New Study Predicts Post-Op Spine Complications

Wait, we are using a preop risk assessment for thoracic and lumbar fusions that lacks bone quality information? Yep…but perhaps that is changing.

New work from the Twin Cities Spine Center in Minnesota and Loma Linda University Medical Center in California has found that adding bone health information “significantly” improved the predictive ability to predict complications.

The study, “Adding Vertebral Bone Quality to the Fusion Risk Score: Does It Improve Predictions of Postoperative Complications?” was published in the July 1, 2024, edition of Spine.

“The Fusion Risk Score was introduced by Hartin et al. [here] at the Twin Cities Spine Center in 2013 as a method of objectively quantifying the risk of postoperative complications in patients undergoing thoracic and lumbar fusion surgery,” explained co-author Omar Ramos, M.D.

“It was later validated by Deogaonkar et al. in 2018. The Vertebral Bone Quality score was presented in 2019 by Ehresman et al. as a tool to assess bone quality using a lumbar MRI and predict vertebral compression fractures in patients with spinal metastasis. Since then, multiple studies have reported on the use of the Vertebral Bone Quality score to assess bone quality in the lumbar, thoracic, and cervical spine.”

According to Ramos and his colleagues, dual-energy x-ray absorptiometry overestimates bone quality in patients with spinal degenerative disease and obesity. As a result, he and his colleagues opted for an MRI–based technique to assess bone quality. (This is practical as MRI is already part of the standard preoperative workup.)

For this study, the researchers collected data from 353 patients who had elective thoracic and lumbar spinal fusion from January 2019 to June 2020.

The resulting data, said Ramos, clearly favored incorporating the Vertebral Bone Quality score into the Fusion Risk Score. Indeed, the resulting synergies significantly improved the surgeon’s ability to predict bone quality, and, notably, the risk of reoperation.

“Using both scores offered better predictive ability for major and minor adverse events than did use of the Fusion Risk Score alone.”

“A higher Vertebral Bone Quality score,” explained Dr. Ramos, “correlates to lower bone quality and higher risk of osteopenia or osteoporosis being present. In these patients, a quantitative CT or DXA [dual-energy x-ray absorptiometry] scan should be obtained to formally evaluate for the presence of osteoporosis, and if present, treatment should be initiated to minimize the risks associated with spine surgery in the osteoporotic patient, such as hardware-related complications, fractures, etc.”

The authors emphasize the importance of understanding a patient’s preoperative bone quality as it opens up opportunities for optimization before surgery and may influence surgical planning as well as surgical outcomes.

“Further study is needed to find the exact Vertebral Bone Quality score that best correlates with the presence of osteopenia and osteoporosis as different publications have found different thresholds,” said Dr. Ramos to OTW. “Also, although the Vertebral Bone Quality score shows promise in the assessment of vertebral bone quality, quantitative CT of the spine remains a much more reliable option in the assessment of the bone quality preoperatively.”