Challenges of Spine Surgery in Patients With Osteoporosis

Commentary by Ali A. Baaj, MD

Management of spine surgery in patients with osteoporosis poses many challenges, given the additional complexity that poor-quality bone introduces to the surgical management. In a supplement to the October issue of Neurosurgery, researchers discuss factors to optimize the perioperative medical management of spine surgery in patients with osteoporosis.
“Osteoporosis presents well-known challenges in the surgical treatment of patients with spinal disorders”“Osteoporosis presents well-known challenges in the surgical treatment of patients with spinal disorders,” commented Ali A. Baaj, MD, Assistant Professor of Neurological Surgery, Weill Cornell Medical College, Cornell University, New York, NY. “Potential for implant subsidence and failure, hardware complications, and rapidly progressive adjacent level degenerative disease all contribute to a higher risk profile for patients undergoing major spinal operations.

“In the study by Lubelski et al, the authors accurately emphasize the morbidity and potential complications associated with osteoporosis, and furthermore present excellent recommendations for perioperative management to optimize the chances of surgical success,” Dr. Baaj said. “Whether basic measures are instituted, such as ensuring that patients are at least on calcium and vitamin D, or if they are in need of more aggressive treatments, for example, with bisphosphonates or hormonal replacement therapy, the key is to identify and manage the diagnosis preoperatively. For elective complex spine cases, the surgeon must temper his or her enthusiasm to offer surgical intervention until the osteoporotic patient is adequately treated.”

Osteoporosis Screening Guidelines for Elderly Patients
Current guidelines from the American College of Radiology recommend asymptomatic screening in all women ages 65 years and older and all men older than 70 years of age. Screening also is recommended in younger women with the following risk factors: estrogen deficiency, low body mass, history of amenorrhea, current cigarette use, or loss of height/thoracic kyphosis.

For patients with osteoporosis, Dr. Lubelski et al recommend a multidisciplinary approach to optimize preoperative medical management that includes the spine surgeon, primary care physician, endocrinologist, and physical therapist. In addition to promoting discontinuation of factors that may impede fusion success, such as use of anti-inflammatory medications and smoking, management with the medical therapies shown in the Table should be considered.
“Further clinical data are needed for more conclusive guidelines. The current evidence suggests that, perioperatively, osteoporosis treatment should be continued regardless of a recent or upcoming spine surgery,” Lubeski et al noted. The authors added that physical therapy should be included in the management plan to increase strength and balance.