Abstract
Summary
We investigated the effect of posterior lumbar fusion surgery on the regional volumetric bone mineral density (vBMD) measured by quantitative computed tomography. Surgery negatively affected the regional vBMD in adjacent levels. Interbody fusion was independently associated with vBMD decline and preoperative epidural steroid injections (ESIs) were associated with less postoperative vBMD decline.
Introduction
Few studies investigate postoperative BMD changes after lumbar fusion surgery utilizing quantitative computed tomography (QCT). Additionally, it remains unclear what preoperative and operative factors contribute to postoperative BMD changes. The purpose of this study is to investigate the effect of lumbar fusion surgery on regional volumetric bone mineral density (vBMD) in adjacent vertebrae and to identify potential modifiers for postoperative BMD change.
Methods
The data of patients undergoing posterior lumbar fusion with available pre- and postoperative CTs were reviewed. The postoperative changes in vBMD in the vertebrae one or two levels above the upper instrumented vertebra (UIV+1, UIV+2) and one level below the lower instrumented vertebra (LIV+1) were analyzed. As potential contributing factors, history of ESI, and the presence of interbody fusion, as well as various demographic/surgical factors, were included.
Results
A total of 90 patients were included in the study analysis. Mean age (±SD) was 62.1 ± 11.7. Volumetric BMD (±SD) in UIV+1 was 115.4 ± 36.9 mg/cm3 preoperatively. The percent vBMD change in UIV+1 was − 10.5 ± 12.9% (p < 0.001). UIV+2 and LIV+1 vBMD changes showed similar trends. After adjusting with the interval between surgery and the secondary CT, non-Caucasian race, ESI, and interbody fusion were independent contributors to postoperative BMD change in UIV+1.
Conclusions
Posterior lumbar fusion surgery negatively affected the regional vBMDs in adjacent levels. Interbody fusion was independently associated with vBMD decline. Preoperative ESIs were associated with less postoperative vBMD decline, which was most likely a result of a preoperative decrease in vBMD due to ESIs.
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References
Bjerke BT, Zarrabian M, Aleem IS, Fogelson JL, Currier BL, Freedman BA, Bydon M, Nassr A (2018) Incidence of osteoporosis-related complications following posterior lumbar fusion. Global Spine J 8:563–569
O'Leary PT, Bridwell KH, Lenke LG, Good CR, Pichelmann MA, Buchowski JM, Kim YJ, Flynn J (2009) Risk factors and outcomes for catastrophic failures at the top of long pedicle screw constructs: a matched cohort analysis performed at a single center. Spine 34:2134–2139
Dubrovsky AM, Lim MJ, Lane NE (2018) Osteoporosis in rheumatic diseases: anti-rheumatic drugs and the skeleton. Calcif Tissue Int 102:607–618
Haugeberg G, Uhlig T, Falch JA, Halse JI, Kvien TK (2000) Bone mineral density and frequency of osteoporosis in female patients with rheumatoid arthritis: results from 394 patients in the Oslo County Rheumatoid Arthritis register. Arthritis Rheum 43:522–530
Briot K, Etcheto A, Miceli-Richard C, Dougados M, Roux C (2016) Bone loss in patients with early inflammatory back pain suggestive of spondyloarthritis: results from the prospective DESIR cohort. Rheumatology (Oxford) 55:335–342
Munoz-Ortego J, Vestergaard P, Rubio JB, Wordsworth P, Judge A, Javaid MK, Arden NK, Cooper C, Diez-Perez A, Prieto-Alhambra D (2014) Ankylosing spondylitis is associated with an increased risk of vertebral and nonvertebral clinical fractures: a population-based cohort study. J Bone Miner Res 29:1770–1776
Bultink IE, Vis M, van der Horst-Bruinsma IE, Lems WF (2012) Inflammatory rheumatic disorders and bone. Curr Rheumatol Rep 14:224–230
Moor D, Aggarwal G, Quiney N (2017) Systemic response to surgery. Surg Oxf Int Ed 35:220–223
Watt DG, McSorley ST, Park JH, Horgan PG, McMillan DC (2017) A postoperative systemic inflammation score predicts short- and long-term outcomes in patients undergoing surgery for colorectal cancer. Ann Surg Oncol 24:1100–1109
Lofdahl E, Soderlund C, Radegran G (2019) Bone mineral density and osteoporosis in heart transplanted patients: a single-center retrospective study at Skane University Hospital in Lund 1988-2016. Clin Transpl e13477
Myers MA, Casciani T, Whitbeck GM Jr, Puzas EJ (1996) Vertebral body osteopenia associated with posterolateral spine fusion in humans. Spine 21:2368–2371
Bogdanffy GM, Ohnmeiss DD, Guyer RD (1995) Early changes in bone mineral density above a combined anteroposterior L4-S1 lumbar spinal fusion. A clinical investigation. Spine 20:1674–1678
Erdogan B, Bagis T, Sen O, Erkanli S, Altinors N, Aslan E, Aydin MV, Atalay B (2003) Effects of lumbar disc surgery on bone mineral density in women with lumbar disc disease. Adv Ther 20:114–120
Beller G, Belavy DL, Sun L, Armbrecht G, Alexandre C, Felsenberg D (2011) WISE-2005: bed-rest induced changes in bone mineral density in women during 60 days simulated microgravity. Bone 49:858–866
McGregor AH, Dicken B, Jamrozik K (2006) National audit of post-operative management in spinal surgery. BMC Musculoskelet Disord 7:47
Yu EW, Thomas BJ, Brown JK, Finkelstein JS (2012) Simulated increases in body fat and errors in bone mineral density measurements by DXA and QCT. J Bone Miner Res 27:119–124
Guglielmi G, Floriani I, Torri V, Li J, van Kuijk C, Genant HK, Lang TF (2005) Effect of spinal degenerative changes on volumetric bone mineral density of the central skeleton as measured by quantitative computed tomography. Acta Radiol 46:269–275
Adams JE (2009) Quantitative computed tomography. Eur J Radiol 71:415–424
Guglielmi G, Grimston SK, Fischer KC, Pacifici R (1994) Osteoporosis: diagnosis with lateral and posteroanterior dual X-ray absorptiometry compared with quantitative CT. Radiology 192:845–850
Brown JK, Timm W, Bodeen G, Chason A, Perry M, Vernacchia F, DeJournett R (2017) Asynchronously calibrated quantitative bone densitometry. J Clin Densitom 20:216–225
Shepherd JA, Schousboe JT, Broy SB, Engelke K, Leslie WD (2015) Executive summary of the 2015 ISCD Position Development Conference on Advanced Measures from DXA and QCT: fracture prediction beyond BMD. J Clin Densitom 18:274–286
Salzmann SN, Ortiz Miller C, Carrino JA, Yang J, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP (2019) BMI and gender increase risk of sacral fractures after multilevel instrumented spinal fusion compared with bone mineral density and pelvic parameters. Spine J 19:238–245
Salzmann SN, Shirahata T, Yang J, Miller CO, Carlson BB, Rentenberger C, Carrino JA, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP (2019) Regional bone mineral density differences measured by quantitative computed tomography: does the standard clinically used L1-L2 average correlate with the entire lumbosacral spine? Spine J 19:695–702
American College of Radiologist (2018) ACR–SPR–SSR practice parameter for the performance of musculoskeletal quantitative computed tomography (QCT). https://www.acr.org/-/media/ACR/Files/Practice-Parameters/QCT.pdf. Accessed 11/14/2018
Alarkawi D, Bliuc D, Nguyen TV, Eisman JA, Center JR (2016) Contribution of lumbar spine BMD to fracture risk in individuals with T-score discordance. J Bone Miner Res 31:274–280
Lipscomb HJ, Grubb SA, Talmage RV (1989) Spinal bone density following spinal fusion. Spine 14:477–479
Demir O, Oksuz E, Deniz FE, Demir O (2017) Assessing the effects of lumbar posterior stabilization and fusion to vertebral bone density in stabilized and adjacent segments by using Hounsfield unit. J Spine Surg 3:548–553
Garner HW, Paturzo MM, Gaudier G, Pickhardt PJ, Wessell DE (2017) Variation in attenuation in L1 trabecular bone at different tube voltages: caution is warranted when screening for osteoporosis with the use of opportunistic CT. AJR Am J Roentgenol 208:165–170
Balci A, Kalemci O, Kaya FG, Akyoldas G, Yucesoy K, Ozaksoy D (2016) Early and long-term changes in adjacent vertebral body bone mineral density determined by quantitative computed tomography after posterolateral fusion with transpedicular screw fixation. Clin Neurol Neurosurg 145:84–88
Kerezoudis P, Rinaldo L, Alvi MA, Hunt CL, Qu W, Maus TP, Bydon M (2018) The effect of epidural steroid injections on bone mineral density and vertebral fracture risk: a systematic review and critical appraisal of current literature. Pain Med 19:569–579
Liu Y, Carrino JA, Dash AS, Chukir T, Do H, Bockman RS, Hughes AP, Press JM, Stein EM (2018) Lower spine volumetric bone density in patients with a history of epidural steroid injections. J Clin Endocrinol Metab
Nah SY, Lee JH, Lee JH (2018) Effects of epidural steroid injections on bone mineral density and bone turnover markers in patients taking anti-osteoporotic medications. Pain Phys 21:E435–E447
Marshall LM, Zmuda JM, Chan BK, Barrett-Connor E, Cauley JA, Ensrud KE, Lang TF, Orwoll ES, Osteoporotic Fractures in Men Research G (2008) Race and ethnic variation in proximal femur structure and BMD among older men. J Bone Miner Res 23:121–130
Cauley JA (2011) Defining ethnic and racial differences in osteoporosis and fragility fractures. Clin Orthop Relat Res 469:1891–1899
Ferguson JF, Patel PN, Shah RY et al (2013) Race and gender variation in response to evoked inflammation. J Transl Med 11:63
Takahashi J, Ebara S, Kamimura M, Kinoshita T, Misawa H, Shimogata M, Tozuka M, Takaoka K (2002) Pro-inflammatory and anti-inflammatory cytokine increases after spinal instrumentation surgery. J Spinal Disord Tech 15:294–300
Starkweather AR, Witek-Janusek L, Nockels RP, Peterson J, Mathews HL (2008) The multiple benefits of minimally invasive spinal surgery: results comparing transforaminal lumbar interbody fusion and posterior lumbar fusion. J Neurosci Nurs 40:32–39
Wu DH, Hatzopoulos AK (2019) Bone morphogenetic protein signaling in inflammation. Exp Biol Med 244:147–156
Acknowledgments
We would like to thank J. Waldman, Hospital for Special Surgery; J.K. Brown and A. Chason, Mindways Software, for their technical support.
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This study was approved by the Institutional Review Board at the Hospital for Special Surgery (IRB no. 2016-0751). The informed consent from each patient was waived because of the retrospective nature of this study.
Conflicts of interest
IO, CJ, SNS, COM, TS, CR, and JS declare that they have no conflict of interest.
JAC served as a consultant/scientific advisory board member for Pfizer, Carestream, and Image Analysis Group.
AAS has received ownership interest from Paradigm Spine, LLC., and Spinal Kinetics, Inc., research support from Spinal Kinetics, Inc., and MiMedx Group, Inc., served as a consultant/scientific advisory board member for Clariance Inc., Nuvasive, Inc., Capital Royality, LP., Kuros Biosciences AG, Ortho Development Corp, 4WEB, Inc., Leerink Partners, LLC., and Depuy Orthopaedics, Inc.
FPC has received royalties from Nuvasive, Inc., served as a consultant/scientific advisory board member Vertical Spine, LLC., 4WEB Medical, Healthpoint Capital Partners, LP, Orthobond Corporation, Woven Orthopedic Technologies, received ownership interest from VBVP VI, LLC., received research support from Spinal Kinetics, Inc.; Ivy Healthcare Capital Partners, LLC; ISPH II, LLC; NuVasive, Inc., Mallinckrodt Pharmaceuticals, Centinel Spine, Inc. (fka Raymedica, LLC), Beatrice & Samuel A. Seaver Foundation, 4WEB Medical, Woven Orthopedic Technologies, Depuy Synthes, Orthobond Corporation, Pfizer, Inc., Paradigm Spine, LLC,7D Surgical, Inc. received others from Spinal Kinetics, Inc., Vertical Spine, LLC, Bonovo Orthopedics, Inc., Viscogliosi Brothers, LLC, Liventa Bioscience (fka AF Cell Medical), Woven Orthopedic Technologies, Healthpoint Capital Partners, LP, Paradigm Spine, LLC, Tissue Differentiation Intelligence, LLC.
FPG has received royalties from Lanx/Zimmer Biomet Spine, Depuy Synthes Spine, Nuvasive, Inc., Ortho Development Corp., ownership interest from Healthpoint Capital Partners, Paradigm Spine, LLC, Centinel Spine, Inc., and Liventa BioSciences, Inc., grant from Nuvasive, Inc., and MiMedx Group, Inc., outside of this work and served as a consultant for Ortho Development Corp, Nuvasive, Inc., Depuy Synthes Spine, and Lanx/Zimmer Biomet Spine.
APH has received research support from Pfizer, Inc., grants from Nuvasive, Inc., and 4WEB Medical.
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Okano, I., Jones, C., Salzmann, S.N. et al. Postoperative decrease of regional volumetric bone mineral density measured by quantitative computed tomography after lumbar fusion surgery in adjacent vertebrae. Osteoporos Int 31, 1163–1171 (2020). https://doi.org/10.1007/s00198-020-05367-3
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DOI: https://doi.org/10.1007/s00198-020-05367-3