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Filley A, Baldwin A, Ben-Natan AR, Hansen K, Arora A, Xiao A, Hammond D, Chen C, Tweedt I, Rohde J, Link T, Berven S, Sawyer A. The influence of osteoporosis on mechanical complications in lumbar fusion surgery: a systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100327. [PMID: 38962714 PMCID: PMC11219986 DOI: 10.1016/j.xnsj.2024.100327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 07/05/2024]
Abstract
Background Adults undergoing spine surgery often have underlying osteoporosis, which may be a risk factor for postoperative complications. Although these associations have been described, osteoporosis remains profoundly underdiagnosed and undertreated in the spine surgery population. A thorough, comprehensive systematic review summarizing the relationships between bone mineral density (BMD) and specific complications of lumbar fusion surgery could be a valuable resource for raising awareness and supporting clinical practice changes. Methods PubMed, Embase, and Web of Science databases were searched for original clinical research articles reporting on BMD, or surrogate measure, as a predictor of complications in adults undergoing elective lumbar fusion for degenerative disease or deformity. Endpoints included cage subsidence, screw loosening, pseudarthrosis, vertebral fracture, junctional complications, and reoperation. Results A total of 71 studies comprising 12,278 patients were included. Overall, considerable heterogeneity in study populations, methods of bone health assessment, and definition and evaluation of clinical endpoints precluded meta-analysis. Nevertheless, low BMD was associated with higher rates of implant failures like cage subsidence and screw loosening, which were often diagnosed with concomitant pseudarthrosis. Osteoporosis was also a significant risk factor for proximal junctional kyphosis, particularly due to fracture. Many studies found surgical site-specific BMD to best predict focal complications. Functional outcomes were inconsistently addressed. Conclusions Our findings suggest osteoporosis is a significant risk factor for mechanical complications of lumbar fusion. These results emphasize the importance of preoperative osteoporosis screening, which allows for medical and surgical optimization of high-risk patients. This review also highlights current practical challenges facing bone health evaluation in patients undergoing elective surgery. Future prospective studies using standardized methods are necessary to strengthen existing evidence, identify optimal predictive thresholds, and establish specialty-specific practice guidelines. In the meantime, an awareness of the surgical implications of osteoporosis and utility of preoperative screening can provide for more informed, effective patient care.
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Affiliation(s)
- Anna Filley
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Avionna Baldwin
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Alma Rechav Ben-Natan
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Keith Hansen
- Department of General Surgery, University of California, San Francisco, CA, USA
| | - Ayush Arora
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Angel Xiao
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Deana Hammond
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Caressa Chen
- Loyola University Medical Center; Maywood IL, USA
| | - Isobel Tweedt
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, USA
| | - James Rohde
- Department of Integrative Biology, University of California Berkeley, USA
| | - Thomas Link
- Department of Radiology and Biomedical Imagery, University of California, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
| | - Aenor Sawyer
- Department of Orthopaedic Surgery, University of California, 435 Warren Drive, Apt 11, San Francisco, CA, USA
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Schaefer C, Mafi A, Beil FT, Schroeder M, Rolvien T. Skeletal Status in Patients Scheduled for Elective Lumbar Spine Surgery: Comparison of Discectomy, Decompression, Fusion, and Revision. Global Spine J 2024; 14:380-389. [PMID: 35604317 PMCID: PMC10802513 DOI: 10.1177/21925682221105005] [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] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVES To investigate and compare the prevalence of low bone mineral density (BMD) and abnormal laboratory bone metabolism parameters in patients undergoing elective primary discectomy, decompression, and fusion and to outline possible differences in these parameters between patients undergoing revision for skeletal vs non-skeletal complications. METHODS We retrospectively evaluated BMD measurements by dual-energy x-ray absorptiometry (DXA) in 389 consecutive patients scheduled for elective lumbar spine surgery. Next to demographic characteristics, laboratory bone metabolism parameters were assessed. Group comparisons were performed between primary discectomy, decompression, and fusion. In patients scheduled for revision surgery after fusion, potential differences in the skeletal status between those with skeletal vs non-skeletal complications were analyzed. RESULTS Osteoporosis by T-score was detected in 6.7%, 11.0% and 14.7% of the patients undergoing discectomy, decompression and fusion, respectively. While vitamin D deficiency (67.6%) and hyperparathyroidism (16.4%) were frequently detected, no differences in laboratory bone metabolism markers could be found between the groups. Female sex (P<.001), higher age (P=.01) and lower BMI (P<.001) were associated with lower BMD. In the cohort of patients undergoing revision surgery due to complications after fusion, those with skeletal complications did not differ in BMD or bone metabolism from those with non-skeletal complications. CONCLUSIONS Osteoporosis represents a relevant comorbidity in patients scheduled for elective spine surgery, which is why DXA should be routinely performed in these patients. However, DXA may provide limited information in identifying patients at increased risk for skeletal complications after fusion.
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Affiliation(s)
- Christian Schaefer
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Germany
- Department of Spine Surgery, Klinikum Bad Bramstedt, Germany
| | - Afshin Mafi
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Germany
| | - Frank Timo Beil
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Germany
| | - Malte Schroeder
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Germany
- Department of Spine Surgery, Klinikum Bad Bramstedt, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Germany
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Yeshoua BJ, Singh S, Liu H, Assad N, Dominy CL, Pasik SD, Tang JE, Patel A, Shah KC, Ranson W, Kim JS, Cho SK. Association Between Age-stratified Cohorts and Perioperative Complications and 30-day and 90-day Readmission in Patients Undergoing Single-level Anterior Cervical Discectomy and Fusion. Clin Spine Surg 2024; 37:E9-E17. [PMID: 37559220 DOI: 10.1097/bsd.0000000000001509] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 06/21/2023] [Indexed: 08/11/2023]
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE To assess perioperative complication rates and readmission rates after ACDF in a patient population of advanced age. SUMMARY OF BACKGROUND DATA Readmission rates after ACDF are important markers of surgical quality and, with recent shifts in reimbursement schedules, they are rapidly gaining weight in the determination of surgeon and hospital reimbursement. METHODS Patients 18 years of age and older who underwent elective single-level ACDF were identified in the National Readmissions Database (NRD) and stratified into 4 cohorts: 18-39 ("young"), 40-64 ("middle"), 65-74 ("senior"), and 75+ ("elderly") years of age. For each cohort, the perioperative complications, frequency of those complications, and number of patients with at least 1 readmission within 30 and 90 days of discharge were analyzed. χ 2 tests were used to calculate likelihood of complications and readmissions. RESULTS There were 1174 "elderly" patients in 2016, 1072 in 2017, and 1010 in 2018 who underwent ACDF. Their rate of any complication was 8.95%, 11.00%, and 13.47%, respectively ( P <0.0001), with dysphagia and acute posthemorrhagic anemia being the most common across all 3 years. They experienced complications at a greater frequency than their younger counterparts (15.80%, P <0.0001; 16.98%, P <0.0001; 21.68%, P <0.0001). They also required 30-day and 90-day readmission more frequently ( P <0.0001). CONCLUSION It has been well-established that advanced patient age brings greater risk of perioperative complications in ACDF surgery. What remains unsettled is the characterization of this age-complication relationship within specific age cohorts and how these complications inform patient hospital course. Our study provides an updated analysis of age-specific complications and readmission rates in ACDF patients. Orthopedic surgeons may account for the rise in complication and readmission rates in this population with the corresponding reduction in length and stay and consider this relationship before discharging elderly ACDF patients.
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Affiliation(s)
- Brandon J Yeshoua
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sirjanhar Singh
- Department of Orthopaedics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Helen Liu
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nima Assad
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Calista L Dominy
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sara D Pasik
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Justin E Tang
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Akshar Patel
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kush C Shah
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - William Ranson
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jun S Kim
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Samuel K Cho
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY
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He J, Chen H, Wu T, Rong X, Ding C, Wang B, Liu H. Is Cervical Disc Arthroplasty an Effective Treatment for Cervical Degenerative Disease With Osteopenia? Global Spine J 2023:21925682231190612. [PMID: 37459175 DOI: 10.1177/21925682231190612] [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] [Indexed: 12/22/2023] Open
Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVES To evaluate postoperative outcomes of single-level cervical disc arthroplasty (CDA) in patients with osteopenia and compare these results with a matched cohort of normal bone mineral density (BMD). METHODS Patients who had undergone single-level CDA were collected and screened. Included patients were divided into the osteopenia group and the normal group. 38 eligible patients with osteopenia were included in the final analysis. Subsequently, a 1:1 match was utilized. Clinical, radiographic data, and complications were recorded. Appropriate statistical methods were applied to conduct analysis using SPSS version 24.0. RESULTS The mean follow-up time was 30.5 ± 27.3 months. The osteopenia group achieved satisfactory clinical outcomes, with no significant intergroup differences. Additionally, there were no significant differences between groups in any of the radiological parameters, either in cervical alignment or segmental height, or range of motion. The radiological incidence rate of adjacent segmental degeneration and heterotopic ossification (HO) was comparable in both groups, respectively, with a similar composition of ROM-limiting HO. However, the osteopenia group had a tendency of more implant subsidence (2.7% vs 15.2%). The logistic regression analysis showed the osteopenia group had a significantly higher incidence rate of anterior bone loss (ABL) (OR = 5.37, 95% CI: 1.50 - 19.22). CONCLUSIONS Single-level CDA for patients with osteopenia achieved similar satisfactory clinical outcomes compared with the normal BMD group. Meanwhile, the osteopenia group maintained adequate sagittal balance and segmental height. Based on this observation, this option may be feasible for selected patients with osteopenia.
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Affiliation(s)
- Junbo He
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Hua Chen
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Tingkui Wu
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Rong
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Ding
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Beiyu Wang
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Liu
- Department of Orthopedic Surgery, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
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Al-Hashimi L, Klotsche J, Ohrndorf S, Gaber T, Hoff P. Trabecular Bone Score Significantly Influences Treatment Decisions in Secondary Osteoporosis. J Clin Med 2023; 12:4147. [PMID: 37373840 DOI: 10.3390/jcm12124147] [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: 05/11/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
The trabecular bone score (TBS) can be determined in addition to the Dual Energy X-ray Absorptiometry (DXA) for bone mineral density (BMD) measurement to diagnose, evaluate, and stratify bone loss and decide on appropriate treatment in patients at risk. Especially in patients with secondary osteoporosis, TBS detects restricted bone quality. To investigate the influence of an additional evaluation of TBS on patients' treatment strategy decisions, we enrolled 292 patients, with a high proportion of patients with secondary osteoporosis, from one outpatient unit over one year. Patients eligible for BMD measurement had the option to opt-in for TBS measurement. We analyzed demographic data, leading diagnoses, bone metabolism parameters, and results of BMD and TBS measurements. More than 90% of patients consented to TBS measurement. TBS measurement influenced the decision in approximately 40% of patients with a treatment indication for anti-osteoporotic drugs. We demonstrate that depending on the underlying disease/risk spectrum, 21-25.5% of patients had an unremarkable BMD measurement with poor bone quality shown in the TBS measurement. In patients with secondary osteoporosis, the use of TBS supplementary to DXA seems useful to better assess fracture risk and, thus, to initiate therapy for osteoporosis in these patients in time.
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Affiliation(s)
- Leith Al-Hashimi
- MVZ Endokrinologikum Berlin am Gendarmenmarkt, 10117 Berlin, Germany
- Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Rheumatology and Clinical Immunology, Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Jens Klotsche
- German Rheumatism Research Centre (DRFZ) Berlin, a Leibniz Institute, 10117 Berlin, Germany
| | - Sarah Ohrndorf
- Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Rheumatology and Clinical Immunology, Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Timo Gaber
- Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Rheumatology and Clinical Immunology, Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Paula Hoff
- MVZ Endokrinologikum Berlin am Gendarmenmarkt, 10117 Berlin, Germany
- Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Department of Rheumatology and Clinical Immunology, Universitätsmedizin Berlin, 10117 Berlin, Germany
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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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