Layout 1


Thematic Section: Advances in Musculoskeletal and Neuromuscular Rehabilitation | Maccarone & Masiero 
Eur J Transl Myol 34 (4) 12311, 2024 doi: 10.4081/ejtm.2024.12311

Osteoporosis is the most common bone disease and a
significant global public health problem called “the 

silent epidemic of the 21st century”.1 This skeletal disorder 
is characterized by decreased bone density, resulting in an 
increased fracture risk, leading to disability, independence, 
economic burden, and mortality.2,3 About 50% of white 
women and 20% of men may experience an osteoporotic 
fracture in their lifetime.2 As life expectancy increases in 
developing countries, osteoporosis is expected to become 
more prevalent.4 Vertebrae, distal radius, and proximal 
femur are at higher risk of osteoporotic fractures.3 
Osteoporosis brought poor surgical outcomes.5 Fragility 
fractures during orthopedic surgery are more incident in 
osteoporotic bone.5 Postoperatively, osteoporosis is 
associated with an increased risk of implementation 

failures, extended hospitalization, rate of revision surgery, 
and higher patient mortality.6 This skeletal disorder is a 
chronic asymptomatic disease; thus, many patients with 
undiagnosed osteoporosis have been deprived of treatment. 
In contrast, early diagnosis and timely treatment can prevent 
fragility fractures. 
Bone Mineral Density (BMD) is the amount of minerals in 
the bone tissue.7 According to the World Health Organiza-
tion (WHO), BMD T score ≤ −2.5 describes osteoporosis 
in Dual-energy X-ray Absorptiometry (DXA).8 Various 
scanning methods are available to measure BMD and dia-
gnosis of osteoporosis. DXA is a commonly used method 
for BMD analysis.7 DXA uses absorption of high and low-
energy X-ray photons to evaluate bone density. The DXA 
test can measure the whole body, usually the hips and the 

Abstract 

Osteoporosis, a common bone disorder, increases fracture and spinal surgery complications risk. 
This study evaluates the potential of the Magnetic Resonance Imaging (MRI)-based Vertebral 
Bone Quality (VBQ) score as an alternative for assessing bone density in lumbosacral fusion 
surgery patients. In a prospective cohort study from April 2021 to November 2022, 134 patients 
with lumbar degenerative diseases underwent lumbar Dual-Energy X-ray Absorptiometry (DXA) 
and lumbosacral non-contrast T1-weighted MRI. VBQ scores were calculated and analyzed using 
IBM SPSS Statistics and MedCalc software. Osteopenia/Osteoporosis patients exhibited 
significantly higher VBQ scores than normal bone mineral density patients (3.37±0.51 vs. 
2.99±0.44, P<0.001). VBQ correlated significantly with lumbar DXA T scores (r value= -0.415, 
p<0.001). Receiver Operating Characteristic (ROC) analysis showed VBQ AUC values of 0.730 
(CI 95% 0.647-0.803, P<0.001) and 0.839 (CI 95% 0.765-0.897, P<0.001) for 
Osteopenia/Osteoporosis and osteoporosis diagnosis, respectively. The study suggests MRI-
derived VBQ scores may benefit pre-lumbosacral fusion surgery bone density assessment, 
potentially improving patient care and aiding osteoporosis detection in spinal surgery candidates.  
Key Words: vertebral bone quality; magnetic resonance imaging; osteoporosis; osteopenia; spinal 
fusion surgery. 

Eur J Transl Myol 34 (4) 12311, 2024 doi: 10.4081/ejtm.2024.12311

Vertebral bone quality score as a new tool for osteoporosis diagnosis 
in patients undergoing lumbosacral fusion surgery:  
a single center cohort study 
Arvin Najafi,1 Ali Baradaran Bagheri,2 Dorsa Hadavi,3 Aidin Mobedi,4 
Salman Azarsina,1 Pouria Chaghamirzayi5 

1Departement of Orthopedic Surgery, Shahid Madani Hospital, Alborz University of Medical 
Sciences, Karaj, Iran; 2Department of Neurosurgery, Shahid Madani Hospital, Alborz University 
of Medical Sciences, Karaj, Iran; 3Department of Radiology, Tehran University of Medical 
Sciences, Tehran, Iran; 4Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, 
Iran; 5Clinical research development unit of Shahid Madani Hospital, Alborz University of 
Medical Science, Karaj, Iran. 
 
This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0) which permits 
any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. 

- 1 -

Non
-co

mmerc
ial

 us
e o

nly



Osteoporosis new diagnosis tool in lumbosacral fusion surgery 
Eur J Transl Myol 34 (4) 12311, 2024 doi: 10.4081/ejtm.2024.12311

lower spine. In this method, we need to know the patient’s 
age, T-score, and Z-score to determine whether the patient 
has osteoporosis. The main disadvantage of DXA is that 
currently, there is no standardization in the measurement of 
bone and soft tissue.7 Additionally, pregnancy, recent con-
sumption of oral contrast, degenerative changes, severe de-
formities, and the presence of a foreign body in the study 
area are the other disadvantages of DXA. 
Moreover, the precision of BMD measurement may be 
disrupted by vascular calcification and obesity. An alter-
native method of bone density measurement is the verte-
bral bone quality (VBQ) score, measured based on 
Magnetic Resonance Imaging (MRI). One of the advan-
tages of MRI is that since osteoporosis is an asympto-
matic disease, many patients are not examined with 
DXA, and their condition is not detected. However, the 
same patients may be scanned with MRI because of low 
back pain and complications caused by osteoporosis.9 
Due to few studies in these fields and various findings in 
different studies,10,11 we aimed to determine MRI-based 
vertebral bone quality score accuracy for osteoporosis in 
patients undergoing lumbosacral fusion surgery for lum-
bar degenerative diseases. 
 
 
Materials and Methods 
Study design and participants 
This prospective cohort study was conducted at Shahid 
Madani Educational and Medical Center, Karaj, Iran, from 
April 2021 to November 2022. Based on inclusion and ex-
clusion criteria, we enrolled 139 patients referred to our 
center due to lumbar degenerative diseases. Aged more 
than 50 years men and women (only postmenopausal), 
candidates for lumbar fusion surgery for degenerative dis-
eases of the lumbar spine, underwent lumbar DXA and 
lumbosacral noncontract T1 weighted MRI (1.5 T) within 
eight weeks before surgery, and consent to participate in 
the study, were inclusion criteria. Exclusion criteria in-
cluded a history of spine tuberculosis, spinal infection, 
malignancies, Modic changes, bone islands, metastasis, 
bone masses, radiotherapy treatment, diagnosis of meta-
bolic bone disease, previous spinal fracture, and lumbar 
spine surgery. For each patient who met the inclusion crit-
eria, demographic information was collected, including 
age, gender, Body Mass Index (BMI), comorbidities (Dia-
betes mellitus, cardiovascular diseases, rheumatic dis-
eases), smoking history (current smoker), long-term 
corticosteroid use (therapeutic daily doses more than 30 
days during last day) and prior diagnosis of osteoporosis 
and osteopenia during the previous year. 
 
Bone mass densitometry and diagnostic category 
All patients underwent a DXA of the lumbar spine (L1-4) 
under the supervision of a rheumatologist within eight 
weeks before surgery in a single center. Patients were ex-
amined by DXA (Lunar DPX-Bravo, GE Healthcare) of the 
lumbar spine (L1-4) according to the manufacturer’s stan-
dard protocol, and T-scores were recorded. The osteoporosis 
diagnostic categories from the World Health Organization 

were used to categorize the areal BMD measured with 
DXA: osteoporosis, T score≤-2.5; osteopenia; -2.5 <T 
score<-1; and normal T score≥-1. 
 
MRI-based VBQ score 
Noncontract T1 weighted MRI of the lumbar spine (L1-4) 
was conducted by 1.5 T MRI (Philips Ingenia, Eindhoven, 
the Netherlands) with a standard protocol including sagittal 
cuts for L1–L4 vertebra using T 1 weighted spine-echo 
sequence (TSE, repetition time=400 ms, echo time=16 ms, 
squared field of view=160 * 304 * 48 mm, slice thick-
ness=4 mm). 
Two authors (Orthopedic and radiology specialists) who 
were blinded to patients’ DXA results calculated the VBQ 
score for each patient independently. To measure the Ver-
tebral Bone Quality (VBQ) score, the Regions Of Interest 
(ROIs) are first placed in the middle of the L1 to L4 verte-
brae and the cerebrospinal fluid at the L3 level. Then, signal 
intensities (SI) are calculated in each ROI. 
The VBQ score is calculated according to the SI correspon-
ding to each ROI with the help of the following formula 
(The location of ROIs and how to calculate VBQ is accord-
ing to the study of Ehresman et al.):11 

 
 

 
 
Statistical analysis 
For descriptive analysis, data normality was assessed 
using Kolmogorov-Smirnov and Shapiro-Wilk Tests. In 
the case of data normality, an independent t-test was used, 
and Mann-Whitney for non-normally distributed data. 
Categorical data are expressed as percentages and were 
analyzed using Fisher’s exact test (using IBM SPSS Sta-
tistics software, version 28.0, SPSS, Chicago, Illinois). 
The Pearson correlation coefficient was used to analyze 
the correlation between the T-score and the VBQ score 
and inter-rater reliability was calculated for the VBQ core 
(using MedCalc for Windows Software, version 19.4, Os-
tend, Belgium). A receiver operating characteristic curve 
(ROC) was used (using MedCalc for Windows Software, 
version 19.4, Ostend, Belgium) to analyze the differential 
value of the VBQ score in osteoporosis and calculate its 
specificity, sensitivity, and area under the curve (AUC). 
The Youden index was used to determine the cutoff value 
for the VBQ score to differentiate patients with osteopo-
rosis/osteopenia and osteoporosis. A p-value <0.05 was 
considered statistically significant. 
 
 
Results 
Of 139 patients who met the inclusion criteria, 134 were 
examined in this study, and five were excluded because of 
incomplete data. The mean age of patients was 67.6 
(Sd=8.5) and 59% (n=79) were female. The most common 
primary diagnosis was lumbar disc herniation (75.4%, 
n=101). Osteopenia/osteoporosis had been diagnosed prior 
in 19.4% (n=26). Regarding BMD, Based on DXA T-score 
results, osteoporosis (23.1%, n=31), osteopenia (38.1%, 

- 2 -

Non
-co

mmerc
ial

 us
e o

nly



Osteoporosis new diagnosis tool in lumbosacral fusion surgery 
Eur J Transl Myol 34 (4) 12311, 2024 doi: 10.4081/ejtm.2024.12311

n=51), and normal BMD (38.8%, n=52) were diagnosed. 
The characteristics of patients are shown in Table 1. 
The mean VBQ score in Osteopenia/Osteoporosis patients 
was significantly higher than normal BMD patients 
(P<0.001). The mean DXA T score of the lumbar spine was 
-1.03 (Sd=1.49). VBQ score and lumbar DXA T score were 
found to have a significant linear correlation (r value= 
-0.415, p<0.001), Figure 1. Between the two independent 
authors, the VBQ score inter-rater reliability was good 
(ICC=0.84).  
Using ROC to analyze VBQ score AUC, as diagnostic tools 
for Osteopenia/Osteoporosis and osteoporosis were 0.730 
(Cl 95% 0.647-0.803, P<0.001) and 0.839 (Cl 95% 0.765-
0.897, P<0.001), respectively (Figures 2 and 3). The sensi-
tivity, specificity, and cut-off value of the VBQ score based 
on the highest Youden index for diagnosing osteopenia/os-
teoporosis and osteoporosis are calculated and are shown 
in Table 2. 
 
 
Discussion 
This study aimed to determine MRI-based VBQ score ac-
curacy for osteoporosis diagnosis in patients undergoing 
lumbosacral fusion surgery. Osteoporosis is a prevalent 
condition defined by reduced bone mass and deterioration 
of bone microarchitecture. It has become a worldwide epi-
demic, mainly attributed to the increasing proportion of eld-
erly individuals.12,13 Many patients fail to receive timely 

diagnoses, resulting in inadequate identification and man-
agement and, underdiagnosis and under-treatment.14 It is 
imperative to know the patient’s BMD status before spinal 
fusion surgery in terms of the occurrence of complications 
and fractures; on the other hand, in many patients (for var-
ious reasons such as the lack of request by the surgeon and 
the impossibility of doing DXA), the DXA BMD results 

- 3 -

 
Table 1. The characteristics of patients. 

Variables*                               Total                             Normal BMD        Osteopenia/Osteoporosis           P value 
                                            n=134 (%)                            n=52 (%)                        n=82, (%) 

Age (years)                         67.68 (8.55)                          66.34 (8.81)                     68.53 (8.33)                        0.163 

Gender (male)                       55 (41.0)                               25 (48.1)                          30 (36.5)                           0.210 

BMI (Kg/m2)                       26.68 (3.69)                          26.22 (3.74)                     26.96 (3.64)                        0.261 

Smoking (yes)                         9 (6.7)                                   1 (1.9)                              8 (9.8)                             0.153 

Long-term steroid use             4 (3.0)                                   1 (1.9)                              3 (3.7)                             0.999 

Comorbidities 
  Diabetes mellitus                 20 (14.9)                                6 (11.5)                            14 (17.1)                           0.461 
  Cardiovascular diseases      42 (31.3)                               19 (36.5)                          23 (28.0)                           0.342 
  Rheumatoid diseases             7 (5.2)                                   2 (3.8)                              5 (6.1)                             0.706 

Primary diagnosis 
  Lumbar disc herniation      101 (75.4)                              42 (80.8)                          59 (72.0)                           0.306 
  Lumbar spinal stenosis        33 (24.6)                               10 (19.2)                          23 (28.0)                                

VBQ score                           3.22 (0.52)                            2.99 (0.44)                       3.37 (0.51)                        <0.001 

*Continuous variables were expressed as means and standard deviation; Categorical variables represent counts 
and frequencies. BMI, Body mass index; VBQ, Vertebral bone quality.

Figure 1. VBQ score correlated with the Lumbar DXA T 
score.

Non
-co

mmerc
ial

 us
e o

nly



Osteoporosis new diagnosis tool in lumbosacral fusion surgery 
Eur J Transl Myol 34 (4) 12311, 2024 doi: 10.4081/ejtm.2024.12311

before surgery is not available.10,15,16 DXA screening rates 
in eligible individuals are low despite effective therapies 
for poor bone quality.17 Therefore, many surgical patients 
arrive without baseline DXA data. When patients need 
spine fusion surgery, DXA might delay surgery. Con-
sequently, it is essential to use available alternative diagnos-
tic/screening methods.  
We enrolled 134 patients and 82 were diagnosed with os-
teoporosis/osteopenia (Lumbar DXA T score <-1). In os-
teoporosis/osteopenia patients, the VBQ score was 
significantly higher than in normal BMD patients, and a 
significant negative linear correlation was found between 
the VBQ score and the lumbar DXA T score. In the study 
of Ehresman et al.,10 by examining spinal surgery patients, 
a significant difference was seen in the VBQ score of pa-
tients with osteoporosis/osteopenia compared to patients 

with normal BMD, and a negative and significant correla-
tion was observed between VBQ score and lumbar DXA T 
score, which is in line with our findings. The Pu et al.18 
study reported similar results regarding the correlation be-
tween VBQ score and lumbar DXA T score in spinal sur-
gery patients. A systematic review and meta-analysis also 
found moderate and negative significant correlations be-
tween VBQ score and lumbar DXA T score in spinal sur-
gery patients.19 These findings show the significant 
correlations between these two scores in patients who are 
candidates for spinal surgery, which is very important in 
identifying alternative diagnostic/screening methods for 
BMD in these patients.  
Regarding the accuracy of the VBQ score for diagnosing 
osteoporosis and osteopenia/osteoporosis in these patients 
based on the DXA lumbar T score WHO category, we 

- 4 -

 
Table 2. The accuracy of the VBQ score for diagnosing Osteopenia/Osteoporosis and osteoporosis based on the 
DXA T score category.  

Diagnosis                                 AUC        CI 95%          Yo           Cut-off           SE               SP           P value 

Osteoporosis                            0.839     0.765-0.897      0.54            3.38           83.87          70.87         <0.001 

Osteopenia/Osteoporosis         0.730     0.647-0.803      0.41            3.37           58.54          82.69         <0.001 

AUC, Area under the curve; Yo, Youden index; SE, Sensitivity; SP, Specificity. 

Figure 3. Area under the curve (AUC) using ROC anal-
ysis illustrating the accuracy of VBQ score for osteopo-
rosis diagnosis based on lumbar DXA T score category.

Figure 2. Area under the curve (AUC) using ROC anal-
ysis illustrating the accuracy of VBQ score for osteope-
nia/osteoporosis diagnosis based on lumbar DXA T 
score category.

Non
-co

mmerc
ial

 us
e o

nly



Osteoporosis new diagnosis tool in lumbosacral fusion surgery 
Eur J Transl Myol 34 (4) 12311, 2024 doi: 10.4081/ejtm.2024.12311

found the AUC of 0.83 and 0.73, with VBQ score cut-off 
value of 3.38 and 3.37, respectively. The sensitivity and 
specificity were 83% and 70% for osteoporosis and 58% 
and 82% for osteopenia/osteoporosis, respectively. Ehres-
man et al.10 found a similarly high sensitivity (81%) for 
the VBQ score in diagnosing osteoporosis/osteopenia. Al-
though their study had a smaller sample size, the AUC of 
0.81 indicates a robust discriminatory ability, which aligns 
with our findings. Pu et al.18 reported slightly higher speci-
ficities (87%) for osteoporosis diagnosis with a VBQ 
score greater than 3.05. They have also demonstrated good 
AUC values for osteoporosis (0.81) and osteopenia (0.79), 
which aligns with the diagnostic accuracy we observed. 
Salzmann et al.20 found a VBQ score cutoff value of more 
than 2.38 for osteoporosis/osteopenia diagnosis, sensitiv-
ity (74%) and specificity (57%) were slightly lower, the 
AUC of 0.70 still suggests a reasonable discriminatory ca-
pacity for the VBQ score in diagnosing bone density ab-
normalities. Chang et al.21 reported an excellent AUC of 
0.80 for the VBQ score in diagnosing osteoporosis/os-
teopenia in patients with spinal degenerative disease. Kim 
et al.22 study revealed that a greater VBQ score was asso-
ciated with the presence of osteoporosis (area under the 
curve=0.754, P=0.006). The cut-off VBQ for osteoporosis 
was 2.6 (Youden index 0.484; sensitivity: 58%; specific-
ity: 90%), which further supports the VBQ score’s dia-
gnostic potential. Also, a recent study found that the VBQ 
score was independently associated with low BMD (OR: 
4.134, 95% CI 2.136–8.000, P< 0.001), and the area under 
the ROC curve indicated that the diagnostic accuracy of 
the VBQ score for predicting low BMD was 81% in pa-
tients with adolescent idiopathic scoliosis.23  
In light of the findings, as mentioned earlier, our research 
highlights the importance of the VBQ score in assessing 
bone density in patients enduring lumbosacral fusion sur-
gery. Osteoporosis is a global health concern, especially 
among the geriatric population, necessitating accurate and 
prompt diagnoses. Before surgery, patients frequently lack 
baseline DXA data, which can potentially delay vital proce-
dures. The VBQ score is a valuable alternative diagnostic 
and screening tool in this context. 
This prospective cohort study’s strengths include well-de-
fined inclusion and exclusion criteria, multiple diagnostic 
tools (DXA and MRI-based VBQ score) to assess bone den-
sity, robust statistical analysis methods, and clinical rel-
evance in addressing alternative diagnostic approaches in 
osteoporosis patients undergoing spinal surgery. The study’s 
single-center nature, small sample size, and lack of external 
validation limit its generalizability and scope. These 
strengths and limitations should guide this field’s research 
interpretation and direction. 
 
 
Conclusions 
In conclusion, our study highlights the potential of the 
MRI-based Vertebral Bone Quality (VBQ) score as a 
promising tool for assessing bone density in patients un-
dergoing lumbosacral fusion surgery. Osteoporosis, a 
widespread health concern, necessitates effective diagnos-
tic methods, and traditional approaches like Dual-energy 

X-ray absorptiometry (DXA) have limitations. Our find-
ings demonstrate a significant correlation between VBQ 
scores and lumbar DXA T scores, indicating the potential 
of VBQ as an alternative diagnostic tool. The study also 
shows higher VBQ scores in patients with osteoporosis or 
osteopenia, suggesting its diagnostic accuracy. However, 
the study acknowledges limitations such as its single-
center nature and the need for larger-scale validation 
studies. Despite these limitations, our results suggest that 
the VBQ score could be a valuable alternative for timely 
osteoporosis diagnosis in the context of spinal surgery, im-
proving patient care. 
 
 
List of abbreviations 
VBQ, Vertebral bone quality 
MRI, Magnetic resonance imaging 
DXA, Dual-energy X-ray absorptiometry 
BMD, Bone mineral density 
WHO, World Health Organization 
AUC, Area under the curve 
Yo, Youden index 
SE, Sensitivity 
SP, Specificity 
ROC, Receiver operating characteristic curve 
 
 
Contributions 
Conceptualization: AN; Methodology: ABB, AM; Formal 
analysis and investigation: AM, SA, DH, DC; Writing - 
original draft preparation: DH, PC; Writing - review and 
editing: SA, AN, PC, Supervision: ABB. All authors read 
and approved the final manuscript. 
 
 
Conflict of interest 
No funding was received for conducting this study. The au-
thors have no relevant financial or non-financial interests 
to disclose.  
 
 
Ethics approval 
All procedures performed in studies involving human par-
ticipants were under the ethical standards of the institutional 
and/or national research committee and with the 1964 Hel-
sinki Declaration and its later amendments or comparable 
ethical standards. The Alborz University of Medical 
Sciences Ethics Committee approved the study protocol 
(Project number: IR.ABZUMS.REC.1400202). 
 
 
Consent to participate 
Informed consent was obtained from all individual partici-
pants included in the study.  
 
 
Availability of data and materials 
The datasets generated during and/or analyzed during the 

- 5 -

Non
-co

mmerc
ial

 us
e o

nly



Osteoporosis new diagnosis tool in lumbosacral fusion surgery 
Eur J Transl Myol 34 (4) 12311, 2024 doi: 10.4081/ejtm.2024.12311

current study are available from the corresponding author 
upon reasonable request. 
 
 
Acknowledgments 
The authors thank Shahid Madani’s clinical research devel-
opment unit for their assistance. 
 
 
Corresponding author 
Pouria Chaghamirzayi, MD, Clinical research development 
unit of Shahid Madani Hospital, Alborz University of Med-
ical Science, Karaj, Iran. 
Tel.: +98.9028902005 
ORCID ID: 0000-0002-0100-1190 
E-mail: Pouriachaghamirzayi@yahoo.com   
 
Arvin Najafi 

ORCID ID: 0000-0002-1762-7876 
E-mail: Arvin.najafi@gmail.com 
 
Ali Baradaran Bagheri 

ORCID ID: 0000-0002-8964-8430 
E-mail: parsmedicine@gmail.com 
 
Dorsa Hadavi  
ORCID ID: 0000-0002-1068-5790 
E-mail: Hadavidorsa@gmail.com 
 
Aidin Mobedi  
ORCID ID: 0000-0002-8577-9687 
E-mail: Aidinmobedi.med@gmail.com 
 
Salman Azarsina 
ORCID ID: 0000-0001-6167-5499 
E-mail: Dr.Sazarsina@gmail.com 
 
 
References 
  1. Aibar-Almazán A, Voltes-Martínez A, Castellote-Ca-

ballero Y, et al. Current status of the diagnosis and man-
agement of osteoporosis. Int J Molecular Sci 2022; 
23:9465. 

  2. Nowakowska-Płaza A, Wroński J, Płaza M, et al. Dia-
gnostic agreement between radiofrequency echographic 
multispectrometry and dual-energy X-ray absorptiome-
try in the assessment of osteoporosis in a Polish group 
of patients. Polish Arch Intern Med (Polskie Archiwum 
Medycyny Wewnetrznej) 2021;131:840-7. 

  3. Alawi M, Begum A, Harraz M, et al. Dual-energy X-
ray absorptiometry (DEXA) scan versus computed to-
mography for bone density assessment. Cureus 
2021;13. 

  4. Lane NE. Epidemiology, etiology, and diagnosis of os-
teoporosis. Am J Obstetr Gynecol 2006;194:S3-S11. 

  5. Chang E, Nickel B, Binkley N, et al. A novel osteo-
porosis screening protocol to identify orthopedic sur-
gery patients for preoperative bone health 
optimization. Geriatric Orthop Surg Rehabil 2022;13: 
21514593221116413. 

  6. Mugge L, DeBacker Dang D, Caras A, et al. Osteopo-
rosis as a risk factor for intraoperative complications 
and long-term instrumentation failure in patients with 
scoliotic spinal deformity. Spine 2022;47:1435-42. 

  7. Fathima SN, Selvi RT, Beham MP. Assessment of BMD 
and Statistical Analysis for Osteoporosis Detection. 
Biomed Pharmacol J 2019;12:1907-14. 

  8. Ginsberg C, Ix JH. Diagnosis and management of os-
teoporosis in advanced kidney disease: a review. Am J 
Kidney Dis 2022;79:427-36. 

  9. Shayganfar A, Khodayi M, Ebrahimian S, Tabrizi Z. 
Quantitative diagnosis of osteoporosis using lumbar 
spine signal intensity in magnetic resonance imaging. 
Br J Radiol 2019;92:20180774. 

10. Ehresman J, Pennington Z, Schilling A, et al. Novel 
MRI-based score for assessment of bone density in op-
erative spine patients. Spine J 2020;20:556-62. 

11. Ehresman J, Ahmed AK, Lubelski D, et al. Vertebral 
bone quality score and postoperative lumbar lordosis 
associated with need for reoperation after lumbar fu-
sion. World Neurosurg 2020;140:e247-e52. 

12. Sözen T, Özışık L, Başaran NÇ. An overview and man-
agement of osteoporosis. Eur J Rheumatol 2017;4:46. 

13. Rachner TD, Khosla S, Hofbauer LC. Osteoporosis: 
now and the future. Lancet 2011;377:1276-87. 

14. Lewiecki EM, Leader D, Weiss R, Williams SA. Chal-
lenges in osteoporosis awareness and management: re-
sults from a survey of US postmenopausal women. J 
Drug Assess 2019;8:25-31. 

15. Soshi S, Shiba R, Kondo H, Murota K. An experimental 
study on transpedicular screw fixation in relation to os-
teoporosis of the lumbar spine. Spine 1991;16:1335-41. 

16. Halvorson TL, Kelley LA, Thomas KA, et al. Effects 
of bone mineral density on pedicle screw fixation. Spine 
1994;19:2415-20. 

17. Dell R, Greene D. Is osteoporosis disease management 
cost effective? Curr Osteop Rep 2010;8:49-55. 

18. Pu M, Zhong W, Heng H, et al. Vertebral bone quality 
score provides preoperative bone density assessment for 
patients undergoing lumbar spine surgery: a retrospec-
tive study. J Neurosurg Spine 2023;1:1-10. 

19. Ahmad A, Crawford CH, 3rd, Glassman SD, et al. Cor-
relation between bone density measurements on CT or 
MRI versus DEXA scan: A systematic review. N Am 
Spine Soc J 2023;14:100204. 

20. Salzmann SN, Okano I, Jones C, Zhu J, Lu S, Onyek-
were I, et al. Preoperative MRI-based vertebral bone 
quality (VBQ) score assessment in patients undergoing 
lumbar spinal fusion. Spine J 2022;22:1301-8. 

21. Chen Z, Lei F, Ye F, et al. MRI-based vertebral bone 
quality score for the assessment of osteoporosis in pa-
tients undergoing surgery for lumbar degenerative dis-
eases. J Orthop Surg Res 2023;18:257. 

22. Kim AYE, Lyons K, Sarmiento M, et al. MRI-Based 
Score for Assessment of Bone Mineral Density in Op-
erative Spine Patients. Spine (Phila Pa 1976) 2023;48: 
107-12. 

23. Yang D-d, Li Y, Tian J-y, et al. MRI-based vertebral 
bone quality score as a novel bone status marker of pa-
tients with adolescent idiopathic scoliosis. Sci Rep 
2024;14:12518. 

- 6 -

Non
-co

mmerc
ial

 us
e o

nly

mailto:Pouriachaghamirzayi@yahoo.com
mailto:Arvin.najafi@gmail.com
mailto:parsmedicine@gmail.com
mailto:Hadavidorsa@gmail.com
mailto:Aidinmobedi.med@gmail.com
mailto:Dr.Sazarsina@gmail.com


Osteoporosis new diagnosis tool in lumbosacral fusion surgery 
Eur J Transl Myol 34 (4) 12311, 2024 doi: 10.4081/ejtm.2024.12311

Disclaimer 
All claims expressed in this article are solely those of the 
authors and do not necessarily represent those of their af-
filiated organizations, or those of the publisher, the editors 
and the reviewers. Any product that may be evaluated in 
this article or claim that may be made by its manufacturer 
is not guaranteed or endorsed by the publisher. 

Submitted: 25 January 2024. 
Accepted: 21 June 2024. 

Early access: 16 September 2024.

- 7 -

Non
-co

mmerc
ial

 us
e o

nly