Association of osteopenia and osteoporosis with higher rates of pseudarthrosis and revision surgery in adult patients undergoing single-level lumbar fusion

Abstract

OBJECTIVEPatients with osteopenia or osteoporosis who require surgery for symptomatic degenerative spondylolisthesis may have higher rates of postoperative pseudarthrosis and need for revision surgery than patients with normal bone mineral densities (BMDs). To this end, the authors compared rates of postoperative pseudarthrosis and need for revision surgery following single-level lumbar fusion in patients with normal BMD with those in patients with osteopenia or osteoporosis. The secondary outcome was to investigate the effects of pretreatment with medications that prevent bone loss (e.g., teriparatide, bisphosphonates, and denosumab) on these adverse outcomes in this patient cohort.METHODSPatients undergoing single-level lumbar fusion between 2007 and 2017 were identified. Based on 1:1 propensity matching for baseline demographic characteristics and comorbidities, 3 patient groups were created: osteopenia (n = 1723, 33.3%), osteoporosis (n = 1723, 33.3%), and normal BMD (n = 1723, 33.3%). The rates of postoperative pseudarthrosis and revision surgery were compared between groups.RESULTSThe matched populations analyzed in this study included a total of 5169 patients in 3 groups balanced at baseline, with equal numbers (n = 1723, 33.3%) in each group: patients with a history of osteopenia, those with a history of osteoporosis, and a control group of patients with no history of osteopenia or osteoporosis and with normal BMD. A total of 597 complications were recorded within a 2-year follow-up period, with pseudarthrosis (n = 321, 6.2%) being slightly more common than revision surgery (n = 276, 5.3%). The odds of pseudarthrosis and revision surgery in patients with osteopenia were almost 2-fold (OR 1.7, 95% CI 1.26–2.30) and 3-fold (OR 2.73, 95% CI 1.89–3.94) higher, respectively, than those in patients in the control group. Similarly, the odds of pseudarthrosis and revision surgery in patients with osteoporosis were almost 2-fold (OR 1.92, 95% CI 1.43–2.59) and > 3-fold (OR 3.25, 95% CI 2.27–4.65) higher, respectively, than those in patients in the control group. Pretreatment with medications to prevent bone loss prior to surgery was associated with lower pseudarthrosis and revision surgery rates, although the differences did not reach statistical significance.CONCLUSIONSPostoperative pseudarthrosis and revision surgery rates following single-level lumbar spinal fusion are significantly higher in patients with osteopenia and osteoporosis than in patients with normal BMD. Pretreatment with medications to prevent bone loss prior to surgery decreased these complication rates, although the observed differences did not reach statistical significance.

Cortical Trajectory Fixation Versus Traditional Pedicle-Screw Fixation in the Treatment of Lumbar Degenerative Patients with Osteoporosis: A Prospective Randomized Controlled Trial

“…It has been well proven that surgical complications, such as instrument failure (cage migration, screw loosening, and pseudarthrosis) and subsequent vertebral compression fractures, correlate with osteoporosis. 24,25 Both PS loosening and cage migration are correlated with an increase in back pain, rate of nonunion, and pseudarthrosis, leading to poor quality of life. 26,27 In the treatment of elder patients with osteoporotic LDD, many surgical techniques have hsve shown satisfactory fusion rates and good stability, including cement augmentation of PS, expandable PSs, and CBT-screw fixation.…”

Emerging Issues Questioning the Current Treatment Strategies for Lumbar Disc Herniation

“…Smoking, metabolic disorders, surgical instrumentation and technique, and fusion location have been demonstrated as the risk factors for pseudarthrosis ( 103 , 104 ). In addition to this, osteopenia and osteoporosis have been suggested as another risk factor for pseudarthrosis, and implant failure, such as screw loosening ( 105 , 106 ). Post-operative back pain was reported in the patients undergoing lumbar fusion procedures.…”

Cervical Spondylotic Myelopathy: An Updated Review

“…Optimizing medical conditions prior to spine surgery is being increasingly performed to improve outcomes, and avert adverse events [19]. Khalid, et al [20] reported higher rates of postoperative pseudoarthrosis and revision surgery following a single-level lumbar spinal fusion in patients with osteopenia and osteoporosis compared to patients with normal Bone mineral densities (BMD). The authors note that pretreatment with medications to prevent bone loss prior to surgery decreased complication rates.…”