Osteoporosis and low bone mineral density are among the most consequential and most frequently overlooked risk factors in elective spine surgery, and optimizing bone health before the operating room is increasingly treated as a standard of care rather than an option, according to an article written by orthopedic surgeons Atahan Durbas, MD, and Sheeraz Qureshi, MD, in the Summer 2026 issue of Vertebral Columns. Dr. Qureshi is chief medical officer for HSS Florida, part of New York City-based Hospital for Special Surgery, and Dr. Qureshi is a spine surgery research fellow at HSS.
Six things to know:
- Compromised bone quality is common and widely undiagnosed. One-third to one-half of patients presenting for instrumented spine procedures meet criteria for osteoporosis or osteopenia, Dr. Durbas and Dr. Qureshi wrote. Most are unaware of the diagnosis at the time of surgical consultation, the article said.
- Poor bone quality drives the complications that most often send patients back to surgery. Those include cage subsidence, pedicle screw loosening and pullout, pseudarthrosis, adjacent-level fracture, and proximal junctional kyphosis or failure in long constructs. The authors framed these costs, borne by patients and health systems, as significant and largely preventable.
- At-risk patients can be identified before surgery. The authors cited guidance — including from the American Academy of Orthopaedic Surgeons, the North American Spine Society and the American Orthopaedic Association’s “Own the Bone” program — that recommends screening women 65 and older, men 70 and older, and younger postmenopausal women and men ages 50-70 with risk factors. It also calls for screening any adult with a fragility fracture, prolonged glucocorticoid use, height loss or other risk factors.
- Three imaging tools anchor assessment. DEXA remains the reference standard but can be inflated by degenerative changes in the lumbar spine. Opportunistic CT Hounsfield units, with measurements at or below 110 to 120 associated with osteoporosis, and the MRI-based vertebral bone quality score, with a value of 3.0 to 3.5 or higher signaling elevated risk, offer complementary options using imaging often already collected, the authors wrote.
- Pharmacologic treatment is the most actionable step. Anabolic agents such as teriparatide, abaloparatide and romosozumab actively build bone and are preferred before instrumented surgery; teriparatide has the most extensive spine-fusion track record. Antiresorptives including bisphosphonates and denosumab slow bone loss. Most protocols recommend at least two to three months of preoperative therapy, with some consensus statements favoring three to six months when feasible, according to the authors.
- The main obstacle is operational. Spine surgeons cannot manage osteoporosis alone, and informal referrals often leave patients lost to follow-up. The authors said successful programs build a specific screening trigger into the new-patient process and a direct route to a bone health clinic, fracture liaison service or endocrinologist. They pointed to single-center data showing dedicated bone health clinics increased treatment initiation and may reduce hardware failures and revisions.
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