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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
  • 31 Downloads

Abstractx

Summary

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.

Introduction

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.

Methods

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.

Results

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).

Conclusions

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.

Keywords

Complications Osteoporosis Spine fusion Volumetric bone density 

Notes

Acknowledgments

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.

References

  1. 1.
    Deyo RA, Nachemson A, Mirza SK (2004) Spinal-fusion surgery—the case for restraint. N Engl J Med 350:722–726PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Bernstein DN, Brodell D, Li Y, Rubery PT, Mesfin A (2017) Impact of the economic downturn on elective lumbar spine surgery in the United States: a National Trend Analysis, 2003 to 2013. Global Spine J 7:213–219PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Deyo RA, Mirza SK, Martin BI (2006) Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976) 31:2724–2727CrossRefGoogle Scholar
  4. 4.
    Hofler RC, Swong K, Martin B, Wemhoff M, Jones GA (2018) Risk of pseudoarthrosis after spinal fusion: analysis from the healthcare cost and utilization project. World Neurosurg 120:e194–e202PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Ong KL, Auerbach JD, Lau E, Schmier J, Ochoa JA (2014) Perioperative outcomes, complications, and costs associated with lumbar spinal fusion in older patients with spinal stenosis and spondylolisthesis. Neurosurg Focus 36:E5PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Salzmann SN, Shirahata T, Yang J, et al. (2018) Regional bone mineral density differences measured by quantitative computed tomography: does the standard clinically used L1-L2 average correlate with the entire lumbosacral spine? Spine JGoogle Scholar
  7. 7.
    Rehman Q, Lang T, Modin G, Lane NE (2002) Quantitative computed tomography of the lumbar spine, not dual x-ray absorptiometry, is an independent predictor of prevalent vertebral fractures in postmenopausal women with osteopenia receiving long-term glucocorticoid and hormone-replacement therapy. Arthritis Rheum 46:1292–1297PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Farhat GN, Cauley JA, Matthews KA, Newman AB, Johnston J, Mackey R, Edmundowicz D, Sutton-Tyrrell K (2006) Volumetric BMD and vascular calcification in middle-aged women: the Study of Women’s Health Across the Nation. J Bone Miner Res 21:1839–1846PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Hopper KD, Wang MP, Kunselman AR (2000) The use of clinical CT for baseline bone density assessment. J Comput Assist Tomogr 24:896–899PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Lee SJ, Binkley N, Lubner MG, Bruce RJ, Ziemlewicz TJ, Pickhardt PJ (2016) Opportunistic screening for osteoporosis using the sagittal reconstruction from routine abdominal CT for combined assessment of vertebral fractures and density. Osteoporos Int 27:1131–1136PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Expert Panel on Musculoskeletal Imaging, Ward RJ, Roberts CC et al (2017) ACR Appropriateness Criteria((R)) osteoporosis and bone mineral density. J Am Coll Radiol 14:S189–S202CrossRefGoogle Scholar
  12. 12.
    Anderson PA, Polly DW, Binkley NC, Pickhardt PJ (2018) Clinical use of opportunistic computed tomography screening for osteoporosis. J Bone Joint Surg Am 100:2073–2081PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Kim KJ, Kim DH, Lee JI, Choi BK, Han IH, Nam KH (2019) Hounsfield units on lumbar computed tomography for predicting regional bone mineral density. Open Med (Wars) 14:545–551CrossRefGoogle Scholar
  14. 14.
    Gausden EB, Nwachukwu BU, Schreiber JJ, Lorich DG, Lane JM (2017) Opportunistic use of CT imaging for osteoporosis screening and bone density assessment: a qualitative systematic review. J Bone Joint Surg Am 99:1580–1590PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Marinova M, Edon B, Wolter K, Katsimbari B, Schild HH, Strunk HM (2015) Use of routine thoracic and abdominal computed tomography scans for assessing bone mineral density and detecting osteoporosis. Curr Med Res Opin 31:1871–1881PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Wagner SC, Formby PM, Helgeson MD, Kang DG (2016) Diagnosing the undiagnosed: osteoporosis in patients undergoing lumbar fusion. Spine (Phila Pa 1976) 41:E1279–E1283CrossRefGoogle Scholar
  17. 17.
    Bjerke BT, Zarrabian M, Aleem IS, Fogelson JL, Currier BL, Freedman BA, Bydon M, Nassr A (2018) Incidence of osteoporosis-related complications following posterior lumbar fusion. Global Spine J 8:563–569PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Balci A, Kalemci O, Kaya FG, Akyoldas G, Yucesoy K, Ozaksoy D (2016) Early and long-term changes in adjacent vertebral body bone mineral density determined by quantitative computed tomography after posterolateral fusion with transpedicular screw fixation. Clin Neurol Neurosurg 145:84–88PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Wang H, Ma L, Yang D, Wang T, Yang S, Wang Y, Wang Q, Zhang F, Ding W (2016) Incidence and risk factors for the progression of proximal junctional kyphosis in degenerative lumbar scoliosis following long instrumented posterior spinal fusion. Medicine (Baltimore) 95:e4443CrossRefGoogle Scholar
  20. 20.
    Liu FY, Wang T, Yang SD, Wang H, Yang DL, Ding WY (2016) Incidence and risk factors for proximal junctional kyphosis: a meta-analysis. Eur Spine J 25:2376–2383PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Bredow J, Boese CK, Werner CM, Siewe J, Lohrer L, Zarghooni K, Eysel P, Scheyerer MJ (2016) Predictive validity of preoperative CT scans and the risk of pedicle screw loosening in spinal surgery. Arch Orthop Trauma Surg 136:1063–1067PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Schwaiger BJ, Gersing AS, Baum T, Noel PB, Zimmer C, Bauer JS (2014) Bone mineral density values derived from routine lumbar spine multidetector row CT predict osteoporotic vertebral fractures and screw loosening. AJNR Am J Neuroradiol 35:1628–1633PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Tempel ZJ, Gandhoke GS, Okonkwo DO, Kanter AS (2015) Impaired bone mineral density as a predictor of graft subsidence following minimally invasive transpsoas lateral lumbar interbody fusion. Eur Spine J 24(Suppl 3):414–419PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Etebar S, Cahill DW (1999) Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg 90:163–169PubMedPubMedCentralGoogle Scholar
  25. 25.
    Liu Y, Carrino JA, Dash AS, Chukir T, Do H, Bockman RS, Hughes AP, Press JM, Stein EM (2018) Lower spine volumetric bone density in patients with a history of epidural steroid injections. J Clin Endocrinol Metab 103:3405–3410PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Liu XS, Cohen A, Shane E et al (2010) Bone density, geometry, microstructure, and stiffness: relationships between peripheral and central skeletal sites assessed by DXA, HR-pQCT, and cQCT in premenopausal women. J Bone Miner Res 25:2229–2238PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Cheuk KY, Hu Y, Tam EMS et al (2019) Bone measurements at multiple skeletal sites in adolescent idiopathic scoliosis-an in vivo correlation study using DXA, HR-pQCT and QCT. Arch Osteoporos 14:70PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Ishikawa K, Toyone T, Shirahata T et al (2018) A novel method for the prediction of the pedicle screw stability: regional bone mineral density around the screw. Clin Spine Surg 31:E473–E480PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Schreiber JJ, Hughes AP, Taher F, Girardi FP (2014) An association can be found between Hounsfield units and success of lumbar spine fusion. HSS J 10:25–29PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Formby PM, Kang DG, Helgeson MD, Wagner SC (2016) Clinical and radiographic outcomes of transforaminal lumbar Interbody fusion in patients with osteoporosis. Global spine journal 6:660–664PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Meredith DS, Schreiber JJ, Taher F, Cammisa FP Jr, Girardi FP (2013) Lower preoperative Hounsfield unit measurements are associated with adjacent segment fracture after spinal fusion. Spine (Phila Pa 1976) 38:415–418CrossRefGoogle Scholar
  32. 32.
    Chin DK, Park JY, Yoon YS, Kuh SU, Jin BH, Kim KS, Cho YE (2007) Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease. Osteoporos Int 18:1219–1224PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Burch S, Feldstein M, Hoffmann PF, Keaveny TM (2016) Prevalence of poor bone quality in women undergoing spinal fusion using biomechanical-CT analysis. Spine (Phila Pa 1976) 41:246–252CrossRefGoogle Scholar
  34. 34.
    Fischer CR, Vasudeva E, Beaubrun B, Messer Z, Cazzullino A, Lehman R (2018) Osteoporosis knowledge among spine surgery patients. Int J Spine Surg 12:689–694PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Phan K, Fadhil M, Chang N, Giang G, Gragnaniello C, Mobbs RJ (2018) Effect of smoking status on successful arthrodesis, clinical outcome, and complications after anterior lumbar interbody fusion (ALIF). World Neurosurg 110:e998–e1003PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    How NE, Street JT, Dvorak MF, Fisher CG, Kwon BK, Paquette S, Smith JS, Shaffrey CI, Ailon T (2018) Pseudarthrosis in adult and pediatric spinal deformity surgery: a systematic review of the literature and meta-analysis of incidence, characteristics, and risk factors. Neurosurg RevGoogle Scholar
  37. 37.
    Daftari TK, Whitesides TE Jr, Heller JG, Goodrich AC, McCarey BE, Hutton WC (1994) Nicotine on the revascularization of bone graft. An experimental study in rabbits. Spine (Phila Pa 1976) 19:904–911CrossRefGoogle Scholar
  38. 38.
    Kwiatkowski TC, Hanley EN Jr, Ramp WK (1996) Cigarette smoking and its orthopedic consequences. Am J Orthop (Belle Mead NJ) 25:590–597Google Scholar
  39. 39.
    France JC, Norman TL, Buchanan MM, Scheel M, Veale M, Ackerman ES, Clovis NB, Kish VL, Simon B (2006) Direct current stimulation for spine fusion in a nicotine exposure model. Spine J 6:7–13PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Kanis JA, Johnell O, Oden A et al (2005) Smoking and fracture risk: a meta-analysis. Osteoporos Int 16:155–162PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Zhu F, Bao H, Liu Z, Bentley M, Zhu Z, Ding Y, Qiu Y (2014) Unanticipated revision surgery in adult spinal deformity: an experience with 815 cases at one institution. Spine (Phila Pa 1976) 39:B36–B44CrossRefGoogle Scholar
  42. 42.
    Puvanesarajah V, Shen FH, Cancienne JM, Novicoff WM, Jain A, Shimer AL, Hassanzadeh H (2016) Risk factors for revision surgery following primary adult spinal deformity surgery in patients 65 years and older. J Neurosurg Spine 25:486–493PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Marquez-Lara A, Nandyala SV, Sankaranarayanan S, Noureldin M, Singh K (2014) Body mass index as a predictor of complications and mortality after lumbar spine surgery. Spine (Phila Pa 1976) 39:798–804CrossRefGoogle Scholar
  44. 44.
    Yadla S, Malone J, Campbell PG, Maltenfort MG, Harrop JS, Sharan AD, Vaccaro AR, Ratliff JK (2010) Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures. Spine J 10:581–587PubMedCrossRefGoogle Scholar
  45. 45.
    Patel N, Bagan B, Vadera S, Maltenfort MG, Deutsch H, Vaccaro AR, Harrop J, Sharan A, Ratliff JK (2007) Obesity and spine surgery: relation to perioperative complications. J Neurosurg Spine 6:291–297PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Burks CA, Werner BC, Yang S, Shimer AL (2015) Obesity is associated with an increased rate of incidental durotomy in lumbar spine surgery. Spine (Phila Pa 1976) 40:500–504CrossRefGoogle Scholar
  47. 47.
    Owens RK 2nd, Djurasovic M, Onyekwelu I, Bratcher KR, McGraw KE, Carreon LY (2016) Outcomes and revision rates in normal, overweight, and obese patients 5 years after lumbar fusion. Spine J 16:1178–1183PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Jiang J, Teng Y, Fan Z, Khan S, Xia Y (2014) Does obesity affect the surgical outcome and complication rates of spinal surgery? A meta-analysis. Clin Orthop Relat Res 472:968–975PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Choudhri TF, Mummaneni PV, Dhall SS et al (2014) Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 4: radiographic assessment of fusion status. J Neurosurg Spine 21:23–30PubMedCrossRefPubMedCentralGoogle Scholar

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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