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Gong DC, Baumann AN, Muralidharan A, Piche JD, Anderson PA, Aleem I. The Association of Preoperative Bone Mineral Density and Outcomes after Anterior Cervical Discectomy and Fusion: A Systematic Review. Clin Spine Surg 2024:01933606-990000000-00336. [PMID: 39041643 DOI: 10.1097/bsd.0000000000001656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/28/2024] [Indexed: 07/24/2024]
Abstract
STUDY DESIGN This is a systematic review. OBJECTIVE To evaluate anterior cervical discectomy and fusion (ACDF) outcomes and complications as a function of preoperative bone mineral density (BMD). SUMMARY OF BACKGROUND DATA Preoperative BMD optimization is commonly initiated before lumbar spinal fusion, but the effects of BMD on ACDF are less known. Consequently, it remains unclear whether preoperative BMD optimization is recommended before ACDF. METHODS This systematic review included relevant clinical articles using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Web of Science, SCOPUS, and MEDLINE from database inception until October 1, 2023. Eligible studies included those evaluating low BMD and outcomes after ACDF. All articles were graded using the Methodological Index for Non-Randomized Studies (MINORS) scale and Critical Appraisal Skills Programme (CASP) assessment tools. RESULTS The initial retrieval yielded 4271 articles for which 4 articles with 671 patients were included in the final analysis. The mean patient age was 56.4 ± 3.9 years, and 331 patients (49.3%) were female. A total of 265 (39.5%) patients had low BMD (T score<-1.0) before ACDF. Preoperative low BMD was associated with cage subsidence in single-level ACDF (odds ratio (OR) 2.57; P=0.063; 95% Confidence Interval (CI): 0.95-6.95), but this result did not reach statistical significance. Osteoporosis (T score<-2.5) was associated with the development of adjacent segment disease following ACDF (OR 4.41; P<0.01; 95% CI: 1.98-9.83). Low pre-operative BMD was associated with reoperation within 2 years (P<.05) and strongly associated with pseudarthrosis (OR: 11.01; P=0.002; 95% CI 2.4-49.9). CONCLUSIONS Patients with low BMD who undergo ACDF have higher rates of subsidence, adjacent segment disease, and pseudarthrosis than those with normal BMD. Given the individual and system-wide burdens associated with these complications, some patients may benefit from preoperative BMD screening and optimization before undergoing ACDF.
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Affiliation(s)
- Davin C Gong
- Department of Orthopedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Anthony N Baumann
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Aditya Muralidharan
- Department of Orthopedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Joshua D Piche
- Department of Orthopedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Paul A Anderson
- Department of Orthopedic Surgery and Rehabilitation, University of Wisconsin UWMF, Madison WI
| | - Ilyas Aleem
- Department of Orthopedic Surgery, University of Michigan Health System, Ann Arbor, MI
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Kim YH, Ha KY, Bae HW, Park HY, Ko YI, Ko MS, Kim SI. The Effects of Longer Use of Teriparatide on Clinical and Radiographic Outcomes after Spinal Fusion in Geriatric Patients. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:946. [PMID: 38929563 PMCID: PMC11205696 DOI: 10.3390/medicina60060946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/31/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024]
Abstract
Background: Teriparatide is an anabolic agent for osteoporosis and is believed to improve the bone healing process. Previous studies showed that teriparatide could enhance not only fracture healing but also spine fusion. It has been reported that use of teriparatide could promote the spine fusion process and decrease mechanical complications. However, there was no consensus regarding optimal treatment duration. The purpose of this study was to compare surgical outcomes between short-duration and long-duration teriparatide treatment after lumbar fusion surgery in elderly patients. Materials and Methods: All consecutive patients older than 60 years who underwent 1-level lumbar fusion surgery for degenerative diseases between January 2015 and December 2019 were retrospectively reviewed. Based on the duration of teriparatide treatment (daily subcutaneous injection of 20 µg teriparatide), patients were subdivided into two groups: a short-duration (SD) group (<6 months) and a long-duration (LD) group (≥6 months). Mechanical complications, such as screw loosening, cage subsidence, and adjacent vertebral fractures, were investigated. Postoperative 1-year union rate was also evaluated on computed tomography. Clinical outcomes were recorded using visual analog scale (VAS) and Oswestry Disability Index (ODI). Between-group differences for these radiographic and clinical outcomes were analyzed. Results: Ninety-one patients were reviewed in this study, including sixty patients in the SD group and thirty-one patients in the LD group. Their mean age was 72.3 ± 6.2 years, and 79 patients were female. Mean T-score was -3.3 ± 0.8. Cage subsidence (6.7% vs. 3.2%), screw loosening (28.3% vs. 35.5%), and adjacent vertebral fracture (6.7% vs. 9.7%) were not significantly different between the SD and LD groups. Union rate at 1-year postoperative was 65.0% in the SD group and 87.1% in the LD group (p = 0.028). Both groups showed improvement in VAS and ODI after surgery. However, the differences of VAS from preoperative to 6 months and 1 year postoperative were significantly higher in the LD group. Conclusions: Longer teriparatide treatment after lumbar fusion surgery resulted in a higher union rate at 1-year postoperative than the shorter treatment. Also, it could be more beneficial for clinical outcomes.
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Affiliation(s)
- Young-Hoon Kim
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Kee-Yong Ha
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Hyun W. Bae
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Hyung-Youl Park
- Department of Orthopedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Young-Il Ko
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Myung-Sup Ko
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Sang-Il Kim
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
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Abe T, Miyazaki M, Sako N, Kanezaki S, Tsubouchi Y, Kaku N. Optimal Intermittent Administration Interval of Abaloparatide for Bone Morphogenetic Protein-Induced Bone Formation in a Rat Spinal Fusion Model. Int J Mol Sci 2024; 25:3655. [PMID: 38612467 PMCID: PMC11011974 DOI: 10.3390/ijms25073655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/11/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Both bone morphogenetic protein 2 (BMP-2) and abaloparatide are used to promote bone formation. However, there is no consensus about their optimal administration. We investigated the optimal administration theory for the pairing of BMP-2 and abaloparatide in a rat spinal fusion model. Group I was only implanted in carriers and saline. Carriers with 3 µg of recombinant human BMP-2 (rhBMP-2) were implanted in other groups. Abaloparatide injections were administered three times a week for group III (for a total amount of 120 µg/kg in a week) and six times a week for group IV (for a total amount of 120 µg/kg in a week) after surgery. They were euthanized 8 weeks after the surgery, and we explanted their spines at that time. We assessed them using manual palpation tests, radiography, high-resolution micro-computed tomography (micro-CT), and histological analysis. We also analyzed serum bone metabolism markers. The fusion rate in Groups III and IV was higher than in Group I, referring to the manual palpation tests. Groups III and IV recorded greater radiographic scores than those in Groups I and II, too. Micro-CT analysis showed that Tbs. Sp in Groups III and IV was significantly lower than in Group I. Tb. N in Group IV was significantly higher than in Group I. Serum marker analysis showed that bone formation markers were higher in Groups III and IV than in Group I. On the other hand, bone resorption markers were lower in Group IV than in Group I. A histological analysis showed enhanced trabecular bone osteogenesis in Group IV. Frequent administration of abaloparatide may be suitable for the thickening of trabecular bone structure and the enhancement of osteogenesis in a rat spinal fusion model using BMP-2 in insufficient doses.
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Affiliation(s)
- Tetsutaro Abe
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita 879-5593, Japan; (T.A.); (N.K.)
| | - Masashi Miyazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita 879-5593, Japan; (T.A.); (N.K.)
| | - Noriaki Sako
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita 879-5593, Japan; (T.A.); (N.K.)
| | - Shozo Kanezaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita 879-5593, Japan; (T.A.); (N.K.)
| | - Yuta Tsubouchi
- School of Physical Therapy, Faculty of Rehabilitation, Reiwa Health Sciences University, Fukuoka 811-0213, Japan
| | - Nobuhiro Kaku
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita 879-5593, Japan; (T.A.); (N.K.)
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Mohanty S, Sardar ZM, Hassan FM, Lombardi JM, Lehman RA, Lenke LG. Impact of Teriparatide on Complications and Patient-Reported Outcomes of Patients Undergoing Long Spinal Fusion According to Bone Density. J Bone Joint Surg Am 2024; 106:206-217. [PMID: 37973052 DOI: 10.2106/jbjs.23.00272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Surgery for adult spinal deformity (ASD) poses substantial risks, including the development of symptomatic pseudarthrosis, which is twice as prevalent among patients with osteoporosis compared with those with normal bone mineral density (BMD). Limited data exist on the impact of teriparatide, an osteoanabolic compound, in limiting the rates of reoperation and pseudarthrosis after treatment of spinal deformity in patients with osteoporosis. METHODS Osteoporotic patients on teriparatide (OP-T group) were compared with patients with osteopenia (OPE group) and those with normal BMD. OP-T patients were matched with OPE patients and patients with normal BMD at a 1:2:2 ratio. All patients had a minimum 2-year follow-up and underwent posterior spinal fusion (PSF) involving >7 instrumented levels. The primary outcome was the 2-year reoperation rate. Secondary outcomes included pseudarthrosis with or without implant failure, proximal junctional kyphosis (PJK), and changes in patient-reported outcomes (PROs). Clinical outcomes were analyzed using conditional logistic regression. Changes in PROs were analyzed using a mixed-effects model. RESULTS Five hundred and forty patients (52.6% normal BMD, 32.9% OPE, 14.4% OP-T) were included. In the unmatched cohort, 2-year reoperation rates (odds ratio [OR] = 0.45 [95% confidence interval (CI): 0.20 to 0.91]) and pseudarthrosis rates (OR = 0.25 [95% CI: 0.08 to 0.61]) were significantly lower in the OP-T group than the OPE group. Seventy-eight patients in the OP-T group were matched to 156 patients in the OPE group. Among these matched patients, at 2 years, 23.1% (36) in the OPE group versus 11.5% (9) in the OP-T group had a reoperation (OR = 0.45, p = 0.0188), 21.8% (34) versus 6.4% (5) had pseudarthrosis with or without implant failure (OR = 0.25, p = 0.0048), and 6.4% (10) versus 7.7% (6) had PJK (OR = 1.18, p = 0.7547), respectively. At 2 years postoperatively, PROs were better among OP-T patients than OPE patients. Subsequently, 78 patients in the OP-T group were matched to 156 patients in the normal BMD group. Among these matched patients, there was no significant difference in 2-year reoperation (OR = 0.85 [95% CI: 0.37 to 1.98]), pseudarthrosis (OR = 0.51 [95% CI: 0.181 to 1.44]), and PJK rates (OR = 0.77 [95% CI: 0.28 to 2.06). CONCLUSIONS Osteoporotic patients on teriparatide demonstrated lower reoperation and symptomatic pseudarthrosis rates 2 years postoperatively compared with osteopenic patients. Moreover, patient-reported and clinical outcomes for osteoporotic patients on teriparatide were not different from those for patients with normal BMD. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sarthak Mohanty
- Department of Orthopaedic Surgery, Och Spine Hospital, Columbia University Irving Medical Center, New York, NY
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Pan TY, Chang CC, Chen HT, Tsou HK, Lin YC, Hsu CH. Effectiveness of Teriparatide for Spine Fusion in Osteoporotic Patient: A Systematic Review and Meta-Analysis of Comparative Studies. World Neurosurg 2023; 179:8-17. [PMID: 37479030 DOI: 10.1016/j.wneu.2023.07.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Our goal was to assess teriparatide's (TP) effectiveness in improving radiographic and functional outcomes after spinal fusion surgery. This meta-analysis included randomized controlled trials (RCTs) and comparative cohort studies. The findings provide valuable insights and guidance for surgeons treating osteoporotic patients undergoing spinal fusion surgery. METHODS We conducted a systematic review to assess TP's efficacy in spinal fusion surgery for osteoporosis. Through thorough selection, data extraction, and quality assessment, we employed network meta-analysis to evaluate radiographic outcomes (fusion rate, screw loosening, vertebral fracture) and changes in bone mineral density measured by Hounsfield units. Functional outcomes were assessed using the Oswestry Disability Index scales. Our study aims to comprehensively understand TP's impact and effectiveness in spinal fusion surgery. RESULTS A total of 868 patients were included in the analysis. All patients underwent thoracolumbar internal fixation fusion surgery and were divided into following 2 groups: the TP treatment group and the control group. The results revealed significant differences in radiological outcomes. The fusion rate showed a significant difference, as well as screw loosening, and bone mineral density measured in Hounsfield units. However, there was no significant difference in vertebral fracture. The TP group demonstrated favorable effects with statistical significance. In terms of functional outcomes, there was no significant difference in the assessment of Oswestry Disability Index scores between the 2 treatment groups. CONCLUSIONS The meta-analysis demonstrated that the TP group exhibited significantly better outcomes, particularly in radiological measures, when compared to the control group. The use of TP in spinal fusion surgery shows promise in reducing postoperative complications and providing overall benefits.
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Affiliation(s)
- Tao-Yin Pan
- Minimally invasive spine and joint center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan, Republic of China
| | - Chien-Chun Chang
- Minimally invasive spine and joint center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan, Republic of China; Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan, Republic of China; Department of Orthopaedic, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan, Republic of China.
| | - Hsien-Te Chen
- Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan, Republic of China; Spine Center, China Medical University Hospital, China Medical University, Taichung, Taiwan, Republic of China; Department of Sport Medicine, College of Health Care, China Medical University, Taichung, Taiwan, Republic of China
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China; Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli County, Taiwan, Republic of China; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, Republic of China
| | - Ying-Chao Lin
- School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China; Department of Neurological Institute, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan, Republic of China
| | - Chin-Hsien Hsu
- Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan, Republic of China
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Baltic SP, Lyons KW, Mariaux F, Mannion AF, Werth PM, Fekete T, Porchet F, Kepler C, McGuire KJ, Lurie JD, Pearson AM. Evaluation of the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system as a guide to surgical technique selection. Spine J 2023; 23:1641-1651. [PMID: 37406861 DOI: 10.1016/j.spinee.2023.06.401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/19/2023] [Accepted: 06/29/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND CONTEXT The role of fusion in degenerative spondylolisthesis (DS) is controversial. The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system was developed to assist surgeons in surgical technique selection based on individual patient characteristics. This system has not been clinically validated as a guide to surgical technique selection. PURPOSE The purpose of this study was to determine if outcomes vary with different surgical techniques across the CARDS categories. STUDY DESIGN/SETTING Prospective cohort study performed at one Swiss and one American spine center. PATIENT SAMPLE Five hundred eight patients with DS undergoing surgical treatment. OUTCOME MEASURES Core Outcomes Measure Index (COMI) at 3 months and 12 months postoperatively. METHODS Patients undergoing surgery for DS were enrolled at 2 institutions and classified according to the CARDS system using dynamic radiographs. The Core Outcome Measure Index (COMI) was completed preoperatively, and 3 and 12 months postoperatively. Surgical technique was classified as uninstrumented (decompression alone or decompression with uninstrumented fusion) or instrumented (decompression with pedicle screw instrumentation with or without interbody fusion). Unadjusted analyses and mixed effect models compared COMI scores between the two surgery technique groups (uninstrumented vs instrumented), stratified by CARDS category over time. Reoperation rates were also compared between the surgery technique groups stratified by CARDS category. Partial funding was given through NASS grant for clinical research. RESULTS Five hundred five out of 508 patients enrolled in the study had sufficient data to be classified according to CARDS. Seven percent were classified as CARDS A, 28% as CARDS B, 48% as CARDS C, and 17% as CARDS D (CARDS A most "stable," CARDS D least "stable"). One hundred and thirty-three patients (26%) underwent decompression alone, 30 (6%) underwent decompression and uninstrumented fusion, 42 (8%) underwent decompression and posterolateral instrumented fusion, and 303 (60%) underwent decompression with posterolateral and interbody instrumented fusion. Patients in the least "stable" categories tended to be less likely to be treated with an uninstrumented technique (CARDS D 19% vs 32% for the other categories, p=.10). There were no significant differences in 3 or 12-month COMI scores between surgical technique groups stratified by CARDS category in the unadjusted or adjusted analyses. In the unadjusted analyses, there was a trend towards less improvement in 12-month COMI change score in the CARDS D patients in the uninstrumented group compared to the instrumented group (-2.7 vs -4.1, p=.10). Reoperation rates were not significantly different between the surgical technique groups stratified by CARDS category. CONCLUSIONS In general, outcomes for uninstrumented and instrumented surgical techniques were similar across the CARDS categories. Surgeons likely took factors included in CARDS into account during surgical technique selection. This resulted in a low number of CARDS D (n=15) patients being treated with uninstrumented techniques, which limited the statistical power of this analysis. As such, this study does not validate CARDS as a useful classification system for surgical technique selection in DS.
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Affiliation(s)
- Steven P Baltic
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756, USA
| | - Keith W Lyons
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756, USA
| | - Francine Mariaux
- Department of Teaching, Research and Development, Spine Division, Schulthess Klinik, Lengghalde 2, Zurich 8008, CH, Switzerland
| | - Anne F Mannion
- Department of Teaching, Research and Development, Spine Division, Schulthess Klinik, Lengghalde 2, Zurich 8008, CH, Switzerland
| | - Paul M Werth
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756, USA
| | - Tamas Fekete
- Department of Teaching, Research and Development, Spine Division, Schulthess Klinik, Lengghalde 2, Zurich 8008, CH, Switzerland
| | - Francois Porchet
- Department of Teaching, Research and Development, Spine Division, Schulthess Klinik, Lengghalde 2, Zurich 8008, CH, Switzerland
| | - Christopher Kepler
- Orthopaedics, Thomas Jefferson University, 833 Chestnut St, Suite 1402, Philadelphia, PA 19107, USA
| | - Kevin J McGuire
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756, USA
| | - Jon D Lurie
- Department of Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756, USA
| | - Adam M Pearson
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756, USA.
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He XY, Chen HX, Zhao ZR. Efficacy and safety of different anti-osteoporotic drugs for the spinal fusion surgery: A network meta-analysis. World J Clin Cases 2023; 11:7350-7362. [PMID: 37969460 PMCID: PMC10643061 DOI: 10.12998/wjcc.v11.i30.7350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/10/2023] [Accepted: 09/28/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Administering anti-osteoporotic agents to patients perioperatively is a widely accepted approach for improving bone fusion rates and reducing the risk of complications. The best anti-osteoporotic agents for spinal fusion surgery remain unclear. AIM To investigate the efficacy and safety of different anti-osteoporotic agents in spinal fusion surgery via network meta-analysis. METHODS Searches were conducted in four electronic databases (PubMed, EMBASE, Web of Science, the Cochrane Library and China National Knowledge Infrastructure (CNKI) from inception to November 2022. Any studies that compared anti-osteoporotic agents vs placebo for spinal fusion surgery were included in this network meta-analysis. Outcomes included fusion rate, Oswestry disability index (ODI), and adverse events. Network meta-analysis was performed by R software with the gemtc package. RESULTS In total, 13 randomized controlled trials were included in this network meta-analysis. Only teriparatide (OR 3.2, 95%CI: 1.4 to 7.8) was more effective than placebo in increasing the fusion rate. The surface under the cumulative ranking curve (SUCRA) of teriparatide combined with denosumab was the highest (SUCRA, 90.9%), followed by teriparatide (SUCRA, 74.0%), zoledronic acid (SUCRA, 43.7%), alendronate (SUCRA, 41.1%) and risedronate (SUCRA, 35.0%). Teriparatide (MD -15, 95%CI: -28 to -2.7) and teriparatide combined with denosumab (MD -20, 95%CI: -40 to -0.43) were more effective than placebo in decreasing the ODI. The SUCRA of teriparatide combined with denosumab was highest (SUCRA, 90.8%), followed by teriparatide (SUCRA, 74.5%), alendronate (SURCA, 52.7), risedronate (SURCA, 52.1%), zoledronic acid (SURCA, 24.2%) and placebo (SURCA, 5.6%) for ODI. The adverse events were not different between groups. CONCLUSION This network meta-analysis suggests that teriparatide combined with denosumab and teriparatide alone significantly increase the fusion rate and decrease the ODI without increasing adverse events. Based on current evidence, teriparatide combined with denosumab or teriparatide alone is recommended to increase the fusion rate and to reduce ODI in spinal fusion patients.
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Affiliation(s)
- Xiao-Yuan He
- Spinal Surgery, Hainan Province Clinical Medical Center, Haikou 570100, Hainan Province, China
| | - Huan-Xiong Chen
- Spinal Surgery, Hainan Province Clinical Medical Center, Haikou 570100, Hainan Province, China
| | - Zhi-Rong Zhao
- Spinal Surgery, Hainan Province Clinical Medical Center, Haikou 570100, Hainan Province, China
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Nagata K, Dimar JR, Carreon LY, Glassman SD. Preoperative Optimization: Risk Factors for Perioperative Complications and Preoperative Modification. Neurosurg Clin N Am 2023; 34:505-517. [PMID: 37718097 DOI: 10.1016/j.nec.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Adult spinal deformity (ASD) is common and the complication rate in ASD surgery is high due to its invasiveness. There are several factors that increase the risk of complications with ASD surgery. These include age, past medical history, frailty, osteoporosis, or operative invasiveness. Risk factors for perioperative complications can be categorized as modifiable and non-modifiable. The purpose of this article is to present the current available evidence on risk factors for perioperative complications, with a focus on frailty, osteoporosis, surgical site infection prevention, and hip-spine syndrome. In addition, we present the latest evidence for patient-specific surgical risk assessment and surgical planning.
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Affiliation(s)
- Kosei Nagata
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
| | - John R Dimar
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA.
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
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Mimura T, Tsutsumimoto T, Yui M, Misawa H. Does fusion status following posterolateral lumbar fusion in the treatment for stable lumbar degenerative spondylolisthesis affect the long-term surgical outcomes? A propensity score-weighted analysis of consecutive patients. J Orthop Sci 2022; 27:990-994. [PMID: 34364757 DOI: 10.1016/j.jos.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 05/12/2021] [Accepted: 07/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The surgical strategy of lumbar degenerative spondylolisthesis (LDS) is controversial, especially regarding whether or not fusion should be used. Although some reports have indicated that decompression combined with fusion may be better than decompression alone in the treatment of LDS, the effect of fusion status after uninstrumented posterolateral lumbar fusion (PLF) on the outcomes of patients with stable LDS remains unknown. This study aimed to evaluate the surgical outcomes of uninstrumented PLF for stable LDS and clarify whether radiographic fusion status could affect surgical outcomes. METHODS A total of 93 consecutive patients who had undergone single-level uninstrumented PLF for Meyerding grade I LDS without preoperative dynamic instability with a minimum follow-up period of 5 years were retrospectively studied. Patients were divided into two groups: nonunion (52 patients) and union (41 patients). The primary outcomes were the 5-year percent recovery of postoperative Japanese Orthopaedic Association (JOA) scores, Oswestry Disability Index (ODI), Visual analog scale (VAS) scores, and reoperation rate. The outcome scores were compared between the groups using the inverse probability weighting method using propensity scores. RESULTS The union and nonunion groups had comparable weighted means of the 5-year postoperative clinical score for the percent recovery of the JOA score (70.2% vs. 71.1%, P = 0.86), ODI (14.5 vs.14.6, P = 0.98), VAS of low back pain (20.3 vs. 18.7 mm, P = 0.72), and VAS of leg pain (24.0 vs. 19.4 mm, P = 0.43). The reoperation rate was 2.4% (one case of adjacent segment pathology) in the union group and 0% in the nonunion group (P = 0.44). CONCLUSION The fusion status following uninstrumented PLF had no significant effect on the 5-year postoperative clinical outcomes and reoperation rate in patients with Meyerding grade I LDS without dynamic instability.
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Affiliation(s)
- Tetsuhiko Mimura
- Spine Center, Yodakubo Hospital, 2857 Furumachi, Nagawa, Nagano, 386-0603, Japan
| | | | - Mutsuki Yui
- Spine Center, Yodakubo Hospital, 2857 Furumachi, Nagawa, Nagano, 386-0603, Japan
| | - Hiromichi Misawa
- Spine Center, Yodakubo Hospital, 2857 Furumachi, Nagawa, Nagano, 386-0603, Japan
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10
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Sardar ZM, Coury JR, Cerpa M, DeWald CJ, Ames CP, Shuhart C, Watkins C, Polly DW, Dirschl DR, Klineberg EO, Dimar JR, Krohn KD, Kebaish KM, Tosi LL, Kelly M, Lane NE, Binkley NC, Berven SH, Lee NJ, Anderson P, Angevine PD, Lehman RA, Lenke LG. Best Practice Guidelines for Assessment and Management of Osteoporosis in Adult Patients Undergoing Elective Spinal Reconstruction. Spine (Phila Pa 1976) 2022; 47:128-135. [PMID: 34690329 DOI: 10.1097/brs.0000000000004268] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Expert consensus study. OBJECTIVE This expert panel was created to establish best practice guidelines to identify and treat patients with poor bone health prior to elective spinal reconstruction. SUMMARY OF BACKGROUND DATA Currently, no guidelines exist for the management of osteoporosis and osteopenia in patients undergoing spinal reconstructive surgery. Untreated osteoporosis in spine reconstruction surgery is associated with higher complications and worse outcomes. METHODS A multidisciplinary panel with 18 experts was assembled including orthopedic and neurological surgeons, endocrinologists, and rheumatologists. Surveys and discussions regarding the current literature were held according to Delphi method until a final set of guidelines was created with over 70% consensus. RESULTS Panelists agreed that bone health should be considered in every patient prior to elective spinal reconstruction. All patients above 65 and those under 65 with particular risk factors (chronic glucocorticoid use, high fracture risk or previous fracture, limited mobility, and eight other key factors) should have a formal bone health evaluation prior to undergoing surgery. DXA scans of the hip are preferable due to their wide availability. Opportunistic CT Hounsfield Units of the vertebrae can be useful in identifying poor bone health. In the absence of contraindications, anabolic agents are considered first line therapy due to their bone building properties as compared with antiresorptive medications. Medications should be administered preoperatively for at least 2 months and postoperatively for minimum 8 months. CONCLUSION Based on the consensus of a multidisciplinary panel of experts, we propose best practice guidelines for assessment and treatment of poor bone health prior to elective spinal reconstructive surgery. Patients above age 65 and those with particular risk factors under 65 should undergo formal bone health evaluation. We also established guidelines on perioperative optimization, utility of various diagnostic modalities, and the optimal medical management of bone health in this population.Level of Evidence: 5.
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Affiliation(s)
- Zeeshan M Sardar
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Josephine R Coury
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Meghan Cerpa
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | | | | | | | - Colleen Watkins
- West Virginia University School of Medicine, J.W. Ruby Memorial Hospital, WV
| | | | | | | | - John R Dimar
- Norton Leatherman Spine, University of Louisville, Louisville, KY
| | | | | | - Laura L Tosi
- Children's National Hospital, George Washington University, WA
| | | | | | | | | | - Nathan J Lee
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | | | - Peter D Angevine
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Ronald A Lehman
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Lawrence G Lenke
- Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
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11
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Bergholt NL, Demirel A, Pedersen M, Ding M, Kragstrup TW, Andersen T, Deleuran BW, Foldager CB. Intermittent Hypoxic Therapy Inhibits Allogenic Bone-Graft Resorption by Inhibition of Osteoclastogenesis in a Mouse Model. Int J Mol Sci 2021; 23:323. [PMID: 35008749 PMCID: PMC8745522 DOI: 10.3390/ijms23010323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/14/2021] [Accepted: 12/24/2021] [Indexed: 01/04/2023] Open
Abstract
Systemic Intermittent Hypoxic Therapy (IHT) relies on the adaptive response to hypoxic stress. We investigated allogenic bone-graft resorption in the lumbar spine in 48 mice. The mice were exposed to IHT for 1 week before surgery or 1 week after surgery and compared with controls after 1 and 4 weeks. Complete graft resorption was observed in 33-36% of the animals in the control group, but none in the preoperative IHT group. Increased bone-graft volume was demonstrated by micro-computed tomography in the preoperative IHT group after 1 week (p = 0.03) while a non-significant difference was observed after 4 weeks (p = 0.12). There were no significant differences in the postoperative IHT group. Increased concentration of immune cells was localized in the graft area, and more positive tartrate-resistant acid phosphatase (TRAP) staining was found in controls compared with IHT allogenic bone grafts. Systemic IHT resulted in a significant increase of the major osteoclast inhibitor osteoprotegerin as well as osteogenic and angiogenic regulators Tgfbr3, Fst3l, Wisp1, and Vegfd. Inflammatory cytokines and receptor activator of nuclear factor kappa-B ligand (RANKL) stimulators IL-6, IL-17a, IL-17f, and IL-23r increased after 1 and 4 weeks, and serum RANKL expression remained constant while Ccl3 and Ccl5 decreased. We conclude that the adaptive response to IHT activates numerous pathways leading to inhibition of osteoclastic activity and inhibition of allogenic bone-graft resorption.
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Affiliation(s)
- Natasja Leth Bergholt
- Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus, Denmark; (N.L.B.); (A.D.)
| | - Ari Demirel
- Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus, Denmark; (N.L.B.); (A.D.)
| | - Michael Pedersen
- Comparative Medicine Laboratory, Aarhus University, 8200 Aarhus, Denmark;
| | - Ming Ding
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and University of Southern Denmark, 5000 Odense, Denmark;
| | - Tue Wenzel Kragstrup
- Department of Biomedicine, Aarhus University, 8000 Aarhus, Denmark; (T.W.K.); (T.A.); (B.W.D.)
- Department of Rheumatology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Thomas Andersen
- Department of Biomedicine, Aarhus University, 8000 Aarhus, Denmark; (T.W.K.); (T.A.); (B.W.D.)
| | - Bent Winding Deleuran
- Department of Biomedicine, Aarhus University, 8000 Aarhus, Denmark; (T.W.K.); (T.A.); (B.W.D.)
- Department of Rheumatology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Casper Bindzus Foldager
- Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus, Denmark; (N.L.B.); (A.D.)
- Comparative Medicine Laboratory, Aarhus University, 8200 Aarhus, Denmark;
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12
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Abraham S, Vives M, Cottrell JA, Mitchell A, Lin HN, Effiong L, Iqbal E, Jingar N, Kim B, Shah N, Munoz W, Chaudhary SB, Lin SS, Benevenia J, O'Connor JP. Local insulin application has a dose-dependent effect on lumbar fusion in a rabbit model. J Tissue Eng Regen Med 2021; 15:442-452. [PMID: 33608970 DOI: 10.1002/term.3182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/05/2021] [Indexed: 11/11/2022]
Abstract
The purpose of this study was to determine if locally applied insulin has a dose-responsive effect on posterolateral lumbar fusion. Adult male New Zealand White rabbits underwent posterolateral intertransverse spinal fusions (PLFs) at L5-L6 using suboptimal amounts of autograft. Fusion sites were treated with collagen sponge soaked in saline (control, n = 11), or with insulin at low (5 or 10 units, n = 13), mid (20 units, n = 11), and high (40 units, n = 11) doses. Rabbits were euthanized at 6 weeks. The L5-L6 spine segment underwent manual palpation and radiographic evaluation performed by two fellowship trained spine surgeons blinded to treatment. Differences between groups were evaluated by analysis of variance on ranks followed by post-hoc Dunn's tests. Forty-three rabbits were euthanized at the planned 6 weeks endpoint, while three died or were euthanized prior to the endpoint. Radiographic evaluation found bilateral solid fusion in 10%, 31%, 60%, and 60% of the rabbits from the control and low, mid, and high-dose insulin-treated groups, respectively (p < 0.05). As per manual palpation, 7 of 10 rabbits in the mid-dose insulin group were fused as compared to 1 of 10 rabbits in the control group (p < 0.05). This study demonstrates that insulin enhanced the effectiveness of autograft to increase fusion success in the rabbit PLF model. The study indicates that insulin or insulin-mimetic compounds can be used to promote bone regeneration.
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Affiliation(s)
- Sangeeta Abraham
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Michael Vives
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Jessica A Cottrell
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Ashley Mitchell
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Hsuan-Ni Lin
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Linda Effiong
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Emaad Iqbal
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Neel Jingar
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Brian Kim
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Neel Shah
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - William Munoz
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Saad B Chaudhary
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Sheldon S Lin
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Joseph Benevenia
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - J Patrick O'Connor
- Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA
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13
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Arlt H, Besschetnova T, Ominsky MS, Fredericks DC, Lanske B. Effects of systemically administered abaloparatide, an osteoanabolic PTHrP analog, as an adjuvant therapy for spinal fusion in rats. JOR Spine 2021; 4:e1132. [PMID: 33778406 PMCID: PMC7984001 DOI: 10.1002/jsp2.1132] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Abaloparatide is a parathyroid hormone receptor agonist that increases bone formation and reduces vertebral and nonvertebral fracture risk in women with postmenopausal osteoporosis. Animal studies indicate abaloparatide stimulates vertebral bone formation and enhances bony bridging and biomechanical stability of fracture calluses. AIMS The current study is evaluating the potential utility for abaloparatide as an adjunct therapy for spinal fusions. MATERIAL AND METHODS The effects of 14 or 28 days of daily subcutaneous injections of abaloparatide (20 μg/kg/d) or vehicle were evaluated in 32 male Sprague-Dawley rats starting 1 day after noninstrumented posterolateral fusion (PLF) with bone autograft. Fusion mass microarchitecture was analyzed by micro-computed tomography (micro-CT) and serum markers of bone formation and bone resorption were evaluated. Motion segments were scored in a blinded manner as fused or unfused by postmortem radiography and manual palpation. RESULTS Abaloparatide-treated rats showed higher bone formation (serum osteocalcin) at day 14 and 28 compared with vehicle controls, without increases in the bone resorption marker serum TRACP-5b. Micro-CT showed greater trabecular number in fusion masses from the abaloparatide group vs vehicle controls at day 14. Manual palpation and radiography indicated no fusions in either group at day 14, whereas 25% of vehicle-treated rats and 50% of abaloparatide-treated rats had bilateral fusion at day 28. DISCUSSION AND CONCLUSION In summary, this rat PLF model showed that abaloparatide treatment was associated with higher levels of the bone formation marker osteocalcin, improved fusion mass architecture, and a non- significant 2-fold higher fusion rate compared with vehicle.
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Affiliation(s)
- Heike Arlt
- Research & DevelopmentRadius Health, Inc.WalthamMassachusettsUSA
| | | | | | - Douglas C. Fredericks
- Department of Orthopedics and RehabilitationUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Beate Lanske
- Research & DevelopmentRadius Health, Inc.WalthamMassachusettsUSA
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14
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Kim HJ, Dash A, Cunningham M, Schwab F, Dowdell J, Harrison J, Zaworski C, Krez A, Lafage V, Agarwal S, Carlson B, McMahon DJ, Stein EM. Patients with abnormal microarchitecture have an increased risk of early complications after spinal fusion surgery. Bone 2021; 143:115731. [PMID: 33157283 PMCID: PMC9518007 DOI: 10.1016/j.bone.2020.115731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/12/2022]
Abstract
Spine fusion is one of the most common orthopedic surgeries, with more than 400,000 cases performed annually. While these procedures correct debilitating pain and deformities, complications occur in up to 45%. As successful fusion rests upon early stability of hardware in bone, patients with structural skeletal deficits may be at particular risk for complications. Few studies have investigated this relationship, and none have used higher order imaging to evaluate microstructural mechanisms for complications. Standard DXA measurements are subject to artifact in patients with spinal disease and therefore provide limited information. The goal of this prospective study was to investigate pre-operative bone quality as a risk factor for early post-operative complications using high resolution peripheral QCT (HR-pQCT) measurements of volumetric BMD (vBMD) and microarchitecture. We hypothesized that patients with low vBMD and abnormal microarchitecture at baseline would have more skeletal complications post-operatively. Conversely, we hypothesized that pre-operative DXA measurements would not be predictive of complications. Fifty-four subjects (mean age 63 years, BMI 27 kg/m2) were enrolled pre-operatively and followed for 6 months after multi-level lumbar spine fusion. Skeletal complications occurred in 14 patients. Patients who developed complications were of similar age and BMI to those who did not. Baseline areal BMD and Trabecular Bone Score by DXA did not differ. In contrast, HR-pQCT revealed that patients who developed complications had lower trabecular vBMD, fewer and thinner trabeculae at both the radius and tibia, and thinner tibial cortices. In summary, abnormalities of both trabecular and cortical microarchitecture were associated the development of complications within the first six months following spine fusion surgery. Our results suggest a mechanism for early skeletal complications after fusion. Given the burgeoning number of fusion surgeries, further studies are necessary to investigate strategies that may improve bone quality and lower the risk of post-operative complications.
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Affiliation(s)
- Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Alexander Dash
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Matthew Cunningham
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Frank Schwab
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - James Dowdell
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Jonathan Harrison
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Caroline Zaworski
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Alexandra Krez
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Sanchita Agarwal
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States of America
| | - Brandon Carlson
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Donald J McMahon
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America
| | - Emily M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, United States of America.
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15
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Tsai SHL, Chien RS, Lichter K, Alharthy R, Alvi MA, Goyal A, Bydon M, Fu TS, Lin TY. Teriparatide and bisphosphonate use in osteoporotic spinal fusion patients: a systematic review and meta-analysis. Arch Osteoporos 2020; 15:158. [PMID: 33030619 DOI: 10.1007/s11657-020-00738-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/13/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE Osteoporosis is one of the most common conditions among adults worldwide. It also presents a challenge among patients undergoing spinal surgery. Use of Teriparatide and bisphosphonates in such patients has been shown to improve outcomes after fusion surgery, including successful fusion, decreased risk of instrumentation failure, and patient-reported outcomes. Herein, we performed a systematic review and indirect meta-analysis of available literature on outcomes of fusion surgery after use of bisphosphonates or Teriparatide. METHODS We conducted a comprehensive search of all databases (Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus) to identify studies assessing outcomes of spinal fusion among osteoporotic patients after use of Teriparatide or bisphosphonate. Four authors independently screened electronic search results, and all four authors independently performed study selection. Two authors performed independent data extraction and assessed the studies' risk of bias assessment using standardized forms of Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) and Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I). RESULTS Nineteen studies were included in the final analysis. A total of 13 studies evaluated the difference in fusion rate between bisphosphonates and Teriparatide or control group. Fusion rate was higher for bisphosphonates (effect size (ES) 83%, 95% CI 77-89%) compared with Teriparatide (ES 71%, 95% CI 57-85%), with the p value for heterogeneity between groups without statistical significance (p = 0.123). Five studies assessed the impact of using bisphosphonate or Teriparatide on screw loosening. The rate of screw loosening was higher for bisphosphonates (ES 19%, 95% CI 13-25%) compared with Teriparatide (ES 13%, 95% CI 9-16%) without statistical significance (p = 0.52). CONCLUSION Our results indicate that while both agents may be associated with positive outcomes, bisphosphonates may be associated with a higher fusion rate, while Teriparatide may be associated with lower screw loosening. The decision to treat with either agent should be tailored individually for each patient keeping in consideration the adverse effect and pharmacokinetic profiles.
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Affiliation(s)
- Sung Huang Laurent Tsai
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of medicine, Chang Gung University, Taoyuan 333, Taiwan., F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Ruei-Shyuan Chien
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of medicine, Chang Gung University, Taoyuan 333, Taiwan., F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Katie Lichter
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Raghad Alharthy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Anshit Goyal
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Tsai-Sheng Fu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of medicine, Chang Gung University, Taoyuan 333, Taiwan., F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Tung-Yi Lin
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of medicine, Chang Gung University, Taoyuan 333, Taiwan., F7, No 222 Mai-King Road, Keelung, Taiwan.
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16
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Cheng SH, Kuo YJ, Chen C, Kang YN. Effects of teriparatide and bisphosphonate on spinal fusion procedure: A systematic review and network meta-analysis. PLoS One 2020; 15:e0237566. [PMID: 32870946 PMCID: PMC7462270 DOI: 10.1371/journal.pone.0237566] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/14/2020] [Indexed: 01/11/2023] Open
Abstract
Background Giving patients anti-osteoporotic agents peri-operatively is a well-accepted strategy to increase fusion rate and prevent complications. The purpose of this study was to investigate effectiveness of teriparatide and bisphosphonate on fusion surgery of thoracic and lumbar spine. Methods We searched EMBASE and PubMed for randomized clinical trials (RCTs) and prospective comparative studies using teriparatide or bisphosphonate in peri-operative spinal fusion surgery. Our synthesized data of fusion rate, Oswestry disability index (ODI), and adverse event in contrast-based network meta-analysis. Pooled results were presented in risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Results Our search hit eight RCTs and three prospective studies with 676 patients receiving spinal surgery. Pooled result showed that teriparatide+Denosumab leads to significantly higher fusion rate than placebo (RR, 2.84; 95% CI: 1.22 to 6.60) and bisphosphonate (RR, 2.59; 95% CI: 1.13 to 5.96). We did not observe significant finding among placebo, teriparatide, and bisphosphonate in the two network models. Conclusion This is the first network meta-analysis providing an overview of the use of teriparatide and bisphosphonate for spinal fusion surgery. Teriparatide treatments are worth to be consider for spinal fusion surgery.
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Affiliation(s)
- Shih-Hao Cheng
- Department of Orthopedics, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Department of Orthopedics, Cheng Hsin General Hospital, Taipei, Republic of China (Taiwan)
| | - Yi-Jie Kuo
- Department of Orthopedics, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Republic of China (Taiwan)
| | - Chiehfeng Chen
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Cochrane Taiwan, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
| | - Yi-No Kang
- Cochrane Taiwan, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Republic of China (Taiwan)
- Institute of Health Policy & Management, College of Public Health, National Taiwan University, Taipei, Republic of China (Taiwan)
- * E-mail:
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17
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Chakravarthy V, Patel A, Kemp W, Steinmetz M. Surgical Treatment of Lumbar Spondylolisthesis in the Elderly. Neurosurg Clin N Am 2019; 30:341-352. [PMID: 31078235 DOI: 10.1016/j.nec.2019.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
By 2060, population projections estimate the number of individuals older than 65 will double. Prevalence of degenerative spondylolisthesis is reported as 4.1%-11.1% within the general population. Given the growing older population, the need for evidence-based guidance is essential. Regarding benefit derived from decompression alone versus decompression plus fusion for degenerative spondylolisthesis, the consensus is that all patients do not require a fusion; however, clarity around clearly identifying this cohort is lacking. Nevertheless, instrumented fusion is an effective strategy in the elderly. Numerous options exist, and individual patient characteristics as well as surgeon experience should be evaluated when planning surgery.
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Affiliation(s)
- Vikram Chakravarthy
- Department of Neurosurgery, Cleveland Clinic Learner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44106, USA
| | - Arpan Patel
- University of Arizona School of Medicine, 1501 N Campbell Avenue, Tucson, AZ 85724, USA
| | - William Kemp
- Department of Neurosurgery, Cleveland Clinic Learner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44106, USA
| | - Michael Steinmetz
- Department of Neurosurgery, Cleveland Clinic Learner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44106, USA.
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