Abstract
Objective To develop consensus-based guidance for bone health optimization in instrumented spine surgery, specifically addressing the limited guidance available in the Thai context.
Methods The study utilized a modified Delphi technique, engaging 10 orthopedic surgeons from Thailand with expertise in complex spine surgery and osteoporosis management. A targeted literature review was conducted, followed by 2 online surveys and a face-to-face consensus meeting to develop and refine the statements. Twenty-five main statements and 45 substatements that focused on patient evaluation, assessment tools, and risk stratification were drafted for the panel’s deliberation.
Results There was unanimous agreement on the necessity of evaluating bone health before instrumented spine surgery in patients aged ≥60 years, while evaluation was considered optional for those aged 50 to 59 years. The panelists supported using the fracture risk assessment tool score for clinical evaluation and recommended using several assessment tools, including dual-energy x-ray absorptiometry scans for specific age groups, Computed Tomography Hounsfield Unit, Trabecular Bone Score, and vertebral fracture assessment for bone health evaluation if available. Treatment recommendations included bone-forming agents as the first-line therapy for patients at high risk and very high risk and specialized surgical techniques for patients at very high risk. Surgical delay of at least 3 months should also be considered for patients at very high risk/with severe osteoporosis who have been scheduled for instrumented spine surgery.
Conclusion This guidance includes patient screening, evaluation, and treatment for patients with poor bone health based on risk stratification, including normal/low risk, osteopenia/intermediate risk, osteoporosis/high risk, and severe osteoporosis/very high risk. Spine surgeons should be aware of poor bone health and consider bone health optimization to improve surgical outcomes and prevent osteoporosis-related complications.
Clinical Relevance Bone health optimization is crucial for instrumented spine surgery. Spine surgeons should consider bone health optimization guidance, including patient screening for poor bone health, assessment tools for evaluating bone health, and treatment for patients with poor bone health, to improve surgical results and minimize poor bone health–related complications.
Level of Evidence 5.
Introduction
The management of bone health in spine surgery patients represents a critical challenge in surgical practice, particularly given the high prevalence of osteoporosis in this population. Fan et al found that 78.7% of spine surgery patients aged 50 years or older are affected by poor bone health, including osteoporosis and osteopenia,1 highlighting a significant clinical concern. The presence of osteoporosis or undiagnosed bone health conditions substantially increases the risk of poor postoperative outcomes and complications.1 It has been shown that osteoporotic patients have significantly higher rates of osteoporosis-related complications (ORCs), including revision surgery, proximal junctional kyphosis, pseudarthrosis, and instrumentation failure following posterior lumbar fusion, compared with those with normal bone density.2 Diebo et al also demonstrated higher complications in osteoporotic patients following long cervical spine fusion compared with those without osteoporosis.2 Given these significant risks, strategies to optimize bone health have become increasingly important in spine surgery.
Bone health optimization (BHO) has emerged as a comprehensive, evidence-based approach that encompasses patient screening, preoperative assessment, and appropriate pharmacological interventions.3,4 By managing poor bone health prior to spine surgery, BHO aims to reduce the risk of unfavorable outcomes and complications and promote long-term bone health. Despite the critical impact of bone health on surgical outcomes, preoperative screening rates remain suboptimal. Studies have reported that fewer than half of patients undergoing spinal fusion surgery receive preoperative bone mineral density (BMD) testing.5,6 This gap largely stems from a lack of physician awareness and the absence of comprehensive BHO guidance in spine surgery, particularly in Asia, including Thailand.7 Given the growing evidence on the importance of BHO in improving surgical outcomes and reducing complications, there is an urgent need for updated, consensus-based guidelines to standardize perioperative bone health management and enhance patient outcomes.3,4 This study aimed to develop consensus-based guidance and recommendations for BHO in patients undergoing instrumented spine surgery in Thailand throughout the pre-, peri-, and postoperative phases, thereby addressing the current lack of national guidelines.
Methods
This study utilized a modified Delphi method to develop expert consensus on BHO for instrumented spine surgery. The process began with a targeted literature review conducted using the Medline and Scopus databases. This review aimed to support the drafting of consensus statements, with the Medical Subject Headings terms detailed in the Appendix. From this review, 25 main statements with a total of 45 substatements were proposed and categorized into 3 sections: patient evaluation for BHO, assessment tools for evaluating bone health, and criteria for risk stratification and recommendations. These statements were subsequently reviewed and refined by 2 clinical advisors to ensure their accuracy and relevance. Importantly, the 2 clinical advisors did not participate in the voting process to minimize the risk of bias.
To develop the consensus, 10 orthopedic surgeons specializing in complex spine surgery and osteoporosis management in Thailand, who have at least 10 years of experience, were identified and invited to participate as expert panelists. The formal consensus exercise was conducted through 2 online surveys and 1 face-to-face consensus meeting between December 2024 and February 2025. The online survey forms were disseminated to the panelists for self-completion. The panelists rated each statement on a 4-point Likert scale, where 0 represented “strongly disagree,” 1 represented “disagree,” 2 represented “agree,” and 3 represented “strongly agree.” To minimize bias and prevent dominance by any expert, the rating was conducted anonymously in the online survey. Statements that achieved 70% or more agreement or strong agreement were considered to have reached “consensus agreement.” Conversely, statements with 30% or less agreement or strong agreement were considered to have “consensus disagreement,” and those in between were categorized as having “no consensus.”8 The strength of recommendation was calculated based on the median score of ratings among the experts. The median score ranged from 0 to 3, where a median score of 3 indicated the highest recommendation and 0 the lowest recommendation.
The aggregated consensus rating results were presented at the face-to-face consensus meeting held in December 2024. During this meeting, the ratings of statements and statements with “no consensus” or “consensus disagreement” were discussed further. Following the meeting, statements were revised and shared with panelists to rate their agreement using an online survey. The methodology details are shown in Figure 1.
Process of methodology following the modified Delphi technique.
Results
The proportion of panelists who rated strong agreement or agreement, as well as the strength of recommendation for each statement, is shown in Table 1. The statements with no consensus or disagreement from the first round of voting are provided in the supplement table.
Final recommendations, consensus percentages, and strength of recommendations.
Patient Evaluation for BHO
The panelists reached consensus that evaluating bone health prior to instrumented spine surgery is necessary. Patients aged 60 years or older should undergo assessment (100% agreement). For patients aged 50 to 59 years, evaluation may be optional and should be based on the surgeon’s clinical judgment regarding the appropriateness of bone health assessment before spine surgery (90% agreement). Furthermore, the panelists agreed that spine surgeons should evaluate osteoporosis risk factors, fracture history, and fall history in patients prior to instrumented spine surgery (100% agreement).
Assessment Tools for Evaluating Bone Health
The panelists reached consensus that the fracture risk assessment tools (FRAX) score should be considered 1 of the important assessment tools in bone health evaluation for patients prior to instrumented spine surgery (100% agreement). BMD testing by using dual energy x-ray absorptiometry (DXA) should be performed in women aged 65 years or older and men aged 70 years or older, regardless of clinical risk factors (100% agreement). Risk factors requiring BMD testing using DXA are presented in Table 2.
Risk factors requiring BMD testing using dual-energy x-ray absorptiometry.
For patients who present with characteristics that may limit DXA test accuracy at the spine—such as severe spinal curvature, deformity, scoliosis, nearby metal objects causing interference, ascites, or sclerosis of endplates and cortical bone—alternative testing sites such as hip or distal radius should be considered, or additional tools may be used to assess BMD (100% agreement).
The panelists reached consensus on optional tools for BMD assessment. Computed Tomography Hounsfield Unit (CT-HU) was agreed to be used for identifying osteoporosis in certain cases as an alternative to DXA, particularly when CT images are already available (80% agreement). Furthermore, the panelists recommended that vertebral fracture assessment should be performed prior to instrumented spine surgery. In cases where vertebral fracture assessment is not available, lateral imaging of the thoracic and lumbar spine with plain radiography is recommended to identify spinal fractures (70% agreement).
The panelists agreed on additional tools beyond DXA for BMD assessment: CT-HU for osteoporosis detection (80%), Trabecular Bone Score (TBS) for patients with type 2 diabetes mellitus (T2DM; 70%) and patients with primary hyperparathyroidism (PHPT) (90%), and magnetic resonance imaging (MRI)-based vertebral bone quality score (VBQ) as a supplementary tool (80%).
Additionally, measurement of serum 25-hydroxyvitamin D level before instrumented spine surgery is recommended as an indicator for bone health evaluation (70% agreement).
Risk Stratification and Recommendations
Criteria for Stratifying Risk of Surgical Failure Due to Poor Bone Health
The panelists reached 100% agreement on risk stratification: (1) normal/low risk for patients with no fracture history and T score > −1.0 or CT-HU > 150; (2) osteopenia/intermediate risk for patients with no fracture history and T score −1.0 to −2.4; (3) osteoporosis/high risk for patients with any of the following: hip/spine fracture, T score ≤ −2.5, T score −1.0 to −2.4 with complex spine surgery, FRAX major osteoporotic fracture (MOF) 20% to 30%, hip fracture risk ≥3%, or VBQ > 3.0; and (4) severe osteoporosis/very high risk for patients with recent/multiple fractures, T score < −3.5, T score ≤ −2.5 with complex spine surgery, or FRAX MOF > 30% ( Table 1 and Figure 2 ).
Consensus-based guidance for bone health optimization in spine surgery. BMD, bone mineral density; CT, computed tomography; DXA, dual energy x-ray absoptiometry; FRAX, fracture risk assessment tool; HU, Hounsfield unit; MOF, major osteoporotic fracture; MRI, magnetic resonance imaging; TBS, trabecular bone score; VBQ, vertebral bone quality; VFA, vertebral fracture assessment; Vit, vitamin.
Treatment Recommendation
Treatment recommendation varies depending on risk stratification. Most panelists agreed that all patients aged ≥60 years undergoing spinal surgery, or individuals of any age with evidence of low calcium or vitamin D levels, should receive vitamin D and calcium supplementation prior to spine surgery (90% agreement).
For patients with osteoporosis or high risk and patients with severe osteoporosis or very high risk, panelists recommended pharmacological treatment with bone-forming agents as the first-line treatment and antiresorptive agents as the second-line option if the first-line treatment is intolerable or unaffordable. Regarding surgical techniques for patients with severe osteoporosis or at very high risk, most panelists agreed that cement augmentation (90% agreement) and dual-thread screws (100% agreement) should be considered for pedicle screw fixation in patients classified as very high risk.
Duration of Treatment Before Surgery and Surgical Delay Consideration
For patients in the very high-risk group, starting osteoporosis treatment at least 3 months before spinal surgery is recommended (80% agreement). Additionally, surgery should be delayed for a minimum of 3 months (90% agreement) or up to 9 months for complex procedures or those associated with a high risk of complications (70% agreement).
Postoperative Treatment
For high-risk patients, those who initiated bone-forming agents preoperatively should continue the therapy postoperatively for a minimum of 9 months. However, in patients classified as very high risk, bone-forming agents should be continued postoperatively until the full course of treatment is completed (100% agreement). Furthermore, after completing treatment with bone-forming agents, transitioning to antiresorptive therapy is recommended to maintain the gain in bone density and support long-term bone health (100% agreement). The detailed flowchart for BHO in instrumented spine surgery patients is shown in Figure 2.
Discussion
Patient Evaluation for BHO
Preoperative bone health screening should be considered for patients undergoing instrumented spine surgery, as poor bone status and osteoporosis are common among these patients.9 These conditions are associated with worse outcomes and increased complications following thoracolumbar spine surgery.10 While Sardar et al recommended that all patients older than 65 years undergo bone health assessment using a BMD test before spine reconstructive surgery, regardless of other known risk factors,4 our panelists suggested that bone health evaluation should be considered for patients aged 60 years or older prior to instrumented spine surgery. Additionally, spine surgeons may consider assessing patients aged 50 to 59 years before instrumented spine surgery, if deemed appropriate.
Our panelists recommended age 60 years as the minimum age for bone health evaluation based on a study of osteoporosis patients in Thailand. This study reported that the prevalence of osteoporosis in postmenopausal women was 20.2% among those aged 60 to 70 years, compared with 8.9% in those younger than 60 years.11 Furthermore, the prevalence of osteoporosis at the lumbar spine was 18.7% in individuals aged 60 to 70 years, compared with 8.0% in those younger than 60 years. This is consistent with findings reported by Liu et al, who found that close to 50% of postmenopausal women aged 55 to 65 years in China had poor bone health.12
Assessment Tools for Evaluating Bone Health
Clinical assessment, including fracture history and risk, should be included in the initial step of bone health screening before instrumented spine surgery. The FRAX tool, which calculates the 10-year probability of hip fracture and MOF affecting the spine, proximal humerus, and forearm, should be incorporated into this initial process. As the most widely used fracture risk assessment instrument, FRAX complements the patient’s fracture history by providing a standardized quantitative evaluation of future fracture risk, enabling surgeons to make more informed decisions regarding surgical planning and potential preventive interventions.13
Several imaging tools can be used for assessing bone status, with BMD measurement using DXA as the most commonly used and the current gold standard.14 This study recommended that BMD testing using DXA should be performed in women aged 65 years or older and in men aged 70 years or older, prior to instrumented spine surgery, regardless of clinical risk factors. Asavamongkolkul et al found that the prevalence of osteoporosis in Thai older adults is significantly higher in women than in men. Among individuals aged 60 to 65 years, 26.1% of women have osteoporosis, compared with only 7.1% of men. Similarly, in the 66-to-70 age group, 31.8% of women have osteoporosis, compared with 14.3% of men.15
In contrast, Sardar et al reported that BMD testing (either DXA or CT-HU) is recommended for all patients older than 65 year, regardless of gender, before spine reconstruction surgery. Additionally, they stratified patients younger than 65 years into 2 age groups with distinct risk profiles.4 They raised concerns that gender-specific age thresholds may lead to underdiagnosis of impaired bone health in male patients. Nonetheless, our recommendation for gender-specific age thresholds is consistent with several clinical practice guidelines that recommend different age cut-offs for men and women when performing BMD testing with DXA.3,16
Beyond age-based screening, spine surgeons should consider DXA screening for patients with additional risk factors, such as complex spine surgery and early menopause, as part of bone health screening criteria, regardless of age. This recommendation is supported by several studies highlighting the crucial role of bone health in surgical outcomes. Anand et al incorporated BMD testing in their spinal deformity complexity checklist to evaluate the difficulty in performing minimally invasive adult spinal deformity (ASD) surgery.17 Additionally, Gupta et al found that osteoporotic patients had higher rates of revision surgery following a long spinal fusion for ASD.1
Nonetheless, it is acknowledged that despite high specificity, DXA has low sensitivity in predicting fragility fractures.18 Cranney et al found that more than half of fragility fractures occurred in postmenopausal individuals without osteoporosis.19 Osteoporosis is characterized by low bone mass and microstructural deterioration of bone tissue. DXA primarily measures the bone mass but not the bone microarchitecture, which also influences the overall bone strength.20
TBS should also be obtained as a supplemental tool and part of DXA if available for fracture risk assessment, especially for patients with T2DM and PHPT. TBS can improve fracture risk prediction in nonosteoporotic patients because it reflects the bone microstructure. In addition, TBS helps detect bone microstructure deterioration, which increases the fracture risk in patients with T2DM and PHPT, in which the BMD value from DXA is often normal or even elevated.21
The CT-HU is another useful opportunistic method for evaluating bone density, where the patient already has preoperative CT images. St. Jeor et al reported that HU values less than 110 were associated with ORCs and poor patient outcomes.22 Girdler et al used lumbar HU less than 160 as the cutoff value for further bone health evaluation if the patient needs surgical intervention.23 However, Sardar et al suggested that CT-HU should not be used as a substitute for DXA because the diagnosis of osteoporosis/osteopenia by HU remains questionable due to a lack of standardized criteria.4 Nevertheless, as DXA might not be readily accessible in some health care facilities, the panelists opined that opportunistic CT-HU could serve as an alternative tool to identify poor bone health patients, particularly given that CT data might be more readily available in some health care settings.
The opportunistic MRI-based VBQ utilizes T1-weighted lumbar MRI for assessing trabecular bones.24 The benefit of this tool is that MRI is routinely performed before patients undergo spine surgery, and no additional software is needed for the measurement. It has been demonstrated that the VBQ score is correlated with DXA BMD value and has a diagnostic value for poor bone quality.25 We suggest that it could be used to support the detection of osteoporosis if available in clinical settings. However, the cutoff value for diagnosis of osteoporosis/osteopenia remains controversial.24
In addition to clinical criteria and imaging, serum 25-hydroxyvitamin D levels should also be measured before instrumented spine surgery. This recommendation is supported by evidence from Ravindra et al, who reported that vitamin D deficiency is common among patients undergoing elective spinal fusion procedures.26 Additionally, Bajaj et al indicated that preoperative vitamin D deficiency is associated with poorer surgical outcomes after spine surgery.27 Sardar et al also suggested measuring serum 25-hydroxyvitamin D in patients undergoing reconstructive spine surgery.4
Risk Stratification and Recommendations
After completion of the bone status evaluation, each patient can be stratified into 4 categories based on their risk for surgical failure due to poor bone health according to several clinical, radiographic, and surgical factors for appropriate BHO and surgical strategies. Overall, all patients aged ≥60 years or individuals of any age with evidence of low calcium or vitamin D levels, regardless of risk classification, should receive calcium and vitamin D supplements as a baseline intervention before instrumented spine surgery to promote bone health if not precluded. Various studies demonstrated that vitamin D supplements have several benefits in elective spine fusion surgery. Kerezoudis et al reported that addressing vitamin D deficiency may enhance the likelihood of successful arthrodesis following spinal fusion surgery.28 Hu et al showed that vitamin D supplements provide a shorter time to fusion in patients undergoing lumbar spinal fusion.29
Presently, the most common medications used for treating osteoporosis are bisphosphonates and teriparatide.30 Studies have shown that both medications help accelerate bone fusion during the short-term follow-up period in osteoporotic patients who undergo spinal fusion surgery. Additionally, McClung et al showed that bone-forming agents, including teriparatide and romosozumab, can increase BMD more rapidly than bisphosphonates.31 Buerba et al also demonstrated that teriparatide showed superior fusion rates to bisphosphonates in thoracolumbar spinal fusion.32 While romosozumab is a novel bone-forming agent with a distinct dual action mechanism, including promoting bone formation and inhibiting bone resorption,33 studies have demonstrated promising results using romosozumab for BHO. These include a reduced incidence of fractures due to proximal junctional kyphosis and ORCs.34,35
Evidence regarding the type of osteoporotic medication to be administered prior to spine surgery remains contradictory. In this study, the panelists concluded that patients with high risk/osteoporosis should be treated with bone-forming medications such as teriparatide, abaloparatide, and romosozumab as the first-line treatment. Antiresorptive agents such as bisphosphonates and denosumab should be considered as second-line treatment if the bone-forming agents are contraindicated or unaffordable. The expert panelists supported the use of bone-forming agents as they can increase BMD more rapidly than antiresorptive agents.31 They emphasize the importance of rapidly building bone in a short period before surgery for patients undergoing instrumented spine surgery. This emphasis on rapid new bone formation is also highlighted in the recommendations by Anderson et al.3
We also highlighted that even in patients with a BMD T score of −1.0 to −2.4, which is defined as osteopenia by WHO criteria,36 should be categorized as high risk of surgical failure due to poor bone health if the patient has been scheduled for complex spine surgery, such as ASD correction surgery, and multilevel (>5 levels) instrumented fusion surgery. Diebo et al performed long (>4 levels) cervical fusion surgery and demonstrated that patients with osteoporosis had higher medical and surgical complications, including nonunion, than those without osteoporosis.2 However, several practice guidelines recommended different BHO strategies for patients in this risk category.3,4 Anderson et al also classified the patients at risk into 4 categories. They recommended treating the patients with high risk/osteoporosis with antiresorptive medication as first-line treatment and considering delaying the surgery and suggested using an anabolic agent instead if the patient has some modifying factors, including CT-HU <110, degraded TBS, revision surgery, complex reconstruction (eg, osteotomy and multilevel fusion), and prior surgical failure related to the bone.3 Sardar et al did not categorize patients separately as high risk/osteoporosis and very high risk/severe osteoporosis, as done in the present study.4 They recommended using bone-forming medications as the first-line treatment for patients with osteoporosis (classified as high risk/osteoporosis and very high risk/severe osteoporosis in this study) and those with osteopenia (classified as intermediate-risk/osteopenia category in this study) prior to spine reconstructive surgery and consider using the antiresorptive agents if the bone-forming agent is contraindicated or unaffordable. Girdler et al also preferred anabolic medications prior to spine surgery in osteopenia and osteoporosis.23
However, our panelists concluded that osteoporosis drugs may not be necessary for patients with osteopenia undergoing instrumented spine surgery, and supplementation with calcium and vitamin D alone is sufficient. Nevertheless, our panelists suggested considering bone-forming or antiresorptive agents for patients with osteopenia undergoing selected complex spine procedures. Similarly, Anderson et al suggested that preoperative optimizing calcium and vitamin D is typically the only BHO strategy required for patients with osteopenia, but emphasized that those undergoing higher-risk procedures, such as multilevel surgery, should receive bone-forming or antiresorptive agents due to increased surgical risk.3
Evidence regarding surgical delay due to poor bone health is also scarce and disputed.3 Our panelists concluded that surgical delay is not necessary for the high-risk/osteoporosis category. Sardar et al also stated that spine reconstructive surgery can be performed as scheduled if the appropriate medical treatment regarding poor bone health is already addressed before surgery.4 In contrast, Anderson et al recommended that spine surgeons should consider delaying surgery in some osteoporosis patients indicated for treatment with anabolic medication.3 Also, Girdler et al often withheld elective spine surgery for patients with poor bone health and referred the patients to bone endocrinology for further evaluation and treatment to improve BMD.23
For patients at very high risk/with severe osteoporosis, the present study also recommended treating the poor bone condition with bone-forming agents as the first-line treatment and considering antiresorptive agents as the second-line treatment. Additionally, the surgeon should consider withholding the elective spine surgery for at least 3 months, and the patient should receive medical treatment for severe osteoporosis during this delayed period. The delay should be extended up to 9 months in more complex spine procedures and those with a higher risk of ORCs. Bone-forming agents, including romosozumab, should be considered as the study showed its benefit in increasing BMD at the lumbar spine by approximately 4.8% within 3 months of initiation.31 Additionally, the effect of romosozumab on increasing BMD has been observed to be more pronounced than that of teriparatide and bisphosphonates at 3, 6, 9, and 12 months following the start of treatment.31 Anderson et al also suggested that this patient’s category should be treated for at least 3 months with the bone-forming agent and considered a surgical delay.3 Sardar et al recommended treating poor bone health patients with an anabolic agent for at least 2 months preoperatively or up to 6 months for elective multilevel spine reconstructive surgery.4
The bone-forming medications that start in the preoperative period should be continued in the postoperative period for at least 9 months in patients at high risk/with osteoporosis and until the full course of treatment is completed in patients at very high risk/with severe osteoporosis. In this regard, Sardar et al recommended an 8-month postoperative duration of anabolic agents for patients with poor bone status who underwent spine reconstructive surgery.4 Additional therapy with antiresorptive agents following the completion of bone-forming agents should be considered to maintain the increased bone density following the administration of bone-forming agents and support long-term bone health.37
Surgical strategies and planning are also critical and affect surgical outcomes. The panelists concluded that cement-augmented pedicle screw fixation and dual-thread pedicle screws should be considered for patients at very high risk/ with severe osteoporosis to prevent ORCs. Hudson et al also emphasized these strategies to optimize the instrumentation of patients with poor bone health.38 Peng et al also usually used cement-augmented pedicle screws when BMD was less than −3.5.39 However, routine use of these instruments is not recommended for single-segment low-grade isthmic spondylolisthesis because it demonstrated comparable outcomes and complications compared with the traditional pedicle screw technique. Anderson et al also recommended accepting less ASD correction and preserving posterior spinal elements and soft tissue at the proximal end of the construct in osteoporotic patients.3 Girdler et al preferred combined anterior and posterior fusion to improve load sharing of the construct and extend fusion to the pelvis to lessen implant failure risk in osteoporotic patients.23
A key strength of this study is the comprehensive incorporation of various risk factors, investigations, pharmacological approaches, and surgical recommendations, ensuring tailored guidance for patients across different risk categories. Additionally, the use of the Modified Delphi method with expert input provides a solid foundation for consensus building, enhancing the reliability and applicability of the guidance. However, this study has some limitations. First, this guidance is based on the opinions of a limited number of experienced orthopedic spine specialists. Second, we did not include recommendations regarding nonpharmacological treatments for poor bone health. Further research is needed to validate this practice guidance to ensure that it can improve patients’ bone health, enhance surgical outcomes, and reduce the incidence of ORCs.
Conclusions
The expert panelists established comprehensive practice guidance for BHO in patients undergoing instrumented spine surgery in Thailand. This guidance includes patient screening, evaluation, and treatment for patients with poor bone health based on risk stratification, encompassing normal/low risk, osteopenia/intermediate risk, osteoporosis/high risk, and severe osteoporosis/very high risk. Spine surgeons should recognize poor bone health and consider BHO to enhance surgical outcomes and prevent ORCs.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Disclosures and Conflicts of Interest Sirinthip Petcharapiruch and Supitchaya Changsatja are employees of IQVIA. All other authors declare no competing interests.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
References
- 1.↵Gupta A , Cha T , Schwab J , et al . Osteoporosis increases the likelihood of revision surgery following a long spinal fusion for adult spinal deformity. Spine J. 2021;21(1):134–140. 10.1016/j.spinee.2020.08.002
- 2.↵Diebo BG , Scheer R , Rompala A , et al . The impact of osteoporosis on 2-year outcomes in patients undergoing long cervical fusion. J Am Acad Orthop Surg. 2023;31(1):e44–e50. 10.5435/JAAOS-D-22-00361
- 3.↵Anderson PA , Binkley NC , Bernatz JT . Bone health optimization (BHO) in spine surgery. Spine (Phila Pa 1986). 2023;48(11):782–790. 10.1097/BRS.0000000000004618
- 4.↵Sardar ZM , Coury JR , Cerpa M , et al . Best practice guidelines for assessment and management of osteoporosis in adult patients undergoing elective spinal reconstruction. Spine (Phila Pa 1976). 2022;47(2):128–135. 10.1097/BRS.0000000000004268
- 5.↵Dipaola CP , Bible JE , Biswas D , Dipaola M , Grauer JN , Rechtine GR . Survey of spine surgeons on attitudes regarding osteoporosis and osteomalacia screening and treatment for fractures, fusion surgery, and pseudoarthrosis. Spine J. 2009;9(7):537–544. 10.1016/j.spinee.2009.02.005
- 6.↵Yamamoto K , Tanaka S . Survey on actual management of osteoporosis with the japanese medical data vision database in elderly patients undergoing spinal fusion. J Clin Med. 2024;13(10):2806. 10.3390/jcm13102806
- 7.↵Lee J-K , Leong JF , Thong F-Y , et al . A bone health optimization framework for malaysia: a position paper by the malaysian bone health optimization network (mybone). Arch Osteoporos. 2024;19(1):88. 10.1007/s11657-024-01448-6
- 8.↵Shang Z . Use of delphi in health sciences research: a narrative review. Medicine (Baltimore). 2023;102(7):e32829. 10.1097/MD.0000000000032829
- 9.↵Bernatz JT , Winzenried AE , Hare KJ , et al . Effect of bone health optimization on osteoporosis screening and treatment before thoracolumbar fusion. J Am Acad Orthop Surg Glob Res Rev. 2022;6(3):e21. 10.5435/JAAOSGlobal-D-21-00253
- 10.↵Zhao L , Xie T , Wang X , et al . Clinical and radiological evaluation of cage subsidence following oblique lumbar interbody fusion combined with anterolateral fixation. BMC Musculoskelet Disord. 2022;23(1):214. 10.1186/s12891-022-05165-4
- 11.↵Chanidkul P , Sribenjalak D , Charoenngam N , Pongchaiyakul C . The proportion of thai postmenopausal women who would be eligible for anti-osteoporosis therapy. PLoS One. 2023;18(2):e0279829. 10.1371/journal.pone.0279829
- 12.↵Liu J , Xia R-L , Li C , Song Q , Cui X-L , Chao A-J . The prevalence of osteoporosis in postmenopausal women in urban tianjin, china and its related factors. Menopause. 2023;30(7):774–780. 10.1097/GME.0000000000002204
- 13.↵Kanis JA , Hans D , Cooper C , et al . Interpretation and use of FRAX in clinical practice. Osteoporos Int. 2011;22(9):2395–2411. 10.1007/s00198-011-1713-z
- 14.↵Schreiber JJ , Anderson PA , Hsu WK . Use of computed tomography for assessing bone mineral density. Neurosurg Focus. 2014;37(1):E4. 10.3171/2014.5.FOCUS1483
- 15.↵Asavamongkolkul A , Adulkasem N , Chotiyarnwong P , et al . Prevalence of osteoporosis, sarcopenia, and high falls risk in healthy community-dwelling thai older adults: a nationwide cross-sectional study. JBMR Plus. 2024;8(2):ziad020. 10.1093/jbmrpl/ziad020
- 16.↵Charatcharoenwitthaya N , Jaisamrarn U , Songpatanasilp T , et al . Summary of the thai osteoporosis foundation (TOPF) clinical practice guideline on the diagnosis and management of osteoporosis 2021. Osteoporos Sarcopenia. 2023;9(2):45–52. 10.1016/j.afos.2023.06.001
- 17.↵Anand N , Mummaneni PV , Uribe JS , et al . Spinal deformity complexity checklist for minimally invasive surgery: expert consensus from the minimally invasive international spine study group. World Neurosurg. 2023;173:e472–e477. 10.1016/j.wneu.2023.02.082
- 18.↵Schini M , Johansson H , Harvey NC , Lorentzon M , Kanis JA , McCloskey EV . An overview of the use of the fracture risk assessment tool (FRAX) in osteoporosis. J Endocrinol Invest. 2024;47(3):501–511. 10.1007/s40618-023-02219-9
- 19.↵Cranney A , Jamal SA , Tsang JF , Josse RG , Leslie WD . Low bone mineral density and fracture burden in postmenopausal women. CMAJ. 2007;177(6):575–580. 10.1503/cmaj.070234
- 20.↵Therdyothin A , Amphansap T , Apiromyanont K . Trabecular bone score as an additional therapeutic decision tool in osteoporosis and osteopenia. Osteoporos Sarcopenia. 2022;8(3):123–130. 10.1016/j.afos.2022.09.001
- 21.↵Harvey NC , Glüer CC , Binkley N , et al . Trabecular bone score (TBS) as a new complementary approach for osteoporosis evaluation in clinical practice. Bone. 2015;78:216–224. 10.1016/j.bone.2015.05.016
- 22.↵St. Jeor JD , Jackson TJ , Xiong AE , et al . Average lumbar Hounsfield units predicts osteoporosis-related complications following lumbar spine fusion. Global Spine J. 2022;12(5):851–857. 10.1177/2192568220975365
- 23.↵Girdler SJ , Lindsey MH , Sebastian AS , Nassr A . Osteoporosis evaluation and management in spine surgery. J Am Acad Orthop Surg. 2024;32(18):e909–e918. 10.5435/JAAOS-D-24-00311
- 24.↵Hu F , Li X , Zhao D , Chen C , Liu G , Yang Q . The diagnostic value of MRI-based vertebral bone quality score for osteoporosis or osteopenia in patients undergoing lumbar surgery: a meta-analysis. Osteoporos Int. 2024;35(11):1881–1895. 10.1007/s00198-024-07190-6
- 25.↵Kim AYE , Lyons K , Sarmiento M , Lafage V , Iyer S . MRI-based score for assessment of bone mineral density in operative spine patients. Spine (Phila Pa 1986). 2023;48(2):107–112. 10.1097/BRS.0000000000004509
- 26.↵Ravindra VM , Godzik J , Guan J , et al . Prevalence of vitamin D deficiency in patients undergoing elective spine surgery: a cross-sectional analysis. World Neurosurg. 2015;83(6):1114–1119. 10.1016/j.wneu.2014.12.031
- 27.↵Bajaj A , Shah RM , Goodwin AM , Kurapaty S , Patel AA , Divi SN . The role of preoperative vitamin D in spine surgery. Curr Rev Musculoskelet Med. 2023;16(2):48–54. 10.1007/s12178-022-09813-z
- 28.↵Kerezoudis P , Rinaldo L , Drazin D , et al . Association between vitamin D deficiency and outcomes following spinal fusion surgery: a systematic review. World Neurosurg. 2016;95:71–76. 10.1016/j.wneu.2016.07.074
- 29.↵Hu M-H , Tseng Y-K , Chung Y-H , Wu N-Y , Li C-H , Lee P-Y . The efficacy of oral vitamin D supplements on fusion outcome in patients receiving elective lumbar spinal fusion-a randomized control trial. BMC Musculoskelet Disord. 2022;23(1):996. 10.1186/s12891-022-05948-9
- 30.↵Govindarajan V , Diaz A , Perez-Roman RJ , Burks SS , Wang MY , Levi AD . Osteoporosis treatment in patients undergoing spinal fusion: a systematic review and meta-analysis. Neurosurg Focus. 2021;50(6):E9. 10.3171/2021.3.FOCUS2175
- 31.↵McClung MR , Grauer A , Boonen S , et al . Romosozumab in postmenopausal women with low bone mineral density. N Engl J Med. 2014;370(5):412–420. 10.1056/NEJMoa1305224
- 32.↵Buerba RA , Sharma A , Ziino C , et al . Bisphosphonate and teriparatide use in thoracolumbar spinal fusion: a systematic review and meta-analysis of comparative studies. Spine (Phila Pa 1986). 1976;43(17):e1014–e1023. 10.1097/BRS.0000000000002608
- 33.↵Ishikawa K , Tani S , Toyone T , et al . The potential effect of romosozumab on perioperative management for instrumentation surgery. JOR Spine. 2024;7(3):e1356. 10.1002/jsp2.1356
- 34.↵Sawada Y , Takahashi S , Yasuda H , et al . Effect of romosozumab administration on proximal junctional kyphosis in corrective spinal fusion surgery. Spine J. 2025;25(6):1218–1228. 10.1016/j.spinee.2024.12.021
- 35.↵Inose H , Takahashi S , Teraguchi M , et al . Romosozumab versus bisphosphonates for preventing subsequent vertebral fractures after balloon kyphoplasty: comparison using data from two prospective multicenter studies. JBMR Plus. 2025;9(1):ziae137. 10.1093/jbmrpl/ziae137
- 36.↵Kanis JA , Johnell O , Oden A , Jonsson B , De Laet C , Dawson A . Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone. 2000;27(5):585–590. 10.1016/s8756-3282(00)00381-1
- 37.↵Cosman F , Lewiecki EM , Eastell R , et al . Goal-directed osteoporosis treatment: ASBMR/BHOF task force position statement 2024. J Bone Miner Res. 2024;39(10):1393–1405. 10.1093/jbmr/zjae119
- 38.↵Hudson M , Meyer J , Evans A , Krishna C , Smith ZA , Bakhsheshian J . Evaluating osteoporosis and bone quality in the aging spine: modern considerations for surgical management in the geriatric population. Geroscience. 2024;46(5):5287–5301. 10.1007/s11357-024-01171-7
- 39.↵Peng J-C , Guo H-Z , Zhan C-G , et al . Comparison of pedicle screw fixation with or without cement augmentation for treating single-segment isthmic spondylolisthesis in the osteoporotic spine. Sci Rep. 2023;13(1):827. 10.1038/s41598-023-27539-x
