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Girdler SJ, Lindsey MH, Sebastian AS, Nassr A. Osteoporosis Evaluation and Management in Spine Surgery. J Am Acad Orthop Surg 2024:00124635-990000000-01059. [PMID: 39083525 DOI: 10.5435/jaaos-d-24-00311] [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: 03/16/2024] [Accepted: 05/31/2024] [Indexed: 08/02/2024] Open
Abstract
Osteoporosis is a global health problem affecting over 200 million people worldwide and 54 million adults in the United States. Approximately half of all postmenopausal women will have an osteoporosis-related fracture during their lifetime. In the United States, the direct medical cost related to osteoporosis is expected to exceed $25 billion by 2025. Management of osteoporosis in vertebral fractures and elective spine surgery is of the utmost concern, given the high prevalence of osteoporosis in the general population and the increased risk of complication in this population. New pharmacologic treatment options such as anabolic medications and diagnostic tools including Hounsfield unit measurements on routine computed tomography scans are available to orthopaedic and spinal surgeons to help best manage this condition. This review serves as an update to diagnosis, management, and treatment of patients with osteoporosis undergoing spinal surgery.
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Affiliation(s)
- Steven J Girdler
- From the Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Wang Z, Zhang J, Chen Q, Huang Y, Song Y, Liu L, Feng G. Different cervical vertebral bone quality scores for bone mineral density assessment for the patients with cervical degenerative disease undergoing ACCF/ACDF: computed tomography and magnetic resonance imaging-based study. J Orthop Surg Res 2023; 18:927. [PMID: 38053202 DOI: 10.1186/s13018-023-04422-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Bone mineral density (BMD) is important for the outcome of cervical spine surgery. As the gold standard of assessing BMD, dual-energy X-ray absorptiometry scans are often not ordered or go unreviewed in patients' charts. As the supplement, MRI-based vertebral bone quality (VBQ) was found to accurately predict osteopenia/osteoporosis and postoperative complications in lumbar spine. However, discussion of the efficiency of VBQ in cervical spine is lacking. And measurement methods of VBQ in cervical spine are diverse and not universally acknowledged like lumbar spine. We aimed to compare the predictive performance of three kinds of different Cervical-VBQ (C-VBQ) scores for bone mineral density assessment in patients undergoing cervical spine surgery. HU value of cervical spine was set as a reference. METHODS Adult patients receiving cervical spine surgery for degenerative diseases were retrospectively included between Jan 2015 and Dec 2022 in our hospital. The VBQ scores and HU value were measured from preoperative MRI and CT. The correlation between HU value/C-VBQs (named C-VBQ1/2/3 according to different calculating methods) and DEXA T-score was analyzed using univariate linear correlation and Pearson's correlation. We evaluated the predictive performance of those two parameters and achieved the most appropriate cutoff value by comparing the receiver operating characteristic (ROC) curves. RESULTS 106 patients (34 patients with T ≥ - 1.0 vs 72 patients with T < - 1.0) were included (mean age: 51.95 ± 10.94, 48 men). According to Pearson correlation analysis, C-VBQ1/2/3 and HU value were all significantly correlated to DEXA T-score (Correlation Coefficient (r): C-VBQ1: - 0.393, C-VBQ2: - 0.368, C-VBQ3: - 0.395, HU value: 0.417, p < 0.001). The area under the ROC curve (AUC) was calculated (C-VBQ1: 0.717, C-VBQ2: 0.717, C-VBQ3: 0.727, HU value: 0.746). The AUC of the combination of C-VBQ3 and HU value was 0.786. At last, the most appropriate cutoff value was determined (C-VBQ1: 3.175, C-VBQ2: 3.005, C-VBQ3: 2.99, HU value: 299.85 HU). CONCLUSIONS Different MRI-based C-VBQ scores could all be potential and alternative tools for opportunistically screening patients with osteopenia and osteoporosis before cervical spine surgery. Among them, C-VBQ calculated in ASIC2-C7/SIT1-CSF performed better. We advised patients with C-VBQ higher than cutoff value to accept further BMD examination.
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Affiliation(s)
- Zhe Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jingyao Zhang
- Core Facilities of West China Hospital, Sichuan University, Chengdu, China
| | - Qian Chen
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Huang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yueming Song
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
| | - Limin Liu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
| | - Ganjun Feng
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
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Chaddha R, Agrawal G, Koirala S, Ruparel S. Osteoporosis and Vertebral Column. Indian J Orthop 2023; 57:163-175. [PMID: 38107796 PMCID: PMC10721779 DOI: 10.1007/s43465-023-01046-7] [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: 09/03/2023] [Accepted: 11/07/2023] [Indexed: 12/19/2023]
Abstract
Background Osteoporosis is an age-related metabolic disease which has a significant impact on bone health and overall quality of life. It is gaining importance as a major medical consideration with the rapid increase in geriatric population globally. It increases the risk of vertebral fractures, progressive spinal deformities and neurological complications, contributing significantly to morbidity and mortality. Increase in life expectancy and advancement of medical technology has led to an increase in the proportion of geriatric patients undergoing orthopaedic procedures. It is becoming vital to adequately evaluate, investigate and treat osteoporosis before planning spinal surgery, especially spinal fusions and instrumentation. Content Historically, osteoporosis was considered a contraindication to spine surgery adding to the burden of Disability Adjusted Life Years (DALYs) and mortality. Conversely, osteoporotic patients who underwent spine surgery were not adequately optimized, leading to an increase in failure and complication rates. Better understanding of the pathophysiology of osteoporosis and the biomechanics of an osteoporotic spine with knowledge of current standards of treatment of osteoporosis facilitate the timely and adequate management of this disease. Advances in surgical and anaesthetic techniques facilitate successful surgeries on high-risk elderly and osteoporotic patients with multiple comorbidities allowing for a significantly high predictability for long-term positive outcomes.This article discusses the biomechanics of the osteoporotic spine, the diagnosis and management of osteoporotic patients with spinal disease, and the new treatments, recommendations, surgical indications, strategies and advances in instrumentation in patients with osteoporosis who require spinal surgery. Implications In this article, the authors aim to provide a generalized overview for better understanding of the pathophysiological processes underlying osteoporosis in the vertebral column. This review provides a comprehensive set of guidelines for overall health and management of spine patients with pathologies, either caused by or compounded with osteoporosis. An overview of current techniques, strategies and technologies designed to address the challenges associated with spine surgery in osteoporotic patients is also outlined. Sources Content for this article has been sourced from routinely cited articles available via PubMed, from National Institute of Health consensus development conference, from the recommendations by World Health Organization technical report series, from previous articles by the authors and from the protocols established by the authors in their clinical practice based on experience and detailed case reviews.
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Affiliation(s)
- Ram Chaddha
- Head of Department, Orthopaedic Surgery, Lilavati Hospital and Research Centre, Mumbai, India
- Orthopaedic Spine Surgery, Lilavati Hospital and Research Centre, Mumbai, India
| | - Gaurav Agrawal
- Orthopaedic Spine Surgery, Lilavati Hospital and Research Centre, Mumbai, India
| | | | - Sameer Ruparel
- Orthopaedic Spine Surgery, Lilavati Hospital and Research Centre, Mumbai, India
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Sunder A, Chhabra H, Aryal A. Geriatric spine fractures - Demography, changing trends, challenges and special considerations: A narrative review. J Clin Orthop Trauma 2023; 43:102190. [PMID: 37538298 PMCID: PMC10393813 DOI: 10.1016/j.jcot.2023.102190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/16/2023] [Indexed: 08/05/2023] Open
Abstract
The aim of this manuscript was to summarize the demography and changing trends of geriatric spinal injuries and to enumerate the challenges and special considerations in the care of geriatric spinal injuries. PubMed, Scopus and Embase databases were searched for literature on geriatric spine fractures using MeSH terms 'aged', 'aged, 80 and over', 'elderly', 'spinal fracture/epidemiology', spinal fracture/therapy∗' and keywords pertaining to the same. The search results were screened for appropriate articles and reviewed. There is a high community prevalence of elderly vertebral fractures ranging from 18% to as high as 51%. The proportion of older patients among the spinal injured is rising as well. There is a higher chance of missing spinal injuries in the elderly and clinical guidelines may not be applicable to this patient group. Classification and surgical treatment are different from younger adult counterparts as the elderly osteoporotic spine behaves differently biomechanically. There is a high incidence of respiratory complications both for surgically and conservatively managed groups. Older age generally is associated with a higher complication rate including mortality.
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Affiliation(s)
- Aditya Sunder
- Indian Spinal Injuries Centre, New Delhi, 110070, India
| | - H.S. Chhabra
- Indian Spinal Injuries Centre, New Delhi, 110070, India
| | - Aayush Aryal
- Indian Spinal Injuries Centre, New Delhi, 110070, India
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Lu HT, Lin JY, Tsuei YC, Hsu YF, Chen CY, Cheng SH, Chu W, Li C, Chu WC. Impact of Aspiration Percutaneous Vertebroplasty in Reducing Bone Cement Leakage and Enhancing Distribution-An Ex Vivo Study in Goat Vertebrae. Bioengineering (Basel) 2023; 10:795. [PMID: 37508822 PMCID: PMC10376675 DOI: 10.3390/bioengineering10070795] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/22/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
Osteoporosis-induced vertebral compression fracture (OVCF) occurs commonly in people over the age of 50, especially among menopausal women. Besides conservative therapy, minimally invasive percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) have been widely used in clinical treatment and achieved good efficacy. However, the leakage of bone cement (CL) during vertebroplasty (PV) is a major risk that can cause (serious) complications such as compression of the spinal cord, pulmonary embolism, or even paraplegia. In this study, we introduced a new aspiration technique with standard PV procedures (APV) to ameliorate the risk of leakage with quantitative verifications of its effectiveness. APV intends to create a differential pressure to guide the direction of cement flow within the vertebrae. To test this technique, Nubian goats' ex vivo vertebral bodies (VBs) were used to simulate the PV surgical process in humans. Results show that the proposed APV has a lower leakage rate of 13% compared to the 53% of conventional PV. Additionally, the APV approach achieves more uniform cement distribution via the 9-score method with a value of 7 ± 1.30 in contrast to 4 ± 1.78 by conventional PV.
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Affiliation(s)
- Hsin-Tzu Lu
- Institute of Biomedical Engineering, National Yang-Ming Chiao-Tung University, Taipei 11221, Taiwan
| | - Jia-Yi Lin
- Institute of Biomedical Engineering, National Yang-Ming Chiao-Tung University, Taipei 11221, Taiwan
| | - Yu-Chuan Tsuei
- Institute of Biomedical Engineering, National Yang-Ming Chiao-Tung University, Taipei 11221, Taiwan
- Department of Orthopedics, Cheng Hsin General Hospital, Taipei 11221, Taiwan
| | - Yung-Fu Hsu
- Institute of Biomedical Engineering, National Yang-Ming Chiao-Tung University, Taipei 11221, Taiwan
| | - Chung-Yi Chen
- Institute of Biomedical Engineering, National Yang-Ming Chiao-Tung University, Taipei 11221, Taiwan
| | - Shih-Hao Cheng
- Institute of Biomedical Engineering, National Yang-Ming Chiao-Tung University, Taipei 11221, Taiwan
- Department of Orthopedics, Cheng Hsin General Hospital, Taipei 11221, Taiwan
| | - William Chu
- Department of Orthopedics, Cheng Hsin General Hospital, Taipei 11221, Taiwan
| | - Chuan Li
- Institute of Biomedical Engineering, National Yang-Ming Chiao-Tung University, Taipei 11221, Taiwan
| | - Woei-Chyn Chu
- Institute of Biomedical Engineering, National Yang-Ming Chiao-Tung University, Taipei 11221, Taiwan
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Falowski SM, Koga SF, Northcutt T, Garamszegi L, Leasure J, Block JE. Improving the Management of Patients with Osteoporosis Undergoing Spinal Fusion: The Need for a Bone Mineral Density-Matched Interbody Cage. Orthop Res Rev 2021; 13:281-288. [PMID: 34934366 PMCID: PMC8684416 DOI: 10.2147/orr.s339222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/03/2021] [Indexed: 11/23/2022] Open
Abstract
With an increasingly aging population globally, a confluence has emerged between the rising prevalence of degenerative spinal disease and osteoporosis. Fusion of the anterior spinal column remains the mainstay surgical intervention for many spinal degenerative disorders. However, decreased vertebral bone mineral density (BMD), quantitatively measured by dual x-ray absorptiometry (DXA), complicates treatment with surgical interbody fusion as weak underlying bone stock increases the risk of post-operative implant-related adverse events, including cage subsidence. There is a necessity for developing cages with advanced structural designs that incorporate bioengineering and architectural principles to tailor the interbody fusion device directly to the patient’s BMD status. Specifically, lattice-designed cages that mimic the web-like structure of native cancellous bone have demonstrated excellent resistance to post-operative subsidence. This article provides an introductory profile of a spinal interbody implant designed intentionally to simulate the lattice structure of human cancellous bone, with a similar modulus of elasticity, and specialized to match a patient’s bone status across the BMD continuum. The implant incorporates an open pore design where the degree of pore compactness directly corresponds to the patient’s DXA-defined BMD status, including patients with osteoporosis.
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Affiliation(s)
- Steven M Falowski
- Argires-Marotti Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | | | | | | | | | - Jon E Block
- Independent Clinical Consultant, San Francisco, CA, USA
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