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Objective: The purpose of this study was to identify risk factors for pseudarthrosis in patients undergoing anterior cervical discectomy and fusion (ACDF) with a focus on the role of bone mineral density (BMD) on arthrodesis., Methods: We retrospectively reviewed a prospectively collected database of patients undergoing 1- to 4-level ACDF for degenerative indications between 2012 and 2018 at a single institution. All patients were required to have undergone a preoperative dual-energy x-ray absorptiometry (DEXA) scan. Fusion status was assessed on computed tomography (CT) scans obtained 1 year postoperatively. Patients were divided into subgroups based on fusion status and compared on the basis of demographic, BMD, and surgical variables to determine risk factors for pseudarthrosis., Results: We identified 79 patients for inclusion in this study. Fusion was achieved in 65 patients (82%), while 14 patients (18%) developed pseudarthrosis. The pseudarthrosis subgroup demonstrated significantly lower BMD than their counterparts who achieved successful fusion in both mean hip (-1.4 ± 1.2 vs. -0.2 ± 1.2, respectively; P = 0.002) and spine T-scores (-0.8 ± 1.8 vs. 0.6 ± 1.9, respectively; P = 0.02). The pseudarthrosis group had a substantially higher proportion of patients with osteopenia (57.1% vs. 20.0%) and osteoporosis (21.5% vs. 6.2%; P < 0.001) than the fusion group. Multivariate analysis demonstrated osteopenia (odds ratio [OR] 8.76, P = 0.04), osteoporosis (OR 9.97, P = 0.03), and low BMD (OR 11.01, P = 0.002) to be associated with an increased likelihood of developing pseudarthrosis., Conclusions: The results of this study suggest that both osteopenia and osteoporosis are associated with increased rates of pseudarthrosis in patients undergoing elective ACDF., (Copyright © 2022 Elsevier Inc. All rights reserved.)

➤: Osteoporosis is common in orthopaedic patients, not only in those sustaining fragility fractures but also in patients ≥50 years old who are having elective orthopaedic surgery., ➤: The American Society for Bone and Mineral Research (ASBMR) has developed consensus-based recommendations for secondary fracture prevention for all patients who are ≥65 years old with a hip or spine fracture., ➤: The ASBMR encourages orthopaedic surgeons to "Own the Bone," by beginning prevention of a secondary fracture during hospitalization for a fragility fracture, if practicable, and arranging follow-up for continued bone health care after discharge., ➤: The International Society for Clinical Densitometry (ISCD) recognized that many poor outcomes and complications of elective orthopaedic surgery are related to osteoporosis., ➤: The ISCD used an evidence-based approach to create official positions to identify which patients ≥50 years old who are having elective orthopaedic surgery should undergo assessment of bone health and how this should be performed., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G344)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Objective: The goal of this study was to compare different recognized definitions of osteoporosis in patients with degenerative lumbar spine pathology undergoing elective spinal fusion surgery to determine which patient population should be considered for preoperative optimization., Methods: A retrospective review of patients in whom lumbar spine surgery was planned at 2 academic medical centers was performed, and the rate of osteoporosis was compared based on different recognized definitions. Assessments were made based on dual-energy x-ray absorptiometry (DXA), CT Hounsfield units (HU), trabecular bone score (TBS), and fracture risk assessment tool (FRAX). The rate of osteoporosis was compared based on different definitions: 1) the WHO definition (T-score ≤ -2.5) at total hip or spine; 2) CT HU of < 110; 3) National Bone Health Alliance (NBHA) guidelines; and 4) "expanded spine" criteria, which includes patients meeting NBHA criteria and/or HU < 110, and/or "degraded" TBS in the setting of an osteopenic T-score. Inclusion criteria were adult patients with a DXA scan of the total hip and/or spine performed within 1 year and a lumbar spine CT scan within 6 months of the physician visit., Results: Two hundred forty-four patients were included. The mean age was 68.3 years, with 70.5% female, 96.7% Caucasian, and the mean BMI was 28.8. Fracture history was reported in 53.8% of patients. The proportion of patients identified with osteoporosis on DXA, HUs, NBHA guidelines, and the authors' proposed "expanded spine" criteria was 25.4%, 36.5%, 75%, and 81.9%, respectively. Of the patients not identified with osteoporosis on DXA, 31.3% had osteoporosis based on HU, 55.1% had osteoporosis with NBHA, and 70.4% had osteoporosis with expanded spine criteria (p < 0.05), with poor correlations among the different assessment tools., Conclusions: Limitations in the use of DXA T-scores alone to diagnose osteoporosis in patients with lumbar spondylosis has prompted interest in additional methods of evaluating bone health in the spine, such as CT HU, TBS, and FRAX, to inform guidelines that aim to reduce fracture risk. However, no current osteoporosis assessment was developed with a focus on improving outcomes in spinal surgery. Therefore, the authors propose an expanded spine definition for osteoporosis to identify a more comprehensive cohort of patients with potential poor bone health who could be considered for preoperative optimization, although further study is needed to validate these results in terms of clinical outcomes.

Osteoporosis is a common and debilitating condition characterized by diminished bone mass and architecture leading to bone fragility. Antiresorptive medicines like bisphosphonates (and less commonly denosumab) are the typical first-line agents for the medical treatment of osteoporosis. However, newer anabolic agents have been shown to improve bone mass and architecture, as well as reduce fracture risk, to a greater degree than traditional antiresorptive therapies. Teriparatide (human recombinant parathyroid hormone (PTH) 1-34, Forteo, Ely Lilly, Indianapolis, IN), which was the first in class to be approved in the United States, is the most widely used anabolic osteoporosis medicine and has shown significant benefit over traditional antiresorptive therapies. However, abaloparatide (synthetic parathyroid-related peptide (PTHrP), Tymlos, Radius Health, Waltham, MA), the second drug in this family, has recently become available for use. In this narrative review, we review the mechanism, effects, and benefits of abaloparatide compared to alternative treatments as well as discuss the current literature in regard to its effect on osteoporosis-related complications in the spine., Competing Interests: Dr Paul A Anderson reports personal fees from Radius Medical, Amgen, Titan spine, Medtronic, Regeneration Technologies inc, outside the submitted work. The authors report no other conflicts of interest in this work., (© 2020 Thompson et al.)

Study Design: Retrospective cohort study of the Own the Bone database which is a fracture liaison service designed to improve recognition and treatment of osteoporosis., Objective: To use the Own the Bone (OTB) database to 1) examine the specific demographics of patients presenting with a low-energy clinical vertebral fracture (VFX) and 2) compare demographic and fracture-specific risk factors between patients with clinical VFX versus patients with nonvertebral low-energy fracture (NVFX)., Summary of Background Data: Large database studies have described risk factors for developing VFX. It is well described that a history of previous VFX portends an increased risk of future VFX. Few studies have reported cohorts from a fracture liaison service such as the OTB initiative., Methods: 35,039 unique cases of fragility fracture occurred between 2009 and 2016 and were included in analysis. VFX accounted for 3395 (9.9%) of the presenting fractures at OTB enrollment. The demographics, lifestyle factors, medication use, and fracture-specific data for patients in the OTB registry with vertebral fractures were summarized and then statistically compared to those with nonvertebral fragility fractures., Results: The majority of VFX patients were Caucasian, postmenopausal women (74.4%). There was an increased likelihood of presenting with a vertebral fracture in patients who sustained a previous VFX after the age of 50, while patients who sustained a prior nonvertebral fracture (NVFX) were more likely to present with a subsequent NVFX. After controlling for patients with a history of fracture after the age of 50, VFX patients (vs. NVFX) were more likely to be age 70-79, class 1 obesity, with a history of taking anti-osteoporotic prescription medications., Conclusions: Multiple factors were associated with a significantly increased risk of VFX compared with NVFX. Understanding the risk factors unique to fragility VFX is a critical component for targeting "at-risk" patients and preventing future osteoporosis-related fractures and their consequences., Level of Evidence: 4.

Kummel disease is the eponym for avascular necrosis of the vertebral body after a vertebral compression fracture. As our population ages, the prevalence of osteoporosis, its most common fragility fracture (vertebral compression fracture), and Kummel disease will increase. The purpose of this article is to report a prototypical case with complete radiographic and histologic workup and to provide facts regarding Kummel disease that are salient to the primary care provider.

Background Context: Untreated osteoporosis causes decreased bone mineral density, which predisposes to fragility fractures. Low-energy vertebral compression fractures are the most common type of osteoporotic fragility fracture. Prior studies have shown that only one-quarter of patients diagnosed with an osteoporotic fracture are referred or treated for osteoporosis., Purpose: To identify the rate of therapeutic interventions for patients aged 50 years and older within a capitated population who sustained low impact vertebral compression fractures over a 6-month period., Study Design/setting: Retrospective observational study., Patient Sample: The reports of all imaging studies of the chest, abdomen, and spine taken from July to December 2002 within a large military health-care system were queried on the Composite Health Computer System (CHCS). The sample included patients 50 years or older who had a low-energy vertebral compression fracture., Outcome Measures: The computerized medical records were examined for osteoporotic medication prescriptions, referrals to endocrinology, and to dual-energy X-ray absorptiometry (DEXA) scans. These results were compared with results obtained from a similar study on osteoporotic distal radius fractures., Results: The records of 156 patients (average age: 77.3y; 78 women, 78 men) meeting the inclusion criteria were analyzed to determine what proportion was followed-up with osteoporosis interventions. Within 1 year after the fracture, 39% (37 females, 24 males) had undergone a DEXA scan, 35% (37 females, 18 males) had been referred to endocrinology, 38% (47 females, 12 males) were receiving active osteoporosis treatment, and 51% (55 females, 25 males) were receiving any form of osteoporosis-directed medication. The rate of medical intervention was similar to the rate of intervention after distal radius fragility fractures (n=111; 30% active medication; 47% any osteoporosis medication) (p>.21). The rate of all interventions was significantly greater for women than men., Conclusions: Although the likelihood of intervention is slightly greater after vertebral compression fractures than for distal radius fractures, orthopedic surgeons, emergency room physicians, and primary care providers continue to miss opportunities, especially in males, to diagnose and/or initiate active therapeutic interventions for osteoporosis in patients presenting with osteoporosis-related fragility fractures.

Low-energy wrist (distal radius) fractures are hallmarks of osteoporosis. Prompt diagnosis and treatment of osteoporosis reduce refracture rates. We retrospectively determined the type and frequency of osteoporosis-related interventions rendered to patients 50 years and older in the year after a wrist fragility fracture. In addition, we compared the rates of intervention between men and women. Data were collected from the computerized medical record of one military healthcare system. We identified 111 patients who sustained wrist fragility fractures between July and December 2002. Endocrinology referrals, dual-energy xray absorptiometry scans, and osteoporosis medication prescriptions in the year after their fracture were recorded. Overall, 28 patients (25%) were referred to endocrinology, 22 patients (20%) had a dual-energy xray absorptiometry scan, 33 patients (30%) were prescribed an approved medication for treatment of osteoporosis, and 52 patients (47%) were prescribed one of these medications and/or vitamin D and calcium. Sixty percent of patients received at least one intervention. All diagnostic and medical interventions were more likely ordered for women than men. Orthopaedic surgeons continue to miss opportunities to initiate diagnostic and therapeutic interventions for patients, especially men, presenting with fragility fractures.

Purpose of the study: Teriparatide (Human recombinant Parathyroid Hormone 1-34) is an anabolic agent that is frequently used in patients with osteoporosis and has been extensively investigated with animal model and clinical studies in current literature. The purpose of the study was to evaluate the impact of teriparatide on bone mineral density and fusion. Materials and methods: The findings from preclinical studies that have investigated the role of teriparatide in animal models are summarized in presented review. Results: Overall, the studies show an improvement in bone mineral density and increased fusion rates for osteoporotic animals undergoing spine fusion with teriparatide use. Conclusion: Further studies should be conducted for unanswered questions, such as teriparatide use before surgery, the effect on cervical fusion and surgery related complications. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective cohort study. Objective. Hounsfield units (HUs) are known to correlate with clinical outcomes, but no study has evaluated how they correlate with biomechanical computed tomography (BCT) and dual-energy x-ray absorptiometry (DXA) measurements. Summary of Background. Low bone mineral density (BMD) represents a major risk factor for fracture and poor outcomes following spine surgery. DXA can provide regional BMD measurements but has limitations. Opportunistic HUs provide targeted BMD estimates; however, they are not formally accepted for diagnosing osteoporosis in current guidelines. More recently, BCT analysis has emerged as a new modality endorsed by the International Society for Clinical Densitometry for assessing bone strength. Methods. Consecutive cases from 2017 to 2022 at a single institution were reviewed for patients who underwent BCT in the thoracolumbar spine. BCT-measured vertebral strength, trabecular BMD, and the corresponding American College of Radiology Classification were recorded. DXA studies within three months of the BCT were reviewed. Pearson Correlation Coefficients were calculated, and receiver-operating characteristic curves were constructed to assess the predictive capacity of HUs. Threshold analysis was performed to identify optimal HU values for identifying osteoporosis and low BMD. Results. Correlation analysis of 114 cases revealed a strong relationship between HUs and BCT vertebral strength (r= 0.69; P<0.0001; R²=0.47) and trabecular BMD (r =0.76; P<0.0001; R2=0.58). However, DXA poorly correlated with opportunistic HUs and BCT measurements. HUs accurately predicted osteoporosis and low BMD (Osteoporosis: C= 0.95, 95% CI 0.89--1.00; Low BMD: C=0.87, 95% CI 0.79--0.96). Threshold analysis revealed that 106 and 122 HUs represent optimal thresholds for detecting osteoporosis and low BMD. Conclusion. Opportunistic HUs strongly correlated with BCTbased measures, while neither correlated strongly with DXA-based BMD measures in the thoracolumbar spine. HUs are easy to perform at no additional cost and provide accurate BMD estimates at noninstrumented vertebral levels across all American College of Radiology-designated BMD categories. [ABSTRACT FROM AUTHOR]

To review outcomes of patients undergoing spinal fusion with prophylactic cement augmentation (CA) of pedicle screws and adjacent levels. In a retrospective case-control study, 59 patients underwent CA of pedicle screws for spinal fusion between 2003 and 2018. Most patients (83%) underwent postoperative CA, while 17% underwent intraoperative CA. Outcomes of CA techniques were compared, and patients undergoing CA for a thoracolumbar fusion (n = 51) were compared with a cohort not undergoing CA (n = 39). Mean follow-up was 3 years. In patients receiving CA, survivorship free of proximal junctional kyphosis (PJK) was 94%, 60%, and 20% at 2, 5, and 10 years postoperatively. Survivorship free of revision was 95%, 83%, and 83% at 2, 5, and 10 years postoperatively. Development of PJK (P = 0.02, odds ratio [OR] 24.44) was associated with revision surgery. There were 4 (7%) cardiopulmonary complications. Patients who received CA for thoracolumbar fusion were older (70 years vs. 65 years) and were more likely to have osteoporosis (53% vs. 5%) than patients who did not receive CA. CA was associated with a decreased risk of PJK (P = 0.009, OR 0.16), while osteoporosis (P = 0.05, OR 4.10) and fusion length ≥8 levels (P = 0.06, OR 2.65) were associated with PJK. PJK was associated with revision surgery (P = 0.006, OR 12.65). CA allows for substantial rates of radiographic PJK; however, this typically does not result in a need for revision surgery and leads to revision and PJK rates that are comparable to patients undergoing long segment fusions without osteoporosis. [ABSTRACT FROM AUTHOR]

: Background contextBisphosphonates affect bone remodeling and increase bone mass through the inhibition of osteoclasts. Their effect on osteoblasts, and the balance between osteoblastic and osteoclastic activity on bone turnover and healing, is not completely understood. Specifically, the effect of bisphosphonates on spinal fusion has yet to be determined. With the increasing use of bisphosphonates in the elderly population, this effect needs to be delineated.: PurposeTo evaluate the effect of alendronate sodium after an intertransverse process spinal fusion in a rabbit model.: Study design/settingRandomized double-blinded in vivo study of the effect of alendronate sodium in a spinal fusion model.: MethodsFifty New Zealand white rabbits underwent a posterolateral L5–L6 intertransverse process arthrodesis with autogenous iliac crest bone graft. The rabbits were then randomly divided into two groups. Group I received 3 cc of saline placebo per oral gavage, and Group II received 200 μg (approximately 0.05 mg/kg/day) of alendronate sodium dissolved in 3 cc of saline per day for 8 weeks. Upon completion, the rabbits were sacrificed and the lumbar spines harvested, radiographed and graded for motion across the fusion site with manual palpation. Two independent pathologists then prepared and sectioned each left and right fusion mass. Three random ×10 fields were examined and graded for both the cephalad and caudad ends of each section (516 fields). Fusion quality was graded using an established histological scoring scale (score 0 to 7 based on fibrous and bone content of the fusion mass).: ResultsTwo rabbits died on the day of operation, and 48 rabbits survived the operation. Five additional rabbits died within the first 2 postoperative weeks. Thus, 43 rabbits (21 in Group I, 22 in Group II) completed the 8-week course of treatment. Grading each side separately, 26 of 42 fusion masses (62%) in Group I and 24 of 44 fusion masses (55%) in Group II had radiographic evidence of fusion (p = .76). With gross palpation, 11 of 21 motion segments (52%) in Group I versus 13 of 22 motion segments (59%) in Group II were determined to have a solid fusion (p = .76). Histologically, Group I had a higher median score (6.0; range, 0 to 7 vs. 1.0; range, 0 to 7; p<.0001) and a higher fusion rate (76% vs. 45%; p = .004) than Group II.: ConclusionsAlendronate sodium appears to inhibit or delay bone fusion in a rabbit model. Presumably, this occurs as a result of uncoupling the balanced osteoclastic and osteoblastic activity inherent to bone healing. These findings suggest that a discontinuance of alendronate sodium postoperatively during the acute fusion period may be warranted. [Copyright &y& Elsevier]

Vertebral cement augmentation techniques are routinely used to treat osteoporotic vertebral compression fractures (VCFs). In the current study, we used a state-level outpatient database to compare costs and postoperative outcomes between vertebroplasty and kyphoplasty. We queried the 2016 Florida State-Ambulatory Surgery Database of the Healthcare Cost and Utilization Project for patients undergoing thoracolumbar vertebroplasty or kyphoplasty for osteoporotic VCFs. Demographic and clinical characteristics, as well as postoperative outcomes were compared between the 2 groups. A total of 105 patients (11.6%) who underwent vertebroplasty and 801 patients (88.4%) who underwent kyphoplasty were identified. Patients undergoing kyphoplasty were more likely to stay overnight or longer, with the P value trending toward significance (kyphoplasty with >1 day stay: 7.4% vs. vertebroplasty with >1 day stay: 1.9%; P = 0.086). Patients undergoing vertebroplasty had a significantly higher rate of discharge to home routine compared with patients undergoing kyphoplasty (97.1% [ n = 102] vs. 94.1% [n = 754]; P < 0.001). Undergoing kyphoplasty was also associated with higher index admission costs ($40,706 vs. $18,965; P < 0.001) and higher readmission costs ($27,038 vs. $11,341; P = 0.046). The rates of 30-day and 90-day readmission were similar between the 2 groups (all P > 0.05). The rates of 30-day, 90-day, and overall readmission because of a new-onset fracture were also similar (all P > 0.05). However, vertebroplasty had a higher rate of readmissions associated with a procedure within a year (21.9% [ n = 23] vs. 14.5% [ n = 116]; P = 0.047). Our analyses from a state-level database of patients undergoing vertebroplasty and kyphoplasty for osteoporotic VCFs show similar postoperative outcomes for the 2 procedures but a higher cost for kyphoplasty. [ABSTRACT FROM AUTHOR]