For most spine surgery patients, preoperative workup follows a familiar script: bloodwork, imaging of the area to be operated on, maybe a cardiac clearance if there’s a history of heart disease. Bone health rarely makes the list.
Every fusion patient over 60 in Praveen Mummaneni, MD’s practice gets a bone density test before they ever reach the operating room, a protocol he said is still underused across spine surgery and orthopedics despite its effect on reoperation rates.
Dr. Mummaneni, professor and co-director of the University of California San Francisco Spine Center, said failed fusions are often blamed on hardware when the real cause is undiagnosed osteoporosis.
“That [device] is not really what failed,” he said. “What failed was their bone healing capacity.”
Osteoporosis affects an estimated 10 million Americans and disproportionately shows up in patients over 60 — the same population driving much of the growth in elective fusion volume as the U.S. population ages.
San Francisco’s demographics have made the issue especially visible in Dr. Mummaneni’s practice. A large population of older, retired residents north of the city, along with a high share of vegetarians and vegans, means his patients skew more osteoporotic than in many other regions, he said. Dr. Mummaneni automatically screens anyone over 60 headed for fusion, and patients don’t get on his OR schedule without a bone density test.
The test needs to be done in the right place to be useful, he said. Bone spurs in the lumbar or cervical spine can artificially inflate density readings there, masking weak vertebral bone underneath, so Dr. Mummaneni looks instead at the femoral neck of the hip and the wrist. When a bone density test isn’t available, Hounsfield units from a CT scan can serve as a rough substitute. A dual-energy X-ray absorptiometry, or DXA, scan is the standard method used to measure bone mineral density and generate the T-score physicians use to diagnose osteoporosis.
For elective cases, his team brings in an endocrinologist and starts patients on teriparatide for several months before surgery, continuing the medication for up to nine months afterward to support bone healing. Teriparatide is an anabolic agent, meaning it works by stimulating new bone formation rather than simply slowing the breakdown of existing bone, which is how many older osteoporosis drugs function. However, if a case is urgent, it doesn’t mean the patient just goes untreated. Dr. Mummaneni said he will begin the medication after surgery instead, in the hope that it still supports healing even without the preoperative runway.
Dr. Mummaneni said the gap isn’t just a physician problem. Patients are often just as unaware, with little sense of which physician to see if they’re worried about their bone health, and many arrive at his clinic never having had the conversation at all. That’s part of why he thinks the message needs a bigger platform than any one practice can give it.
“This message needs to get out,” he said, adding that it wasn’t part of his own training and still isn’t standard nationally, though he expects that to change as more fellows and residents come up learning it.
He pointed to a national spine summit meeting set for Orlando, Fla., in February 2027, which he said will devote significant time to preoperative optimization and bone health, as one step toward getting the topic into mainstream surgical education rather than treating it as a niche concern.
“Nothing ruins cost effectiveness like having a reoperation,” Dr. Mummaneni said. “So we are trying to make sure that we treat all of this osteoporosis before we get there, and we’re pretty aggressive about it.”
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