Use of teriparatide prior to lumbar fusion surgery lowers two-year complications for patients with poor bone health

doi:10.1016/j.clineuro.2020.106244

Clinical Neurology and Neurosurgery

Volume 198, November 2020, 106244

https://doi.org/10.1016/j.clineuro.2020.106244 Get rights and content

Highlights

•
Poor bone health creates challenges in management of patients undergoing spine fusion.
•
Patients with poor bone health undergoing any lumbar fusion surgery at a single institution were identified.
•
No statistically significant differences in terms of individual complications.
•
Teriparatide use was significantly associated with lower rates of any 2-year complications.

Abstract

Introduction

Poor bone health can create challenges in management which are amplified for patients undergoing spinal fusion. Although previously shown to improve outcomes postoperatively, the impact of preoperative teriparatide use on long-term complications remains unclear. In this study, we investigated the complication rates within two years of surgery for osteoporotic and osteopenic patients using teriparatide prior to lumbar fusion procedures.

Methods

Patients with poor bone health undergoing any lumbar fusion surgery at a single institution between 2008 and 2018 were identified and subsequently divided into two groups as teriparatide and non-teriparatide group. Baseline demographics, patient and surgery related factors, and two-year complications were collected through a retrospective chart review. Multivariable logistic regression was performed to evaluate the association between teriparatide usage and development of any related postoperative complication.

Results

A total of 42 and 114 patients were identified for the teriparatide and non-teriparatide groups, respectively. The median age (IQR) for the teriparatide group was 62 years (55.8−68.8), while the non-teriparatide group had a median (IQR) age of 70 years (64−75.8). Overall, there were no statistically significant differences in terms of individual complications between the groups. However, on adjusted regression analysis, teriparatide use was associated with significantly lower odds of related complications for lumbar fusion patients (p = 0.049).

Conclusion

Teriparatide use prior to lumbar fusion procedures resulted in reduced rate of osteoporosis-related complications within two years postoperatively. Results suggest improved outcomes might be seen in patients with osteopenia and osteoporosis when pre-treating with teriparatide.

Introduction

Osteoporosis and osteopenia are chronic conditions that commonly affect the elderly population [1]. Guidelines currently recommend one time dual-energy X-ray absorptiometry (DXA) scan for bone mineral density (BMD) measurements as a screening tool for bone health for women older than the age of 65 or at 60 with risk factors for osteoporosis, and thousands of patients are diagnosed with osteoporosis annually [2,3]. Similar to osteoporosis, disorders of the vertebral column are highly prevalent in the elderly, a population that frequently present with symptoms due to spinal disorders [4].

Due to the similar profiles for the two conditions, especially in terms of age distribution, there is a considerable chance for a patient with spine pathology to have concurrent osteoporosis or osteopenia [5,6]. This can create challenges in management which are amplified for patients undergoing surgery due to potential risks of hardware failure and pseudarthrosis [7,8].

To address potential risks and improve outcomes, different pharmacologic interventions have been used to augment the healing process and prevent osteoporosis-related complications. Bisphosphonates are a commonly used medication for the treatment of osteoporosis, and their effects on spinal fusion have been assessed previously, with conflicting results [[9], [10], [11]]. On the other hand, studies investigating teriparatide, a parathyroid hormone (PTH) analog, have shown promising results in both animal models and clinical investigations [[12], [13], [14]]. As a relatively new treatment modality, the optimal timing of teriparatide use and its effect on long-term complications remain unclear.

Therefore, the objective of this study was to compare the two-year complication rates for patients who have poor bone health, with or without teriparatide pretreatment before lumbar fusion procedures.

Section snippets

Cohort selection

Following Institutional Review Board approval (IRB no: 15-006838), we obtained a list of all patients undergoing any lumbar fusion surgery at our institution between 2008 and 2018. Patients were further screened for a diagnosis of osteoporosis or osteopenia prior to lumbar fusion, defined by presence of any fragility fracture or World Health Organization (WHO) definitions for abnormal BMD measurements (lowest t-score ≤ −1.0 for osteopenia and lowest t-score ≤ −2.5 for osteoporosis) [2,3]. A

Baseline characteristics

A total of 42 and 114 patients were identified for the teriparatide and non-teriparatide groups, respectively. The median age (IQR) for the teriparatide group was 62 years (55.8−68.8), while the non-teriparatide group had a median (IQR) age of 70 years (64−75.) (p < 0.001). Patients in the teriparatide group were more likely to be on private insurance (n = 25, 59.5 %) or Medicare (n = 17, 40.5 %). In contrast, 62 (58.5 %) of patients in the non-teriparatide group were on Medicare while 44 (41.5

Discussion

Based on a retrospective analysis from a single institution, preoperative teriparatide use reduced complications in patients with poor bone quality when compared with patients who were not started on teriparatide prior to surgery. Although there was a reduction in rates of ASD, screw loosening, pseudoarthrosis, reoperations and 30-day readmissions, this change was not significantly different between two groups. However, significant reduction in any osteoporosis-related postoperative

Conclusion

Teriparatide use prior to lumbar fusion procedures resulted in a reduced rate of individual complications as well as an association with decreased related 2-year complications. Results suggest improved outcomes might be seen in patients with osteopenia and osteoporosis when pre-treating with teriparatide.

Funding

None.

CRediT authorship contribution statement

Yagiz U. Yolcu: Methodology, Conceptualization, Investigation, Resources, Writing - original draft, Writing - review & editing, Visualization. Jad Zreik: Formal analysis, Data curation, Writing - original draft, Writing - review & editing. Mohammed Ali Alvi: Validation, Resources, Writing - review & editing. Nathan R. Wanderman: Validation, Resources, Writing - review & editing. Bayard C. Carlson: Validation, Resources, Writing - review & editing. Ahmad Nassr: Supervision, Visualization,

Declaration of Competing Interest

The authors report no declarations of interest.

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View full text

Use of teriparatide prior to lumbar fusion surgery lowers two-year complications for patients with poor bone health

Highlights

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Cohort selection

Baseline characteristics

Discussion

Conclusion

Funding

CRediT authorship contribution statement

Declaration of Competing Interest

Radiologia

World Neurosurg.

Spine Deform.

Spine J.

Spine J.

Spine J.

Management of O. Prevention and Management of Osteoporosis: Report of a WHO Scientific Group

Clinician’s guide to prevention and treatment of osteoporosis

Osteoporosis Int.

Assessment of fracture risk and its application to screening for postmenopausal osteoporosis

Ann. Saudi Med.

Prevalence of osteoporosis in patients undergoing lumbar fusion for lumbar degenerative diseases: a combination of DXA and hounsfield units

Spine (Phila Pa 1976)

Clinical and radiological comparison of 2 level anterior lumbar interbody fusion with posterolateral fusion and percutaneous pedicle screw in elderly patients with osteoporosis

Medicine (Baltimore)

Incidence of osteoporosis-related complications following posterior lumbar fusion

Global Spine J.

An association can be found between hounsfield units and success of lumbar spine fusion

HSS J.

Does alendronate disturb the healing process of posterior lumbar interbody fusion? A prospective randomized trial

J. Neurosurg. Spine

Effect of zoledronic acid in an L6-L7 rabbit spine fusion model

Eur. Spine J.