As more patients taking GLP-1 medications such as Ozempic seek spine surgery, surgeons need to look beyond weight loss to consider how changes in muscle and bone quality could affect surgical outcomes, Jonathan Rasouli, MD, told Becker’s.
Dr. Rasouli, a spinal neurosurgeon at Paramus, N.J.-based NeuroSpine Plus, discussed how GLP-1 medications are changing surgical decision-making, the potential risks of muscle and bone loss, and what spine surgeons should consider as use of the drugs becomes more widespread.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: As more patients taking GLP-1 medications like Ozempic come into spine practices, how is that changing the way surgeons evaluate who is a good candidate for surgery?
Dr. Jonathan Rasouli: Extra weight used to be a simple hurdle before surgery, but now surgeons need to consider body composition and the timing of weight loss rather than just the scale. A good amount of weight loss can put someone into a safer surgical range and reduce load on the spine, and for some, their symptoms may even improve enough to discuss whether surgery is needed at all.
Along with that, though, rapid weight loss is basically a moving target, so surgeons may put a hold on operating until the weight stabilizes. Guidance for anesthesia says most people can stay on these drugs before elective surgery, with some precautions for those who are at higher risk.
Someone who comes in 50 pounds lighter may appear ideal on paper, but they have less of what that surgery needs for it to work. It’s not about how much weight was lost, but rather what was lost, because those screws have to hold into the bone, and the muscle needs to hold that corrected spine in place.
Q: Weight loss can benefit spine patients, but concerns have also emerged around muscle loss. What implications could that have for recovery and long-term outcomes after spine surgery?
JR: It depends on the bone that holds the screws in place and supports fusion, as well as the muscles that keep the spine stable afterward. These drugs can affect both, and data from a major semaglutide trial on body composition showed a large share of the weight lost was lean mass, not just fat. While that includes water and organ tissue, not just muscle, there is another concern involving bone.
In one randomized trial, those on a GLP-1 alone lost bone density in the hip and spine, though those who also added exercise didn’t. Studies connect weaker or fattier back muscles to mechanical complications after long fusions, which include the potential for the spine to collapse forward just above the hardware.
What we’re seeing is very mixed, though, since several retrospective studies found lower rates of failed fusion in GLP-1 users, which is likely tied to better blood sugar control, though at least one cervical study pointed in the other direction. None of this is randomized at this time, but it is something we should further understand.
With a long deformity correction, the screws end at a certain level, and then the muscles step in from there. So if that muscle has thinned, it’s the top where the spine will most likely fall. Someone can lose weight, get the surgery without a hitch, and still wind up back in surgery because their muscles couldn’t hold it together.
Q: Looking ahead, what do you think spine surgeons will need to do differently as GLP-1 medications become a more common part of their patients’ medical histories?
JR: GLP-1 use needs to be a standard checkpoint in every evaluation before surgery, just like we already ask about blood thinners or smoking. Muscle and bone quality should be part of the evaluation when someone is on these drugs, including checking bone density and reviewing the back muscles on prior MRIs.
There also needs to be coordination with the prescribing doctor on timing and protecting muscle and bone prior to surgery, as they can encourage resistance training and getting enough protein during weight loss.
There’s still more proof needed in all this, though, since most of the current data looks back, and what the specialty needs is prospective, procedure-specific studies.
Much of what we need before surgery is already there on the MRI, where we can see back muscle size and fat infiltration. The shift is more about intentionally reading that information for those on these drugs instead of ordering new tests.
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