Osteoporosis treatment in patients undergoing spinal fusion: a systematic review and meta-analysis

Abstract

OBJECTIVE Bisphosphonates and teriparatide are the most common therapies used in the treatment of osteoporosis. Their impact on fusion rates in osteoporotic patients following spinal fusion has yet to be concretely defined, with previous systematic reviews focusing heavily on bisphosphonates and lacking clinical insight on the utility of teriparatide. Herein the authors present an updated meta-analysis of the utility of both bisphosphonates and teriparatide in improving spinal fusion outcomes in osteoporotic patients. METHODS After a comprehensive search of the English-language literature in the PubMed and Embase databases, 11 clinical studies were included in the final qualitative and quantitative analyses. Of these studies, 9 investigated bisphosphonates, 7 investigated teriparatide, and 1 investigated a combination of teriparatide and denosumab. Odds ratios and 95% confidence intervals were calculated where appropriate. RESULTS A meta-analysis of the postoperative use of bisphosphonate demonstrated better odds of successful fusion as compared to that in controls during short-term monitoring (OR 3.33, 95% CI 1.72–6.42, p = 0.0003) but not long-term monitoring (p > 0.05). Bisphosphonate use was also shown to significantly reduce the likelihood of postoperative vertebral compression fracture (VCF; OR 0.07, 95% CI 0.01–0.59, p = 0.01) and significantly reduce Oswestry Disability Index scores (mean difference [MD] = −2.19, 95% CI −2.94 to −1.44, p < 0.00001) and visual analog scale pain scores (MD = −0.58, 95% CI −0.79 to −0.38, p < 0.00001). Teriparatide was found to significantly increase fusion rates at long-term postoperative periods as compared to rates after bisphosphonate therapy, with patients who received postoperative teriparatide therapy 2.05 times more likely to experience successful fusion (OR 2.05, 95% CI 1.17–3.59, p = 0.01). CONCLUSIONS The authors demonstrate the benefits of bisphosphonate and teriparatide therapy independently in accelerating fusion during the first 6 months after spinal fusion surgery in osteoporotic patients. In addition, they show that teriparatide may have superior benefits in spinal fusion during long-term monitoring as compared to those with bisphosphonates. Bisphosphonates may be better suited in preventing VCFs postoperatively in addition to minimizing postoperative disability and pain.

Comparison of Fusion versus Nonunion After 4-Level and 5-Level Anterior Cervical Diskectomy and Fusion With Anterior Plate Fixation

“…It is well documented that poor bone density impairs arthrodesis. 21 Given the increased incidence of osteoporosis/osteopenia in postmenopausal women, 21 the strikingly high nonunion rates reported in this study may be explained by the overwhelming majority of female being 50 years and older in the nonunion cohort. That said, there were insufficient data to analyze bone density in this study because dual-energy x-ray absorptiometry (DEXA) scan is not routinely obtained in patients undergoing anterior cervical surgery in our practice.…”

“…Two 1level ACDF studies reported 12.5% to 14% revision rates with PEEK and 0% to 1.4% with allograft implants. 13,21 Bolesta et al 11 reported higher reoperation rate of 33.3% in their 3 to 4-level…”

Comparison of postoperative outcomes in patients with and without osteoporosis undergoing single-level anterior cervical discectomy and fusion

“…Another study found osteoporosis to be associated with greater incidence of nonunion [17] . Additional perioperative management of osteoporosis may improve outcomes, and several studies have shown that medical management of osteoporosis can improve fusion rates and reduce mechanical complications following spine surgery [ 11 , 18 , 19 ].…”

“…Anterior cervical decompression and fusion (ACDF) is commonly considered to address degenerative conditions of the cervical spine [1] , [2] , [3] , [4] , [5] , [6] . Noting that osteoporosis may be present in those being considered for ACDF [ 7 , 8 ], the correlation of osteoporosis with ACDF short- and longer-term outcomes is of interest as it may be associated with graft subsidence, bony union, and stresses on adjacent segments [9] , [10] , [11] .…”

Incidence and risk factors for early and late reoperation following lumbar fusion surgery

“…All patients undergoing elective surgery at our center receive preoperative optimization of internal diseases (e.g., perioperative blood glucose and blood pressure control). Based on previous studies, we designed an anti-osteoporosis regimen for osteoporosis patients [10][11][12]. For those patients, intravenous zoledronic acid 5 mg was given on day 7 after surgery and oral calcium and vitamin D were taken daily from the initiation of therapy until the last follow-up date.…”