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Purpose <p>Computed tomography-based Hounsfield unit (HU) measurements can be used to evaluate localized bone mineral density preoperatively in spinal fusion patients. While multiple studies have reported HU cutoffs predictive of screw loosening, cage subsidence, proximal junctional kyphosis/failure (PJK/PJF), and other mechanical complications, a standardized validated HU threshold has not been established.</p> Methods <p>A comprehensive search of PubMed, Scopus, Embase, and Cochrane Library was performed for articles that reported HU measurements in thoracolumbar or lumbar fusion patients with and without postoperative complications. Random-effects meta-analyses were performed to compare mean HU in patients with and without complications. Global threshold was generated through pooled analyses of studies that reported HU cutoffs. This threshold was validated on studies that did not identify any HU cutoff.</p> Results <p>Across 42 studies (6,240 patients), mean age was 61.7 years, 39.0% were males, and mean CCI was 2.4. In total, 36.1% had cage subsidence, 29.4% had screw loosening, 32.9% had PJK/PJF, and 18.0% had other mechanical complications. Meta-analyses revealed that patients with mechanical/junctional complications had 0.8 standard deviations (95%CI = 0.7-1.0, <i>p</i> &lt; 0.01) lower HU than control patients. From the 25 studies (3,103 patients) that reported HU cutoffs, a global threshold of 118 HU (sensitivity = 72.9%, specificity = 63.9%) was established. From the remaining 17 studies (3,137 patients) that did not report HU cutoffs, patients below this threshold had 2.8 times (95%CI = 1.9–4.1, <i>p</i> &lt; 0.01) higher odds of complications than patients above this threshold (sensitivity = 45.8%, specificity = 77.4%).</p> Conclusion <p>In patients undergoing thoracolumbar or lumbar fusions, preoperative Hounsfield unit values under 118 were associated with a 2.8-fold higher risk of postoperative mechanical and junctional complications. Preoperative surgical planning may utilize this threshold to guide surgical optimization and planning. Specifically, a simple stratification model, with &lt; 120 HU as high risk, 120–150 HU as intermediate risk, and &gt; 150 HU as low risk may facilitate clinical application and promote standardized HU assessments.</p> Level of evidence <p>Level III, Therapeutic Study.</p>

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Generation and validation of a Hounsfield unit (HU) threshold for predicting mechanical and junctional complications following thoracolumbar or lumbar fusion: a systematic review and meta-analysis

  • 期刊论文

  • 发表日期：

    2025年8月4日

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  • Manjot Singh,
  • Jinho Kim,
  • Joseph Nassar,
  • Andrew Xu,
  • Simbarashe Peresuh,
  • Krish Shah,
  • Michael Farias,
  • Bassel Diebo,
  • Alan Daniels

摘要

Purpose

Computed tomography-based Hounsfield unit (HU) measurements can be used to evaluate localized bone mineral density preoperatively in spinal fusion patients. While multiple studies have reported HU cutoffs predictive of screw loosening, cage subsidence, proximal junctional kyphosis/failure (PJK/PJF), and other mechanical complications, a standardized validated HU threshold has not been established.

Methods

A comprehensive search of PubMed, Scopus, Embase, and Cochrane Library was performed for articles that reported HU measurements in thoracolumbar or lumbar fusion patients with and without postoperative complications. Random-effects meta-analyses were performed to compare mean HU in patients with and without complications. Global threshold was generated through pooled analyses of studies that reported HU cutoffs. This threshold was validated on studies that did not identify any HU cutoff.

Results

Across 42 studies (6,240 patients), mean age was 61.7 years, 39.0% were males, and mean CCI was 2.4. In total, 36.1% had cage subsidence, 29.4% had screw loosening, 32.9% had PJK/PJF, and 18.0% had other mechanical complications. Meta-analyses revealed that patients with mechanical/junctional complications had 0.8 standard deviations (95%CI = 0.7-1.0, p < 0.01) lower HU than control patients. From the 25 studies (3,103 patients) that reported HU cutoffs, a global threshold of 118 HU (sensitivity = 72.9%, specificity = 63.9%) was established. From the remaining 17 studies (3,137 patients) that did not report HU cutoffs, patients below this threshold had 2.8 times (95%CI = 1.9–4.1, p < 0.01) higher odds of complications than patients above this threshold (sensitivity = 45.8%, specificity = 77.4%).

Conclusion

In patients undergoing thoracolumbar or lumbar fusions, preoperative Hounsfield unit values under 118 were associated with a 2.8-fold higher risk of postoperative mechanical and junctional complications. Preoperative surgical planning may utilize this threshold to guide surgical optimization and planning. Specifically, a simple stratification model, with < 120 HU as high risk, 120–150 HU as intermediate risk, and > 150 HU as low risk may facilitate clinical application and promote standardized HU assessments.

Level of evidence

Level III, Therapeutic Study.