Effect of Bone Health Optimization on Osteoporosis Screening and Treatment Before Thoracolumbar Fusion

Abstract

Objective:Osteoporosis is not rare in thoracolumbar spine fusion patients and may portend poorer surgical outcomes. Implementation of a bone health optimization (BHO) clinic improves osteoporosis screening and treatment in the total joint arthroplasty population. We hypothesize that preoperative osteoporosis is common, under-recognized, and undertreated in thoracolumbar fusion patients and that a BHO clinic will increase preoperative osteoporosis screening rates and pharmacologic osteoporosis treatment in this population.Methods:This retrospective case series includes adults older than 30 years who underwent elective thoracolumbar spine fusion at a single tertiary care center before and after creation of a BHO referral clinic. Data collected included preoperative osteoporosis risk factors, prior dual-energy radiograph absorptiometry testing, and prior osteoporosis pharmacotherapy. Fracture risk was estimated using the fracture risk assessment tool with and without bone mineral density (BMD), and the US National Osteoporosis Foundation criteria for screening and treatment were applied.Results:Ninety patients were included in the pre-BHO group; 53 patients met criteria for BMD measurement, but only 10 were tested within 2 years preoperatively. Sixteen patients (18%) met criteria for osteoporosis pharmacotherapy, but only 5 of the 16 (31%) received osteoporosis medication within 6 months of surgery. There were 87 patients in the post-BHO group, and 19 were referred to the BHO clinic. BMD measurement was done in 17 of the patients (89%) referred to the BHO clinic compared with 10% for those not referred. All patients (n = 7) referred to the BHO clinic meeting treatment criteria received treatment within 6 months before surgery, whereas only 25% of the patients not referred received treatment.Discussion:Osteoporosis is not rare in adults undergoing thoracolumbar spine fusion with ∼13% to 18% meeting criteria for pharmacotherapy. Preoperative BHO referral increases screening and treatment.

Bone Health Optimization (BHO) in Spine Surgery

“…Preoperative bone status screening in spine surgery patients is important because osteoporosis is common in this population and can portend worse outcomes after surgery. Approximately 20% of patients undergoing spine fusion have osteoporosis 10. In older adults undergoing spine fusion (50 yr of age or greater), 14.5% of men and 51.3% of women have osteoporosis 11.…”

“…Approximately 20% of patients undergoing spine fusion have osteoporosis. 10 In older adults undergoing spine fusion (50 yr of age or greater), 14.5% of men and 51.3% of women have osteoporosis. 11 In those with osteoporosis, fewer than 1 in 3 receive appropriate treatment before surgery.…”

“…11 With the initiation of a BHO program, preoperative screening and treatment can be significantly improved (89% screening rate, 100% treatment rate). 10 Poor bone health has been linked to worse outcomes and complications after spine surgery. 3 These complications include implant failure, screw loosening, fracture, kyphosis, subsidence of interbody devices, proximal junctional fracture, and fusion failure.…”

“…In those with osteoporosis, fewer than 1 in 3 receive appropriate treatment before surgery 11. With the initiation of a BHO program, preoperative screening and treatment can be significantly improved (89% screening rate, 100% treatment rate) 10…”

The influence of osteoporosis on mechanical complications in lumbar fusion surgery: a systematic review

“…However, despite this prevalence and association with poor outcomes, osteoporosis remains profoundly underdiagnosed and undertreated in the spine surgery population [ 12 , 13 ]. Although many surgeons anecdotally recognize the challenges of instrumenting osteoporotic bone and may modify their surgical plan in the setting of this diagnosis, dedicated bone health assessments are infrequently performed preoperatively [ [14] , [15] , [16] ].…”