A Systematic Review of Treatment Strategies for Degenerative Lumbar Spine Fusion Surgery in Patients With Osteoporosis

Fischer, Charla R.; Hanson, Gregory J.; Eller, Melinda; Lehman, Ronald A.

doi:10.1177/2151458516669204

Cited by 32 publications

(32 citation statements)

References 32 publications

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“…For instance, augmented screw fixation using polymethylmethacrylate (PMMA) is recommended in osteoporotic bone ( 34 , 35 ), because it improves the fixation and fatigue strength according to ex vivo investigations ( 36 ), reduces the risk of screw loosening and screw pullout ( 37 ), and increases fusion rates with maintained correction angles in vivo ( 38 ). Adapted surgical techniques like PMMA-augmented screw fixations and long-segment constructs are considered to reduce the risk of instrumentation failure in osteoporotic patients ( 34 , 39 , 40 ). Long-segment constructs seem to be beneficial in order to avoid ending within a spinal transition zone or a kyphotic section ( 22 , 41 , 42 ), as these regions are typically prone to ASD, adjacent vertebral body fractures, or implant failure.…”

Section: Discussionmentioning

confidence: 99%

Opportunistic Osteoporosis Screening Reveals Low Bone Density in Patients With Screw Loosening After Lumbar Semi-Rigid Instrumentation: A Case-Control Study

et al. 2021

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ObjectiveDecreased bone mineral density (BMD) impairs screw purchase in trabecular bone and can cause screw loosening following spinal instrumentation. Existing computed tomography (CT) scans could be used for opportunistic osteoporosis screening for decreased BMD. Purpose of this case-control study was to investigate the association of opportunistically assessed BMD with the outcome after spinal surgery with semi-rigid instrumentation for lumbar degenerative instability.MethodsWe reviewed consecutive patients that had primary surgery with semi-rigid instrumentation in our hospital. Patients that showed screw loosening in follow-up imaging qualified as cases. Patients that did not show screw loosening or—if no follow-up imaging was available (n = 8)—reported benefit from surgery ≥ 6 months after primary surgery qualified as controls. Matching criteria were sex, age, and surgical construct. Opportunistic BMD screening was performed at L1 to L4 in perioperative CT scans by automatic spine segmentation and using asynchronous calibration. Processing steps of this deep learning-driven approach can be reproduced using the freely available online-tool Anduin (https://anduin.bonescreen.de). Area under the curve (AUC) was calculated for BMD as a predictor of screw loosening.ResultsForty-six elderly patients (69.9 ± 9.1 years)—23 cases and 23 controls—were included. The majority of surgeries involved three spinal motion segments (n = 34). Twenty patients had low bone mass and 13 had osteoporotic BMD. Cases had significantly lower mean BMD (86.5 ± 29.5 mg/cm³) compared to controls (118.2 ± 32.9 mg/cm³, p = 0.001), i.e. patients with screw loosening showed reduced BMD. Screw loosening was best predicted by a BMD < 81.8 mg/cm³ (sensitivity = 91.3%, specificity = 56.5%, AUC = 0.769, p = 0.002).ConclusionPrevalence of osteoporosis or low bone mass (BMD ≤ 120 mg/cm³) was relatively high in this group of elderly patients undergoing spinal surgery. Screw loosening was associated with BMD close to the threshold for osteoporosis (< 80 mg/cm³). Opportunistic BMD screening is feasible using the presented approach and can guide the surgeon to take measures to prevent screw loosening and to increase favorable outcomes.

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Section: Discussionmentioning

confidence: 99%

Opportunistic Osteoporosis Screening Reveals Low Bone Density in Patients With Screw Loosening After Lumbar Semi-Rigid Instrumentation: A Case-Control Study

et al. 2021

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“…PMMA-augmented screw fixations and other technical modifications like long-segment constructs is considered to reduce the risk of instrumentation failure in osteoporotic patients (4,41,42). Multiple points of fixation have been recommended in the osteoporotic spine for a long time (43).…”

Section: Resultsmentioning

confidence: 99%

Association of bone mineral density with reoperation rate following instrumented lumbar spinal fusion: a retrospective cohort and case-control study

Löffler¹,

Loreck²,

Sollmann³

et al. 2019

Preprint

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Low bone mineral density (BMD) is believed to influence the outcome of instrumented spinal surgery and can lead to reoperation. Purpose of this observational and case-control study was to investigate the association of BMD with the risk of reoperation following instrumented lumbar spinal fusion (LSF).For the observational study, 81 patients were included who received LSF with and without augmentation. For the case-control study, 18 patients who had reoperation following LSF were matched to 26 patients who did not have reoperation (matched by sex, age +/-5 years, fused levels and PMMA-augmentation). Opportunistic BMD screening was performed in perioperative CT scans using asynchronous calibration. Mean BMD was compared between patients with and without reoperation in augmented and non-augmented surgeries.In the observational study, prevalence of osteoporosis (BMD < 80 mg/cc) was 29% in non-augmented and 85% in augmented LSF. Seven of 48 patients with non-augmented (15%) and 4 of 33 patients with augmented LSF (12%) had reoperation. In non-augmented LSF, patients with reoperation had significantly lower BMD than patients without reoperation (P = 0.005). The best cut-off to predict reoperation after non-augmented LSF was BMD < 83.7 mg/cc. In the case-control study, patients with reoperation presented numerically lower BMD of 78.8 +/-33.1 mg/cc than patients without reoperation with BMD of 89.4 +/-39.7 mg/cc (P = 0.357).Despite much lower BMD surgeries with PMMA-augmentation showed no higher reoperation rate compared to non-augmented surgeries. Patients with reoperation following LSF showed slightly lower BMD compared to matched patients without reoperation, but the difference was not statistically significant. Opportunistic BMD screening can be performed in preoperative CT, thus informing about osteoporotic bone, a potential risk factor of surgery failure. Abbreviations BMDbone mineral density DXA dual-energy X-ray absorptiometry HU Hounsfield unit LSF lumbar spinal fusion MDCT multidetector computed tomography PMMA polymethyl methacrylate QCT quantitative computed tomography ROC receiver operating characteristic ROI regions of interest 3

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“…We used prescription data to identify most widely accepted pharmacological treatments for osteoporosis, which included bisphosphonates (Risedronate sodium, Ibandronate sodium and Alendronate sodium, Zoledronic Acid), and Teriparatide. 1,[11][12][13][14] In our patient cohort, there were less than 10 patients who had Denosumab treatment. These patients were excluded from analysis to maintain consistency and include only most prevalent pharmacotherapies.…”

Section: Pharmacological Treatment Of Osteoporosismentioning

confidence: 99%

Prevalence of Osteoporosis Treatment and Its Effect on Post-Operative Complications, Revision Surgery and Costs After Multi-Level Spinal Fusion

Jain

Labaran

Phillips

et al. 2020

Global Spine Journal

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Study Design: Retrospective cohort study. Objective: To study the prevalence of pre-operative osteoporosis treatment, and its effect on risk of ORC, revision surgery and costs in osteoporotic patients undergoing ≥3-level spinal fusion for degenerative pathology. Methods: Patients and procedures of interest were included using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding. Our outcome measures were ORC at 1-year post-operatively and included instrumentation complications, pathological fracture, and revision surgery. Kaplan-Meier survival curves and Cox proportional hazards analysis was done to study the effect of osteoporosis treatment on risk of ORC. Results: We included a total of 849 patients with documented osteoporosis undergoing ≥3-level spinal fusion. White (85.6%), female (82.7%), and 60-79 years of age (79.9%) was the most common demographic. Of entire cohort, 121(14.3%) were on osteoporosis treatment prior to spinal fusion. Of treated patients, 52/121 (43.0%) had continued prescriptions at 1 year post-operatively. Treated patients and not-treated patients had 1-year ORC incidence of 9.1% and 15.0%, respectively. The average 1-year reimbursement/patient for managing ORC was $3,053 (treated) and $21,147 (not-treated). On adjusted cox analysis, pre-operative osteoporosis treatment was associated with a lower risk of ORC (HR: 0.53, 95% CI: 0.28-0.99, p = 0.04). Conclusions: Pre-operative osteoporosis treatment is associated with lower risk of ORC and revision surgery at 1-year after ≥3-level spinal fusion. There is a low incidence of osteoporosis treatment prior to spinal fusion, and subsequently a low rate of treatment continuation after surgery. These findings highlight the need for heightened awareness, patient education and management of osteoporosis before elective multi-level spinal fusion.

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A Systematic Review of Treatment Strategies for Degenerative Lumbar Spine Fusion Surgery in Patients With Osteoporosis

Cited by 32 publications

References 32 publications

Opportunistic Osteoporosis Screening Reveals Low Bone Density in Patients With Screw Loosening After Lumbar Semi-Rigid Instrumentation: A Case-Control Study

Opportunistic Osteoporosis Screening Reveals Low Bone Density in Patients With Screw Loosening After Lumbar Semi-Rigid Instrumentation: A Case-Control Study

Association of bone mineral density with reoperation rate following instrumented lumbar spinal fusion: a retrospective cohort and case-control study

Prevalence of Osteoporosis Treatment and Its Effect on Post-Operative Complications, Revision Surgery and Costs After Multi-Level Spinal Fusion

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