Investigators have found that nearly half of about 300 patients planning to undergo spinal fusion surgery for pain were newly diagnosed with osteoporosis or osteopenia.1

Metabolic bone disease affects around 200 million people across the world and has a high prevalence in the United States among adults 50 years of age and older. In their study, using criteria from the American College of Radiology, investigators found that 43.6% of spine fusion patients were diagnosed with osteopenia and 14.9% had osteoporosis.

The osteoporosis/osteopenia diagnoses occurred even in patients who had undergone dual-energy X-ray absorptiometry (DXA) bone density scans that did not reveal such findings. This suggests that the osteoporosis incidence is higher than previously known, according to Alexander Hughes, MD, orthopedic surgeon with the Hospital for Special Surgery in New York City. Hughes was the study’s senior investigator.

“I was not surprised that the incidence of patients with metabolic bone deficiency is higher than the previously understood rates,” Hughes says. “In men, we have not typically focused on diagnosing bone deficiency because insufficiency fractures impact females at a higher rate.”

What physicians should keep in mind is that poor bone density and quality in men can lead to perioperative complications, the same as for women. “Therefore, it’s important to understand this aspect of a patient’s health before embarking upon spinal surgery,” Hughes says.

The study results suggest that surgeons should routinely scan spine fusion patients older than age 50 years for osteoporosis. “We feel it is helpful to have bone densities performed on all patients undergoing spinal fusion surgery,” Hughes says. “Quantitative computed tomography (QCT) is readily derived from standard pre-op CT scans. Therefore, in this context, it is not an additional procedure or study.”

Surgeons need this information to reduce risk to spine fusion patients. “Osteoporosis or bone health deficiencies can be effectively managed and safely navigated if spine surgeons are aware of the underlying condition,” Hughes says. “There are many perioperative medications available and new surgery technologies that improve outcomes in this setting.”

When metabolic bone deficiency is unrecognized, it can lead to intraoperative or postoperative fractures, Hughes warns.

“Furthermore, healing of the bones can fail to take place after surgery,” he adds.

The Hospital for Special Surgery uses QCT routinely and is solely replacing DXA scans as a more reliable measure of bone density. “We are moving toward using QCT on all preoperative patients undergoing spinal fusion surgery,” Hughes says.

The study’s findings are novel because the majority of prior orthopedic literature on osteoporosis prevalence is based on DXA data and femoral neck measurements rather than lumbar spine QCT.

“The takeaway is that through continued research into the underlying global health of patients, we are maximizing outcomes following spinal surgery,” Hughes says.


  1. Carlson B, Salzmann SN, Shirahata T, et al. Prevalence of osteopenia and osteoporosis diagnosed by quantitative computed tomography in 296 consecutive lumbar fusion patients. Presented at the American Academy of Orthopaedic Surgeons Annual Meeting, March 12, 2019, Las Vegas.