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Hudson M, Meyer J, Evans A, Krishna C, Smith ZA, Bakhsheshian J. Evaluating osteoporosis and bone quality in the aging spine: modern considerations for surgical management in the geriatric population. GeroScience 2024; 46:5287-5301. [PMID: 38703277 PMCID: PMC11336023 DOI: 10.1007/s11357-024-01171-7] [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: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024] Open
Abstract
Surgical management paradigms of spinal pathologies in the aging population carry inherent substantial risks, with surgical complications being more prevalent among patients with osteoporosis compared to those with normal bone mineral density. In this narrative review, we aim to highlight important clinical understanding and considerations in perioperative evaluation and management of patients elected to undergo spinal surgery. Osteoporosis is a well-defined risk factor for mechanical complications following spinal surgery, and as such, perioperative optimization of bone health in the setting of surgery for geriatric patients remains a critical research area alongside intraoperative surgical augmentation techniques. Surgical techniques to circumvent challenges with instrumentation of poor bone mineral density have included augmentation of pedicle screw fixation, including segmental bicortical screw fixation techniques, cement augmentation with fenestrated screws, or use of expandable pedicle screws to improve bone-implant interface. Judicious selection of treatment modalities and subsequent perioperative optimization is paramount to minimize surgical complications. Contemporary guidelines and evolving paradigms in perioperative evaluation, optimization, and management of the aging spine include the advent of quantitatively evaluating computed tomography (CT) via assessment of the magnitude of Hounsfield units. Prescribing pharmacotherapeutic agents and monitoring bone health requires a multidisciplinary team approach, including endocrinologists and geriatricians to coordinate high-quality care for advanced-age patients who require surgical management of their spinal disorders.
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Affiliation(s)
- Miles Hudson
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, AZ, USA.
| | - Jenna Meyer
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Alexander Evans
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Chandan Krishna
- Department of Neurosurgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Zachary A Smith
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Ishikawa K, Tani S, Toyone T, Tsuchiya K, Towatari T, Oshita Y, Yamamura R, Wada K, Nagai T, Shirahata T, Inagaki K, Yoshifumi K. The potential effect of romosozumab on perioperative management for instrumentation surgery. JOR Spine 2024; 7:e1356. [PMID: 39104831 PMCID: PMC11299907 DOI: 10.1002/jsp2.1356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 05/27/2024] [Accepted: 07/01/2024] [Indexed: 08/07/2024] Open
Abstract
Background Age-related changes in bone health increase the risk for complications in elderly patients undergoing orthopedic surgery. Osteoporosis is a key therapeutic target that needs to be addressed to ensure successful instrumentation surgery. The effectiveness of pharmacological interventions in orthopedic surgery, particularly the new drug romosozumab, is still unknown. We aim to evaluate the effect of 3-month romosozumab treatment on biomechanical parameters related to spinal instrumentation surgery, using the Quantitative Computed Tomography (QCT)-based Finite Element Method (FEM). Methods This open-labeled, prospective study included 81 patients aged 60 to 90 years, who met the osteoporosis criteria and were scheduled for either romosozumab or eldecalcitol treatment. Patients were assessed using blood samples, dual-energy absorptiometry (DXA), and QCT. Biomechanical parameters were evaluated using FEM at baseline and 3 months post-treatment. The primary endpoints were biomechanical parameters at 3 months, while secondary endpoints included changes in regional volumetric bone mineral density around the pedicle (P-vBMD) and vertebral body (V-vBMD). Results Romosozumab treatment led to significant gains in P-vBMD, and V-vBMD compared to eldecalcitol at 3 months. Notably, the romosozumab group showed greater improvements in all biomechanical parameters estimated by FEM at 3 months compared to the eldecalcitol group. Conclusion Romosozumab significantly increased the regional vBMD as well as biomechanical parameters, potentially offering clinical benefits in reducing post-operative complications in patients with osteoporosis undergoing orthopedic instrumentation surgery. This study highlights the novel advantages of romosozumab treatment and advocates further research on its effectiveness in perioperative management.
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Affiliation(s)
- Koji Ishikawa
- Department of Orthopaedic Surgery, School of MedicineShowa UniversityTokyoJapan
- Department of Orthopaedic SurgeryDuke UniversityDurhamNorth CarolinaUSA
| | - Soji Tani
- Department of Orthopaedic Surgery, School of MedicineShowa UniversityTokyoJapan
| | - Tomoaki Toyone
- Department of Orthopaedic Surgery, School of MedicineShowa UniversityTokyoJapan
| | - Koki Tsuchiya
- Department of Orthopaedic Surgery, School of MedicineShowa UniversityTokyoJapan
| | - Tomoko Towatari
- Department of Orthopaedic Surgery, School of MedicineShowa UniversityTokyoJapan
| | - Yusuke Oshita
- Department of Orthopaedic SurgeryShowa University Northern Yokohama HospitalYokohamaKanagawaJapan
- Department of Orthopaedic SurgeryYamanashi Red Cross HospitalFujikawaguchikoYamanashiJapan
| | - Ryo Yamamura
- Department of Orthopaedic Surgery, School of MedicineShowa UniversityTokyoJapan
| | - Kazuki Wada
- Department of Orthopaedic Surgery, School of MedicineShowa UniversityTokyoJapan
- Department of Orthopaedic SurgeryYamanashi Red Cross HospitalFujikawaguchikoYamanashiJapan
| | - Takashi Nagai
- Department of Orthopaedic Surgery, School of MedicineShowa UniversityTokyoJapan
- Department of Rehabilitation Medicine, School of MedicineShowa UniversityTokyoJapan
| | - Toshiyuki Shirahata
- Department of Orthopaedic SurgeryShowa University Koto Toyosu HospitalTokyoJapan
| | - Katsunori Inagaki
- Department of Orthopaedic Surgery, School of MedicineShowa UniversityTokyoJapan
| | - Kudo Yoshifumi
- Department of Orthopaedic Surgery, School of MedicineShowa UniversityTokyoJapan
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Al-Najjar YA, Quraishi DA, Kumar N, Hussain I. Bone Health Optimization in Adult Spinal Deformity Patients: A Narrative Review. J Clin Med 2024; 13:4891. [PMID: 39201032 PMCID: PMC11355164 DOI: 10.3390/jcm13164891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/13/2024] [Accepted: 08/16/2024] [Indexed: 09/02/2024] Open
Abstract
Osteoporosis and low bone mineral density (BMD) pose significant challenges in adult spinal deformity surgery, increasing the risks of complications such as vertebral compression fractures, hardware failure, proximal junctional kyphosis/failure, and pseudoarthrosis. This narrative review examines the current evidence on bone health optimization strategies for spinal deformity patients. Preoperative screening and medical optimization are crucial, with vitamin D supplementation showing particular benefit. Among the pharmacologic agents, bisphosphonates demonstrate efficacy in improving fusion rates and reducing hardware-related complications, though the effects may be delayed. Teriparatide, a parathyroid hormone analog, shows promise in accelerating fusion and enhancing pedicle screw fixation. Newer anabolic agents like abaloparatide and romosozumab require further study but show potential. Romosozumab, in particular, has demonstrated significant improvements in lumbar spine BMD over a shorter duration compared to other treatments. Surgical techniques like cement augmentation and the use of larger interbody cages can mitigate the risks in osteoporotic patients. Overall, a multifaceted approach incorporating medical optimization, appropriate pharmacologic treatment, and tailored surgical techniques is recommended to improve outcomes in adult spinal deformity patients with compromised bone quality. Future research should focus on optimizing the treatment protocols, assessing the long-term outcomes of newer agents in the spine surgery population, and developing cost-effective strategies to improve access to these promising therapies.
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Affiliation(s)
| | | | | | - Ibrahim Hussain
- Department of Neurological Surgery, Och Spine at New York Presbyterian at the Weill Cornell Medical Center, 525 East 68th Street, New York, NY 10065, USA; (Y.A.A.-N.); (D.A.Q.); (N.K.)
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Katayanagi J, Konuma H, Yanase T, Inose H, Tanaka T, Iida T, Morishita S, Jinno T. Independent Risk Factors of Proximal Junctional Kyphosis with Vertebral Fracture After Spinal Long Fusion: Survivorship Analysis of Adult Spinal Deformity Surgery Patients. World Neurosurg 2024; 188:e597-e605. [PMID: 38843968 DOI: 10.1016/j.wneu.2024.05.174] [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: 12/10/2023] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024]
Abstract
OBJECTIVE This study aimed to identify risk factors for postoperative proximal junctional kyphosis (PJK) with vertebral fracture in adult spinal deformity (ASD) patients. We performed a survival analysis considering various factors, including osteoporosis. METHODS This single-center retrospective study included 101 ASD patients (mean age: 67.2 years, mean follow-up: 8.1 years). We included patients aged ≥50 years with abnormal radiographic variables undergoing corrective long spinal fusion. The main outcome measure was PJK with vertebral fracture, analyzed based on patient data, radiographic measurements, sagittal parameters, bone mineral density, and osteoporosis medication. RESULTS PJK occurred in 37.6% of patients, with vertebral fracture type 2 accounting for 65% of these cases. Kaplan-Meier analysis indicated a median PJK-free survival time of 60.7 months. Existing vertebral fracture (grade 1 or higher or grade 2 or higher) was a significant risk factor for PJK with vertebral fracture, with hazard ratios of 4.58 and 5.61, respectively. The onset time of PJK with vertebral fracture was 1.5 months postoperatively, with 44% of these cases occurring within 1 month and 64% within 2 months. CONCLUSIONS PJK with vertebral fracture affected 25% of ASD patients, emphasizing the importance of osteoporosis evaluation. Existing vertebral fracture emerged as a significant independent risk factor, surpassing bone mineral density. This study provides valuable insights for spine surgeons, highlighting the need to provide osteoporosis treatment and emphasize potential postoperative complications during discussions with patients.
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Affiliation(s)
- Junya Katayanagi
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan.
| | - Hiroki Konuma
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Tsukasa Yanase
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Hiroyuki Inose
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Tomoyuki Tanaka
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Takahiro Iida
- Department of Orthopedic Surgery, Teine Keijinnkai Hospital, Sapporo, Hokkaido, Japan
| | - Shingo Morishita
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Bunkyo City, Tokyo, Japan
| | - Tetsuya Jinno
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
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Kuo CC, Soliman MAR, Baig RA, Aguirre AO, Ruggiero N, Donnelly BM, Siddiqi M, Khan A, Quiceno E, Mullin JP, Pollina J. Vertebral Bone Quality Score as a Predictor of Adjacent Segment Disease After Lumbar Interbody Fusion. Neurosurgery 2024; 95:284-296. [PMID: 38334396 DOI: 10.1227/neu.0000000000002864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/20/2023] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVE With lumbar spine fusion being one of the most commonly performed spinal surgeries, investigating common complications such as adjacent segment disease (ASD) is a high priority. To the authors' knowledge, there are no previous studies investigating the utility of the preoperative magnetic resonance imaging-based vertebral bone quality (VBQ) score in predicting radiographic and surgical ASD after lumbar spine fusion. We aimed to investigate the predictive factors for radiographic and surgical ASD, focusing on the predictive potential of the VBQ score. METHODS A single-center retrospective analysis was conducted of all patients who underwent 1-3 level lumbar or lumbosacral interbody fusion for lumbar spine degenerative disease between 2014 and 2021 with a minimum 12 months of clinical and radiographic follow-up. Demographic data were collected, along with patient medical, and surgical data. Preoperative MRI was assessed in the included patients using the VBQ scoring system to identify whether radiographic ASD or surgical ASD could be predicted. RESULTS A total of 417 patients were identified (mean age, 59.8 ± 12.4 years; women, 54.0%). Eighty-two (19.7%) patients developed radiographic ASD, and 58 (13.9%) developed surgical ASD. A higher VBQ score was a significant predictor of radiographic ASD in univariate analysis (2.4 ± 0.5 vs 3.3 ± 0.4; P < .001) and multivariate analysis (odds ratio, 1.601; 95% CI, 1.453-1.763; P < .001). For surgical ASD, a significantly higher VBQ score was seen in univariate analysis (2.3 ± 0.5 vs 3.3 ± 0.4; P < .001) and served as an independent risk factor in multivariate analysis (odds ratio, 1.509; 95% CI, 1.324-1.720; P < .001). We also identified preoperative disk bulge and preoperative existence of adjacent segment disk degeneration to be significant predictors of both radiographic and surgical ASD. Furthermore, 3-level fusion was also a significant predictor for surgical ASD. CONCLUSION The VBQ scoring system might be a useful adjunct for predicting radiographic and surgical ASD.
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Affiliation(s)
- Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo , Egypt
| | - Rehman Ali Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | - Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Nicco Ruggiero
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Brianna M Donnelly
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | - Manhal Siddiqi
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | - Esteban Quiceno
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | - Jeffrey P Mullin
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | - John Pollina
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
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Butrico C, Meisel HJ, Sage K. Patient Comorbidities, Their Influence on Lumbar Spinal Fusion Surgery, and Recommendations to Reduce Unfavorable Outcomes. J Am Acad Orthop Surg 2024:00124635-990000000-01058. [PMID: 39083527 DOI: 10.5435/jaaos-d-23-01167] [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: 12/05/2023] [Accepted: 06/19/2024] [Indexed: 08/02/2024] Open
Abstract
Improvements in healthcare management have led to a decrease in perioperative and postoperative complications. However, perioperative medical complications and mortality rates continue to increase in patients undergoing elective spinal surgeries. This trend is driven by the increase in the older population and the rise in the number of patients with more than two comorbidities. Managing patients with multiple comorbidities requires additional resources, augmenting the financial and societal burden. Despite the high risk of complications and mortality, patients with multiple comorbidities undergo spinal surgery for degenerative spinal conditions daily. These findings highlight the need for heightened awareness, patient education, and management of comorbidities before elective spinal surgeries. This article comprehensively reviews literature on the effects of medical comorbidities on spinal fusion surgery outcomes to increase awareness of the surgical complications associated with comorbidities. In addition, suggested preoperative and postoperative comorbidity management strategies are outlined.
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Affiliation(s)
- Casey Butrico
- From the Kuros Biosciences, Bilthoven, The Netherlands (Butrico and Sage), and the Department of Neurosurgery, Bergmannstrost Hospital, Halle, Germany (Meisel)
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Raad M, Kim AH, Durand WM, Kebaish KM. Low bone mineral density: a primer for the spine surgeon. Spine Deform 2024:10.1007/s43390-024-00913-z. [PMID: 39060777 DOI: 10.1007/s43390-024-00913-z] [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: 04/04/2024] [Accepted: 06/01/2024] [Indexed: 07/28/2024]
Abstract
Within spinal surgery, low bone mineral density is associated with several postoperative complications, such as proximal junctional kyphosis, pseudoarthrosis, and screw loosening. Although modalities such as CT and MRI can be utilized to assess bone quality, DEXA scans, the "Gold Standard" for diagnosing osteoporosis, is not routinely included in preoperative workup. With an increasing prevalence of osteoporosis in an aging population, it is critical for spine surgeons to understand the importance of evaluating bone mineral density preoperatively to optimize postoperative outcomes. The purpose of this state-of-the-art review is to provide surgeons a summary of the evaluation, treatment, and implications of low bone mineral density in patients who are candidates for spine surgery.
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Affiliation(s)
- Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St. 5th Floor, Baltimore, MD, 21205, USA
| | - Andrew H Kim
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St. 5th Floor, Baltimore, MD, 21205, USA
| | - Wesley M Durand
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St. 5th Floor, Baltimore, MD, 21205, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St. 5th Floor, Baltimore, MD, 21205, USA.
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Sheth NP, Smith JR, Winzenrieth R, Humbert L, Wang Y, Boxberger JI, Bostrom MP. Effects of Abaloparatide on Bone Mineral Density in Proximal Femoral Regions Corresponding to Arthroplasty Gruen Zones: A Study of Postmenopausal Women with Osteoporosis. J Bone Joint Surg Am 2024; 106:1162-1170. [PMID: 38691582 DOI: 10.2106/jbjs.23.01334] [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: 05/03/2024]
Abstract
BACKGROUND Low hip bone mineral density (BMD) in patients who undergo total hip arthroplasty (THA) increases the risk of periprosthetic fractures, implant instability, and other complications. Recently, emphasis has been placed on bone health optimization: treating low BMD prior to a planned orthopaedic implant procedure in an effort to normalize BMD and reduce the potential risk of future complications. Abaloparatide is a U.S. Food and Drug Administration-approved osteoanabolic agent for men and postmenopausal women with osteoporosis and a candidate drug for bone health optimization that, in addition to benefits at the spine, increases hip BMD and reduces nonvertebral fracture risk. We hypothesized that abaloparatide would improve BMD in proximal femoral regions surrounding a virtual THA stem. METHODS This post hoc analysis obtained dual x-ray absorptiometry (DXA) hip scans from 500 randomly selected postmenopausal women with osteoporosis from the Phase-3 Abaloparatide Comparator Trial in Vertebral Endpoints (ACTIVE, NCT01343004) study after 0, 6, and 18 months of abaloparatide (250 patients) or placebo (250 patients). Hip DXA scans underwent 3-dimensional (3D) modeling via 3D-Shaper, followed by virtual resection of the proximal femur and simulated placement of a tapered, flat-wedge hip stem that guided delineation of the Gruen zones that were fully (zones 1 and 7) or largely (zones 2 and 6) captured in the scanning region. Integral, cortical, and trabecular volumetric BMD, cortical thickness, and cortical surface BMD (the product of cortical volumetric BMD and cortical thickness) were determined for each zone. RESULTS Compared with placebo, the abaloparatide group showed greater increases in integral volumetric BMD in all zones at months 6 and 18; cortical surface BMD in zones 1, 6, and 7 at month 6; cortical thickness, cortical volumetric BMD, and cortical surface BMD in all zones at month 18; and trabecular volumetric BMD in zones 1 and 7 at months 6 and 18. CONCLUSIONS Abaloparatide increases BMD in proximal femoral regions that interact with and support femoral stems, suggesting that abaloparatide may have value for preoperative or potentially perioperative bone health optimization in patients with osteoporosis undergoing THA. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Neil P Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Yamei Wang
- Radius Health, Inc., Boston, Massachusetts
| | | | - Mathias P Bostrom
- Adult Reconstruction & Joint Replacement, Hospital for Special Surgery, New York, NY
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Gelvez D, Dong K, Redlich N, Williams J, Bhandutia A, Shamassian B. Treatment Strategies in the Osteoporotic Spine. Orthop Clin North Am 2024; 55:403-413. [PMID: 38782511 DOI: 10.1016/j.ocl.2024.01.001] [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: 05/25/2024]
Abstract
This article reviews the appropriate assessment and management of osteoporotic compression fractures and discusses the implications of osteoporosis on initial patient evaluation, medical optimization for surgery, selection of instrumentation, and surgical technique. Adverse outcomes associated with osteoporosis are discussed. Failure to appropriately evaluate, optimize, and treat spine patients with osteoporotic bone can lead to disastrous complications. Weakened bone can lead to implant failure through cage subsidence and screw pullout, as well as, peri-implant fractures, failure of deformity correction, and proximal kyphosis. These risks must be taken into account when considering operative interventions in these patients.
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Affiliation(s)
- Daniel Gelvez
- LSU-HSC Department of Orthopaedics, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA.
| | - Katherine Dong
- LSU-HSC Department of Orthopaedics, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Nathan Redlich
- LSU-HSC Department of Orthopaedics, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Jestin Williams
- LSU-HSC Department of Orthopaedics, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Amit Bhandutia
- LSU-HSC Department of Orthopaedics, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
| | - Berje Shamassian
- LSU-HSC Department of Neurosurgery, 2021 Perdido Street, 7th Floor, New Orleans, LA 70112, USA
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Kumar RP, Adida S, Lavadi RS, Mitha R, Legarreta AD, Hudson JS, Shah M, Diebo B, Fields DP, Buell TJ, Hamilton DK, Daniels AH, Agarwal N. A guide to selecting upper thoracic versus lower thoracic uppermost instrumented vertebra in adult spinal deformity correction. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2742-2750. [PMID: 38522054 DOI: 10.1007/s00586-024-08206-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/26/2024] [Accepted: 02/24/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE Operative treatment of adult spinal deformity (ASD) has been shown to improve patient health-related quality of life (HRQOL). Selection of the uppermost instrumented vertebra (UIV) in either the upper thoracic (UT) or lower thoracic (LT) spine is a pivotal decision with effects on operative and postoperative outcomes. This review overviews the multifaceted decision-making process for UIV selection in ASD correction. METHODS PubMed was queried for articles using the keywords "uppermost instrumented vertebra", "upper thoracic", "lower thoracic", and "adult spinal deformity". RESULTS Optimization of UIV selection may lead to superior deformity correction, better patient-reported outcomes, and lower risk of proximal junctional kyphosis (PJK) and failure (PJF). Patient alignment characteristics, including preoperative thoracic kyphosis, coronal deformity, and the magnitude of sagittal correction influence surgical decision-making when selecting a UIV, while comorbidities such as poor body mass index, osteoporosis, and neuromuscular pathology should also be taken in to account. Additionally, surgeon experience and resources available to the hospital may also play a role in this decision. Currently, it is incompletely understood whether postoperative HRQOLs, functional and radiographic outcomes, and complications after surgery differ between selection of the UIV in either the UT or LT spine. CONCLUSION The correct selection of the UIV in surgical planning is a challenging task, which requires attention to preoperative alignment, patient comorbidities, clinical characteristics, available resources, and surgeon-specific factors such as experience.
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Affiliation(s)
- Rohit Prem Kumar
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Samuel Adida
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Raj Swaroop Lavadi
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Rida Mitha
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Andrew D Legarreta
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joseph S Hudson
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Manan Shah
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Daryl P Fields
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
- Neurological Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
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11
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Katayanagi J, Konuma H, Yanase T, Inose H, Tanaka T, Iida T, Morishita S, Jinno T. Predictive role of FRAX© for postoperative proximal junctional kyphosis with vertebral fracture after adult spinal deformity surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2777-2786. [PMID: 38816534 DOI: 10.1007/s00586-024-08309-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 04/29/2024] [Accepted: 05/11/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE To identify risk factors, including FRAX (a tool for assessing osteoporosis) scores, for development of proximal junctional kyphosis (PJK), defined as Type 2 in the Yagi-Boachie classification (bone failure), with vertebral fracture (VF) after surgery for symptomatic adult spinal deformity. METHODS This was a retrospective, single institution study of 127 adults who had undergone corrective long spinal fusion of six or more spinal segments for spinal deformity and been followed up for at least 2 years. The main outcome was postoperative development of PJK with VF. Possible predictors of this outcome studied included age at surgery, BMI, selected radiographic measurements, bone mineral density, and 10-year probability of major osteoporotic fracture (MOF) as determined by FRAX. We also analyzed use of medications for osteoporosis. Associations between the selected variables and PJK with VF were assessed by the Mann-Whitney, Fishers exact, and Wilcoxon signed-rank tests, and Kaplan-Meier analysis, as indicated. RESULTS Forty patients (31.5%) developed PJK with VF postoperatively,73% of them within 6 months of surgery. Statistical analysis of the selected variables found that only a preoperative estimate by FRAX of a > 15% risk of MOF within 10 years, pelvic tilt > 30° at first standing postoperatively and lower instrumented level (fusion terminating at the pelvis) were significantly associated with development of PJK with VF. CONCLUSION Preoperative assessment of severity of osteoporosis using FRAX provides an accurate estimate of risk of postoperative PJK with VF after surgery for adult spinal deformity.
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Affiliation(s)
- Junya Katayanagi
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan.
| | - Hiroki Konuma
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Tsukasa Yanase
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Hiroyuki Inose
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Tomoyuki Tanaka
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Takahiro Iida
- Department of Orthopedic Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Shingo Morishita
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuya Jinno
- Department of Orthopedic Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
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12
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Yamamoto K, Tanaka S. Survey on Actual Management of Osteoporosis with the Japanese Medical Data Vision Database in Elderly Patients Undergoing Spinal Fusion. J Clin Med 2024; 13:2806. [PMID: 38792348 PMCID: PMC11121966 DOI: 10.3390/jcm13102806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Background: No actual data on spinal fusion and management of osteoporosis in Japan have been reported. The aim of the survey was to investigate pre- and post-operative management of osteoporosis, including testing and prescription, in elderly patients undergoing spinal fusion in Japan. Methods: Medical data on patients aged 65 years or older undergoing spinal fusion from April 2018 to March 2022 were extracted from the medical data vision (MDV) database containing health insurance claims data from Japanese acute care hospitals to investigate fusion area, pre- and post-operative osteoporosis tests (bone mineral density and osteoporosis markers), prescriptions of osteoporosis medications, and other information. Results: The analysis set consisted of 26,959 patients. Annual pre-operative BMD testing rates and osteoporosis markers testing rates were higher than the post-operative rates without significant annual changes. The post-operative prescription rate of osteoporosis medications throughout the target period was approximately two times higher than the preoperative rate. The drug with highest pre- and post-operative prescription rates was teriparatide (TPTD) followed by bisphosphonates, showing that the prescription rate of TPTD proportionally increased with the length of fusion area. Conclusions: It was suggested that patients aged 65 years or older undergoing spinal fusion might receive insufficient osteoporosis tests. Despite no trend in the testing rate with the length of fusion area, some tendency was observed in the selection of osteoporosis medications. In patients with osteoporosis undergoing spinal fusion, early examination, diagnosis, and therapeutic intervention may improve the prognoses, and solid testing and prescriptions are therefore expected.
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Affiliation(s)
- Kenta Yamamoto
- Pharmaceutical R&D Business and Strategy Division, Musculoskeletal Pharmaceutical Brand Strategy, Asahi Kasei Pharma Corporation, 1-1-2 Yurakucho, Chiyoda-ku, Tokyo 100-0006, Japan;
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13
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Taniwaki H, Hoshino M, Kinoshita Y, Matsumura A, Namikawa T, Kato M, Takahashi S, Nakamura H. Lower preoperative Hounsfield unit values as a risk factor for poor 5-year clinical outcomes after lumbar spine surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:11-18. [PMID: 37882830 DOI: 10.1007/s00586-023-07995-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 10/01/2023] [Accepted: 10/06/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE Hounsfield Unit (HU) value has been associated with future osteoporotic fractures and postoperative complications. However, no studies on the impact of low HU values on mid-term clinical outcomes following lumbar spine surgery have been reported. We aimed to evaluate the usefulness of preoperative HU values for 5-year clinical outcomes following lumbar spine surgery. METHODS We enrolled 200 patients who underwent lumbar surgery (≤ 3-disc levels) for lumbar spinal stenosis. HU values were assessed using preoperative lumbar computed tomography as part of routine preoperative planning for lumbar surgery. Patients were divided into two groups based on the cutoff value of the HU values obtained from the receiver operating characteristic curve for the incidence of vertebral fractures within five years postoperatively. Clinical scores preoperatively and 1, 2, and 5 years postoperatively, including Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and Short Form-36 (SF-36), were compared using a mixed-effects model. RESULTS Comparative analysis indicated that all domains of JOABPEQ, except for lumbar function, and the physical component summary of the SF-36 were significantly worse in the low HU group than in the high HU group. Using multiple regression analysis, low HU values were significantly correlated with worse 5-year postoperative scores in all domains of JOABPEQ and SF-36. CONCLUSION Low preoperative HU values are a risk factor for poor 5-year clinical outcomes after lumbar spine surgery. HU values are not only a valuable tool for analyzing bone mineral density but also may be a valuable poor prognostic factor of postoperative clinical outcomes.
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Affiliation(s)
- Hiroshi Taniwaki
- Department of Orthopedic Surgery, Osaka City General Hospital, 2-13-22, Miyakojima Hon-Dori, Miyakojima-Ku, Osaka City, Osaka, 534-0021, Japan.
| | - Masatoshi Hoshino
- Department of Orthopedic Surgery, Osaka City General Hospital, 2-13-22, Miyakojima Hon-Dori, Miyakojima-Ku, Osaka City, Osaka, 534-0021, Japan
| | - Yuki Kinoshita
- Department of Orthopedic Surgery, Osaka City General Hospital, 2-13-22, Miyakojima Hon-Dori, Miyakojima-Ku, Osaka City, Osaka, 534-0021, Japan
| | - Akira Matsumura
- Department of Orthopedic Surgery, Osaka City General Hospital, 2-13-22, Miyakojima Hon-Dori, Miyakojima-Ku, Osaka City, Osaka, 534-0021, Japan
| | - Takashi Namikawa
- Department of Orthopedic Surgery, Osaka City General Hospital, 2-13-22, Miyakojima Hon-Dori, Miyakojima-Ku, Osaka City, Osaka, 534-0021, Japan
| | - Minori Kato
- Department of Orthopedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shinji Takahashi
- Department of Orthopedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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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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15
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Diltz ZR, West EJ, Colatruglio MR, Kirwan MJ, Konrade EN, Thompson KM. Perioperative Management of Comorbidities in Spine Surgery. Orthop Clin North Am 2023; 54:349-358. [PMID: 37271563 DOI: 10.1016/j.ocl.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The number of spinal operations performed in the United States has significantly increased in recent years. Along with these rising numbers, there has been a corresponding increase in the number of patient comorbidities. The focus of this article is to review comorbidities in Spine surgery patients and outline strategies to optimize patients and avoid complications.
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Affiliation(s)
- Zachary R Diltz
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Eric J West
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Matthew R Colatruglio
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Mateo J Kirwan
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Elliot N Konrade
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Kirk M Thompson
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA.
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El Miedany Y, Toth M, Elwakil W, Saber S. Post-Fracture Care Program: Pharmacological Treatment of Osteoporosis in Older Adults with Fragility Fractures. Curr Osteoporos Rep 2023:10.1007/s11914-023-00791-w. [PMID: 37300602 DOI: 10.1007/s11914-023-00791-w] [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] [Accepted: 05/22/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE OF REVIEW To present and discuss the recently published scientific evidence on the approach, mode of action, and timing of osteoporosis therapy initiation after fragility fractures. RECENT FINDINGS A comprehensive management approach is required to reduce mortality and morbidity associated with fragility fractures. This will help to reduce the risk of missing the diagnosis of osteoporosis as the underlying disorder while at the same time promoting the timely treatment of osteoporosis. The target is to minimize the incidence of post-traumatic disability and to reduce the imminent fracture risk. This article will present a Bone-Care algorithm for the diagnosis and management of fragility fractures in patients presenting for trauma surgery. This algorithm has been developed based on recently published national as well as international guidelines for implementation in standard clinical practice. International figures revealed that only a small proportion of those patients at high risk of sustaining a fragility fracture receive osteoporosis therapy. Based on the best currently available evidence, it is safe to start osteoporosis therapy in the acute post-fracture period (the optimal therapeutic window of romosozumab is the late endochondral phase/throughout bone remodeling). The right Bone-Care pathway ensures the delivery of a comprehensive management approach that meets the global call to action. All parameters including risk, benefit, compliance, and cost should be considered on an individual base for all kinds of therapy.
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Affiliation(s)
- Yasser El Miedany
- Institute of Medical Sciences, Canterbury Christ Church University, Canterbury, UK.
| | - Mathias Toth
- King's College, London, UK
- Darent Valley Hospital, Kent, UK
| | - Walaa Elwakil
- Rheumatology, Physical Medicine and Rehabilitation, Alexandria University, Alexandria, Egypt
| | - Sally Saber
- Rheumatology and Rehabilitation, Ain Shams University, Cairo, Egypt
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Malacon K, Beach I, Touponse G, Rangwalla T, Lee J, Zygourakis C. Trends in Management of Osteoporosis Following Primary Vertebral Compression Fracture. J Endocr Soc 2023; 7:bvad085. [PMID: 37388575 PMCID: PMC10306270 DOI: 10.1210/jendso/bvad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Indexed: 07/01/2023] Open
Abstract
Purpose Osteoporosis affects more than 200 million individuals worldwide and predisposes to vertebral compression fractures (VCFs). Given undertreatment of fragility fractures, including VCFs, we investigate current anti-osteoporotic medication prescribing trends. Methods Patients 50 and older with a diagnosis of primary closed thoracolumbar VCF between 2004 and 2019 were identified from the Clinformatics® Data Mart database. Multivariate analysis was performed for demographic and clinical treatment and outcome variables. Results Of 143 081 patients with primary VCFs, 16 780 (11.7%) were started on anti-osteoporotic medication within a year; 126 301 (88.3%) patients were not started on medication. The medication cohort was older (75.4 ± 9.3 vs 74.0 ± 12.3 years, P < .001), had higher Elixhauser Comorbidity Index scores (4.7 ± 6.2 vs 4.3 ± 6.7, P < .001), was more likely to be female (81.1% vs 64.4%, P < .001), and was more likely to have a formal osteoporosis diagnosis (47.8% vs 32.9%) than the group that did not receive medication. Alendronate (63.4%) and calcitonin (27.8%) were the most commonly initiated medications. The proportion of individuals receiving anti-osteoporotic medication within the year following VCF peaked in 2008 (15.2%), then declined until 2012 with a modest increase afterward. Conclusions Osteoporosis remains undertreated after low-energy VCFs. New anti-osteoporotic medication classes have been approved in recent years. Bisphosphonates remain the most prescribed class. Increasing recognition and treatment of osteoporosis is paramount to decreasing the risk of subsequent fractures.
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Affiliation(s)
- Karen Malacon
- School of Medicine, Stanford University Medical Center, Stanford, CA 94305, USA
| | - Isidora Beach
- Department of Neurosurgery, Larner College of Medicine at The University of Vermont, Burlington, VT 05405, USA
| | - Gavin Touponse
- School of Medicine, Stanford University Medical Center, Stanford, CA 94305, USA
| | - Taiyeb Rangwalla
- Department of Neurosurgery, Dell Medical School, The University of Texas at Austin, Austin, TX 78712, USA
| | - Jennifer Lee
- Department of Medicine, Stanford University Medical Center, Stanford, CA 94305, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Corinna Zygourakis
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA 94305, USA
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18
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Fan ZQ, Yan XA, Li BF, Shen E, Xu X, Wang H, Zhuang Y. Prevalence of osteoporosis in spinal surgery patients older than 50 years: A systematic review and meta-analysis. PLoS One 2023; 18:e0286110. [PMID: 37228067 DOI: 10.1371/journal.pone.0286110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION In spine surgery, poor bone condition is associated with several complications like adjacent segment fractures, proximal junctional kyphosis, and screw loosening. Our study explored the prevalence of osteoporosis in spinal surgery patients older than 50 years through a systematic review and meta-analysis. METHODS This systematic review and meta-analysis were conducted according to the PRISMA criteria. Three electronic databases, including PubMed, EMBASE, and Web of Science, were searched from inception to August 2022. We used the random-effects model to calculate the overall estimates, and the heterogeneity was measured using Cochran's Q and I2 tests. Meta-regression and subgroup analyses were used to determine the source of the heterogeneity. RESULTS Based on the inclusion and criteria, we chose ten studies with 2958 individuals for our analysis. The prevalence of osteoporosis, osteopenia, and osteoporosis/osteopenia in the spinal surgery patients was 34.2% (95%CI: 24.5%-44.6%), 43.5% (95%CI: 39.8%-47.2%), and 78.7% (95%CI: 69.0%-87.0%), respectively. Regarding different diagnoses, the prevalence was highest in patients with lumbar scoliosis (55.8%; 95%CI: 46.8%-64.7%) and the lowest in patients with cervical disc herniation (12.9%; 95%CI: 8.1%-18.7%). In age groups 50-59, 50-69,70-79, the prevalence was 27.8%, 60.4%, 75.4% in females, and 18.9%, 17.4%, 26.1% in males. CONCLUSIONS This study showed a high prevalence of osteoporosis in patients undergoing spine surgery, especially in females, people of older age, and patients who received degenerative scoliosis and compression fractures. Current osteoporosis screening standards for patients undergoing spine surgery may not be adequate. Orthopedic specialists should make more efforts regarding preoperative osteoporosis screening and treatment.
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Affiliation(s)
- Zhi-Qiang Fan
- Department of Pelvic and Acetabular Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xin-An Yan
- Department of Pelvic and Acetabular Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bao-Feng Li
- Department of Pelvic and Acetabular Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Erdong Shen
- Department of Pelvic and Acetabular Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xin Xu
- Department of Pelvic and Acetabular Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Hu Wang
- Department of Pelvic and Acetabular Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yan Zhuang
- Department of Pelvic and Acetabular Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, China
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Schömig F, Becker L, Schönnagel L, Völker A, Disch AC, Schnake KJ, Pumberger M. Avoiding Spinal Implant Failures in Osteoporotic Patients: A Narrative Review. Global Spine J 2023; 13:52S-58S. [PMID: 37084355 PMCID: PMC10177307 DOI: 10.1177/21925682231159066] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES With an aging population, the prevalence of osteoporosis is continuously rising. As osseous integrity is crucial for bony fusion and implant stability, previous studies have shown osteoporosis to be associated with an increased risk for implant failure and higher reoperation rates after spine surgery. Thus, our review's purpose was to provide an update of evidence-based solutions in the surgical treatment of osteoporosis patients. METHODS We summarize the existing literature regarding changes associated with decreased bone mineral density (BMD) and resulting biomechanical implications for the spine as well as multidisciplinary treatment strategies to avoid implant failures in osteoporotic patients. RESULTS Osteoporosis is caused by an uncoupling of the bone remodeling cycle based on an unbalancing of bone resorption and formation and resulting reduced BMD. The reduction in trabecular structure, increased porosity of cancellous bone and decreased cross-linking between trabeculae cause a higher risk of complications after spinal implant-based surgeries. Thus, patients with osteoporosis require special planning considerations, including adequate preoperative evaluation and optimization. Surgical strategies aim towards maximizing screw pull-out strength, toggle resistance, as well as primary and secondary construct stability. CONCLUSIONS As osteoporosis plays a crucial role in the fate of patients undergoing spine surgery, surgeons need to be aware of the specific implications of low BMD. While there still is no consensus on the best course of treatment, multidisciplinary preoperative assessment and adherence to specific surgical principles help reduce the rate of implant-related complications.
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Affiliation(s)
- Friederike Schömig
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Luis Becker
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lukas Schönnagel
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Völker
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Alexander C Disch
- University Comprehensive Spine Center, University Center for Orthopedics, Traumatology and Plastic Surgery, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St Marien gGmbH, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Keaveny TM, Adams AL, Fischer H, Brara HS, Burch S, Guppy KH, Kopperdahl DL. Increased risks of vertebral fracture and reoperation in primary spinal fusion patients who test positive for osteoporosis by Biomechanical Computed Tomography analysis. Spine J 2023; 23:412-424. [PMID: 36372353 DOI: 10.1016/j.spinee.2022.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND CONTEXT While osteoporosis is a risk factor for adverse outcomes in spinal fusion patients, diagnosing osteoporosis reliably in this population has been challenging due to degenerative changes and spinal deformities. Addressing that challenge, biomechanical computed tomography analysis (BCT) is a CT-based diagnostic test for osteoporosis that measures both bone mineral density and bone strength (using finite element analysis) at the spine; CT scans taken for spinal evaluation or previous care can be repurposed for the analysis. PURPOSE Assess the effectiveness of BCT for preoperatively identifying spinal fusion patients with osteoporosis who are at high risk of reoperation or vertebral fracture. STUDY DESIGN Observational cohort study in a multi-center integrated managed care system using existing data from patient medical records and imaging archives. PATIENT SAMPLE We studied a randomly sampled subset of all adult patients who had any type of primary thoracic (T4 or below) or lumbar fusion between 2005 and 2018. For inclusion, patients with accessible study data needed a preop CT scan without intravenous contrast that contained images (before any instrumentation) of the upper instrumented vertebral level. OUTCOME MEASURES Reoperation for any reason (primary outcome) or a newly documented vertebral fracture (secondary outcome) occurring up to 5 years after the primary surgery. METHODS All study data were extracted using available coded information and CT scans from the medical records. BCT was performed at a centralized lab blinded to the clinical outcomes; patients could test positive for osteoporosis based on either low values of bone strength (vertebral strength ≤ 4,500 N women or 6,500 N men) and/or bone mineral density (vertebral trabecular bone mineral density ≤ 80 mg/cm3 both sexes). Cox proportional hazard ratios were adjusted by age, presence of obesity, and whether the fusion was long (four or more levels fused) or short (3 or fewer levels fused); Kaplan-Meier survival was compared by the log rank test. This project was funded by NIH (R44AR064613) and all physician co-authors and author 1 received salary support from their respective departments. Author 6 is employed by, and author 1 has equity in and consults for, the company that provides the BCT test; the other authors declare no conflicts of interest. RESULTS For the 469 patients analyzed (298 women, 171 men), median follow-up time was 44.4 months, 11.1% had a reoperation (median time 14.5 months), and 7.7% had a vertebral fracture (median time 2.0 months). Overall, 25.8% of patients tested positive for osteoporosis and no patients under age 50 tested positive. Compared to patients without osteoporosis, those testing positive were at almost five-fold higher risk for vertebral fracture (adjusted hazard ratio 4.7, 95% confidence interval = 2.2-9.7; p<.0001 Kaplan-Meier survival). Of those positive-testing patients, those who tested positive concurrently for low values of both bone strength and bone mineral density (12.6% of patients overall) were at almost four-fold higher risk for reoperation (3.7, 1.9-7.2; Kaplan-Meier survival p<.0001); the remaining positive-testing patients (those who tested positive for low values of either bone strength or bone mineral density but not both) were not at significantly higher risk for reoperation (1.6, 0.7-3.7) but were for vertebral fracture (4.3, 1.9-10.2). For both clinical outcomes, risk remained high for patients who underwent short or long fusion. CONCLUSION In a real-world clinical setting, BCT was effective in identifying primary spinal fusion patients aged 50 or older with osteoporosis who were at elevated risks of reoperation and vertebral fracture.
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Affiliation(s)
- Tony M Keaveny
- Departments of Mechanical Engineering and Bioengineering, University of California, Berkeley, CA, USA.
| | - Annette L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Heidi Fischer
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Harsimran S Brara
- Department of Neurosurgery, Southern California Permanente Medical Group, Los Angeles, CA, USA
| | - Shane Burch
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Kern H Guppy
- Department of Neurosurgery, Kaiser Permanente Medical Group, Sacramento, CA, USA
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Shen Y, Sardar ZM, Chase H, Coury JR, Cerpa M, Lenke LG. Predicting Bone Health Using Machine Learning in Patients undergoing Spinal Reconstruction Surgery. Spine (Phila Pa 1976) 2023; 48:120-126. [PMID: 36302158 DOI: 10.1097/brs.0000000000004511] [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] [Received: 05/14/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022]
Abstract
STUDY DESIGN Retrospective study of data collected prospectively. OBJECTIVE The goal of this study is to create a predictive model of preoperative bone health status in adult patients undergoing adult spinal reconstructive (ASR) surgery using machine learning (ML). SUMMARY OF BACKGROUND DATA Despite understanding that bone health impacts spine surgery outcomes, spine surgeons lack the tools to risk stratify patients preoperatively to determine who should undergo bone health screening. An ML approach mines patterns in data to determine the risk for poor bone health in ASR patients. MATERIALS AND METHODS Two hundred and eleven subjects over the age of 30 with dual energy X-ray absorptiometry scans, who underwent spinal reconstructive surgery were reviewed. Data was collected by manual and automated collection from the electronic health records. The Weka software was used to develop predictive models for multiclass classification of healthy, osteopenia, and osteoporosis (OPO) bone status. Bone status was labeled according to the World Health Organization (WHO) criteria using dual energy X-ray absorptiometry T scores. The accuracy, sensitivity, specificity, and area under the receiver operating curve (AUC) were calculated. The model was evaluated on a test set of unseen data for generalizability. RESULTS The prevalence of OPO was 23.22% and osteopenia was 52.61%. The random forest model achieved optimal performance with an average sensitivity of 0.81, specificity of 0.95, and AUC of 0.96 on the training set. The model yielded an averaged sensitivity of 0.64, specificity of 0.78, and AUC of 0.69 on the test set. The model was best at predicting OPO in patients. Numerous patient features exhibited predictive value, such as body mass index, insurance type, serum sodium level, serum creatinine level, history of bariatric surgery, and the use of medications such as selective serotonin reuptake inhibitors. CONCLUSION Predicting bone health status in ASR patients is possible with an ML approach. Additionally, data mining using ML can find unrecognized risk factors for bone health in ASR surgery patients.
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Affiliation(s)
- Yong Shen
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian
| | - Zeeshan M Sardar
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian
| | - Herbert Chase
- Department of Biomedical Informatics, Columbia University, New York City, NY
| | - Josephine R Coury
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian
| | - Meghan Cerpa
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian
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22
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Advancement in the Treatment of Osteoporosis and the Effects on Bone Healing. J Clin Med 2022; 11:jcm11247477. [PMID: 36556093 PMCID: PMC9781093 DOI: 10.3390/jcm11247477] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
Osteoporosis (OP) is a major global health concern, with aging being one of the most important risk factors. Osteoarthritis (OA) is also an age-related disorder. Patients with OP and/or OA may be treated surgically for fractures or when their quality of life is impaired. Poor bone quality due to OP can seriously complicate the stability of a bone fixation construct and/or surgical fracture treatment. This review summarizes the current knowledge on the pathophysiology of normal and osteoporotic bone healing, the effect of a bone fracture on bone turnover markers, the diagnosis of a low bone mineral density (BMD) before surgical intervention, and the effect of available anti-osteoporosis treatment. Interventions that improve bone health may enhance the probability of favorable surgical outcomes. Fracture healing and the treatment of atypical femoral fractures are also discussed.
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23
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Medical optimization of osteoporosis for adult spinal deformity surgery: a state-of-the-art evidence-based review of current pharmacotherapy. Spine Deform 2022; 11:579-596. [PMID: 36454531 DOI: 10.1007/s43390-022-00621-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/19/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE Osteoporosis is a common, but challenging phenomenon to overcome in adult spinal deformity (ASD) surgery. Several pharmacological agents are at the surgeon's disposal to optimize the osteoporotic patient prior to undergoing extensive reconstruction. Familiarity with these medications will allow the surgeon to make informed decisions on selecting the most appropriate adjuncts for each individual patient. METHODS A comprehensive literature review was conducted in PubMed from September 2021 to April 2022. Studies were selected that contained combinations of various terms including osteoporosis, specific medications, spine surgery, fusion, cage subsidence, screw loosening, pull-out, junctional kyphosis/failure. RESULTS Bisphosphonates, denosumab, selective estrogen receptor modulators, teriparatide, abaloparatide and romosozumab are all pharmacological agents currently available for adjunctive use. While these medications have been shown to have beneficial effects on improving bone mineral density in the osteoporotic patient, varying evidence is available on their specific effects in the context of extensive spine surgery. There is still a lack of human studies with use of the newer agents. CONCLUSION Bisphosphonates are first-line agents due to their low cost and robust evidence behind their utility. However, in the absence of contraindications, optimizing bone quality with anabolic medications should be strongly considered in preparation for spinal deformity surgeries due to their beneficial and favorable effects on fusion and hardware compared to the anti-resorptive medications.
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Mikula AL, Lakomkin N, Pennington Z, Pinter ZW, Nassr A, Freedman B, Sebastian AS, Abode-Iyamah K, Bydon M, Ames CP, Fogelson JL, Elder BD. Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine. J Neurosurg Spine 2022; 37:694-702. [PMID: 35561697 DOI: 10.3171/2022.3.spine22197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to analyze risk factors and avoidance techniques for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in the upper thoracic spine with an emphasis on bone mineral density (BMD) as estimated by Hounsfield units (HU). METHODS A retrospective chart review identified patients at least 50 years of age who underwent instrumented fusion extending from the pelvis to an upper instrumented vertebra (UIV) between T1 and T6 and had a preoperative CT, pre- and postoperative radiographs, and a minimum follow-up of 12 months. HU were measured in the UIV, the vertebral body cephalad to the UIV (UIV+1), and the L3 and L4 vertebral bodies. Numerous perioperative variables were collected, including basic demographics, smoking and steroid use, preoperative osteoporosis treatment, multiple frailty indices, use of a proximal junctional tether, UIV soft landing, preoperative dual-energy x-ray absorptiometry, spinopelvic parameters, UIV screw tip distance to the superior endplate, UIV pedicle screw/pedicle diameter ratio, lumbar lordosis distribution, and postoperative spinopelvic parameters compared with age-adjusted normal values. RESULTS Eighty-one patients were included in the study (21 men and 60 women) with a mean (SD) age of 66 years (6.9 years), BMI of 29 (5.5), and follow-up of 38 months (25 months). Spinal fusion constructs at the time of surgery extended from the pelvis to a UIV of T1 (5%), T2 (15%), T3 (25%), T4 (33%), T5 (21%), and T6 (1%). Twenty-seven patients (33%) developed PJK and/or PJF; 21 (26%) had PJK and 15 (19%) had PJF. Variables associated with PJK/PJF with p < 0.05 were included in the multivariable analysis, including HU at the UIV/UIV+1, HU at L3/L4, DXA femoral neck T-score, UIV screw tip distance to the superior endplate, UIV pedicle screw/pedicle diameter ratio, and postoperative lumbar lordosis distribution. Multivariable analysis (area under the curve = 0.77) demonstrated HU at the UIV/UIV+1 to be the only independent predictor of PJK and PJF with an OR of 0.96 (p = 0.005). Patients with < 147 HU (n = 27), 147-195 HU (n = 27), and > 195 HU (n = 27) at the UIV/UIV+1 had PJK/PJF rates of 59%, 33%, and 7%, respectively. CONCLUSIONS In patients with upper thoracic-to-pelvis spinal reconstruction, lower HU at the UIV and UIV+1 were independently associated with PJK and PJF, with an optimal cutoff of 159 HU that maximizes sensitivity and specificity.
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Affiliation(s)
| | | | | | | | - Ahmad Nassr
- 2Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brett Freedman
- 2Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arjun S Sebastian
- 2Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Mohamad Bydon
- 1Department of Neurological Surgery, Mayo Clinic, Rochester
| | - Christopher P Ames
- 4Department of Neurological Surgery, University of California, San Francisco, California
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25
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Mikula AL, Pennington Z, Lakomkin N, Clarke MJ, Rose PS, Bydon M, Freedman B, Sebastian AS, Lu L, Kowalchuk RO, Merrell KW, Fogelson JL, Elder BD. Independent predictors of vertebral compression fracture following radiation for metastatic spine disease. J Neurosurg Spine 2022; 37:617-623. [PMID: 35426824 DOI: 10.3171/2022.2.spine211613] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to determine independent risk factors for vertebral compression fracture (VCF) following radiation for metastatic spine disease, including low bone mineral density as estimated by Hounsfield units (HU). METHODS A retrospective chart review identified patients with a single vertebral column metastasis treated with radiation therapy, a pretreatment CT scan, and a follow-up CT scan at least 6 weeks after treatment. Patients with primary spine tumors, preradiation vertebroplasty, preradiation spine surgery, prior radiation to the treatment field, and proton beam treatment modality were excluded. The HU were measured in the vertebral bodies at the level superior to the metastasis, within the tumor and medullary bone of the metastatic level, and at the level inferior to the metastasis. Variables collected included basic demographics, Spine Instability Neoplastic Score (SINS), presenting symptoms, bone density treatment, primary tumor pathology, Weinstein-Boriani-Biagini (WBB) classification, Enneking stage, radiation treatment details, chemotherapy regimen, and prophylactic vertebroplasty. RESULTS One hundred patients with an average age of 63 years and average follow-up of 18 months with radiation treatment dates ranging from 2017 to 2020 were included. Fifty-nine patients were treated with external-beam radiation therapy, with a median total dose of 20 Gy (range 8-40 Gy). Forty-one patients were treated with stereotactic body radiation therapy, with a median total dose of 24 Gy (range 18-39 Gy). The most common primary pathologies included lung (n = 22), prostate (n = 21), and breast (n = 14). Multivariable logistic regression analysis (area under the curve 0.89) demonstrated pretreatment HU (p < 0.01), SINS (p = 0.02), involvement of ≥ 3 WBB sectors (p < 0.01), primary pathology other than prostate (p = 0.04), and ongoing chemotherapy treatment (p = 0.04) to be independent predictors of postradiation VCF. Patients with pretreatment HU < 145 (n = 32), 145-220 (n = 31), and > 220 (n = 37) had a fracture rate of 59%, 39%, and 11%, respectively. An HU cutoff of 157 was found to maximize sensitivity (71%) and specificity (75%) in predicting postradiation VCF. CONCLUSIONS Low preradiation HU, higher SINS, involvement of ≥ 3 WBB sectors, ongoing chemotherapy, and nonprostate primary pathology were independent predictors of postradiation VCF in patients with metastatic spine disease. Low bone mineral density, as estimated by HU, is a novel and potentially modifiable risk factor for VCF.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lichun Lu
- 3Department of Physiology and Biomedical Engineering; and
| | - Roman O Kowalchuk
- 4Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth W Merrell
- 4Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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26
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Best Practice Guidelines for Assessment and Management of Osteoporosis in Adult Patients Undergoing Elective Spinal Reconstruction: Erratum. Spine (Phila Pa 1976) 2022; 47:E581. [PMID: 35960933 DOI: 10.1097/brs.0000000000004450] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Raad M, Ortiz-Babilonia C, Hassanzadeh H, Puvanesarajah V, Kebaish K, Jain A. Cost-utility Analysis of Neoadjuvant Teriparatide Therapy in Osteopenic Patients Undergoing Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2022; 47:1121-1127. [PMID: 35797582 DOI: 10.1097/brs.0000000000004409] [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: 04/18/2022] [Accepted: 05/10/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cost-utility analysis study. OBJECTIVE This study aims to evaluate the cost-utility of neoadjuvant teriparatide therapy in osteopenic patients undergoing adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA There is increasing evidence supporting preoperative use of anabolic agents such as teriparatide for preoperative optimization of ASD patients with poor bone density. However, such treatments are associated with added costs. To our knowledge, the cost-utility of teriparatide in osteopenic patients undergoing ASD surgery has not been established. MATERIALS AND METHODS A decision-analysis model was developed for a hypothetical 68-year-old female patient with osteopenia ( T score <-1.0) undergoing a T11 to pelvis instrumented spinal fusion for ASD. A comprehensive literature review was conducted to create estimates for event probabilities, costs, and quality adjusted life years at each node. Key model assumptions were that administration of a 4-month preoperative teriparatide course reduced 2-year postoperative reoperation rates [for pseudarthrosis from 5% to 2.5% and for proximal junctional failure (PJF) from 15% to 5%]. Monte Carlo simulations were used to calculate the mean incremental cost utility ratio and incremental net monetary benefits. One-way sensitivity analysis was used to estimate the contribution of individual parameters to uncertainty in the model. RESULTS Teriparatide was the favored strategy in 82% of the iterations. The mean incremental cost utility ratio for the teriparatide strategy was negative (higher net benefit, lower net cost), and lower than the willingness-to-pay threshold of $50,000 per quality adjusted life year. Teriparatide use was associated with a mean incremental net monetary benefit of $3,948. One-way sensitivity analysis demonstrated that the factors with the greatest impact on the model were the incidence of PJF in the no teriparatide group, the duration and monthly cost of treatment, and the cost of reoperation due to PJF. CONCLUSIONS Neoadjuvant teriparatide is a cost-effective strategy to reduce postoperative complications in patients with osteopenia undergoing ASD surgery.
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Affiliation(s)
- Micheal Raad
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Carlos Ortiz-Babilonia
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
- Department of Orthopaedic Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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28
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In Response to a Letter to the Editor. Spine (Phila Pa 1976) 2022; 47:E467-E468. [PMID: 35193999 DOI: 10.1097/brs.0000000000004321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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29
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Letter to the Editor concerning "Best Practice Guidelines for Assessment and Management of Osteoporosis in Adult Patients Undergoing Elective Spinal Reconstruction". Spine (Phila Pa 1976) 2022; 47:E466-E467. [PMID: 35066536 DOI: 10.1097/brs.0000000000004323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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