Managing the Patient with Osteoporosis Undergoing Spinal Surgery

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1 11/4/16 DISCLOSURES Managing the Patient with Osteoporosis Undergoing Spinal Surgery MEDTRONIC LILLY MISONIX SHANE BURCH MD, MS, FRCSC Associate Professor in Residence UCSF Department of Orthopedic Surgery OVERVIEW LIFE IS A KYPHOSING EVENT

2 OSTEOPOROSIS OSTEOPOROSIS Described by the French pathologist Jean Georges Chretien Frederic Martin Lobstein the Younger ( ) Greek words osteo (bone) and poros (little hole), referring to the cavities which were observed by the pathologist in certain patients' bones a systemic disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture Osteoporosis can be defined clinically by either: WHO - Low bone mineral density (BMD g/cm2) T-score of -2.5) A history of fragility fracture Fragility fracture is frequently described as a fracture occurring as the result of minimal trauma or a fall from standing height or less D. Schapira, C. Schapira Osteoporosis: the evolution of a scientific term Osteoporos Int, 2 (1992), pp NOT JUST BMD Lumbar Vertebral Strength vs. Age O.N. Diagnostics, Berkeley, CA 2

3 BONE STRENGTH BONE STRENGTH BMD Morphology Mineralization Volume Architecture Turn-over rate EULERS PRINCIPLE VERTEBRAL COMPRESSION FRACTURES 16X STRONGER 3

4 PREVALENCE OSTEOPOROSIS IN MEN fractures occur 5 10 years later than women men aged 50 years, the lifetime risk of any osteoporotic fracture located in the hip, the spine or the distal forearm has been estimated at 13 % compared with 40 % in Females prevalence of vertebral fractures in men ranges from 29 % in the sixth decade to 39 % in the ninth decade low testosterone / decreasing plasma estradiol levels BURDEN IMPACT OF VCFS 2 million fractures occur each year as a result of osteoporosis or osteopenia, including 300,000 hip fractures, 547,000 vertebral fractures 135,000 pelvic fractures. Postmenopausal white women have a 40% lifetime risk of at least one osteoporotic fracture cost: $19,000,000,000 (2005) Impaired gait, poor balance Disability, reduced quality of life Reduced lung function Early satiety, gastric distress Future facture risk Excess mortality Mortality following a VCF: RR=8.64 Consequences are independent of acute fracture pain Cauley, J. A., D. E. Thompson, et al. (2000). "Risk of mortality following clinical fractures." Osteoporos Int 11(7):

5 UNDERTREATMENT ETIOLOGY Substantial undertreatment among women diagnosed with osteoporosis in a US managed care population: a retrospective analysis." Siris, E. S., A. Modi, et al. " Curr Med Res Opin. 65,344 patients, mean age 65.7 year: dx - osteoporosis 42,033 patients (64.3%) received no OP medication Estrogen deficiency Osteoblasts proliferate Increase in RANKL Proliferation of osteoclasts Increase in bone turnover 23,311 patients (35.7%) received OP treatment I have an enormous favor to ask you CELL SIGNALLING SECONDARY OSTEOPOROSIS Hyperparathyroidism Chronic glucocorticoid use (>3mo) Alcohol abuse (>3 / day) Diabetes (type I and II) Hypogonadism - men Ovarian failure Smoking Low Ca intake Immobilization 5

6 TRENDS IN SPINE SURGERY FOR THE ELDERLY increasing trend to perform surgery in the elderly Weinstein, J. N., J. D. Lurie, et al. (2006). "United States' trends and regional variations in lumbar spine surgery: " Spine (Phila Pa 1976) 31(23): Deyo, R. A. and S. K. Mirza (2006). "Trends and variations in the use of spine surgery." Clin Orthop Relat Res 443: INTERSECTION OF DISEASE PREVALENCE OF SCOLIOSIS osteoporosis spinal disorders adult degenerative scoliosis / kyphosis up to 65% in adult volunteers less prevalent in other studies Surgical candidates Schwab, F., A. Dubey, et al. (2005). "Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population." Spine (Phila Pa 1976) 30(9):

7 11/4/16 OSTEOPOROSIS 7

8 PREVALENCE OF OSTEOPOROSIS IN SPINE PATIENTS 1300 cases reviewed over age 50 very common 15% males (46% with osteopenia) vs 50% female Chin, D. K., J. Y. Park, et al. (2007). "Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease." Osteoporos Int 18(9): CT BASED STRENGTH ASSESSMENT Use Finite Element Analysis to Virtually Load to Failure AGE FRACTURE RISK ASSESSMENT HISTORY OF: Smoking Prior Fracture Family Hx ETOH Corticosteroid use colored by local stiffness (red high; blue low) BMD BONE TURNOVER Wang JBMR

9 PRIOR FRACTURE INCREASES FUTURE FRACTURE RISK PRIOR FRACTURE INCREASES RISK Lindsay 2001 analyzed VCF risk within one year in patients with 0, 1 or 2 or more prior VCFs. (JAMA 2001) Lindsay 2005 used the same patient cohort to analyze VCF risk within one year in patients with 0, 1, 2, 3, 4, 5, 6, 7, or 8 prior VCFs. (Osteoporos Int 2005) Lindsay Jama 2001 FRACTURE DEFORMITY AND RISK Increasing fracture risk with increasing deformity DEXA - BMD QCT - BMD BONE ASSESSMENT CT-FEA BMD + strength Bone Volume BV/TV Bone Formation: PINP Bone Resoption: CTX Black J Bone Min Res

10 SURGICAL PERSPECTIVE CHANGING BIOLOGY bone strength screw pull out 500,00 bone graft procedures performed in US /yr adjacent fractures fusion potential MSCs + vascular supply failure to fuse - pseudarthrosis Caplan, A. I. (2007), Adult mesenchymal stem cells for tissue engineering versus regenerative medicine. Journal of Cellular Physiology, 213: doi: /jcp

11 SYSTEMIC TREATMENT Anti-Resorptive Anabolic Bone Forming Well we removed the growth, but the operation left you paralyzed from the neck down CALCIUM / VIT D BISPHOSPHONATES inhibition of farnesyl pyrophosphate synthase interferes with isoprenylation of small guanosine triphosphatases at ruffled border National Osteoporosis Foundation Clinician s guide to prevention and treatment of osteoporosis National Osteoporosis Foundation, Washington, DC (2014) disrupts attachment and promotes early apoptosis 11

12 Treatment with 10 mg of alendronate daily for 10 years produced mean increases in bone mineral density of 13.7 percent at the lumbar spine (95 percent confidence interval, 12.0 to 15.5 percent), 10.3 percent at the trochanter (95 percent confidence interval, 8.1 to 12.4 percent), 5.4 percent at the femoral neck (95 percent confidence interval, 3.5 to 7.4 percent), and 6.7 percent at the total proximal femur (95 percent confidence interval, 4.4 to 9.1 percent) as compared with base-line values Cohen, A., E. M. Stein, et al. "Teriparatide for idiopathic osteoporosis in premenopausal women: a pilot study." J Clin Endocrinol Metab 98(5): BMD increased at the spine (10.8 +/- 8.3% [SD]), 71% increase in trabecular bone stiffness 12

13 ANTI-SCLEROSTINS Glycoprotein secreted by osteocytes Inhibits the wnt pathway Increases RANK-L Inhibits bone formation McClung, M. R., A. Grauer, S. Boonen, M. A. Bolognese, J. P. Brown, A. Diez-Perez, B. L. Langdahl, J. Y. Reginster, J. R. Zanchetta, S. M. Wasserman, L. Katz, J. Maddox, Y. C. Yang, C. Libanati and H. G. Bone (2014). "Romosozumab in postmenopausal women with low bone mineral density." N Engl J Med 370(5): overall initial mean graft volume was 6251 mm3 decreased to 2842 mm3 by 18 months after surgery (P < 0.001) more than one half of the initial graft bone volume was being absorbed during the consolidation processes of the graft bone 13

14 Spine (Phila Pa 1976) Apr 15;38(8):

15 Alendronate vs. Vit D N=40 randomized; osteoporosis; PEEK + TCP + autograft 95% alendronate vs 65% Vit D fusion rate

16 11/4/16 Animal studies show that bisphosphonates impede fusion maturation Unclear effect on mechanical strength Not demonstrated in one human paper INTRA-OP CONSIDERATIONS maximize pull-out strength of pedicle screws - optimal trajectory (fit and fill pedicle) augment UIV+1 (increases stiffness - prevents creep) augment UIV - increases pull out strength of prox screws maintain posterior ligamentous structure intact - prevent lig failure multiple osteotomies to generate a harmonious and balanced curve across the TL junction (dont end in kyphosis) bilateral S2-alar-iliac bolts optimal choice of bonegraft / bonegraft substitute 16

17 STIFFNESS J Korean Neurosurg Soc November; 52(5): FORTEO SPINE FUSION STUDY SUMMARY UCSF FDA trial: assessment of the use of FORTEO in patients undergoing spinal fusion greater than two levels intermittent dose of PTH promotes osteoblasts over osteoclasts double blind randomized controlled trial >65; 2 or more levels; posterolateral fusion - Ct scan at 1 year n=90; 20ug vs placebo daily injection Osteoporosis is a pandemic Not all about BMD Systemic therapy we should be part of the choice admin 2 weeks prior to fusion, 8 weeks after fusion 17

18 THANK YOU Thank You 18

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