Document Type: CURRENT CONCEPTS REVIEW

Authors

Spine Department. Fundacion Jimenez Diaz University Hospital, Madrid. Spain

Abstract

Osteoporosis has become a major medical problem as the aged population of the world rapidly grows. Osteoporosis
predisposes patients to fracture, progressive spinal deformities, and stenosis, and is subject to be a major concern
before performing spine surgery, especially with bone fusions and instrumentation. Osteoporosis has often been
considered a contraindication for spinal surgery, while in some instances patients have undergone limited and inadequate
procedures in order to avoid concomitant instrumentation. As the population ages and the expectations of older patients
increase, the demand for surgical treatment in older patients with osteoporosis and spinal degenerative diseases
becomes progressively more important. Nowadays, advances in surgical and anesthetic technology make it possible to
operate successfully on elderly patients who no longer accept disabling physical conditions. This article discusses the
biomechanics of the osteoporotic spine, the diagnosis and management of osteoporotic patients with spinal conditions,
as well as the novel treatments, recommendations, surgical indications, strategies and instrumentation in patients with
osteoporosis who need spine operations.

Keywords

Main Subjects

1. Klibanski A, Adams-Campbell L, Bassford T, Blair SN,
Boden SD, Dickersin K, et al. Osteoporosis prevention,
diagnosis, and therapy. J Am Med Assoc. 2001;
285(6):785-95.
2. Bono CM, Einhorn. TA. Overview of osteoporosis:
pathophysiology and determinants of bone strength.
Eur Spine J. 2003; 12(Suppl 2):S90-6.
3. Chin DK, Park JY, Yoon YS, Kuh SU, Jin BH, Kim KS, et al.
Prevalence of osteoporosis in patients requiring spine
surgery: incidence and significance of osteoporosis in
spine disease. Osteoporos Int. 2007; 18(9):1219-24.
4. Ponnusamy KE, Iyer S, Gupta G, Khanna AJ.
Instrumentation of the osteoporotic spine:
biomechanical and clinical considerations. Spine J.
2011; 11(1):54-63.
5. Hadjipavlou AG, Katonis PG, Tzermiadianos MN,
Tsoukas GM, Sapkas G. Principles of management of
osteometabolic disorders affecting the aging spine.
Eur Spine J. 2003; 12(Suppl 2):S113-31.
6. Ritter MA, Albohm MJ, Keating EM, Faris PM, Meding
JB. Life expectancy after total hip arthroplasty. J
Arthroplasty. 1998;13(8):874-5.
7. Schrøder HM, Kristensen PW, Petersen MB, Nielsen
PT. Patient survival after total knee arthroplasty.
5-year data in 926 patients. Acta Orthop Scand. 1998;
69(1):35-8.
8. White A, Panjabi M. Clinical biomechanics of the spine.
2nd ed. Philadelphia: Lippincott, Williams & Wilkins;
1990.
9. Ferguson SJ, Steffen T. Biomechanics of the aging
spine. Eur Spine J. 2003; 12 (Suppl 2):S97-103.
10. Mazess RB. On aging bone loss. Clin Orthop. 1982;
165:239-252.
11. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton
I, Broy SB, et al. Risk of new vertebral fracture in the
year following a fracture. JAMA. 2001; 285(3):320–23.
12. Keller TS, Harrison DE, Colloca CJ, Harrison D, Janik
TJ. Prediction of osteoporotic spinal deformity. Spine.
2003; 28(5):455-62.
13. Lowe TG. Scheuermann disease. JBJS. 1990; 72(6):940-5.
14. Ismail AA, Cooper C, Felsenberg D, Varlow J, Kanis
JA, Silman AJ, et al. Number and type of vertebral
deformities: epidemiological characteristics and
relation to back pain and height loss. European
Vertebral Osteoporosis Study Group. Osteoporosis
Int. 1999; 9(3):206-13.
15. Kanter AS, Asthagiri AR, Shaffrey CI. Aging spine:
challenges and emerging techniques. Clin Neurosurg.
2007; 54:10-8.
16. Benoist M. Natural history of the aging spine. Eur
Spine J. 2003; 12(2):S86-S89.
17. Sengupta DK, Herkowitz HN. Lumbar spinal stenosis:
Treatment strategies and indications for surgery.
Orthop Clin North Am. 2003; 34(2):281-95.
18. Margulies JY, Payzer A, Nyska M, Neuwirth MG, Floman
Y, Robin GC. The relationship between degenerative
changes and osteoporosis in the lumbar spine. Clin
Orthop. 1996; (324):145–52.
19. Paiva LC, Filardi S, Pinto-Neto AM, Samara A,
Marques Neto JF. Impact of degenerative radiographic
abnormalities and vertebral fractures on spinal bone
density of women with osteoporosis. Sao Paulo Med J.
2002; 120(1):9-12.
20. Muraki S, Yamamoto S, Ishibashi H, Horiuchi T, Hosoi
T, Orimo H, et al. Impact of degenerative spinal
diseases on bone mineral density of the lumbar spine
in elderly women. Osteoporos Int. 2004; 15(9):724-8.
21. Harada A, Okuizumi H, Miyagi N, Genda E. Correlation
between bone mineral density and intervertebral disc
degeneration. Spine. 1998; 23(8):857-61.
22. Nuti R, Righi G, Martini G, Turchetti V, Lepore C,
Doretti V. Diagnostic approach to osteoporosis and
spondyloarthrosis in post-menopausal women by
total body dual-photon absorptiometry. Clin Exp
Rheum. 1988; 6(1):47–51.
23. Chin DK, Park JY, Yoon YS, Kuh SU, Jin BH, Kim KS, et al.
Prevalence of osteoporosis in patients requiring spine
surgery: incidence and significance of osteoporosis in
spine disease. Osteoporos Int. 2007; 18(9):1219-24.
24. Vogt MT, Rubin DA, San Valentin R, Palermo L,
Donaldson WF, Nevitt M, et al. Lumbar listhesis
and lower back symptoms in elderly white women.
The study of osteoporotic fractures. Spine. 1998;
23(23):2640-7.
25. Bassewitz HL, Herkowitz HN. Osteoporosis of
the spine: Medical and surgical strategies. Univ
Pennsylvania Orthopaed J. 2000; 13:35-42.
26. De Wald CJ, Stanley T. Instrumentation-related
complications of multilevel fusions for adult spinal
deformity patients over age 65. surgical considerations
and treatment options in patients with poor bone
quality. Spine. 2006; 31(Suppl 19): S144–51.
27. Andersen T, Christensen FB, Niedermann B, Helmig P,
Høy K, Hansen ES, et al. Impact of instrumentation in 

lumbar spinal fusion in elderly patients: 71 patients
followed for 2-7 years. Acta Orthop. 2009; 80(4):445-50.
28. Butler Jr TE, Asher MA, Jayaraman G, Nunley PD,
Robinson RG. The strength and stiffness of thoracic
implant anchors in osteoporotic spines. Spine (Phila
Pa 1976). 1994; 19(17):1956-62.
29. Coe JD, Warden KE, Herzig MA, McAfee PC. Influence of
bone mineral density on the fixation of thoracolumbar
implants: a comparative study of transpedicular
screws, laminar hooks, and spinous process
wiresSpine (Phila Pa 1976). 1990; 15(9):902–907.
30. Greenfield RT 3rd, Capen DA, Thomas Jr JC, Nelson R,
Nagelberg S, Rimoldi RL, et al. Pedicle screw fixation
for arthrodesis of the lumbosacral spine in the elderly.
An outcome study. Spine. 1998; 23(13):1470–5.
31. Cohen DB. Management of scoliosis in the osteoporotic
patient. Semin Spine Surg. 2009; 21(1):33-40
32. Jost B, Cripton PA, Lund T, Oxland TR, Lippuner K,
Jaeger P, et al. Compressive strength of interbody
cages in the lumbar spine: the effect of cage shape,
posterior instrumentation and bone density. Eur
Spine J. 1998; 7(2):132-41.
33. Amendola L, Gasbarrini A, Fosco M, Simoes CE, Terzi
S, De Iure F, et al. Fenestrated pedicle screws for
cement-augmented purchase in patients with bone
softening: a review of 21 cases. J Orthop Traumatol.
2011; 12(4):193-9.
34. Burval DJ, McLain RF, Milks R, Inceoglu S. Primary
pedicle screw augmentation in osteoporotic lumbar
vertebrae: biomechanical analysis of pedicle fixation
strength. Spine (Phila Pa 1976). 2007; 32(10):1077–83.
35. Chang MC, Liu CL, Chen TH. Polymethylmethacrylate
augmentation of pedicle screw for osteoporotic spinal
surgery: a novel technique. Spine (Phila Pa 1976).
2008; 33(10):E317–24
36. Cho KJ, Suk SI, Park SR, Kim JH, Kim SS, Choi
WK, et al. Complications in posterior fusion and
instrumentation for degenerative lumbar scoliosis.
Spine (Phila Pa 1976). 2007; 32(20):2232–7.
37. Deyo RA, Martin BI, Ching A, Tosteson AN, Jarvik
JG, Kreuter W, et al. Interspinous spacers compared
to decompression or fusion for lumbar stenosis:
complications and repeat operations in the medicare
population. Spine (Phila Pa 1976). 2013; 38(10):865-72.
38. Hilibrand AS, Moore DC, Graziano GP. The role of
pediculolaminar fixation in compromised pedicle
bone. Spine (Phila Pa 1976). 1996; 21(4):445-51.
39. Hu MH, Wu HTH, Chang MC, Yu WK, Wang ST, Liu CL.
Polymethylmethacrylate augmentation of the pedicle
screw: the cement distribution in the vertebral body.
Eur Spine J. 2011; 20(8):1281–88.
40. Liljenqvist U, Hackenberg L, Link T, Halm H. Pullout
strength of pedicle screws versus pedicle and laminar
hooks in the thoracic spine. Acta Orthop Belg. 2001;
67(2):157-63.
41. Masaya Y, Akihiro K, Riya K, Kinoshita M, Abe M.
Efficacy of novel-concept pedicle screw fixation
augmented with calcium phosphate cement in the
osteoporotic spine. J Orthop Sci. 2005; 10(1):56–61.
42. Okuyama K, Abe E, Suzuki T, Tamura Y, Chiba M, Sato
K. Influence of bone mineral density on pedicle screw
fixation: a study of pedicle screw fixation augmenting
posterior lumbar interbody fusion in elderly patients.
Spine J. 2001; 1(6):402–7.
43. Paré PE, Chappuis JL, Rampersaud R, Agarwala AO,
Perra JH, Erkan S, et al. Biomechanical evaluation of
a novel fenestrated pedicle screw augmented with
bone cement in osteoporotic spines. Spine (Phila Pa
1976). 2011; 36(18):E1210–4.
44. Postacchini F. Surgical management of lubar spinal
stenosis. Spine. 1999; 24(10):1043-7.
45. Tan JS, Bailey CS, Dvorak MF, Fisher CG, Cripton PA,
Oxland TR. Cement augmentation of vertebral screws
enhances the interface strength between interbody
device and vertebral body. Spine (Phila Pa 1976).
2007; 32(3):334–41.
46. Tan JS, Kwon BK, Samarasekera D, Dvorak MF, Fisher
CG, Oxland TR. Vertebral bone density-a critical
element in the performance of spinal implants. In:
Melkerson MN, Grififith SL, Kirkpatrick JS, editors.
Spinal implants: are we evaluating them appropriately.
West Conshohocken, PA: ASTM International; 2003;. P.
217-30.
47. Vaccaro AR, Scott TB. Indications for instrumentation
in degenerative lumbar spinal disorders. Orthopedics.
2000; 23(3):260-71.
48. Wuisman PI, Van Dijk M, Staal H, Van Royen BJ.
Augmentation of (pedicle) screws with calcium
apatite cement in patients with severe progressive
osteoporotic spinal deformities: an innovative
technique. Eur Spine J. 2000; 9(6):528–3.
49. Yone K, Sakou T, Kawauchi Y, Yamaguchi M, Yanase
M. Indication of fusion for lumbar spinal stenosis in
elderly patients and its significance. Spine (Phila Pa
1976). 1996; 21(2):242–8.
50. Hu SS. Internal fixation in the osteoporotic spine.
Spine. 1997; 22(24): 43S-8.
51. Hasegawa K, Takahashi HE, Uchiyama S, Hirano T,
Hara T, Washio T, et al. An experimental study of
a combination method using a pedicle screw and
laminar hook for the osteoporotic spine. Spine (Phila
Pa 1976). 1997; 22(9):958-63. 

52. Tokuhashi Y, Ajiro Y, Umezawa N. Outcomes of
posterior fusion using pedicle screw fixation in
patients > 70 years with lumbar spinal canal stenosis.
Orthopedics. 2008; 31(11):1096–8.
53. Dodwad SN, Khan SN. Surgical stabilization of the
spine in the osteoporotic patient. Orthop Clin North
Am. 2013; 44(2):243-9.
54. Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus
C. Minimum 5-year analysis of L5–S1 fusion using
sacropelvic fixation (bilateral S1 and iliac screws)
for spinal deformity. Spine (Phila Pa 1976). 2006;
31:303-8.
55. Kwon BK, Elgafy H, Keynan O Fisher CG, Boyd MC,
Paquette SJ, Dvorak MF. Progressive junctional
kyphosis at the caudal end of lumbar instrumented
fusion: etiology, predictors, and treatment. Spine
(Phila Pa 1976). 2006; 31(17):1943-51.
56. Zindrick MR, Wiltse LL, Widell EH, Thomas JC,
Holland WR, Field BT, et al. A biomechanical study
of intrapeduncular screw fixation in the lumbosacral
spine. Clin Orthop Relat Res. 1986; (203):99-112.
57. Esses SI, Botsford DJ, Huler RJ, Rauschning W. Surgical
anatomy of the sacrum. A guide for rational screw
fixation. Spine (Phila Pa 1976). 1991; 16(6s): S283-8.
58. Licht NJ, Rowe DE, Ross LM. Pitfalls of pedicle screw
fixation in the sacrum. A cadaver model. Spine (Phila
Pa 1976). 1992; 17(8):892-6.
59. Luk KD, Chen L, Lu WW. A stronger bicortical sacral
pedicle screw fixation through the S1 endplate:an
in vitro cyclic loading and pull-out force evaluation.
Spine (Phila Pa 1976). 2005; 30(5):525-9.
60. Hirano T, Hasegawa K, Washio T, Hara T, Takahashi
H. Fracture risk during pedicle screw insertion in
osteoporotic spine. J Spinal Disord. 1998; 11(6):493-7
61. Yildirim OS, Aksakal B, Hanyaloglu SC, Erdogan F,
Okur A. Hydroxyapatite dip coated and uncoated
titanium poly-axial pedicle screws: an in vivo bovine
model. Spine (Phila Pa 1976). 2006; 31(8):E215-20.
62. Deligianni D, Korovessis P, Porte-Derrieu MC, Amedee
J. Fibronectin preadsorbed on hydroxyapatite together
with rough surface structure increases osteoblasts’
adhesion ‘‘in vitro’’: the theoretical usefulness of
fibronectin preadsorption on hydroxyapatite to
increase permanent stability and longevity in spine
implants. J Spinal Disord Tech. 2005; 18(3):257-62.
63. Sandén B, Olerud C, Petrén-Mallmin M, Larsson S.
Hydroxyapatite coating improves fixation of pedicle
screws. A clinical study. J Bone Joint Surg Br. 2002;
84(3):387-91.
64. Cook SD, Barbera J, Rubi M, Salkeld SL, Whitecloud
TS. Lumbosacral fixation using expandable pedicle
screws: an alternative in reoperation and osteoporosis.
Spine J. 2001; 1(2):109-14.
65. Hart RA, Prendergast MA. Spine surgery for lumbar
degenerative disease in elderly and osteoporotic
patients. Instr Course Lect. 2007; 56:257-72.
66. Brantley AG, Mayfield JK, Koeneman JB, Clark KR. The
effects of pedicle screw fit: An In Vitro Study. Spine.
1994; 19(5):1752-8.
67. Pfeifer BA, Krag MH, Johnson C. Repair of failed
transpedicle screw fixation. A biomechanical study
comparing polymethylmethacrylate, milled bone,
and matchstick bone reconstruction. Spine (Phila Pa
1976). 1994; 19(3):350-3.
68. Cook SD, Salkeld SL, Stanley T, Faciane A, Miller SD.
Biomechanical study of pedicle screw fixation in
severely osteoporotic bone. Spine J. 2004; 4(4):402-8.
69. Choma TJ, Pfeiffer FM, Swope RW, Hirner JP.
Pedicle screw design and cement augmentation in
osteoporotic vertebrae: effects of fenestrations and
cement viscosity on fixation and extraction. Spine
(Phila Pa 1976). 2012; 37(26):E1628-32.
70. Sawakami K, Yamazaki A, Ishikawa S, Ito T, Watanabe
K, Endo N. Polymethylmethacrylate augmentation
of pedicle screws increases the initial fixation in
osteoporotic spine patients. J Spinal Disord Tech.
2012; 25(2):E28-35.
71. Aydogan M, Ozturk C, Karatoprak O, Tezer M,
Aksu N, Hamzaoglu A. The pedicle screw fixation
with vertebroplasty augmentation in the surgical
treatment of the severe osteoporotic spines. J Spinal
Disord Tech. 2009; 22(6):444-7.
72. Piñera AR, Duran C, Lopez B, Saez I, Correia E, L Alvarez.
Instrumented lumbar arthrodesis in elderly patients:
prospective study using cannulated cemented pedicle
screw instrumentation. Eur Spine J. 2011; 20(Suppl
3):408-14.
73. Frankel BM, Jones T, Wang C. Segmental polymethylmethacrylate-
augmented pedicle screw fixation in
patients with bone softening caused by osteoporosis
and metastatic tumor involvement: a clinical
evaluation. Neurosurgery. 2007; 61(3):531-7.
74. Lubansu A, Rynkowski M, Abeloos L, Appelboom
G, Dewitte O. Minimally invasive spinal arthrodesis
in osteoporotic population using a cannulated and
fenestrated augmented screw: technical description
and clinical experience. Minim Invasive Surg. 2012;
2012:507826.
75. Xie Y, Fu Q, Chen ZQ, Shi ZC, Zhu XD, Wang CF, et al.
Comparison between two pedicle screw augmentation
instrumentations in adult degenerative scoliosis
with osteoporosis. BMC Musculoskelet Disord. 2011;

12(1):286.
76. Singh K, Heller JG, Samartzis D, Price JS, An HS,
Yoon ST, et al. Open vertebral cement augmentation
combined with lumbar decompression for the operative
management of thoracolumbar stenosis secondary to
osteoporotic burst fractures. J Spinal Disord Tech. 2005;
18(5):413-9.
77. Zapatowicz K, Godlewski B, Jekimov R, Grochal
M. Augmentation of transpedicular screws by
intraoperative vertebroplasty. Neurol Neurochir Pol.
2012; 46(6):560-8.
78. Kim HS, Park SK, Joy H, Ryu JK, Kim SW, Ju CI. Bone
cement augmentation of short segment fixation for
unstable burst fracture in severe osteoporosis. J
Korean Neurosurg Soc. 2008; 44(1):8-14.
79. Moon BJ, Cho BJ, Choi EY, Zhang HY.
Polymethylmethacrylate-augmented screw fixation
for stabilization of the osteoporotic spine: a threeyear
follow-up of 37 patients. J Korean Neurosurg Soc.
2009; 46(4):305-11.
80. Erbe EM, Clineff TD, Gualtieri G. Comparison of a new
bisphenola-glycidyl dimethacrylate-based cortical
bone void filler with polymethyl methacrylate. Eur
Spine J. 2001; 10(Suppl 2):S147-52.
81. Kobayashi H, Turner AS, Seim HB, Kawamoto T,
Bauer TW. Evaluation of a silicacontaining bone graft
substitute in a vertebral defect model. J Biomed Mater
Res A. 2010; 92(2):596-603.
82. Cho W, Wu C, Zheng X, Erkan S, Suratwala SJ, Mehbod
AA, et al. Is it safe to back out pedicle screws after
augmentation with polymethyl methacrylate or
calcium phosphate cement? A biomechanical study. J
Spinal Disord Tech. 2011; 24(4):276-9.
83. Gunzburg R, Szpalski M. The conservative surgical
treatment of lumbar spinal stenosis in the elderly. Eur
Spine J. 2003; 12(Suppl 2):S176-80
84. Yi X, McPherson B. Application of X STOP device in the
treatment of lumbar spinal stenosis. Pain Physician.
2010; 13(5):E327-36.
85. Kuchta J, Sobottke R, Eysel P, Simons P. Two-year
results of interspinous spacer (X-Stop) implantation
in 175 patients with neurologic intermittent
claudication due to lumbar spinal stenosis. Eur Spine
J. 2009; 18(6):823-9.
86. Kim DH, Tantorski M, Shaw J, Martha J, Li L, Shanti N,
et al. Occult spinous process fractures associated with
interspinous process spacers. Spine (Phila Pa 1976).
2011; 36(16):E1080-5.
87. Kim DH, Shanti N, Tantorski ME, Shaw JD, Li L,
Martha JF, et al. Assiciation between degenerative
spondylolisthesis and spinous process spacer surgery.
Spine J. 2012; 12(6):466-72.
88. Okuda S, Oda T, Miyauchi A, Haku T, Yamamoto T,
Iwasaki M. Surgical outcomes of posterior lumbar
interbody fusion in elderly patients. J Bone Joint Surg
Am. 2007; 1(2):310-20.
89. Steffen T, Tsantrizos A, Aebi M. Effect of implant
design and endplate preparation on the compressive
strength of interbody fusion constructs. Spine (Phila
Pa 1976). 2000; 25(9):1077-84.
90. Uchida K, Kobayashi S, Nakajima H, Kokubo Y, Yayama
T, Sato R, et al. Anterior expandable strut cage
replacement for osteoporotic thoracolumbar vertebral
collapse. J Neurosurg Spine. 2006; 4(6):454-62.