Department of Orthopedics, University of Louisville, Pediatric Orthopedics, Norton Children's Hospital, Norton Leatherman Spine Center, Louisville, Kentucky, USA.
Clinical Neurosciences Center, University of Utah Health, Salt Lake City, Utah, USA.
Neurosurgery. 2021 Oct 13;89(Suppl 1):S19-S25. doi: 10.1093/neuros/nyab317.
Osteoporosis is a metabolic bone disease that commonly affects the elderly. Degenerative spinal disease that may require surgical intervention is also prevalent in this susceptible population. If undiagnosed or untreated before spine surgery, osteoporosis may result in an increased risk of postoperative adverse events. Nontreatment of osteoporosis preoperatively may be related to a poor understanding of bone physiology, a lack of standardized treatment algorithms, limited cost-effective interventions, and reluctance by spine surgeons to be the primary provider of osteoporosis management.
The objective of this evidence-based review is to develop guidelines for the preoperative assessment and treatment of osteoporosis in patients undergoing spine surgery.
A systematic review of the literature was performed using the National Library of Medicine/PubMed database and Embase for studies relevant to preoperative diagnostic studies that predict increased risk of osteoporosis-related postoperative adverse events and whether the preoperative treatment of low bone mineral density (BMD) in patients with osteoporosis improves outcome.
Out of 281 studies, 17 met the inclusion criteria and were included for systematic review. The task force affirmed a Grade B recommendation that preoperative osteoporosis testing with a dual-energy X-ray absorptiometry scan (T-score < -2.5), a computed tomography scan (Hounsfield units <97.9), and serum vitamin D3 level (<20 ng/mL) predict an increased risk of osteoporosis-related adverse events after spine surgery. The task force determined a Grade B recommendation that preoperative osteoporosis treatment with teriparatide increases BMD, induces earlier and more robust fusion, and may improve select patient outcomes. There is insufficient evidence regarding preoperative treatment with bisphosphonates alone and postoperative outcome.
This evidence-based clinical guideline provides a recommendation that patients with suspected osteoporosis undergo preoperative assessment and be appropriately counseled about the risk of postoperative adverse events if osteoporosis is confirmed. In addition, preoperative optimization of BMD with select treatments improves certain patient outcomes.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/3-preoperative-osteoporosis-assessment.
骨质疏松症是一种常见于老年人的代谢性骨病。在这个易患人群中，也普遍存在需要手术干预的退行性脊柱疾病。如果在脊柱手术前未被诊断或未得到治疗，骨质疏松症可能会增加术后不良事件的风险。术前不治疗骨质疏松症可能与对骨生理学的理解不足、缺乏标准化的治疗算法、有限的经济有效的干预措施以及脊柱外科医生不愿意成为骨质疏松症管理的主要提供者有关。
本循证综述的目的是为脊柱手术患者制定术前评估和骨质疏松症治疗指南。
使用美国国立医学图书馆/PubMed 数据库和 Embase 对文献进行系统回顾，以确定与预测与骨质疏松症相关的术后不良事件风险增加的术前诊断研究以及术前治疗骨质疏松症患者的低骨密度（BMD）是否改善预后相关的研究。
在 281 项研究中，有 17 项符合纳入标准并进行了系统评价。专家组肯定了 B 级推荐，即使用双能 X 射线吸收仪扫描（T 评分< -2.5）、计算机断层扫描（Hounsfield 单位<97.9）和血清维生素 D3 水平（<20 ng/mL）进行术前骨质疏松症检测，可预测脊柱手术后与骨质疏松症相关的不良事件风险增加。专家组确定了 B 级推荐，即使用特立帕肽进行术前骨质疏松症治疗可增加 BMD、更早且更稳健地融合，并可能改善某些患者的预后。关于单独使用双膦酸盐进行术前治疗和术后结局的证据不足。
本循证临床指南建议对疑似骨质疏松症的患者进行术前评估，如果确诊骨质疏松症，应适当告知其术后不良事件的风险。此外，选择治疗方法优化 BMD 可改善某些患者的预后。完整的指南可在 https://www.cns.org/guidelines/browse-guidelines-detail/3-preoperative-osteoporosis-assessment 上获取。
