BMD &lt; 81.8 mg/cm³ (sensitivity = 91.3%, specificity = 56.5%, AUC = 0.769, p = 0.002). Conclusion Prevalence of osteoporosis or low bone mass (BMD ≤ 120 mg/cm³) was relatively high in this group of elderly patients undergoing spinal surgery. Screw loosening was associated with BMD close to the threshold for osteoporosis (&lt; 80 mg/cm³). Opportunistic BMD screening is feasible using the presented approach and can guide the surgeon to take measures to prevent screw loosening and to increase favorable outcomes.