title: Perioperative Medical Management of Spine Surgery Patients With Osteoporosis.
abstract: Management of spine surgery patients with osteoporosis is challenging because of the difficulty of instrumenting and the potential complications, including nonunion and adjacent level fractures. Treatment of this patient population should involve a multidisciplinary approach including the spine surgeon, primary care physician, endocrinologist, and physical therapist. Indication for preoperative treatment before spinal fusion surgery is unclear. All patients should receive calcium and vitamin D. Hormone replacement therapy, including estrogen or selective estrogen receptor modulators, should be considered for elderly female patients with decreased bone mass. Bisphosphonates or intermittent parathyroid hormone are reserved for those with significant bone loss in the spine. Pretreatment with antiresorption medications affect bone remodeling, which is a vital part of graft incorporation and fusion. Although there have been numerous animal studies, there is limited clinical evidence. Accordingly, surgery should be delayed, if possible, to treat the osteoporosis before the intervention. Treatment may include bisphosphonates, as well as newer agents, such as recombinant parathyroid hormone. Further clinical data are needed to understand the relative advantages/disadvantage of antiresorptive vs anabolic agents, as well as the impact of administration of these medications before vs after fusion surgery. Future clinical studies will enable better understanding of the impact of current therapies on biomechanics and fusion outcomes in this unique and increasingly prevalent patient population.
authors.affiliation: *Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio; ‡Cleveland Clinic Center for Spine Health, Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio; §Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland; ¶Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Missouri; ‖Department of Neurosurgery, Jefferson University School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Daniel
authors.initials: D
authors.lastname: Lubelski
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Choma
authors.forename: Michael P
authors.initials: MP
authors.lastname: Steinmetz
authors.forename: James S
authors.initials: JS
authors.lastname: Harrop
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Mroz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D045930:Anabolic Agents / Q000627:therapeutic use; D050071:Bone Density Conservation Agents / Q000627:therapeutic use*; D002116:Calcitonin / Q000627:therapeutic use; D002118:Calcium / Q000627:therapeutic use; D004164:Diphosphonates / Q000627:therapeutic use; D004967:Estrogens / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D010024:Osteoporosis / Q000150:complications / Q000188:drug therapy*; D010281:Parathyroid Hormone / Q000627:therapeutic use*; D019990:Perioperative Care; D020849:Raloxifene Hydrochloride / Q000627:therapeutic use; D011994:Recombinant Proteins; D020845:Selective Estrogen Receptor Modulators / Q000627:therapeutic use*; D013122:Spinal Diseases / Q000150:complications / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods*; D014807:Vitamin D / Q000627:therapeutic use
chemical_list: D045930:Anabolic Agents; D050071:Bone Density Conservation Agents; D004164:Diphosphonates; D004967:Estrogens; D010281:Parathyroid Hormone; D011994:Recombinant Proteins; D020845:Selective Estrogen Receptor Modulators; D014807:Vitamin D; D020849:Raloxifene Hydrochloride; D002116:Calcitonin; D002118:Calcium