Emerging MRI-based spine scoring techniques targeting bone quality to assess osteoporosis, vertebral fracture risk, other spinal degenerative diseases, and post-surgical outcomes.

Osteoporosis is a metabolic skeletal disease defined by reduced bone mass and a higher risk of vertebral fractures. Due to the increasing elderly population worldwide, it is considered a major healthcare challenge for now and the future. Magnetic resonance imaging (MRI), a non-radiation modality, is emerging as an opportunistic tool for assessing osteoporosis using T1-weighted images. While extensive research has been conducted in this area, a unified and comprehensive review encompassing current knowledge, methodologies, diagnostic efficacy, and prospective research direction is still needed. Hence, this review aimed to evaluate the role of emerging MRI scoring techniques for assessing osteoporosis, predicting vertebral fracture risks, evaluating other spinal degenerative diseases, and determining spine surgical outcomes. We highlighted the fundamentals of MRI scoring techniques and their types (anatomical regions, MRI sequences, and field strengths) and also provided an overview of their diagnostic performance in the clinical applications of osteoporosis, vertebral fractures, degenerative diseases, and bone quality, both pre- and postoperatively. The prediction of new fractures and surgical outcomes, i.e., pedicle screw loosening, proximal junction kyphosis, and cage subsidence, was also presented. Considering the pathophysiology of osteoporosis, this review revealed true representation by MRI scores in defining bone quality. Finally, we discussed factors that influence threshold scores, generalizability, reliability, correlations, and lastly, suggested future directions.