Underutilization of preoperative osteoporosis screening and treatment in a national sample of patients with adult spinal deformity

OBJECTIVE Osteoporosis contributes to mechanical complications, such as pedicle screw loosening, instrumentation failure, and pseudarthrosis, following adult spinal deformity (ASD) correction surgery. Research has shown that preoperative medical optimization of patients with osteoporosis can reduce complication rates to levels similar to those seen in patients with normal bone density. However, clinical practices for preoperative bone health optimization remain inconsistent. This study evaluates the proportion of patients with ASD meeting osteoporosis screening criteria and examines trends in preoperative screening and medical management. METHODS Patients who underwent ASD surgery from 2012 to 2022 were identified in the PearlDiver national database using multilevel spinal fusion procedure codes along with a diagnosis of ASD. Screening eligibility was determined using 2022 best practice guidelines: age ≥ 65 or < 65 years with at least one established risk factor. Trends in dual-energy x-ray absorptiometry (DEXA) screening and osteoporosis medical treatment with antiresorptive or anabolic medications were compared between two time periods: 2012–2016 and 2017–2022. Bonferroni correction, with a significance threshold of p < 0.0014, was used for time period comparisons. RESULTS A total of 101,935 patients (61.7% female, mean age 62.1 ± 13.4 years) who underwent ASD surgery were included, of whom 17.0% had ≥ 7 segments fused. The percentage of patients meeting osteoporosis screening criteria increased from 70.2% (2012–2016) to 81.1% (2017–2022) (p < 0.001). Among patients aged 50–64 years, screening eligibility rose significantly from 55.9% to 75.4% between the two time periods (p < 0.001), with current smoking, vitamin D deficiency, and metabolic bone disease as common risk factors. Despite this, DEXA screening rates remained low and did not significantly increase (15.8% to 16.2%, p = 0.146) over the study period. Preoperative osteoporosis diagnosis rates increased from 13.4% to 17.0% (p < 0.001), yet no change was observed in the already low rates of preoperative (14.9% to 13.7%, p = 0.035) and postoperative (13.3% to 11.6%, p = 0.002) medical management in patients with osteoporosis. CONCLUSIONS Although there is increasing recognition of the negative impact of osteoporosis on surgical outcomes and evidence supporting the benefits of preoperative optimization, rates of preoperative screening and treatment have not shown significant improvement. Addressing this issue would benefit from collaborative efforts, such as national initiatives, bone health optimization clinics, and endorsement of standardized guidelines by orthopedic and spine societies. Future research could focus on engaging ASD-focused surgeons to better understand the barriers to osteoporosis screening and preoperative medical management faced by both clinicians and patients.