From the 1Department of Orthopaedics at the Hospital for Special Surgery in New York City, New York, and 2Weill Cornell Medical College in New York City, New York.
BONE HEALTH
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The Role of Preoperative Bone Optimization in Spine Surgery Osteoporosis and low bone mineral density (BMD) are among the most consequential and most frequently overlooked risk factors in elective spine surgery. Based on published literature, approximately one-third to one-half of patients presenting for instrumented spine procedures meet criteria for osteoporosis or osteopenia, and the majority are unaware of the diagnosis at the time of surgical consultation.1,2 Compromised bone quality drives the mechanical complications that most often necessitate a return to the operating room: cage subsidence, pedicle screw loosening and pullout, pseudarthrosis, adjacent-level fracture, and proximal junctional kyphosis or failure (PJK/PJF) in long constructs.2,3 As the surgical population ages and indications broaden, the costs associated with treating these complications—affecting both patients and healthcare systems—are significant and largely preventable. Therefore, preoperative bone health optimization (BHO) is increasingly being accepted as a standard of care rather than just an optional measure.4
How to Identify Patients at Risk Impaired bone quality is common in elective spine patients, with most having osteoporosis or osteopenia detected through preoperative screening. Guidance from societies—including the American Academy of Orthopaedic Surgeons, the North American Spine Society,
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Atahan Durbas, MD and the American Orthopaedic Association’s “Own the Bone” program—recommends screening all women aged ≥65 years, men aged ≥70 years, postmenopausal women younger t han 65 years and men aged 50–70 Sheeraz A. Qureshi, MD, MBA2 years with risk factors, and any adult with a fragility fracture, prolonged glucocorticoid use, >1.5 inches height loss, hyperparathyroidism, chronic kidney disease, malabsorption, or heav y smoking/alcohol use. 2,5 However, in the clinic, many patients were identified using simple criteria like history of fragility fracture, height loss, glucocorticoid use, or FRAX score.1,6 In adult spinal deformity, low BMD is independently associated with higher rates of mechanical failure and revision.7 A recent meta-analysis in degenerative cervical surgery similarly linked osteoporosis to reduced fusion rates and increased complications.8 In short, patients with poor bone quality have worse outcomes, and most can be identified before reaching the operating room. 1
Assessment Tools Dual-energy X-ray absorptiometry (DEXA), opportunistic computed tomography (CT), and magnetic resonance imaging (MRI) vertebral bone quality (VBQ) score can all be
Vertebral Columns Summer 2026