Special Considerations to Improve Clinical Outcomes in Patients with Osteoporosis Undergoing Spine Surgery

Abstract

Background: Osteoporosis is a condition that is commonly encountered, with increasing diagnosis by the medical community with the aging population. Osteoporosis leaves patients susceptible to fragility fractures in the vertebrae and is also associated with degenerative changes, both of which may require intervention from a spine surgeon. The goal of this review is to concisely outline special nonoperative adjuncts, as well as preoperative, intraoperative, and postoperative considerations of osteoporotic patients undergoing spine intervention.Methods: A literature analysis was completed for this narrative review. A database search of PubMed and Google Scholar was conducted using ''osteoporosis'' combined with ''spine,'' ''spine surgery,'' and ''spinal fusion'' without exclusion based on publication date. Articles were screened to exclude duplicate articles and screened for their full text and English language availability.Results: The database search yielded recent publications from which the narrative review was completed. Conclusions: Preoperatively, screening is traditionally completed with dual-energy x-ray absorptiometry (DEXA). Pharmacological therapy modalities currently include teriparatide, raloxifene, denosumab, bisphosphonates, and calcitonin. In order to prevent operative complications associated with osteoporosis, surgeons have found success in increasing the diameter and the length of pedicle screws, limiting pedicle tapping, achieving bicortical or even tricortical purchase, augmenting with polymethyl methacrylate, using iliosacral stabilization, preventing positive sagittal balance, and using adequate fusion products when necessary. Postoperatively, it is important to implant a care plan that includes adequate pain control and necessary care, and to understand risks associated with falls may increase risk of postoperative fragility fractures as well as instrumentation displacement. At this time there are no recommendations in regard to bracing in the postoperative setting.Clinical Relevance: This review article outlines the most current evidence-based medicine with regard to considerations in spine surgery of the osteoporotic patient, and aims to bring about new questions to be investigated in that paradigm.

Impact of Aspiration Percutaneous Vertebroplasty in Reducing Bone Cement Leakage and Enhancing Distribution—An Ex Vivo Study in Goat Vertebrae

“…By injecting cement into the fractured vertebra for vertebral height restoration, PVP provides significant pain relief and improves the overall quality of life for OVCF patients [7,8,12,13,33]. The strength of the vertebral body and spinal stability can be substantially enhanced after this VA method [14][15][16][17].…”

“…The two most common surgical interventions of VA are percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP). Both procedures require the injection of polymethylmethacrylate (PMMA) cement into a compressed vertebral body (VB) to restore and maintain vertebral height [12,13]. A major difference between PKP and PVP is that PKP uses a balloon catheter to expand the collapsed vertebral body before the injection of bone cement, which is more manageable to restore and maintain the VB height during surgery [7].…”

Improving the Management of Patients with Osteoporosis Undergoing Spinal Fusion: The Need for a Bone Mineral Density-Matched Interbody Cage

“…The confluence of these syndromes creates a more challenging and complex interventional strategy for the spine surgeon contemplating interbody fusion. 23 …”

“…The confluence of these syndromes creates a more challenging and complex interventional strategy for the spine surgeon contemplating interbody fusion. 23 A patient with osteoporosis is characterized as having a BMD T-score of ≤ −2.5 standard deviations below the comparative reference value for a young gender-matched population at peak bone mass. 24,25 Osteopenia is the range of bone loss between normal BMD and osteoporosis (ie, T-score; < −1.0 -> −2.5).…”