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The goal of this study was to compare different recognized definitions of osteoporosis in patients with degenerative lumbar spine pathology undergoing elective spinal fusion surgery to determine which patient population should be considered for preoperative optimization.

A retrospective review of patients in whom lumbar spine surgery was planned at 2 academic medical centers was performed, and the rate of osteoporosis was compared based on different recognized definitions. Assessments were made based on dual-energy x-ray absorptiometry (DXA), CT Hounsfield units (HU), trabecular bone score (TBS), and fracture risk assessment tool (FRAX). The rate of osteoporosis was compared based on different definitions 1) the WHO definition (T-score ≤ -2.5) at total hip or spine; 2) CT HU of < 110; 3) National Bone Health Alliance (NBHA) guidelines; and 4) "expanded spine" criteria, which includes patients meeting NBHA criteria and/or HU < 110, and/or "degraded" TBS in the setting of an osteopenic T-score. Inclusth who could be considered for preoperative optimization, although further study is needed to validate these results in terms of clinical outcomes.
One vexing problem after lateral lumbar interbody fusion (LLIF) surgery is cage subsidence. Low bone mineral density (BMD) may contribute to subsidence, and BMD is correlated with Hounsfield units (HUs) on CT. The authors investigated if lower HU values correlated with subsidence after LLIF.

A retrospective study of patients undergoing single-level LLIF with pedicle screw fixation for degenerative conditions at the University of California, San Francisco, by 6 spine surgeons was performed. Data on demographics, cage parameters, preoperative HUs on CT, and postoperative subsidence were collected. Thirty-six-inch standing radiographs were used to measure segmental lordosis, disc space height, and subsidence; data were collected immediately postoperatively and at 1 year. Subsidence was graded using a published grade of disc height loss grade 0, 0%-24%; grade I, 25%-49%; grade II, 50%-74%; and grade III, 75%-100%. HU values were measured on preoperative CT from L1 to L5, and each lumbar vertebral body HU was al HU value was an independent risk factor for severe cage subsidence (p = 0.017, OR 15.694, 95% CI 1.621-151.961).

Lower HU values on preoperative CT are associated with cage subsidence after LLIF. Measurement of preoperative HU values on CT may be useful when planning LLIF surgery.
Lower HU values on preoperative CT are associated with cage subsidence after LLIF. Measurement of preoperative HU values on CT may be useful when planning LLIF surgery.
The authors aimed to compare the efficacy of lumbar vertebral body Hounsfield units (HUs) and pedicle HUs at predicting pedicle screw loosening.

The authors retrospectively assessed 143 patients with L3-5 instrumentation. The patients were classified into one of two groups based on the status of their L3 screws (a screw loosening group or a control group). The pedicle HUs and vertebral HUs of L3 were measured using preoperative lumbar CT scans, and the pedicle HUs were measured in two ways by excluding or by including cortical bone.

The screw loosening rate was 20.3% (n = 29/143) at the 12-month follow-up. The vertebral body HUs and pedicle HUs in the screw loosening group were lower than those in the control group (vertebral body group 98.6 HUs vs 121.4 HUs, p < 0.001; pedicle excluding cortical bone 208.9 HUs vs 290.5 HUs, p = 0.002; pedicle including cortical bone 249.4 HUs vs 337.5 HUs, p < 0.001). The pedicle HUs tended to have a higher area under the receiver operating characteristic curve value in predicting screw loosening, compared with that of vertebral body HUs, but the difference was not statistically significant (p > 0.05). Among patients with low vertebral body HUs of ≤ 130, the loosening rate was much lower in patients with pedicle HUs of ≤ 340 than in those with pedicle HUs of > 340 (31.0% vs 13.0%, respectively; p < 0.05).

Vertebral body HUs alone are insufficient to accurately evaluate the risk of pedicle screw loosening. Therefore, it is important to collect both the pedicle HU and vertebral body HU measurements for surgical planning.
Vertebral body HUs alone are insufficient to accurately evaluate the risk of pedicle screw loosening. Therefore, it is important to collect both the pedicle HU and vertebral body HU measurements for surgical planning.
Approximately 550,000 Americans experience vertebral fracture annually, and most receive opioids to treat the resulting pain. Kyphoplasty of the fractured vertebra is a procedural alternative that may mitigate risks of even short-term opioid use. While reports of kyphoplasty's impact on pain scores are mixed, no large-scale data exist regarding opioid prescribing before and after the procedure. This study was conducted to determine whether timing of kyphoplasty following vertebral fracture is associated with duration or intensity of opioid prescribing.

This retrospective cohort study used 2001-2014 insurance claims data from a single, large private insurer in the US across multiple care settings. Patients were adults with vertebral fractures who were prescribed opioids and underwent balloon-assisted kyphoplasty within 4 months of fracture. Opioid overdose risk was stratified by prescribed average daily morphine milligram equivalents using CDC guidelines. Filled prescriptions and risk categories were evaluvia operative (kyphoplasty) and nonoperative (ongoing opioid) strategies before concluding that kyphoplasty lacks value, and early referral for kyphoplasty may be appropriate to avoid missing a window of efficacy.
New persistent opioid prescribing occurred in nearly one-third of patients undergoing kyphoplasty after vertebral fracture, although early treatment was associated with a reduction in this risk. For patients not naïve to opioids before fracture diagnosis, early kyphoplasty was associated with less persistent elevation of opioid overdose risk. Selleck SR-18292 Subsequent trials must compare opioid use by vertebral fracture patients treated via operative (kyphoplasty) and nonoperative (ongoing opioid) strategies before concluding that kyphoplasty lacks value, and early referral for kyphoplasty may be appropriate to avoid missing a window of efficacy.
The goal of this study was to compare the clinical and radiological outcomes between fenestrated pedicle screws augmented with cement and expandable pedicle screws in percutaneous vertebral fixation surgical procedures for the treatment of degenerative and traumatic spinal diseases in aging patients with osteoporosis.

This was a prospective, single-center study. Twenty patients each in the expandable and cement-augmented screw groups were recruited. Clinical outcomes included visual analog scale (VAS), Oswestry Disability Index (ODI), and satisfaction rates. link2 Radiographic outcomes comprised radiological measurements on the vertebral motion segment of the treated levels. Intraoperative data including complications were collected. All patients completed the clinical and radiological outcomes. Outcomes were compared preoperatively and postoperatively.

An average shorter operative time was found in procedures in which expandable screws were used versus those in which cement-augmented screws were used (p <out strength of screws placed in osteoporotic spine. In this series, clinical and radiological outcomes were equivalent between the 2 groups. To the authors' knowledge, this is the first report comparing the cement augmentation technique versus expandable screws in the treatment of aging patients with osteoporosis.
Expandable pedicle screws and polymethylmethacrylate augmentation of fenestrated screws are both safe and effective techniques to increase the pullout strength of screws placed in osteoporotic spine. In this series, clinical and radiological outcomes were equivalent between the 2 groups. To the authors' knowledge, this is the first report comparing the cement augmentation technique versus expandable screws in the treatment of aging patients with osteoporosis.
Bisphosphonates are used to increase bone strength in treating osteopenia and osteoporosis, but their use for increasing lumbar fusion rates has been controversial. The objective of this study was to determine if preoperative treatment with bisphosphonates affects the reoperation rates for nonunions (operative nonunion rates) following lumbar fusions in patients with osteopenia or osteoporosis.

The authors conducted a cohort study using data from the Kaiser Permanente Spine Registry. Patients (aged ≥ 50 years) with a diagnosis of osteopenia or osteoporosis who underwent primary elective lumbar fusions for degenerative disc disease, deformity, or spondylolisthesis were included in the cohort. Repeated spinal procedures at the index lumbar levels were noted through chart review. Reoperations for symptomatic nonunions (operative nonunions), time to nonunion, and the nonunion spine level(s) were also identified. The crude 2-year cumulative incidence of operative nonunions was calculated as 1 minus the Kaplan-of the low nonunion frequency. Further studies are warranted to the determine if preoperative and postoperative timing of bisphosphonate use has any effect on lumbar fusion rates.
Pyogenic spondylodiscitis affects a fragile patient population. Surgical treatment in cases of instability entails instrumentation, and loosening of this instrumentation is a frequent occurrence in pyogenic spondylodiscitis. The authors therefore attempted to investigate whether low bone mineral density (BMD)-which is compatible with the diagnosis of osteoporosis-is underdiagnosed in patients with pyogenic spondylodiscitis. How osteoporosis was treated and how it affected implant stability were further analyzed.

Charts of patients who underwent operations for pyogenic spondylodiscitis were retrospectively reviewed for clinical data, prior medical history of osteoporosis, and preoperative CT scans of the thoracolumbar spine. In accordance with a previously validated high-fidelity opportunistic CT assessment, average Hounsfield units (HUs) in vertebral bodies of L1 and L4 were measured. Based on the validation study, the authors opted for a conservative cutoff value for low BMD, being compatible with osteopodiscitis. link3 This is the first study to identify a substantially missed opportunity to detect osteoporosis and to start pharmacological treatment after surgery for prevention of implant failure. The authors advocate for routine opportunistic CT evaluation for a better estimation of bone quality to initiate diagnosis and treatment for osteoporosis in these patients.
Relying on past medical history of osteoporosis is insufficient in the management of patients with pyogenic spondylodiscitis. This is the first study to identify a substantially missed opportunity to detect osteoporosis and to start pharmacological treatment after surgery for prevention of implant failure. The authors advocate for routine opportunistic CT evaluation for a better estimation of bone quality to initiate diagnosis and treatment for osteoporosis in these patients.
Opportunistic Hounsfield unit (HU) determination from CT imaging has been increasingly used to estimate bone mineral density (BMD) in conjunction with assessments from dual energy x-ray absorptiometry (DXA). The authors sought to compare the effect of teriparatide on HUs across different regions in the pelvis, sacrum, and lumbar spine, as a surrogate measure for the effects of teriparatide on lumbosacropelvic instrumentation.

A single-institution retrospective review of patients who had been treated with at least 6 months of teriparatide was performed. All patients had at least baseline DXA as well as pre- and post-teriparatide CT imaging. HUs were measured in the pedicle, lamina, and vertebral body of the lumbar spine, in the sciatic notch, and at the S1 and S2 levels at three different points (ilium, sacral body, and sacral ala).

Forty patients with an average age of 67 years underwent a mean of 20 months of teriparatide therapy. Mean HUs of the lumbar lamina, pedicles, and vertebral body were significantly different from each other before teriparatide treatment 343 ± 114, 219 ± 89.
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