Effect of Bone Health Optimization on Osteoporosis Screening and Treatment Before Thoracolumbar Fusion.

OBJECTIVE: Osteoporosis is not rare in thoracolumbar spine fusion patients and may portend poorer surgical outcomes. Implementation of a bone health optimization (BHO) clinic improves osteoporosis screening and treatment in the total joint arthroplasty population. We hypothesize that preoperative osteoporosis is common, under-recognized, and undertreated in thoracolumbar fusion patients and that a BHO clinic will increase preoperative osteoporosis screening rates and pharmacologic osteoporosis treatment in this population. METHODS: This retrospective case series includes adults older than 30 years who underwent elective thoracolumbar spine fusion at a single tertiary care center before and after creation of a BHO referral clinic. Data collected included preoperative osteoporosis risk factors, prior dual-energy radiograph absorptiometry testing, and prior osteoporosis pharmacotherapy. Fracture risk was estimated using the fracture risk assessment tool with and without bone mineral density (BMD), and the US National Osteoporosis Foundation criteria for screening and treatment were applied. RESULTS: Ninety patients were included in the pre-BHO group; 53 patients met criteria for BMD measurement, but only 10 were tested within 2 years preoperatively. Sixteen patients (18%) met criteria for osteoporosis pharmacotherapy, but only 5 of the 16 (31%) received osteoporosis medication within 6 months of surgery. There were 87 patients in the post-BHO group, and 19 were referred to the BHO clinic. BMD measurement was done in 17 of the patients (89%) referred to the BHO clinic compared with 10% for those not referred. All patients (n = 7) referred to the BHO clinic meeting treatment criteria received treatment within 6 months before surgery, whereas only 25% of the patients not referred received treatment. DISCUSSION: Osteoporosis is not rare in adults undergoing thoracolumbar spine fusion with ∼13% to 18% meeting criteria for pharmacotherapy. Preoperative BHO referral increases screening and treatment.

Preoperative bone health assessment and optimization in spine surgery.

OBJECTIVE: The purpose of this investigation was to characterize the bone health in preoperative spine surgery patients. This information will provide a framework to understand the needs and methods for providing bone health optimization in elective spine surgery patients. METHODS: A retrospective study of 104 patients undergoing bone health optimization was performed. Patients were selected based on risk factors identified by the surgeon and suspected compromised bone health. Evaluation included history and examination, laboratory investigations, and bone mineral density (BMD) at 3 sites (femoral neck, lumbar spine, and radius). Patients' bone status was classified using WHO criteria and expanded criteria recommended by the National Osteoporosis Foundation (NOF). The 10-year Fracture Risk Assessment Tool (FRAX) scores of the hip and major osteoporotic fracture (MOF) were calculated with and without femoral neck BMD, with spine BMD, and with the trabecular bone score (TBS). Antiresorptive and anabolic agents were provided in accordance with meeting NOF criteria for treatment of osteoporosis. RESULTS: The mean patient age was 69.0 years, and 81% of patients were female. The mean historical height loss was 5.6 cm, and 54% of patients had a history of fracture. Secondary osteoporosis due to chronic renal failure, inflammatory arthritis, diabetes, and steroid use was common (51%). The mean 25-hydroxy vitamin D was 42.4 ng/ml and was normal in 81% of patients, with only 4 patients being deficient. The mean T-scores were -2.09 (SD 0.71) of the femoral neck, -0.54 (1.71) of the lumbar spine, and -1.65 (1.38) of the distal radius. These were significantly different. The 10-year FRAX MOF score was 20.7%, and that for hip fracture was 6.9% using the femoral neck BMD and was not significantly different without the use of BMD. The FRAX risk-adjusted score using the lumbar spine BMD and TBS was significantly lower than that for the hip. Osteoporosis was present in 32.1% according to WHO criteria compared with 81.6% according to NOF criteria. Antiresorptive medications were recommended in 31 patients and anabolic medications in 44 patients. CONCLUSIONS: Surgeons can reliably identify patients with poor bone health by using simple criteria, including historical height loss, history of fracture, comorbidities associated with osteoporosis, analysis of available imaging, and calculation of FRAX score without BMD. High-risk patients should have BMD testing and bone health assessment. In patients with osteoporosis, a comprehensive preoperative bone health assessment is recommended and, if warranted, pharmacological treatment should be started.

Bone Health Optimization in Orthopaedic Surgery.

BACKGROUND: Osteoporosis is associated with adverse orthopaedic surgical outcomes. Bone health optimization is a preoperative intervention intended to reduce the likelihood of postoperative complications. We aimed to characterize a patient cohort referred for bone health optimization to test the hypothesis that poor bone quality is common in orthopaedic surgery and that many such patients meet guidelines for osteoporosis treatment. METHODS: This retrospective study evaluated 124 patients referred for bone health optimization who were ≥50 years of age and candidates for arthroplasty or thoracolumbar surgery. The Fracture Risk Assessment Tool (FRAX) risk factors and dual x-ray absorptiometry (DXA) results were collected. When available, opportunistic computed tomographic (CT) imaging and the trabecular bone score were evaluated. The World Health Organization (WHO) diagnostic and National Osteoporosis Foundation (NOF) treatment guidelines were applied. RESULTS: All patients were referred by their orthopaedic surgeon; their mean age was 69.2 years, 83% of patients were female, 97% were Caucasian, and 56% had sustained a previous fracture. The mean historical height loss (and standard deviation) was 5.3 ± 3.3 cm for women and 6.0 ± 3.6 cm for men. The mean lowest T-score of the hip, spine, or wrist was -2.43 ± 0.90 points in women and -2.04 ± 0.81 points in men (p < 0.08). Osteoporosis (T-score of ≤-2.5 points) was present in 45% of women and 20% of men; only 3% of women and 10% of men had normal bone mineral density. Opportunistic CT scans identified 60% of patients as likely having osteoporosis. The trabecular bone score identified 34% of patients with degraded bone microarchitecture and 30% of patients with partially degraded bone microarchitecture. The NOF threshold for osteoporosis treatment was met in 91% of patients. Treatment was prescribed in 75% of patients (45% anabolic therapy and 30% antiresorptive therapy). CONCLUSIONS: Osteoporosis, degraded bone microarchitecture, prior fracture, and elevated fracture risk were common. Given the high prevalence of impaired bone health in this cohort, we believe that bone health screening, including FRAX assessment, should be considered in selected patients undergoing orthopaedic surgery as part of the preoperative optimization for all adults who are ≥50 years of age. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.