The Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Osteoporosis Assessment recently was published in Neurosurgery. To develop these recommendations, the authors performed systematic review of the literature using national databases for studies relevant to preoperative diagnostic studies that predict increased risk of osteoporosis-related postoperative complications and whether the preoperative treatment of low bone mineral density (BMD) improves outcome.

Two members of the task force initially screened all the abstracts culled from the literature, followed by all members of the entire task force, who graded the best research articles that answered the two research questions.

The study identified that preoperative assessment with dual-energy X-ray absorptiometry (DXA) scan (T-score < -2.5) or spine CT (HUs < 97.9), and serum vitamin D3 level (<20 ng/mL) predicted a lower fusion rate and instrumentation failure. Teriparatide treatment was associated with earlier fusion, higher fusion rates and less screw loosening, but the evidence was conflicting concerning bisphosphonates. Spine surgeons should assess bone quality and consider treatment prior to surgery.

The authors recommended that patients over age 65 and those who are younger with certain risk factors should undergo formal bone health evaluation prior to elective spinal reconstruction, according to recently published findings by the panel.

In addition to all patients over age 65, patients ages 50 to 64 with various risk factors, including chronic glucocorticoid use, high fracture risk or previous fracture, and limited mobility, should have a bone mineral density (BMD) test and vitamin D3 levels evaluated.

“DXA scans are preferable due to their wide availability while opportunistic CT Hounsfield units of the vertebrae can be useful in identifying poor bone health. In the absence of contraindications, anabolic agents are the first line therapy due to their bone building properties when compared to antiresorptive medications such as bisphosphonates,” the authors recommended, including the lead author, John R. Dimar, M.D., a spine surgeon with Norton Leatherman Spine. “Medications should be administered preoperatively for at least three to six months and postoperatively for minimum eight months, depending on the anticipated level of surgery.”

The authors also published important guidelines that can be reviewed on the effect of nutrition, A1C level and body mass index (BMI), opioid use, and pulmonary function on perioperative optimization in patients undergoing surgery of the spine.

Dr. Dimar’s recently published research