Management of Osteoporosis in Spine Surgery

Abstract

Osteoporosis is a burgeoning clinical problem that is characterized by decreased bone strength and density. It predisposes patients to fragility fractures and debilitating spine deformities. Several complications are associated with spine surgery in patients with osteoporosis, and there is currently no treatment algorithm to guide the spine surgeon. A multidisciplinary approach to treatment of patients with osteoporosis and spine deformity or fracture is encouraged, and preoperative planning is crucial for successful surgical outcomes. Several surgical techniques have been developed to treat osteoporosis-related deformities, including posterior instrumentation with fusion. However, achieving fixation and fusion in these patients can be difficult secondary to poor bone stock. Augmentation methods to improve pedicle screw fixation have evolved, including instrumentation at multiple levels, bioactive cement augmentation, and fenestrated or expandable pedicle screws, but their impact on clinical outcomes remains unknown. Management of osteoporosis in patients undergoing spine surgery is challenging, but with appropriate patient selection, medical optimization, and surgical techniques, these patients can experience pain relief, deformity correction, and improved function.

Osteoporosis in Cervical Spine Surgery

“…25,26 Spine surgery in patients with decreased bone mineral density has also been shown to be predisposed to pseudoarthrosis, adjacent level degeneration, progressive junctional kyphosis, and compression fractures, all of which might, but not necessarily, necessitate a revision procedure. 20,27 The finding that Medicare insurance status was more strongly associated with revision cervical spine surgery might be a reflection of the older age of Medicare patients and their generally higher comorbidities. 28 Urban hospitals were also found to have higher rates of revision cervical spine surgery.…”

“…It is reasonable to assume that options for adequate fixation become limited when patients with severe OS present for surgical consultation. 20 Surgeons might choose more complex constructs such as combined anterior-posterior fusion because they increase load sharing, decrease overall construct strain, and thus lead to increased stability. 20,21 Consequently, surgeons are not just treating the primary condition, but secondarily calculating the risk these patients have construct failure and future revision.…”

Association of bone mineral density with reoperation rate following instrumented lumbar spinal fusion: a retrospective cohort and case-control study

“…PMMA-augmented screw fixations and other technical modifications like long-segment constructs is considered to reduce the risk of instrumentation failure in osteoporotic patients (4,41,42). Multiple points of fixation have been recommended in the osteoporotic spine for a long time (43).…”

Perioperative Medical Management of Spine Surgery Patients With Osteoporosis

“…Because of complications associated with bisphosphonate use (including osteonecrosis of the jaw, serum calcium disruptions and renal impairment, and subtrochanteric femoral fractures), there is still no consensus on the use of these medications in managing osteoporosis. 45 PTH is also used to increase BMD and reduce fracture risk among high-risk patients. The animal studies [46][47][48] investigating PTH revealed that the therapy leads to increased fusion rate and improved fusion structure.…”