Introduction 

Osteoporosis affects 200 million people globally and is linked to complications like screw loosening, vertebral fractures, and pseudarthrosis in spinal surgery.  Despite increased life expectancy, only 44% of surgeons screen for osteoporosis pre-surgery, and just 40% of diagnosed patients receive treatment. Effective perioperative planning, including pharmacological management, is crucial for better outcomes. 

Aim

To evaluate the use of teriparatide and denosumab in planning spinal surgery in an osteoporotic patient with degenerative pathology, emphasizing the fusion rate, bone mineral density, and decreased complications.

Patient Profile

Patients with osteoporosis taken to spinal surgery.

Methods

• 14 comparative studies of teriparatide and denosumab in patients with osteoporosis undergone spinal surgery meta-analyses were selected
• The primary and secondary endpoints of the study were
• Primary Endpoint:
  1. Fusion Rate: effectiveness of teriparatide and denosumab in improving the fusion rate in spinal surgery 
• Secondary Endpoints:
• Screw Loosening Rate: Assessing the reduction in screw loosening with the use of teriparatide and denosumab.
• Bone Mineral Density (BMD): Evaluating the increase in BMD with pharmacological management. 
• Vertebral Fracture Rate: Measuring the decrease in the incidence of vertebral fractures in osteoporotic patients undergoing spinal surgery. 

Results 

Teriparatide showed a fusion rate of 79.28% within the first six months, significantly higher than bisphosphonates and placebo.  It also demonstrated faster fusion compared to bisphosphonates.

Figure 1: Spinal Fusion Rate at 6 Months 

Figure 2 : Screw Loosening Rate at 12 Months

Table 1: Spinal fusion rate outcomes with teriparatide at six months

		Column Fusion Rate		Total
		Appropriate Fusion	Non-union
Use of Teriparatide	Patients taking teriparatide	88	23	111
	Control: Patients who didn’t take teriparatide	55	75	130
	Total	143	98	241

Screw Loosening: Teriparatide reduced screw loosening rates by 81.9% (0.6%) at 12 months compared to bisphosphonates and placebo.

Table 2. Association of teriparatide and screw loosening rate at 12 months

		Loosening rate of columnbolts		Total
		With loosening	Without loosening
Use of Teriparatide	Patients who took teriparatide.	21	95	116
	Control: Patients who didn’t take teriparatide	45	85	130
	Total	66	180	246

 

Bone Mineral Density (BMD): Teriparatide increased BMD by 15.5%, which was 4.5% higher than bisphosphonates.

Vertebral Fractures: Teriparatide decreased the rate of vertebral fractures by 85.4% in patients over 75 years old, showing a significant reduction compared to bisphosphonates.  

Table 3: Association of teriparatide and decreased vertebral fractures compared to bisphosphonates in patients older than 75.

	Teriparatide group	Bisphosphonate group
With fracture (n)	8	17
No fracture (n)	47	30
Total fracture (n)	55	47
Fracture rate (%)	14.5	36.17

 

Denosumab: While clinical studies on denosumab in spinal surgery are limited, it demonstrated a synergistic effect with teriparatide, improving bone microarchitecture and increasing BMD more effectively than monotherapy.

Conclusion

Teriparatide and denosumab should be considered in perioperative spinal planning because of their proven efficacy, synergistic effects, and favorable safety profile. Their use can enhance bone mineral density and reduce complication rates.

Reference 

Coluna 2023;22;3:e270489.