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      Skeletal Status in Patients Scheduled for Elective Lumbar Spine Surgery: Comparison of Discectomy, Decompression, Fusion, and Revision

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          Abstract

          Study Design

          Retrospective Cohort Study

          Objectives

          To investigate and compare the prevalence of low bone mineral density (BMD) and abnormal laboratory bone metabolism parameters in patients undergoing elective primary discectomy, decompression, and fusion and to outline possible differences in these parameters between patients undergoing revision for skeletal vs non-skeletal complications.

          Methods

          We retrospectively evaluated BMD measurements by dual-energy x-ray absorptiometry (DXA) in 389 consecutive patients scheduled for elective lumbar spine surgery. Next to demographic characteristics, laboratory bone metabolism parameters were assessed. Group comparisons were performed between primary discectomy, decompression, and fusion. In patients scheduled for revision surgery after fusion, potential differences in the skeletal status between those with skeletal vs non-skeletal complications were analyzed.

          Results

          Osteoporosis by T-score was detected in 6.7%, 11.0% and 14.7% of the patients undergoing discectomy, decompression and fusion, respectively. While vitamin D deficiency (67.6%) and hyperparathyroidism (16.4%) were frequently detected, no differences in laboratory bone metabolism markers could be found between the groups. Female sex (P<.001), higher age (P=.01) and lower BMI (P<.001) were associated with lower BMD. In the cohort of patients undergoing revision surgery due to complications after fusion, those with skeletal complications did not differ in BMD or bone metabolism from those with non-skeletal complications.

          Conclusions

          Osteoporosis represents a relevant comorbidity in patients scheduled for elective spine surgery, which is why DXA should be routinely performed in these patients. However, DXA may provide limited information in identifying patients at increased risk for skeletal complications after fusion.

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          Most cited references35

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          Epidemiology and outcomes of osteoporotic fractures.

          Steven R Cummings, L. Joseph Melton (2002)
          Bone mass declines and the risk of fractures increases as people age, especially as women pass through the menopause. Hip fractures, the most serious outcome of osteoporosis, are becoming more frequent than before because the world's population is ageing and because the frequency of hip fractures is increasing by 1-3% per year in most areas of the world. Rates of hip fracture vary more widely from region to region than does the prevalence of vertebral fractures. Low bone density and previous fractures are risk factors for almost all types of fracture, but each type of fracture also has its own unique risk factors. Prevention of fractures with drugs could potentially be as expensive as medical treatment of fractures. Therefore, epidemiological research should be done and used to identify individuals at high-risk of disabling fractures, thereby allowing careful allocation of expensive treatments to individuals most in need.
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            Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures.

            D. Marshall, O. Johnell, H. Wedel (1996)
            To determine the ability of measurements of bone density in women to predict later fractures. Meta-analysis of prospective cohort studies published between 1985 and end of 1994 with a baseline measurement of bone density in women and subsequent follow up for fractures. For comparative purposes, we also reviewed case control studies of hip fractures published between 1990 and 1994. Eleven separate study populations with about 90,000 person years of observation time and over 2000 fractures. Relative risk of fracture for a decrease in bone mineral density of one standard deviation below age adjusted mean. All measuring sites had similar predictive abilities (relative risk 1.5 (95% confidence interval 1.4 to 1.6)) for decrease in bone mineral density except for measurement at spine for predicting vertebral fractures (relative risk 2.3 (1.9 to 2.8)) and measurement at hip for hip fractures (2.6 (2.0 to 3.5)). These results are in accordance with results of case-control studies. Predictive ability of decrease in bone mass was roughly similar to (or, for hip or spine measurements, better than) that of a 1 SD increase in blood pressure for stroke and better than a 1 SD increase in serum cholesterol concentration for cardiovascular disease. Measurements of bone mineral density can predict fracture risk but cannot identify individuals who will have a fracture. We do not recommend a programme of screening menopausal women for osteoporosis by measuring bone density.
            Article 0 comments Cited 279 times – based on 0 reviews     Review now
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              Surgical versus nonsurgical therapy for lumbar spinal stenosis.

              James N Weinstein, Tor Tosteson, Jon Lurie … (2008)
              Surgery for spinal stenosis is widely performed, but its effectiveness as compared with nonsurgical treatment has not been shown in controlled trials. Surgical candidates with a history of at least 12 weeks of symptoms and spinal stenosis without spondylolisthesis (as confirmed on imaging) were enrolled in either a randomized cohort or an observational cohort at 13 U.S. spine clinics. Treatment was decompressive surgery or usual nonsurgical care. The primary outcomes were measures of bodily pain and physical function on the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and 1 and 2 years. A total of 289 patients were enrolled in the randomized cohort, and 365 patients were enrolled in the observational cohort. At 2 years, 67% of patients who were randomly assigned to surgery had undergone surgery, whereas 43% of those who were randomly assigned to receive nonsurgical care had also undergone surgery. Despite the high level of nonadherence, the intention-to-treat analysis of the randomized cohort showed a significant treatment effect favoring surgery on the SF-36 scale for bodily pain, with a mean difference in change from baseline of 7.8 (95% confidence interval, 1.5 to 14.1); however, there was no significant difference in scores on physical function or on the Oswestry Disability Index. The as-treated analysis, which combined both cohorts and was adjusted for potential confounders, showed a significant advantage for surgery by 3 months for all primary outcomes; these changes remained significant at 2 years. In the combined as-treated analysis, patients who underwent surgery showed significantly more improvement in all primary outcomes than did patients who were treated nonsurgically. (ClinicalTrials.gov number, NCT00000411 [ClinicalTrials.gov].). Copyright 2008 Massachusetts Medical Society.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Global Spine J
                Journal ID (iso-abbrev): Global Spine J
                Journal ID (hwp): spgsj
                Journal ID (publisher-id): GSJ
                Title: Global Spine Journal
                Publisher: SAGE Publications (Sage CA: Los Angeles, CA )
                ISSN (Print): 2192-5682
                ISSN (Electronic): 2192-5690
                Publication date (Electronic): 23 May 2022
                Publication date (Print): March 2024
                Volume: 14
                Issue: 2
                Pages: 380-389
                Affiliations
                [1 ]Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, Ringgold 37734, universityUniversity Medical Center Hamburg-Eppendorf; , Germany
                [2 ]Department of Spine Surgery, Ringgold 219529, universityKlinikum Bad Bramstedt; , Germany
                Author notes
                [*]Christian Schaefer, MD, Department of Spine Surgery, Klinikum Bad Bramstedt, Bad Bramstedt, Germany. Email: c.schaefer@ 123456klinikumbb.de
                [*]and Tim Rolvien, MD, PhD, Department of Trauma and Orthopaedic Surgery, Division of Orthopeadics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany. Email: t.rolvien@ 123456uke.de
                [†]

                Contributed equally

                Author information
                https://orcid.org/0000-0003-1058-1307
                Article
                Publisher ID: 10.1177_21925682221105005
                DOI: 10.1177/21925682221105005
                PMC ID: 10802513
                PubMed ID: 35604317
                SO-VID: 26d35448-2bd2-4982-868b-0043c3ea5ae3
                Copyright © © The Author(s) 2022
                License:

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License ( https://creativecommons.org/licenses/by-nc-nd/4.0/) which permits non-commercial use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

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                Subject: Original Articles
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                Keywords: dual-energy x-ray absorptiometry,spine surgery,revision,osteoporosis,vitamin d
                Data availability:
                Keywords: dual-energy x-ray absorptiometry, spine surgery, revision, osteoporosis, vitamin d

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