Bone mineral density surrounding the screw thread predicts the risk of pedicle screw loosening

Screw loosening remains a serious complication for patients undergoing pedicle screw fixation surgeries. An accurate risk prediction is significant for prevention of screw loosening through preoperative planning. In this study, we proposed a novel index, namely the bone mineral density surrounding the screw thread (thread BMD), and tested its predictability in screw loosening.

86 screws (18 loosening and 68 non-loosening) from L3-L5 of 20 patients who experienced pedicle screw loosening were analyzed. The preoperative and postoperative quantitative CT scans of the same vertebra were spatially registered and a helix-based approach was developed to extract the thread BMD. BMDs of the vertebral body, the pedicle and the screw trajectory were also measured from the preoperative CT scans. Finite element analysis was conducted to determine pullout strength and tissue failure around the screw. Receiver operating characteristic (ROC) curve analysis was used to assess the performances of all BMD indices and pullout strength in predicting screw loosening. Linear regression was used to examine correlations between different BMD indices and screw pullout strength.

The thread BMD had the greatest value of area under the curve (AUC = 0.73, p = 0.004) compared to vertebral BMD (AUC = 0.51, p = 0.923), pedicle BMD (AUC = 0.56, p = 0.474) and trajectory BMD (AUC = 0.67, p = 0.020). Also, the thread BMD showed a stronger correlation with the pullout strength (r = 0.83, p < 0.001) than vertebral BMD (r = 0.59, p < 0.001), pedicle BMD (r = 0.65, p < 0.001) and trajectory BMD (r = 0.60, p < 0.001).

We developed a novel approach to measure a newly-defined thread BMD, which indicates superior capacities over other BMD indices in predicting pedicle screw loosening.