USE OF TERIPARATIDE IN SURGICAL PLANNING FOR PATIENTS WITH OSTEOPOROSIS

JORDAN, RICARDO CEPEDA; BAZáN, PEDRO LUIS; ADARO, JOSé CARLOS SORIA

doi:10.1590/S1808-185120222203270489

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SYSTEMATIC REVIEW • Coluna/Columna 22 (3) • 2023 • https://doi.org/10.1590/S1808-185120222203270489 copy

USE OF TERIPARATIDE IN SURGICAL PLANNING FOR PATIENTS WITH OSTEOPOROSIS

USO DE TERIPARATIDA NO PLANEJAMENTO CIRÚRGICO DE PACIENTE COM OSTEOPOROSE

USO DE TERIPARATIDA EN LA PLANIFICACIÓN QUIRÚRGICA EN PACIENTES CON OSTEOPOROSIS

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Currently, there are no guidelines for treating osteoporosis in spinal surgery. The rate of complications such as screw loosening, proximal junction kyphosis, cage subsidence, and loss of reduction in fractures is high. Objective: To evaluate the use of teriparatide and denosumab in planning spinal surgery in an osteoporotic patient with degenerative pathology, emphasizing the fusion rate, bone mineral density, and decreased complications. Method: A systematic search was performed in medical reference databases for comparative studies of teriparatide and denosumab in spinal surgery to evaluate fusion, screw loosening, bone mineral density, and decrease in the incidence of vertebral fractures. χ²2 McCoy S, Tundo F, Chidambaram S, Baaj AA. Clinical considerations for spinal surgery in the osteoporotic patient: A comprehensive review. Clin Neurol Neurosurg. 2019;180:40-7. doi:10.1016/j.clineuro.2019.03.010.
https://doi.org/10.1016/j.clineuro.2019.... was implemented for the statistical analysis, according to PRISMA (2020). Result: Fusion rate with teriparatide was 79.28% in the first six months, 95% CI (OR 2.62) and decreased screw loosening rate 81.9% 95% CI (OR 0.6). Increase in bone mineral density 15.5% OR 1.49 (0.77 - 2.86) and decrease in vertebral fracture rate 85.4% OR 0.5. Conclusions: Teriparatide and denosumab should be considered in perioperative spinal planning due to their effectiveness, synergism, and low adverse effects; to improve bone mineral density and decrease the rate of complications. Clinical, comparative, and statistically significant studies are required to confirm this. Level of Evidence II; Systematic Review and Meta-analysis.

Keywords:
Osteoporosis; Surgical Procedures; Operative; Spine; Teriparatide; Denosumab

Author (year)	Sample (n)	Synthesis	Conclusions	Type
Cho (2017)⁹9 Cho PG, Ji GY, Shin DA, Ha Y, Yoon DH, Kim KN. An effect comparison of teriparatide and bisphosphonate on posterior lumbar interbody fusion in patients with osteoporosis: a prospective cohort study and preliminary data. Eur Spine J. 2017;26(3):691-7. doi:10.1007/s00586-015-4342-y. https://doi.org/10.1007/s00586-015-4342-...	47	Evaluation and comparison of teriparatide vs. PLIF bisphosphonate efficacy	Teriparatide increases the rate of early fusion (6m) and bone formation concerning alendronate. Teriparatide 20 micrograms daily for one-year pop fusion 89%.	Cohort R
Tsai (2016)¹¹11 Tsai JN, Uihlein AV, Burnett-Bowie SM, Neer RM, Derrico NP, Lee H, et al. Effects of two years of teriparatide, denosumab, or both on bone microarchitecture and strength (DATA-HRpQCT study). J Clin Endocrinol Metab. 2016;101(5):2023-30. doi:10.1210/jc.2016-1160. https://doi.org/10.1210/jc.2016-1160...	94	Bone formation efficacy of teriparatide, denosumab, and their combination in osteoporosis.	Combining teriparatide and denosumab improves bone architecture in osteoporotic patients concerning individual pharmacological management. Teriparatide 20 mcg/day	Randomized controlled clinical trial. R
Inoue (2014)¹³13 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. J Neurosurg Spine. 2014;21(3):425-31. doi:10.3171/2014.5.SPINE13656. https://doi.org/10.3171/2014.5.SPINE1365...	29	To evaluate the effect of teriparatide on screw torque in fusion surgery patients with osteoporosis.	Administration of teriparatide one month before surgery improves screw torque at fusion.	Cohort . R
Kim (2018)¹⁴14 Kim JW, Park SW, Kim YB, Ko MJ. The effect of postoperative use of teriparatide reducing screw loosening in osteoporotic patients. J Korean Neurosurg Soc. 2018;61(4):494-502. doi:10.3340/jkns.2017.0216. https://doi.org/10.3340/jkns.2017.0216...	84	To determine the effect of teriparatide vs. bisphosphonates on screw loosening in spinal surgery in the osteoporotic patient.	Teriparatide significantly decreases screw loosening by 2.3% vs. bisphosphonates 9.2% p<0.05. Dose 20 mcg/day for six months pop.	Case study. R
Oba (2020)¹⁵15 Oba H, Takahashi J, Yokomichi H, Hasegawa T, Ebata S, Mukaiyama K, et al. Weekly teriparatide versus bisphosphonate for bone union during 6 months after multi-level lumbar interbody fusion for osteoporotic patients: A multicenter, prospective, randomized study. Spine 2020;45(13):863-71. doi:10.1097/BRS.0000000000003426. https://doi.org/10.1097/BRS.000000000000...	104	To compare multilevel fusion in osteoporosis > 50 years teriparatide vs bisphosphonates. Determine the efficacy of teriparatide in posterolateral fusion in osteoporosis.	There is an increasing trend in fusion with teriparatide 46% in the first six months concerning bisphosphonates 32%. No significant differences in multilevel lumbar fusion.	Prospective randomized multicenter clinical trial.
Ohtori (2012)¹⁶16 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. 2012;37(23):E1464-8. doi:10.1097/BRS.0b013e31826ca2a8. https://doi.org/10.1097/BRS.0b013e31826c...	57		The fusion rate with teriparatide was 82% at eight months vs. 68% at ten months with bisphosphonates in posterolateral fusion.	Prospective R
Ohtori (2013)¹⁷17 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. 2013;38(8):E487-92. doi:10.1097/BRS.0b013e31828826dd. https://doi.org/10.1097/BRS.0b013e318288...	62	To evaluate teriparatide efficacy of pedicle screw loosening rate.	Pedicle screw loosening rate 7 to 13% teriparatide vs. 15 to 25% control, one-year p<0.05.	Prospective R
Ebata (2017)¹⁸18 Ebata S, Takahashi J, Hasegawa T, Mukaiyama K, Isogai Y, Ohba T, et al. Role of weekly teriparatide administration in osseous union enhancement within six months after posterior or transforaminal lumbar interbody fusion for osteoporosis-associated lumbar degenerative disorders: A multicenter, prospective randomized study. J Bone Joint Surg Am. 2017;99(5):365-72. doi:10.2106/JBJS.16.00230. https://doi.org/10.2106/JBJS.16.00230...	66	To evaluate bone fusion and bone formation in PLIF or TLIF with teriparatide in patients with osteoporosis by tomography.	Weekly teriparatide 20 mcg increases bone formation and fusion. Indicated for osteoporosis in patients with degenerative spinal pathology.	Prospective randomized multicenter R
Seki (2017)¹⁹19 Seki S, Hirano N, Kawaguchi Y, Nakano M, Yasuda T, Suzuki K, et al. Teriparatide versus low-dose bisphosphonates before and after surgery for adult spinal deformity in female Japanese patients with osteoporosis. Eur Spine J. 2017;26(8):2121-7. doi:10.1007/s00586-017-4959-0. https://doi.org/10.1007/s00586-017-4959-...	58	To evaluate complications in spinal surgery by administering teriparatide and low doses of bisphosphonates.	Perioperative teriparatide decreases complications and maintains the fusion rate more effectively than bisphosphonates in osteoporotic patients with spinal deformity. Screw loosening 0.009, adjacent vertebral fracture 0.00007.	Prospective R
Ide (2018)¹⁰10 Ide M, Yamada K, Kaneko K, Sekiya T, Kanai K, Higashi T, et al. Combined teriparatide and denosumab therapy accelerates spinal fusion following posterior lumbar interbody fusion. Orthop Traumatol Surg Res. 2018;104(7):1043-8. doi:10.1016/j.otsr.2018.07.015. https://doi.org/10.1016/j.otsr.2018.07.0...	16	Evaluating lumbar spinal fusion in osteoporosis with the addition of denosumab to teriparatide.	There is an increase in the rate of spinal fusion and bone formation with the combination of teriparatide and denosumab six months after surgery, p < 0.05.	Prospective randomized clinical trial R
Ebina (2017)²⁰20 Ebina K, Hashimoto J, Kashii M, Hirao M, Kaneshiro S, Noguchi T, et al. The effects of switching daily teriparatide to oral bisphosphonates or denosumab in patients with primary osteoporosis. J Bone Miner Metab. 2017;35(1):91-98.	78	To evaluate the fusion and increase in bone mineral density of teriparatide associated with denosumab and bisphosphonates.	Denosumab associated with teriparatide increases bone mineral density by 6.2 vs. 2.6% concerning bisphosphonates and teriparatide and decreases the rate of bone resorption.	Observational R
Tseng (2012)²¹21 Tseng YY, Su CH, Lui TN, Yeh YS, Yeh SH. Prospective comparison of the therapeutic effect of teriparatide with that of combined vertebroplasty with antiresorptive agents for the treatment of new-onset adjacent vertebral compression fracture after percutaneous vertebroplasty. Osteoporos Int. 2012;23(5):1613-22. doi:10.1007/s00198-011-1730-y. https://doi.org/10.1007/s00198-011-1730-...	50	To evaluate the use of teriparatide alone vs. vertebroplasty plus bisphosphonates in managing vertebral fractures adjacent to previous vertebroplasty for osteoporosis.	Patients treated with teriparatide had a 78.5% decrease in vertebral fractures (post vertebroplasty) odds ratio=0.21; 95% CI l, 0.02-2.10) with VAS (visual analog scale) decrease at six months P < 0.05, concerning the combination of new vertebroplasty and bisphosphonates.	Prospective randomized comparative R
Kaliya-Perumal (2016)²²22 Kaliya-Perumal AK, Lu ML, Luo CA, Tsai TT, Lai PL, Chen LH, et al. Retrospective radiological outcome analysis following teriparatide use in elderly patients undergoing multilevel instrumented lumbar fusion surgery. Medicine. 2017;96(5):e5996. doi:10.1097/MD.0000000000005996. https://doi.org/10.1097/MD.0000000000005...	62	To evaluate the effectiveness of teriparatide in multilevel lumbar fusion in patients with osteoporosis concerning placebo.	Teriparatide in posterolateral multilevel fusion increased the fusion rate by 16.7% and decreased loosening by 11% concerning the control group.	Observational, controlled, retrospective R
Ushirozako (2018)²³23 Ushirozako H, Hasegawa T, Ebata S, Oba H, Ohba T, Mukaiyama K, et al. Weekly Teriparatide Administration and Preoperative Anterior Slippage of the Cranial Vertebra next to Fusion Segment < 2mm Promote Osseous Union after Posterior Lumbar Interbody Fusion. Spine. 2019;44(5):E288-97. doi:10.1097/BRS.0000000000002833. https://doi.org/10.1097/BRS.000000000000...	60	To determine the predictors of lumbar fusion after PLIF.	The administration of teriparatide weekly and for six months postoperatively allows a union rate of 61% vs. 27% and bone bridging of 49% vs. 12% concerning those who did not receive it. p < 0.01.	Multi-center case-control R

		Column Fusion Rate		Total
		Appropriate Fusion	Non-union	Total
Use of Teriparatide	Patients taking teriparatide	88	23	111
Use of Teriparatide	Control. Patients who didn’t take teriparatide	55	75	130
Total		143	98	241

		Loosening rate of column bolts		Total
		With loosening	Without loosening	Total
Use of Teriparatide	Patients who took teriparatide.	21	95	116
Use of Teriparatide	Control. Patients who didn’t take teriparatide	45	85	130
Total		66	180	246

		Bone mineral density		Total
		With increased bone mineral density	No increase in bone mineral density	Total
Drug use	Patients who took teriparatide	5	28	33
Drug use	Patients who took bisphosphonates	4	47	51
Total		9	75	84

		Vertebral Fracture Rate		Total
		Presence of vertebral fracture	No vertebral fracture	Total
Drug use	Patients who took teriparatide	8	47	55
Drug use	Patients who took Bifosfonatos	17	30	47
Total		25	77	102

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[1] All authors declare no potential conflict of interest related to this article.