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OPEN CT Hounsfield unit is a reliable

parameter for screws loosening
or cages subsidence in minimally
invasive transforaminal lumbar
interbody fusion
Yu‑Cheng Yao 1,2, Hsien Chao 2,3, Kun‑Yu Kao 2,4, Hsi‑Hsien Lin 1,2, Shih‑Tien Wang 1,2,5,
Ming‑Chau Chang 1,2, Chien‑Lin Liu 1,2 & Po‑Hsin Chou 1,2*

Retrospective cohort study. To validate computed tomography (CT) radiodensity in Hounsfield units
(HU) as a prognostic marker for pedicle screw loosening or cage subsidence in minimally invasive
transforaminal lumbar interbody fusion (MI-TLIF). The retrospective study involved 198 patients
treated with MI-TLIF. Screw loosening (SL), cage subsidence (CS), and fusion status were assessed by
plain radiographs. The risk factors of SL and CS were identified using logistic regression. A total of 258
levels and 930 screws were analyzed. During a 2-year follow-up, 16.2% and 24.7% of patients had CS
and SL respectively. The cut-off value of L1 HU for predicting SL or CS was 117. The L1 HU < 117 and
BMI ≥ 25 were two independent risk factors. The risk of SL or CS was 4.1 fold in patients L1 HU < 117
and 2.6 fold in patients with BMI ≥ 25. For patients concurrently having BMI ≥ 25 and pre-op L1
HU < 117, the risk was 4.3 fold. Fusion rate and clinical outcome were comparable in patients with SL
or CS. L1 HU < 117 and BMI > 25 were two independent risk factors that can be screened preoperatively
for preventing SL or CS and lead to better management of patients undergoing MI-TLIF.

Lumbar degenerative disease is prevailing worldwide causing refractory low back pain and neurological symp-
toms and may require surgery for ­management1. Transforaminal Lumbar Interbody Fusion (TLIF) is the preferred
treatment choice for degenerative lumbar disease g­ lobally2, which was proposed in 1998 by Harms et al.3. TLIF
is an effective method for the management of a variety of degenerative lumbar diseases. A recent study revealed
good functional outcomes and fusion rates in patients who underwent ­TLIF4. Minimally invasive-TLIF (MI-
TLIF), prevents peri-operative complications such as soft tissue or muscle injury and is associated with low esti-
mated blood loss (EBL), fewer recovery days, and allowing early ambulation to preserve patients’ muscle p ­ ower5.
Cage subsidence and screw loosening are two common complications associated with TLIF with an incidence
rate of 15–34%6–8 and 7–25%9,10 respectively. These complications may cause non-union and are associated with
the clinical outcomes of back pain, leg pain, or diminished physical f­ unction11. Osteoporosis decreases bone
strength (including bone quality and density), by altering the microarchitecture of the bone. Consequently, low
bone mass may increase the complications associated with spine ­surgery12. Recent research has revealed that
osteoporosis promotes complications including cage subsidence and screw ­loosening7,13,14, which significantly
increases overall complications rates after ­TLIF15. Therefore, identifying patients with osteoporosis before surgery
and managing it may largely reduce the incidence of surgical complications.
Dual-energy X-ray absorptiometry (DXA) is the standard tool for evaluating bone mineral density (BMD)16.
However, DXA associated with cortical margins of vertebrae, spinal degeneration such as osteophytes, vascular
calcifications, scoliosis and post-spine surgery may be misinterpreted as increased ­BMD17. DXA is expensive
and carries a risk of higher radiation ­exposure18. Alternatively, studies suggest using vertebral Hounsfield Units
(HU), a quantitative scale for describing radiodensity from existing CT scans to evaluate BMD without additional
cost, time, or radiation exposure. HU is a proven marker for o ­ steoporosis19–21. The HU reading at the L1 level

1
Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan. 2School
of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. 3Department of Medical Education,
Chang Gung Memorial Hospital, Taoyuan, Taiwan. 4Department of Medical Education, Chi Mei Hospital, Tainan,
Taiwan. 5Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan. *email: [email protected]

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is being routinely used to study patients’ BMD of the lumbar ­spine19,22. The purpose of this investigation was to
determine whether preoperatively obtained HU at L1 level is a prognostic marker for predicting cage subsidence
or screw loosening in MI-TLIF and other associated risk factors.

Materials and methods

Study design and participants. The study is based on the retrospective data collected at a single institute
from October 2016 to February 2020. Institutional ethical approval was obtained before the start of this study
by the Human Research Ethics Committee at Taipei Veterans General Hospital (IRB No. 2022-01-018AC). All
methods were performed in accordance with the relevant guidelines and regulations, and all participants pro-
vided written, informed consent to participation.
The inclusion criteria were as follows: (1) Adult patients (2) Underwent MI-TLIF at 1- or 2- levels. (3) Fol-
lowed up for more than 2 years after surgery. (4) Underwent lumbar-CT scan within 6 months before surgery.
The exclusion criteria were: (1) Spinal infection, trauma, or tumor (2) Prior spine surgery (3) Patients lost to
follow-up. The patients were followed up on the 1st, 3rd, 6th, 12th, and 24th months following surgery. The
patients were screened using the visual analog scale score, Oswestry disability index scores, and radiographs
were obtained at each follow-up visit.

Surgical procedures. All surgeries were performed by a single senior surgeon. The patient was placed in
the prone position for fluoroscopy in the anteroposterior (AP) and lateral views to locate the affected level. The
surgical procedure for MI-TLIF included skin incision 2–3 cm laterally from the midline with bilateral decom-
pression and percutaneous pedicle screw insertion. We chose the same side showing sciatica symptoms to per-
form facetectomy. The decompression, disc preparation, and TLIF procedures were performed under a micro-
endoscopic retractor-assisted microscopic visualization. A morselized autologous bone graft accompanied with
a 1-ml demineralized bone matrix (OsteoSelect® DBM Putty, Bacterin International, Inc., Belgrade, MT, USA)
was used for fusion in all patients. We did not use any bone substitutes to increase the bulk of the bone grafts. We
used a banana-shaped polyetheretherketone (PEEK) cage (Rainboo® lumbar cage, A-SPINE, United Orthopedic
Corporation, Taiwan) in all MI-TLIF surgeries. There was no drainage tube insertion after the operation. Post-
­ onths7.
operative spinal bracing was prescribed to all patients for 3–6 m

Data collection. All data were collected through the electronic medical record and picture archiving com-
munication system. Patient demographics and preoperative details such as age, sex, body mass index (BMI),
comorbidities, surgical time, EBL, surgical level, and hospital stay were recorded. Overweight was defined as
BMI ˃ 25, as per the international classification system of the World Health Organization.

HU evaluation. A single brand of CT scanner (iCT256; Philips Brilliance) was used for all participants. CT
parameters included a slice thickness of 3 mm and a tube voltage of 120 kVp. Regions of interest (ROI) were
selected on the axial images of lumbar non-contrast CT at three separate locations: immediately inferior to the
superior end plate, in the middle of the vertebral body, and superior to the inferior end plate (Fig. 1). For each
measurement, the largest possible elliptical ROI was drawn in the vertebral body, excluding the cortical margins,
lateral walls, endplates, or obvious osteophytes to prevent volume averaging. The HU values from the three axial
slices were averaged to give a mean HU value for each lumbar vertebral b ­ ody19.

Radiographic assessment. Radiographic parameters were obtained by standing anterior–posterior lat-

eral plain radiographs. Index-level segmental lordosis was defined as the angle formed between the intersection
of lines parallel to the superior endplate of the cephalic surgical vertebra and the inferior end plate of the caudal
surgical vertebra on the lateral radiographs. Cage position was evaluated using a central point ratio (CPR),
which is the ratio of the distance between the cage midpoint to the posterior edge of the superior endplate of the
inferior vertebra (a) divided by the length of the superior endplate of the inferior vertebra (b) given by: (a/b ×
100%)7. A CPR > 0.5 indicated a more anteriorly displaced cage. Two lines parallel to the inferior endplate of the
superior vertebra and the superior end plate of the inferior vertebra of a disc space formed an intersection. The
angle was defined as disc ­angle23. Disc height was measured as the average of the anterior and posterior edges
of the disc s­ pace24 (Fig. 2). A ≥ 2 mm migration of the cage into the adjacent vertebral body was defined as cage
subsidence. The migration along the superior and/or inferior end plates were labeled as settling of the ­implant6
(Fig. 3). Screw loosening was defined as the presence of at least 1 mm thick radiolucent zone around any pedicle
­screws25 (Fig. 4). The criteria for a solid fusion were defined as bone bridges with at least half of the fusion area
with a minimum density as originally achieved at surgery, is considered to be mechanically solid fusion accord-
ing to BSF (Brantigan, Steffee, Fraser) ­Criteria26.

Statistical analyses. Statistical analyses were performed using IBM SPSS Statistics, Version 25.0 (IBM
Corp., Armonk, NY, USA). Chi-square and Fisher exact tests were used to compare the categorical data of the
two groups. Independent t test was used to compare continuous data. To identify the risk factors for cage subsid-
ence or screw loosening, a univariate logistic regression (LR) analysis was performed. Variables with P ≤ 0.1 in
univariate analyses were entered into a logistic regression model. The results were presented as odds ratios (OR),
with 95% confidence intervals (CI). The receiver operating characteristics curve (ROC) was used to evaluate the
value of HU for predicting cage subsidence and screw loosening; the area under the curve (AUC) was calculated.
The two-tailed significance level was set at P < 0.05.

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Figure 1.  Computed tomography images illustrating the measurement of the HU value in a series of axial views
of L1 vertebrae. Regions of interest were measured on the axial images at three separate locations. Slice (A) was
taken just inferior to the superior end plate, slice (B) was chosen at the middle of the body, and slice (C) was
taken just superior to the inferior end plate. Averaged HU values of the three axial slices were cut-off HU values
for L1 vertebrae. HU hounsfield units.

Figure 2.  (1) The central point ratio (CPR) is the ratio of the distance between the midpoint of the cage and
the posterior edge of the endplate (a); divided by the length of the superior endplate of the inferior vertebra (b).
CPR = a/b × 100%. (2) Segmental lordosis angle (c) was measured at two lines parallel to the superior endplate
of the cephalic surgical vertebra and the inferior end plate of the caudal surgical vertebra of the index level. (3)
Disc height. Two vertical lines (e) and (f) are set at the anterior and posterior edge of the disc space, and the
average of e and f was defined as the disc height. (4) Disc angle. Two lines parallel to the inferior endplate of the
superior vertebra, intersect with the superior end plate of the inferior vertebra of disc space to form an angle.
The angle (d) was defined as the disc angle.

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Figure 3.  Cage subsidence was defined as a cage migrating more than 2 mm into the superior or inferior
endplate of adjacent vertebrae.

Figure 4.  Screw loosening was defined as the presence of at least 1 mm thick radiolucent zone around any
pedicle screw (Halo sign). Bilateral halo sign is evident on L3 level.

Results
Our study included 198 patients with 258 levels and 930 screws. The mean follow-up period for these patients
was 25.3 months. Among 198 patients, 131 were female (66.2%) and 67 were male (33.8%). The mean age of
patients was 66.9 years. Most patients underwent single-level surgery (61.6%), with the most affected level being
L4-L5 (44.4%) (Table 1).

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Variables Results (n = 198)

Clinical parameters
Age, years 66.9 ± 12.1
Sex (male/female) 67/131 (33.8%/66.2%)
Overweight 120 (60.6%)
Diabetes mellitus 48 (24.2%)
Hypertension 94 (47.5%)
Smoking 30 (15.2%)
Follow-up period, months 25.3 ± 11.0
Surgical parameters
Level of surgery
L34 7 (3.5%)
L45 88 (44.4%)
L5S1 27 (13.6%)
L234 3 (1.5%)
L345 46 (23.2%)
L45S1 27 (13.6%)
Total levels
1-level 122 (61.6%)
2-level 76 (38.4%)
Surgery time, minutes 233.7 ± 71.7
EBL, mL 394.7 ± 260.7
Hospital stay, days 7.5 ± 3.7

Table 1.  Demographics of the enrolled patients. Results are shown as mean ± standard deviation (range) or the
number of patients (%). BMI indicates body mass index, BMD bone mineral density, HU Hounsfield unit, VAS
visual analog scale, ODI Oswestry disability index, EBL estimated blood loss.

Radiographic results. During the 2-year follow-up, 32 patients had cage subsidence (16.2%), 49 patients
had screw loosening (24.7%), and none of the patients encountered breaking of screws. Out of 258 cages, 34
occurrences of cage subsidence were noted, and the incidence rate of cage subsidence by the number of cages was
13.2%. Out of 930 screws that were analyzed, 100 screw loosening occurrences were noted, and the incidence
rate of screw loosening by the number of screws was 10.8%.
We classified patients into two groups: patients who encountered cage subsidence or screw loosening were
classified into the “CS/SL” group. Patients who did not encounter cage subsidence and screw loosening were
classified into the “Non-CS/SL” group.
There were 70 patients (35.3%) in the CS/SL group.
The preoperative L1 HU was significantly lower in the CS/SL group than in the Non-CS/SL group (108.3 ± 45.3
vs. 139.8 ± 51.7, P < 0.001). There were no significant differences in age, sex, diabetes, hypertension, and smoking
habits between the two groups (Table 2).
There were more overweight patients (72.9%, P = 0.009) in the CS/SL group. Cage position, disc angle, disc
height and index level segmental lordosis were not significantly different between the two groups at the preop-
erative and postoperative stages. The cut-off value for the mean HU used to predict cage subsidence or screw
loosening was 117 (sensitivity: 67.1%, specificity: 66.4%). The AUC was 0.686 (95% CI 0.608–0.765, P < 0.001).
The result of multivariate LR analysis showed that the variables ‘overweight’ and ‘L1 HU < 117’ were sig-
nificant risk factors associated with cage subsidence or screw loosening. The risk of cage subsidence or screw
loosening increased 2.596-fold (95% CI 1.328–5.075, P = 0.005) in overweight patients (BMI ≥ 25) and 4.100-
fold in patients with lower preoperative ‘L1 HU < 117’ (95% CI 2.173–7.737, P < 0.001). Furthermore, for the
patient with concurrent BMI ≥ 25 and L1 HU < 117, the OR was 4.291 with 95% CI 2.210–8.329, P < 0.001, and
power = 0.991 (Table 3).

Fusion rate and clinical outcomes. Analyses of the clinical outcomes revealed that both groups had
comparable pain-scale results and functional presentation preoperatively. The Non-CS/SL-group patients had
lower pain-scale results and better functional outcomes. The overall fusion rate was 82%, and a lower fusion rate
was noted in CS/SC group (75.7% vs. 84.4%); however, there was no significant difference between the groups
(P = 0.135). Ten patients (5.1%) underwent revision surgery due to nonunion and symptomatic screw loosening,
(four patients in Non-CS/SC group [3.1%]; six patients in CS/SC group [4.4%]. There was no significant differ-
ence between the groups (P = 0.171) (Table 4).

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Variables Non-CS/SL (n = 128) CS/SL (n = 70) P value

Age, years 65.8 ± 12.6 69.0 ± 11.0 0.08
Sex (male) 49 (38.2%) 18(26.8%) 0.074
Overweight 69 (53.9%) 51 (72.9%) 0.009
Diabetes mellitus 31 (24.2%) 17 (24.3%) 0.992
Hypertension 57 (44.5%) 37 (52.9%) 0.262
Smoking 23 (18.0%) 7 (10.0%) 0.135
Segmental LL_preop 16.9 ± 9.6 18.0 ± 11.3 0.533
Segmental LL_postop 17.4 ± 9.7 16.7 ± 10.2 0.693
Segmental LL_delta 0.5 ± 6.6 − 1.4 ± 4.5 0.057
Disc angle_preop 6.4 ± 4.7 7.0 ± 6.0 0.505
Disc angle_postop 8.6 ± 6.2 7.6 ± 5.2 0.384
Disc angle_delta 2.2 ± 5.0 0.6 ± 4.1 0.074
Disc height_preop 0.63 ± 0.26 0.65 ± 0.20 0.784
Disc height_postop 1.02 ± 0.23 0.91 ± 0.29 0.208
Disc height_delta 0.39 ± 0.25 0.32 ± 0.25 0.133
Disc height_delta (%) 225.5 ± 1343.4 59.8 ± 58.7 0.474
Central point ratio (%) 60.9 ± 18.5 59.7 ± 10.7 0.707
Preop L1 HU 139.8 ± 51.7 108.3 ± 45.3 < 0.001

Table 2.  Risk factors of cage subsidence or screw loosening. LL lumbar lordosis, HU Hounsfield unit, CS cage
subsidence, SL screw loosening. Significant values are in bold.

Univariate logistic regression Multivariate logistic

analysis regression analysis
Variable OR (95% CI) P value aOR (95% CI) P value
Age 1.023 (0.997–1.050) 0.083 – –
Gender (male) 0.558 (0.293–1.062) 0.076 – –
Overweight 2.295 (1.221–4.314) 0.01 2.596 (1.328–5.075) 0.005
Smoking 0.507 (0.206–1.250) 0.14 – –
Preop L1 HU < 117 3.789 (2.049–7.007) < 0.001 4.100 (2.173–7.737) < 0.001

Table 3.  Univariate logistic regression analyses and multivariate logistic regression analyses. HU hounsfield
units, OR odds ratio, CI confidence interval. Significant values are in bold.

Variables Non-CS/SL (n = 128) CS/SL (n = 70) P value

VAS_PreOP 6.0 ± 2.4 6.2 ± 2.7 0.599
VAS_PostOP 1.7 ± 1.8 2.6 ± 2.4 0.021
VAS_Delta − 4.1 ± 2.9 − 3.5 ± 3.2 0.248
ODI_PreOP 38.9 ± 15.6 43.7 ± 22.2 0.193
ODI_PostOP 11.8 ± 12.7 19.9 ± 17.4 0.002
ODI_Delta − 26.7 ± 18.6 − 22.7 ± 20.9 0.296
Fusion rate 108 (84.4%) 53 (75.7%) 0.135
Revision rate 4 (3.1%) 6 (8.6%) 0.171

Table 4.  Clinical outcomes of patients between groups. VAS indicates visual analog scale, ODI Oswestry
disability index, CS cage subsidence, SL screw loosening. Significant values are in bold.

Discussion
TLIF involving pedicle screw fixation and interbody cage placement, is a common approach for spine fusion, in
the majority of cases worldwide. Cage subsidence and screw loosening are the common mechanical complications
of TLIF. There are various risk factors for the occurrence of these complications; however, low BMD is the most
common risk f­ actor7,13,14. Our investigation confirmed that HU at the first lumbar level can be used to determine
BMD and to predict the occurrence of mechanical complications associated with MI-TLIF. Being overweight is
also a significant risk factor for cage subsidence or screw loosening following MI-TLIF.

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A survey among spine surgeons showed that only 44% of them routinely opted for DXA examinations prior
to instrumented f­ usion27. Degenerative changes in the lumbar spine can have a confounding effect by increasing
the DXA scores of lumbar BMD, leading to false-negative ­results28. Alternatively, the lumbar CT is one of the
routine examinations that is performed preoperatively. Spine surgeons may utilize the preoperative HU scores
of the lumbar CT scan instead of DXA, to evaluate whether patients are vulnerable to screw loosening or cage
subsidence following MI-TLIF.
The cage subsidence rate (16.2%) in our study was lower than that in other studies. Lin et al.29 showed that
the cage subsidence rate was 36% after 12 months of radiograph follow-up. Yao et al.7 demonstrated that the cage
subsidence rate was 34.1% in patients who underwent MI-TLIF surgery after 12 months of follow-up.
Studies attribute the low density of the cancellous bone to its weakened ability to resist the compression,
leading to cage subsidence. Meanwhile, CT-based HU values have shown a strong correlation with BMD, as the
ability of bone to withstand compression. Jie et al.30 reported that the mean global lumbar HU values of patients
with cage subsidence were significantly low vs. controls (112.4 vs. 140.2); HU of the surgical levels in patients
with cage subsidence was also significantly low vs. controls (113.4 vs. 127.9). Their cut-off values were 132 for
global and 122 for the surgical region.
Barbosa et al.31 established the cut-off HU value of 135 at the L1 level to predict potential cage subsidence.
They showed HU < 135 was an independent risk factor in cage subsidence with OR = 6 (95% CI 1.95–34) accord-
ing to the multivariate analysis.
Until recently, the correlation between BMI and cage subsidence was inconclusive. Most studies predicted that
higher BMI may contribute to a higher risk of cage subsidence. Behrbalk et al.32 reported that patients who had
subsidence after lumbar interbody fusion had significantly higher BMI vs. controls (29.2 vs. 22.1). In addition,
Yao et al.7 reported significantly higher BMI in the cage subsidence group after TLIF vs. controls (27.5 vs. 25.9).
Similarly, our study demonstrated that overweight patients had a 2.596-fold higher risk of cage subsidence or
screw loosening after MI-TLIF.
Previous studies have revealed that the position of the cage and the affected levels were risk factors for cage
­subsidence7. However, in our case, neither cage position nor the levels of fusion were statistically significant to
be the risk factors. The contrast may be attributed to the fact that our surgeons can usually place the cage in
similar positions; hence, the position of the two groups was not significantly different. There were other factors
that had a much stronger impact than these two factors in cage subsidence.
The screw loosening rate in our study (24.7%) was comparable to that of other studies. For example, Ohtori
et al.9 and Kim et al.6 demonstrated that the screw loosening rate was 7–25% after 12 months of follow-up for
short levels of fixation; Tokuhashi et al.33 reported the screw loosening rate was 26.8% after 12 months follow-up
in patients who underwent 1–4 levels of fixation.
Recent research has revealed that lower BMD has a detrimental effect on screw loosening. Poppenborg et al.13
reported that Osteoporosis, which is characterized by low BMD, was strongly associated with loosening. Bredow
et al.34 reported screw loosening in 45 of 365 patients screened. The study revealed that the screw loosening group
had a significantly lower CT-based HU vs. controls (116.3 vs. 132.7) and proposed the cut-off value of 120 HU
for global HU. Schwaiger et al.35 performed a retrospective review of 38 patients who underwent CT imaging
and found osteoporosis to be a significant risk factor for screw loosening in spine instrumentation. They used
117.9 HU as their cut-off which was obtained from the mean HU of L1, L2, and L3 levels, to identify patients with
the risk of screw loosening. In a study involving 253 patients, Zou et al.28 reported a lower preoperative HU in
patients with screw loosening vs. controls (106.8 vs. 129.8). The cut-off value, for identifying high-risk patients
in this study was 110 HU, which was obtained from mean HU of L1 to L4 levels.
Risk factors of screw loosening have also been studied. Wu et al.36 reported that patients with diabetes mellitus
had a significantly higher rate of screw loosening compared to controls (36.0% vs. 15.8%; p = 0.024). In addition,
well-controlled serum glucose (HbA1c ≤ 8.0%) was shown to significantly reduce the chance of screw loosening
(28.6% vs. 71.4%; p = 0.021). Yasushi et al.37 showed that high BMI was a risk factor for screw loosening after
lumbosacral fixation. Studies showed that obesity may increase the mechanical stress of the posterior instrument
due to the change in body shape, which could increase the screw loosening rate. These findings corresponded
to our investigation.
Our study is the first to investigate risk factors of cage subsidence and screw loosening simultaneously and
propose the HU cut-off to predict these complications after MI-TLIF. Low preoperative L1 HU and being over-
weight are indeed significant risk factors for cage subsidence and screw loosening following MI-TLIF. Our
findings are novel and could promote better surgical planning. Consequently, for patients whose preoperative
L1 HU < 117, pedicle screw fixation with bone cement a­ ugmentation38 and administration of t­ eriparatide9 can
be considered to prevent screw loosening. Controlling BMI by losing weight before lumbar fusion surgery also
can prevent the occurrence of both cage subsidence, and screw loosening. Furthermore, endplate sclerosis at
surgical levels may prevent the discovery of cage subsidence following lumbar fusion s­ urgery39.
Our study has a few limitations. Firstly, we did not investigate the relationship between cage subsidence and
endplate injury during surgery. Destruction of the endplate is a potential factor for cage subsidence. However,
all patients were all operated on by a single surgeon, with a consistent surgical technique. We did not measure
index level HU, which can be another limitation. Different scanning protocols may affect the results of HU, and
we applied only one type of CT scanner in the study. Asynchronous phantom-calibrated CT may be a solution
to improve accuracy and precision of measuring the B ­ MD40. Nico Sollmann et al.41. proposed a study that HU
measurments using asynchronous phantom-calibrated can have better correlation to results from QCT. However,
multiple conversion formula were proposed based on different type of CT scan and parameters, we still cannot
to choose a single formula to calibrate HU generally, which is a focus for future efforts.

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Conclusion
In conclusion, pre-operative L1 CT HU is a good predictor of cage subsidence or screw loosening in MI-TLIF.
Patients with both a pre-op L1 HU < 117 and a BMI > 25 may be 4.29 times more likely to experience cage sub-
sidence or screw loosening. Therefore, L1 HU < 117 and BMI > 25 were two independent risk factors that can be
screened preoperatively for preventing SL or CS and lead to better management of patients undergoing MI-TLIF.

Data availability
The datasets used and/or analysed during the current study available from the corresponding author on reason-
able request.

Received: 26 July 2022; Accepted: 20 January 2023

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Author contributions
Y.-C.Y. and P.-H.C. wrote the programs, designed the analysis. Y.-C.Y., H.C., K.-Y.K. and P.-H.C. analyzed the
data, and wrote the paper. H.-H.L., S.-T.W., M.-C.C. and C.-L.L. supervised the conception and edited the
manuscript. All authors discussed and commented on the manuscript.

Competing interests
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to P.-H.C.
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