Osteoporosis Is Underrecognized, Undertreated Among Adults with Spinal Deformity Undergoing Long Fusion
- This retrospective study involved examination of records on 399 patients with adult spinal deformity, age ≥40, who underwent a spinal fusion of at least seven vertebral levels
- 33% of patients were diagnosed with osteoporosis at some point before surgery, but 66% of those patients were not taking any anti-osteoporotic medication
- 21% of men with osteoporosis were on medication, compared with 39% of women (P=0.07)
- Only 19% of patients being treated for osteoporosis were using an anabolic agent
- Surgeons should have a low threshold to test and treat for osteoporosis in patients with adult spinal deformity who will undergo long spinal fusion
Osteoporosis increases the rate of complications after surgery for adult spinal deformity (ASD). Moreover, rates of ASD are known to be higher in patients with osteoporosis.
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In the first study of its kind, researchers from the Orthopaedic Spine Center in the Department of Orthopaedic Surgery at Massachusetts General Hospital recently investigated the prevalence of osteoporosis among patients undergoing long spinal fusion for ASD, and found it to be substantially higher than in the general population. In the Journal of Spine Surgery, they also report that only two-thirds of patients with ASD and osteoporosis were receiving anti-osteoporotic medication.
Thomas D. Cha, MD, MBA, assistant chief of the Orthopaedic Spine Center, Joseph H. Schwab MD, MS, chief of the Orthopaedic Spine Center and director of Spine Oncology & co-director of the Stephan L. Harris Chordoma Center at Mass General Cancer Center, Harold Fogel, MD, spine surgeon, Daniel G. Tobert, MD, spine surgeon, Christopher Bono, MD, executive vice-chair of the Department of Orthopaedic Surgery, and Stuart Hershman, MD, director of Adult Spinal Deformity & Spinal Reconstruction, authored this study along with colleagues from other institutions.
The 399 study subjects underwent surgery for ASD at either of two major academic medical centers from 2010 through 2019. All were at least 40 years old and underwent a spinal fusion of at least seven vertebral levels.
- 33% of ASD patients were diagnosed with osteoporosis at some point before surgery (in comparison, an estimate for the general U.S. population age ≥50 is 10%)
- 34% of patients with osteoporosis had taken anti-osteoporotic medication during at least the 12 weeks immediately before surgery
- Only 21% of men with osteoporosis were on medication, compared with 39% of women; this difference was not statistically significant (P=0.07)
- 22% of patients were taking a bisphosphonate, 17% teriparatide, 4% denosumab, 2% abaloparatide and 2% raloxifene; 9% were using multiple medications
Guidance for the Clinic
Surgeons should have a high index of suspicion for osteoporosis in patients with ASD. Bone density must be assessed before surgery.
Mass General orthopedic surgeons previously reported in The Spine Journal that osteopenia/osteoporosis is missed in one in six patients with ASD because these patients often show falsely elevated bone density in the spine. That paper recommended dual-energy X-ray absorptiometry scans at two or more locations besides the spine.
Surgeons also need to ensure that patients with ASD and osteoporosis have an anti-osteoporotic medication initiated before surgery. In particular, the treatment of men seems to be overlooked too often. Teriparatide use is associated with lower rates of instrumentation failure in ASD patients undergoing long thoracolumbar fusions.
Whatever the medication, patients must be instructed that compliance is crucial to achieving adequate preoperative bone density.
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