Medical optimization of osteoporosis for adult spinal deformity surgery: a state-of-the-art evidence-based review of current pharmacotherapy

Zhang, Andrew; Khatri, Surya; Balmaceno-Criss, Mariah; Alsoof, Daniel; Daniels, Alan H.

doi:10.1007/s43390-022-00621-6

Cited by 11 publications

(7 citation statements)

References 135 publications

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“…Several strategies have been proposed for managing osteoporosis in patients undergoing spinal surgery, with a broad consensus emphasizing the need for preoperative bone health assessment (11)(12)(13). If poor bone health condition is detected, initiation of pharmacological treatment is recommended.…”

Section: Discussionmentioning

confidence: 99%

The potential effect of romosozumab on perioperative management for instrumentation surgery

Ishikawa,

Tani,

Toyone

et al. 2023

Preprint

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BackgroundAge-related changes in bone health increase the risk for complications in elderly patients undergoing orthopedic surgery. Osteoporosis is a key therapeutic target that needs to be addressed to ensure successful instrumentation surgery. The effectiveness of pharmacological interventions in orthopedic surgery, particularly the new drug romosozumab, is still unknown. We aim to evaluate the effect of 3-month romosozumab treatment on biomechanical parameters related to spinal instrumentation surgery, using the Quantitative Computed Tomography (QCT)-based Finite Element Method (FEM).MethodsThis open-labeled, prospective study included 81 patients aged 60 to 90 years, who met the osteoporosis criteria and were scheduled for either romosozumab or eldecalcitol treatment. Patients were assessed using blood samples, dual-energy absorptiometry (DXA), and QCT. Biomechanical parameters were evaluated using FEM at baseline and 3 months post-treatment. The primary endpoints were biomechanical parameters at 3 months, while secondary endpoints included changes in regional volumetric bone mineral density around the pedicle (P-vBMD) and vertebral body (V-vBMD).ResultsRomosozumab treatment led to significant gains in P-vBMD, and V-vBMD compared to eldecalcitol at 3 months. Notably, the romosozumab group showed greater improvements in all biomechanical parameters estimated by FEM at 3 months compared to the eldecalcitol group.ConclusionRomosozumab significantly increased the regional vBMD as well as biomechanical parameters, potentially offering clinical benefits in reducing post-operative complications in patients with osteoporosis undergoing orthopedic instrumentation surgery. This study highlights the novel advantages of romosozumab treatment and advocates further research on its effectiveness in perioperative management.

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Section: Discussionmentioning

confidence: 99%

The potential effect of romosozumab on perioperative management for instrumentation surgery

Ishikawa,

Tani,

Toyone

et al. 2023

Preprint

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“…Once a patient has been diagnosed with osteoporosis, treatment of their bone health is imperative. While bisphosphonates are a first-line treatment for osteoporosis, anabolic medications are favored in spine surgery due to their preferable effects on fusion 19,26 . Prior studies comparing teriparatide and bisphosphonates have demonstrated enhanced fusion, reduced rate of pedicle screw loosening, and increased pedicle screw insertional torque.…”

Section: Methodsmentioning

confidence: 99%

“…While bisphosphonates are a first-line treatment for osteoporosis, anabolic medications are favored in spine surgery due to their preferable effects on fusion. 19,26 Prior studies comparing teriparatide and bisphosphonates have demonstrated enhanced fusion, reduced rate of pedicle screw loosening, and increased pedicle screw insertional torque. Thus, according to the best practice guidelines, anabolic treatment has the best efficacy if initiated at least one to three months before surgery and continued for at least 6 months postoperatively.…”

Section: Osteoporosis and Bone Mineral Densitymentioning

confidence: 99%

Preoperative Optimization for Adult Spinal Deformity Surgery

Katiyar,

Reyes,

Coury

et al. 2023

Spine

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Study Design. Systematic Review Objective. The purpose of this review is to identify modifiable risk factors in patients undergoing adult spinal deformity surgery and compile literature recommendations for preoperative optimization of these risk factors. Summary of Background Data. Optimization of modifiable risk factors not only benefits the patient but also lessens resource and cost burdens on the healthcare system, allowing for better quality and value-based care. There is limited but applicable literature discussing preoperative optimization in adult spinal deformity surgery patients specifically. Methods. We searched PubMed for studies that looked at one of the variables of interest (e.g. osteoporosis, prehabilitation and functional status, multidisciplinary preoperative screening, infection, obesity, nutrition, smoking, diabetes, blood loss, chronic opioid use and psychosocial factors) in adult patients with spinal deformity according to PRISMA guidelines. Results. 70 studies were included in the final review and synthesis of information. Guidelines and recommendations from these studies were compared and compiled into evidence based action items for preoperative optimization of modifiable risk factors prior to adult spinal deformity surgery. Conclusions. While the approach of preoperative optimization of modifiable risk factors may incur additional planning efforts and patient care time, it has the potential to significantly reduce perioperative complications and reduce morbidity and mortality during surgery, thus allowing for improved outcomes, increased quality of life, and satisfaction from this patient population. Level of Evidence. III

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“…Optimization of bone health in the setting of surgery for adult spinal deformity (ASD) remains a critical research area. Although osteoporosis is a well-defined risk factor for reoperation and pseudarthrosis following ASD surgery, few studies have evaluated perioperative strategies to optimize bone health in patients with ASD 1 .…”

Section: Commentarymentioning

confidence: 99%

“…A few additional important points must be considered when discussing the use of teriparatide. First, the cost of teriparatide is high: approximately $850 per week of treatment (wholesale cost, $3,426.50 for a 4-week supply) 1 . However, the high cost of osteoanabolic agents such as teriparatide must be weighed against the reduction in the costs and health-care burden due to complications and reoperations following ASD surgery.…”

Section: Commentarymentioning

confidence: 99%

Does Teriparatide Improve Outcomes in Osteoporotic Patients Undergoing Adult Spinal Deformity Surgery?

Kang

2024

Journal of Bone and Joint Surgery

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Mohanty and colleagues are commended for their research efforts on an important and timely topic. Optimization of bone health in the setting of surgery for adult spinal deformity (ASD) remains a critical research area. Although osteoporosis is a well-defined risk factor for reoperation and pseudarthrosis following ASD surgery, few studies have evaluated perioperative strategies to optimize bone health in patients with ASD 1 .The study by Mohanty et al. is a retrospective cohort analysis from a single-center, single-surgeon patient sample, evaluating the use of perioperative teriparatide for osteoporotic patients undergoing surgery for ASD and comparing their outcomes with cohorts of osteopenic patients and patients with normal bone mineral density (BMD). Patients treated with teriparatide were administered 20 mg daily, typically from 6 months before surgery to 18 months after surgery. Teriparatide is a synthetic version of human parathyroid hormone with an osteoanabolic effect that promotes increased BMD, and its use has been found to be associated with significant reductions in the rates of vertebral and nonvertebral fractures compared with use of bisphosphonates 2 . There are only 2 prior studies evaluating postoperative outcomes in osteoporotic patients with ASD who were treated with teriparatide; thus, the analysis by Mohanty et al. is clearly warranted 3,4 .The additional evidence presented by Mohanty et al. on the use of teriparatide to improve outcomes of ASD surgery is encouraging, but our approbation must be tempered. The propensity-matched analysis does not obviate the risk of selection and treatment bias in the retrospective, single-surgeon sample, and the unmatched analysis should be reviewed with caution given the differences in baseline patient demographic and surgical characteristics between cohorts. One of the main strengths of the study by Mohanty et al. is that the number of osteoporotic patients with ASD who were treated with teriparatide (78) is twice as large as in the prior studies by Yagi et al. 3 (43) and Seki et al. 4 (33). However, both of the Japanese studies were conducted prospectively, whereas Mohanty et al. used a retrospective matched-cohort design. In addition, there are other substantial differences in methodology across the studies, including in the inclusion criteria, comparison cohorts, and duration of teriparatide administration. Yagi et al. 3 included osteoporotic and osteopenic patients with ASD (BMD T-score < -1.0) and compared the outcomes with and without teriparatide, excluded patients treated with 3-column osteotomy, and administered 20 mg of teriparatide once a day from the day after surgery to 18 months after surgery. In contrast, Seki et al. 4 included only osteoporotic patients and compared the outcomes with teriparatide to those with bisphosphonate, included patients treated with 3-column osteotomy, and administered 20 mg of teriparatide once a day from 3 months before surgery to 21 months after surgery followed by bisphosphonate to lock in the BMD gain. Also, th...

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Medical optimization of osteoporosis for adult spinal deformity surgery: a state-of-the-art evidence-based review of current pharmacotherapy

Cited by 11 publications

References 135 publications

The potential effect of romosozumab on perioperative management for instrumentation surgery

The potential effect of romosozumab on perioperative management for instrumentation surgery

Preoperative Optimization for Adult Spinal Deformity Surgery

Does Teriparatide Improve Outcomes in Osteoporotic Patients Undergoing Adult Spinal Deformity Surgery?

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