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

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A Correction to this article was published on 19 December 2022

This article has been updated

Abstract

Purpose

Osteoporosis is a common, but challenging phenomenon to overcome in adult spinal deformity (ASD) surgery. Several pharmacological agents are at the surgeon’s disposal to optimize the osteoporotic patient prior to undergoing extensive reconstruction. Familiarity with these medications will allow the surgeon to make informed decisions on selecting the most appropriate adjuncts for each individual patient.

Methods

A comprehensive literature review was conducted in PubMed from September 2021 to April 2022. Studies were selected that contained combinations of various terms including osteoporosis, specific medications, spine surgery, fusion, cage subsidence, screw loosening, pull-out, junctional kyphosis/failure.

Results

Bisphosphonates, denosumab, selective estrogen receptor modulators, teriparatide, abaloparatide and romosozumab are all pharmacological agents currently available for adjunctive use. While these medications have been shown to have beneficial effects on improving bone mineral density in the osteoporotic patient, varying evidence is available on their specific effects in the context of extensive spine surgery. There is still a lack of human studies with use of the newer agents.

Conclusion

Bisphosphonates are first-line agents due to their low cost and robust evidence behind their utility. However, in the absence of contraindications, optimizing bone quality with anabolic medications should be strongly considered in preparation for spinal deformity surgeries due to their beneficial and favorable effects on fusion and hardware compared to the anti-resorptive medications.

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Data availability

All data reviewed in this manuscript was obtained through publicly-accessible PubMed database.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Louisiana State University, Shreveport, LA, USA

    Andrew S. Zhang

  2. Warren Alpert Medical School of Brown University, Providence, RI, USA

    Surya Khatri & Mariah Balmaceno-Criss

  3. Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA

    Andrew S. Zhang, Daniel Alsoof & Alan H. Daniels

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ASZ, SK, MB-C, DA: conceptualization, literature review, writing–original draft, writing–review and editing, approved for publication, agree to be accountable. AHD: conceptualization, writing–review and editing, supervision, approved for publication, agree to be accountable.

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Author Andrew S. Zhang declares no conflict of interest. Author Surya Khatri declares no conflict of interest. Author Mariah Balmaceno-Criss declares no conflict of interest. Author Daniel Alsoof declares no conflict of interest. Author Alan Daniels declares the following conflict of interests: Consulting fees from Stryker, Orthofix, Spineart, and EOS. Research support from Southern Spine, and Fellowship support from Orthofix.

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Zhang, A.S., Khatri, S., Balmaceno-Criss, M. et al. Medical optimization of osteoporosis for adult spinal deformity surgery: a state-of-the-art evidence-based review of current pharmacotherapy. Spine Deform 11, 579–596 (2023). https://doi.org/10.1007/s43390-022-00621-6

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