Browse > Article
http://dx.doi.org/10.3340/jkns.2017.0216

The Effect of Postoperative Use of Teriparatide Reducing Screw Loosening in Osteoporotic Patients  

Kim, Jae Wook (Department of Neurosurgery, Chung-Ang University Hospital)
Park, Seung Won (Department of Neurosurgery, Chung-Ang University Hospital)
Kim, Young Baeg (Department of Neurosurgery, Chung-Ang University Hospital)
Ko, Myeong Jin (Department of Neurosurgery, Chung-Ang University Hospital)
Publication Information
Journal of Korean Neurosurgical Society / v.61, no.4, 2018 , pp. 494-502 More about this Journal
Abstract
Objective : The loosening of pedicle screws (PS) is one of the frequent problems of spinal surgery in the patients with osteoporosis. Previous studies had revealed that intermittent injection of teriparatide could reduce PS loosening by improving bone mass and quality when their patients took parathyroid hormone for a considerable duration before surgery. However, although the teriparatide is usually used after spine surgery in most clinical situations, there was no report on the efficacy of teriparatide treatment started after spine surgery. The purpose of this retrospective study was to examine the efficacy of teriparatide treatment started immediately after lumbar spinal surgery to prevent pedicle screw loosening in patients with osteoporosis. Methods : We included 84 patients with osteoporosis and degenerative lumbar disease who underwent transforaminal interbody fusion and PS fixation and received parathyroid hormone or bisphosphonate (BP) postoperatively. They were divided into teriparatide group (daily injection of $20{\mu}g$ of teriparatide for 6 months, 33 patients, 172 screws) and BP group (weekly oral administration of 35 mg of risedronate, 51 patients, 262 screws). Both groups received calcium (500 mg/day) and cholecalciferol (1000 IU/day) together. The screw loosening was evaluated with simple radiographic exams at 6 and 12 months after the surgery. We counted the number of patients with PS loosening and the number of loosened PS, and compared them between the two groups. Clinical outcomes were evaluated using visual analog scale (VAS) and Oswestry disability index (ODI) preoperatively, and at 12 months after surgery. Results : There was no significant difference in the age, sex, diabetes, smoking, bone mineral density, body mass index, and the number of fusion levels between the two groups. The number of PS loosening within 6 months after surgery did not show a significant difference between the teriparatide group (6.9%, 12/172) and the BP group (6.8%, 18/272). However, during 6-12 months after surgery, it was significantly lower in the teriparatide group (2.3%, 4/172) than the BP group (9.2%, 24/272) (p<0.05). There was no significant difference in the number of patients showing PS loosening between the teriparatide and BP groups. The teriparatide group showed a significantly higher degree of improvement of the bone mineral density (T-score) than that of BP group (p<0.05). There was no significant difference in the pre- and post-operative VAS and ODI between the groups. Conclusion : Our data suggest that the teriparatide treatment starting immediately after lumbar spinal fusion surgery could reduce PS loosening compared to BP.
Keywords
Parathyroid hormone; Teriparatide; Spinal fusion;
Citations & Related Records
연도 인용수 순위
  • Reference
1 Abe Y, Takahata M, Ito M, Irie K, Abumi K, Minami A : Enhancement of graft bone healing by intermittent administration of human parathyroid hormone (1-34) in a rat spinal arthrodesis model. Bone 41 : 775-785, 2007   DOI
2 Arlot M, Meunier PJ, Boivin G, Haddock L, Tamayo J, Correa‐Rotter R, et al. : Differential effects of teriparatide and alendronate on bone remodeling in postmenopausal women assessed by histomorphometric parameters. J Bone Miner Res 20 : 1244-1253, 2005   DOI
3 Bothmann M, Kast E, Boldt GJ, Oberle J : Dynesys fixation for lumbar spine degeneration. Neurosurg Rev 31 : 189-196, 2008   DOI
4 Bransford R, Goergens E, Briody J, Amanat N, Cree A, Little D : Effect of zoledronic acid in an L6-L7 rabbit spine fusion model. Eur Spine J 16 : 557-562, 2007   DOI
5 Chin DK, Park JY, Yoon YS, Kuh SU, Jin BH, Kim KS, et al. : Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease. Osteoporos Int 18 : 1219- 1224, 2007   DOI
6 Cook SD, Salkeld SL, Whitecloud TS 3rd, Barbera J : Biomechanical evaluation and preliminary clinical experience with an expansive pedicle screw design. J Spinal Diso 13 : 230-236, 2000   DOI
7 Dakhil-Jerew F, Jadeja H, Cohen A, Shepperd JA : Inter-observer reliability of detecting Dynesys pedicle screw using plain X-rays: a study on 50 post-operative patients. Eur Spine J 18 : 1486-1493, 2009   DOI
8 Dempster DW, Cosman F, Kurland ES, Zhou H, Nieves J, Woelfert L, et al. : Effects of daily treatment with parathyroid hormone on bone microarchitecture and turnover in patients with osteoporosis: a paired biopsy study. J Bone Miner Res 16 : 1846-1853, 2001   DOI
9 Fisher JE, Rogers MJ, Halasy JM, Luckman SP, Hughes DE, Masarachia PJ, et al. : Alendronate mechanism of action: geranylgeraniol, an intermediate in the mevalonate pathway, prevents inhibition of osteoclast formation, bone resorption, and kinase activation in vitro. Proc Natl Acad Sci U S A 96 : 133-138, 1999   DOI
10 DeWald CJ, Stanley T : Instrumentation-related complications of mul- tilevel fusions for adult spinal deformity patients over age 65: surgical considerations and treatment options in patients with poor bone quality. Spine (Phila Pa 1976) 31(19 Suppl) : S144-S151, 2006   DOI
11 Flahiff CM, Gober GA, Nicholas RW : Pullout strength of fixation screws from polymethylmethacrylate bone cement. Biomaterials 16 : 533- 536, 1995   DOI
12 Gaines RW Jr : The use of pedicle-screw internal fixation for the operative treatment of spinal disorders. J Bone Joint Surg Am 82 : 1458- 1458, 2000   DOI
13 Graeff C, Timm W, Nickelsen TN, Farrerons J, Marín F, Barker C, et al. : Monitoring teriparatide‐associated changes in vertebral microstructure by high‐resolution CT in vivo: results from the EUROFORS study. J Bone Miner Res 22 : 1426-1433, 2007   DOI
14 Halvorson TL, Kelley LA, Thomas KA, Whitecloud TS 3rd, Cook SD : Effects of bone mineral density on pedicle screw fixation. Spine (Phila Pa 1976) 19 : 2415-2420, 1994   DOI
15 Heinemann DF : Osteoporosis. An overview of the National Osteoporosis Foundation clinical practice guide. Geriatrics 55 : 31-36; quiz 39, 2000
16 Keaveny TM, Donley DW, Hoffmann PF, Mitlak BH, Glass EV, San Martin JA : Effects of teriparatide and alendronate on vertebral strength as assessed by finite element modeling of QCT scans in women with osteoporosis. J Bone Miner Res 22 : 149-157, 2007
17 Inoue G, Ueno M, Nakazawa T, Imura T, Saito W, Uchida K, et al. : Teriparatide increases the insertional torque of pedicle screws during fusion surgery in patients with postmenopausal osteoporosis: Clinical article. J Neurosurg Spine 21 : 425-431, 2014   DOI
18 Jakob F, Oertel H, Langdahl B, Ljunggren O, Barrett A, Karras D, et al. : Effects of teriparatide in postmenopausal women with osteoporosis pretreated with bisphosphonates: 36-month results from the European Forsteo Observational Study. Eur J Endocrinol 166 : 87-97, 2012   DOI
19 Jiang Y, Zhao JJ, Mitlak BH, Wang O, Genant HK, Eriksen EF : Recombinant human parathyroid hormone (1-34) [teriparatide] improves both cortical and cancellous bone structure. J Bone Miner Res 18 : 1932- 1941, 2003   DOI
20 Kanis JA : Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359 : 1929-1936, 2002   DOI
21 Lee JH, Lee JH, Park JW, Shin YH : The insertional torque of a pedicle screw has a positive correlation with bone mineral density in posterior lumbar pedicle screw fixation. J Bone Joint Surg Br 94 : 93-97, 2012   DOI
22 Lehman RA Jr, Dmitriev AE, Cardoso MJ, Helgeson MD, Christensen CL, Raymond JW, et al. : Effect of teriparatide [rhPTH(1, 34)] and calcitonin on intertransverse process fusion in a rabbit model. Spine (Phila Pa 1976) 35 : 146-152, 2010   DOI
23 Moore DC, Maitra RS, Farjo LA, Graziano GP, Goldstein SA : Restoration of pedicle screw fixation with an in situ setting calcium phosphate cement. Spine (Phila Pa 1976) 22 : 1696-1705, 1997   DOI
24 Lehman RA Jr, Kang DG, Wagner SC : Management of osteoporosis in spine surgery. J Am Acad Orthop Surg 23 : 253-263, 2015   DOI
25 Lehman RA Jr, Kuklo TR, Freedman BA, Cowart JR, Mense MG, Riew KD : The effect of alendronate sodium on spinal fusion: a rabbit model. Spine J 4 : 36-43, 2004   DOI
26 Lei W, Wu Z : Biomechanical evaluation of an expansive pedicle screw in calf vertebrae. Eur Spine J 15 : 321-326, 2006   DOI
27 Luk KD, Chen L, Lu WW : A stronger bicortical sacral pedicle screw fixation through the s1 endplate: an in vitro cyclic loading and pull-out force evaluation. Spine (Phila Pa 1976) 30 : 525-529, 2005   DOI
28 McClung MR, San Martin J, Miller PD, Civitelli R, Bandeira F, Omizo M, et al. : Opposite bone remodeling effects of teriparatide and alendronate in increasing bone mass. Arch Intern Med 165 : 1762-1768, 2005   DOI
29 Murad MH, Drake MT, Mullan RJ, Mauck KF, Stuart LM, Lane MA, et al. : Clinical review. Comparative effectiveness of drug treatments to prevent fragility fractures: a systematic review and network meta-analysis. J Clin Endocrinol Metab 97 : 1871-1880, 2012   DOI
30 Nagahama K, Kanayama M, Togawa D, Hashimoto T, Minami A : Does alendronate disturb the healing process of posterior lumbar interbody fusion? A prospective randomized trial: clinical article. J Neurosurg Spine 14 : 500-507, 2011   DOI
31 Ozawa T, Takahashi K, Yamagata M, Ohtori S, Aoki Y, Saito T, et al. : Insertional torque of the lumbar pedicle screw during surgery. J Orthop Sci 10 : 133-136, 2005   DOI
32 Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY, et al. : Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 344 : 1434-1441, 2001   DOI
33 O’Loughlin PF, Cunningham ME, Bukata SV, Tomin E, Poynton AR, Doty SB, et al. : Parathyroid hormone (1-34) augments spinal fusion, fusion mass volume, and fusion mass quality in a rabbit spinal fusion model. Spine (Phila Pa 1976) 34 : 121-130, 2009   DOI
34 Ohtori S, Inoue G, Orita S, Yamauchi K, Eguchi Y, Ochiai N, et al. : Teriparatide accelerates lumbar posterolateral fusion in women with postmenopausal osteoporosis: prospective study. Spine (Phila Pa 1976) 37 : E1464-E1468, 2012   DOI
35 Ohtori S, Inoue G, Orita S, Yamauchi K, Eguchi Y, Ochiai N, et al. : Comparison of teriparatide and bisphosphonate treatment to reduce pedicle screw loosening after lumbar spinal fusion surgery in postmenopausal women with osteoporosis from a bone quality perspective. Spine (Phila Pa 1976) 38 : E487-E492, 2013   DOI
36 Okuyama K, Abe E, Suzuki T, Tamura Y, Chiba M, Sato K : Can insertional torque predict screw loosening and related failures? An in vivo study of pedicle screw fixation augmenting posterior lumbar interbody fusion. Spine (Phila Pa 1976) 25 : 858-864, 2000   DOI
37 Sanden B, Olerud C, Petren-Mallmin M, Johansson C, Larsson S : The significance of radiolucent zones surrounding pedicle screws. Definition of screw loosening in spinal instrumentation. J Bone Joint Surg Br 86 : 457-461, 2004
38 Pfeiffer M, Gilbertson LG, Goel VK, Griss P, Keller JC, Ryken TC, et al. : Effect of specimen fixation method on pullout tests of pedicle screws. Spine (Phila Pa 1976) 21 : 1037-1044, 1996   DOI
39 Quon JA, Sobolev BG, Levy AR, Fisher CG, Bishop PB, Kopec JA, et al. : The effect of waiting time on pain intensity after elective surgical lumbar discectomy. Spine J 13 : 1736-1748, 2013   DOI
40 Rajzbaum G, Grados F, Evans D, Liu-Leage S, Petto H, Augendre-Ferrante B : Treatment persistence and changes in fracture risk, back pain, and quality of life amongst patients treated with teriparatide in routine clinical care in France: results from the European Forsteo Observational Study. Joint Bone Spine 81 : 69-75, 2014   DOI
41 Sawakami K, Yamazaki A, Ishikawa S, Ito T, Watanabe K, Endo N : Polymethylmethacrylate augmentation of pedicle screws increases the initial fixation in osteoporotic spine patients. J Spinal Disord Tech 25 : E28- E35, 2012   DOI
42 Wu ZX, Gong FT, Liu L, Ma ZS, Zhang Y, Zhao X, et al. : A comparative study on screw loosening in osteoporotic lumbar spine fusion between expandable and conventional pedicle screws. Arch Orthop Trauma Surg 132 : 471-476, 2012   DOI
43 Tu CW, Huang KF, Hsu HT, Li HY, Yang SS, Chen YC : Zoledronic acid infusion for lumbar interbody fusion in osteoporosis. J Surg Res 192 : 112-116, 2014   DOI
44 Wray S, Mimran R, Vadapalli S, Shetye SS, McGilvray KC, Puttlitz CM : Pedicle screw placement in the lumbar spine: effect of trajectory and screw design on acute biomechanical purchase. J Neurosurg Spine 22 : 503-510, 2015   DOI
45 Wu J, Huang W, Tsai H, Ko C, Wu C, Tu T, et al. : Pedicle screw loosening in dynamic stabilization: incidence, risk, and outcome in 126 patients. Neurosurg Focus 31 : E9, 2011