Medical Management of Osteoporosis for Elective Spine Surgery

Over 50 million Americans have low bone mass. Poor bone quality is known to complicate spinal fusion surgery, which relies on strong bony purchase to be effective. Unfortunately, many spine surgeons do not perform routine workups for either osteoporosis or osteomalacia. Effective screening and risk factor assessment can allow for appropriate medical management of osteoporosis in the perioperative setting, improving outcomes. Medical management can be grouped into several different categories: vitamins and minerals, bisphosphonates, recombinant parathyroid hormone, estrogen replacement or modification, inhibitors of receptor activator of nuclear factor κ-B ligand (RANKL), and calcitonin. Calcium and vitamin D supplements are the least expensive to prescribe, with minimal side effects and promising animal studies, and thus should be provided to most osteoporotic patients. Recombinant parathyroid hormone can also be considered, as clinical studies have demonstrated impressive results in spine fusion patients. Bisphosphonates, estrogen therapy or selective estrogen receptor modulators, and calcitonin should all be avoided in this patient population given unproven benefit and potentially harmful side-effect profiles. Denosumab is potentially an option, but may not be first line given the general lack of supporting data for its use in perioperative management of spine surgery patients.