Low volumetric bone density is a risk factor for early complications after spine fusion surgery

  • Y. Liu
  • A. Dash
  • A. Krez
  • H. J. Kim
  • M. Cunningham
  • F. Schwab
  • A. Hughes
  • B. Carlson
  • A. Samuel
  • E. Marty
  • H. Moore
  • D. J. McMahon
  • J. A. Carrino
  • R. S. Bockman
  • E. M. SteinEmail author
Original Article



This study aims to investigate lumbar spine (LS) volumetric bone density (vBMD) as a risk factor for complications (pseudoarthrosis, instrumentation failure, adjacent fractures), re-operation, and time to complication after fusion.


Lumbar spine (LS) fusion surgery is increasingly performed worldwide. Complications after fusion result in significant morbidity and healthcare costs. Multiple factors, including osteoporosis, have been suggested to contribute to risk of complications and re-operation. However, most studies have used DXA, which is subject to artifact in patients with spine pathology, and none have investigated the relationship between BMD and timing of post-operative complications. This study aims to investigate LS volumetric bone density (vBMD) as a risk factor for complications (pseudoarthrosis, instrumentation failure, adjacent fractures), re-operation, and time to complication after fusion.


We evaluated a cohort of 359 patients who had initial LS fusion surgery at our institution, had pre-operative LS CTs and post-operative imaging available for review. Demographic factors, smoking status, vBMD, and details of surgical procedure were related to likelihood and timing of post-operative complications.


Mean age was 60 ± 14 years, vBMD 122 ± 37 g/cm3. Median follow-up was 11 months. Skeletal complications occurred in 47 patients (13%); 34 patients (10%) required re-operation. Low vBMD (directly measured and estimated using HU) and smoking were associated with increased risk of skeletal complications. Each increase in baseline vBMD of 10 g/cm3 decreased the complication hazard and increased the complication-free duration in time-to-event analysis (hazard ratio 0.91, 95% CI 0.83–0.98, p < 0.02).


Low vBMD was a significant risk factor for early post-operative complications in patients undergoing LS fusion. Prospective studies are needed to confirm these findings and to elucidate the optimal timing for follow-up and strategies for prevention of post-operative complications in this population.


Complications Osteoporosis Spine fusion Volumetric bone density 



We are grateful for the technicians in the Radiology Department for their assistance.

Compliance with ethical standards

Conflicts of interest

YL, AD, AS, EM, HM, RSB declare they have nothing to disclose. HJK: research support from CSRS, ISSGF; board membership of AO Spine; Royalty from Zimmerbiomet and K2M. MC: research support from K2M, RTI. FS: research support from DePuy Spine, NuVaisve, Stryker, K2M; consulting fees from Globus Medical, K2M, Medtronic, Zimmer Biomet, Medicrea; shareholder of Nemaris INC. AH: research support from Pfizer, NuVasive, 4WEB Medical. BC: research support from Prosidyan. DJM: consulting fees from HSS. JAC: consulting fees from Pfizer, Covera (Spreemo) Health, Simplify Medical; personal fees from ImageBiopsy; other from Carestream, Image Analysis Group. EMS: research support form Novartis; Scientific Advisory Board member for Amgen.


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2020

Authors and Affiliations

  • Y. Liu
    • 1
    • 2
  • A. Dash
    • 1
  • A. Krez
    • 1
  • H. J. Kim
    • 3
  • M. Cunningham
    • 3
  • F. Schwab
    • 3
  • A. Hughes
    • 3
  • B. Carlson
    • 3
    • 4
  • A. Samuel
    • 3
  • E. Marty
    • 3
  • H. Moore
    • 5
  • D. J. McMahon
    • 1
  • J. A. Carrino
    • 6
  • R. S. Bockman
    • 1
  • E. M. Stein
    • 1
    Email author
  1. 1.Division of Endocrinology and Metabolic Bone DiseaseHospital for Special SurgeryNew YorkUSA
  2. 2.Department of MedicineLahey ClinicBurlingtonUSA
  3. 3.Department of OrthopedicsHospital for Special SurgeryNew YorkUSA
  4. 4.Department of OrthopedicsUniversity of Kansas Medical CenterKansas CityUSA
  5. 5.Weill Cornell Medical CollegeNew YorkUSA
  6. 6.Department of RadiologyHospital for Special SurgeryNew YorkUSA

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