Optimization of spine surgery outcomes in patients with osteoporosis: a comprehensive narrative review

Osteoporosis has emerged as a major challenge in spine surgery amid the rapid aging of the global population. Diminished bone quality significantly heightens the risk of postoperative mechanical complications following spinal instrumentation, including screw loosening, proximal junctional kyphosis and failure, cage subsidence, pseudoarthrosis, and loss of surgical correction. These complications often result in poorer clinical outcomes, higher healthcare expenditures, and an increased need for revision surgery. Comprehensive preoperative assessment of bone health represents the initial step in optimizing surgical outcomes in patients with osteoporosis. While dual-energy X-ray absorptiometry remains the gold standard for evaluating bone mineral density, opportunistic computed tomography-based assessments can further refine risk stratification. Secondary causes of osteoporosis should be identified and managed preoperatively. Surgical strategies should prioritize maximizing pedicle screw fixation and minimizing implant-related complications. Key technical considerations include optimization of screw trajectory, diameter, and length; judicious use of cement augmentation; appropriate sacral fixation techniques; and meticulous preservation of vertebral endplates to prevent cage subsidence. In selected cases, the cortical bone trajectory may offer biomechanical advantages for osteoporotic bones, while perioperative pharmacologic optimization further enhances outcomes. Anabolic agents, such as teriparatide, augment bone formation and fusion rates and are recommended as first-line therapy when feasible. Antiresorptive agents typically serve as second-line or maintenance therapy following anabolic treatment. A comprehensive approach integrating systematic bone health assessments, optimized surgical techniques, and appropriate pharmacological management is essential to mitigate implant-related complications and improve surgical outcomes in patients with osteoporosis.