The Effect of Teriparatide in Women with Osteoporosis after Lumbar Posterolateral Fusion or Posterior Lumbar Interbody Fusion

Jeong Ho Seo; Kyu Yeol Lee; Min-Woo Kim

doi:10.4184/jkss.2015.22.3.82

Journal List > J Korean Soc Spine Surg > v.22(3) > 1076083

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Seo, Lee, and Kim: The Effect of Teriparatide in Women with Osteoporosis after Lumbar Posterolateral Fusion or Posterior Lumbar Interbody Fusion

Original Article

Journal of Korean Spine Surg 2015;22(3):82-82.

Published online: 21 September 2015

DOI: https://doi.org/10.4184/jkss.2015.22.3.82

The Effect of Teriparatide in Women with Osteoporosis after Lumbar Posterolateral Fusion or Posterior Lumbar Interbody Fusion

Jeong Ho Seo, M.D., Kyu Yeol Lee, M.D., Ph.D., Min-Woo Kim, M.D.

Department of Orthopedic Surgery, College of Medicine, Dong A University

Corresponding author: Kyu Yeol Lee, M.D. Department of Orthopedic Surgery, College of Medicine, Dong-A University, 1, Dongdaesin-dong 3-ga, Seo-gu, Busan 602-715, Korea TEL: +82-51-240-2867, FAX: +82-51-243-9764 E-mail: gylee@dau.ac.kr

Received 2 July 2015 Revised 3 July 2015 Accepted 28 July 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

Retrospective study.

Objectives

To investiggaate radiologic aannd clinicaall outcomes of teripa.ratide in women with osteoporosis afafer instrume.nted lu.mbambar posterolateral fusion (PLF) or posterior lumbar interbody fusion (PLIF).

Summary of Literature Review

Summary of Literature Review: Teriparatide accelerated lumbar posterolateral fusion in women with postmenopausal osteoporosis. Materials and Methods: Eigh ty-six women older than 65 years old with osteoporosis underwent PLF or PLIF with bone graf t between Februar, 2011 ato May, 2012 pPatients were divided into four group: teriparatide group with local bone (A-1: 13 patients;, teriparatide group with composite bone (A-2: 27 patients; non-teriparatide group with local bone (B-1: 14 patients; and non-teriparatide group with composite bone (B-2: 32 patients). At 3, 6, and 12 months postoperatively, the Oswestry Disability Index (ODI), visual analog scale (VAS), fusion rate, and period of bone union were evaluated.

Results

VAS and ODI improved after surgery in all groups, but no significant differences were notell among the groupses Further, there was no sign ifican t diff erence am ong the groups for age fusion level, and fusiops(p>0.05). Fusion rate was 94.44% in the A-1 group, 92.59% in the A-2 group, 79.17% in the B-1 group, and 76.92% in the B-2 group. Average period of bone union was 3.25 months, 3.65 months, 5.67 months, and 5.65 months respectively. Fusion rate and averag e bone union time ma de no sign ifican t diff ereneen am ong the groups divided by graft materials (p>0.05). However, those in the teriparatide group were significantly superior to those in the nonteriparatide group (p<0.05).

Conclusions

In women with osteoporosis after PLF or PLIF with bonegraft, teriparatide showed superiority in the rate of fusion and the period of bone union.

Keywords: Teriparatide, Posterolateral fusion, Posterior lumbar interbody fusion, Osteoporosis, Parathyroid hormone

REFERENCES

1. Cohen DB, Chotivichit A, Fujita T, et al. Pseudoarthrosis repair. autogenous iliac crest versus femoral ring allograft. Clin Orthop Relat Res. 2000; 371:46–55.

2. Fischgrund JS, Mackay M, Herkowitz HN, et al. 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine (Phila Pa 1976). 1997; 22:2807–12.

3. Weinstein MA, McCabe JP, Cammisa FP Jr. Postoperative spinal wound infection: a review of 2,391 consecutive index procedures. J Spinal Disord. 2000; 13:422–6.

4. Rawlins BA, Michesen CB. Failed lumbosacral fusions: state of the art review. Spine (Phila Pa 1976). 1994; 8:563–71.

5. Miyazaki M, Tsumura H, Wang JC, et al. An update on bone substitutes for spinal fusion. Eur Spine J. 2009; 18:783–99.

6. Aspenberg P, Genant HK, Johansson T, et al. Teriparatide for acceleration of fracture repair in humans: a prospective, randomized, double-blind study of 102 postmenopausal women with distal radial fractures. J Bone Miner Res. 2010; 25:404–14.

7. Lindsay R, Nieves J, Formica C, et al. Randomized controlled study of effect of parathyroid hormone on vertebral bone mass and fracture incidence among postmenopausal women on estrogen with osteoporosis. Lancet. 1997; 350:550–5.

8. Alkhiary YM, Gerstenfeld LC, Krall E, et al. Enhancement of experimental fracture-healing by systemic administration of recombinant human parathyroid hormone (PTH 1-34). J Bone Joint Surg. Am. 2005; 87:731–41.

9. Aspenberg P, Johansson T. Teriparatide improves early callus formation in distal radial fractures. Acta Orthop. 2000; 81:234–6.

10. Seiji Ohtori, Gen Inoue, Sumihisa Orita, et al. Teriparatide accelerates lumbar posterolateral fusion in women with postmenopausal osteoporosis. Spine (Phila Pa 1976). 2012; 37:E1464–8.

11. Tokuhashi Y, Matsuzaki H, Oda H, et al. Clinical course and significance of the clear zone around the pedicle screws in the lumbar degenerative disease. Spine (Phila Pa 1976). 2008; 8:903–8.

12. Tokuhashi Y, Nishimura T, Matsuzaki Y. Clinical results of more than 10 years after posterolateral fusion with pedicle screw fixation for degenerative lumbar spondylolisthesis. Spine (Phila Pa 1976). 2004; 17:185–92.

13. Tan JS, Singh S, Zhu QA, et al. The effect of cement aug-mentation and extension of posterior instrumentation on stabilization and adjacent level effects in the elderly spine. Spine (Phila Pa 1976). 2008; 33:2728–40.

14. Cheong US, Kim DY, Cho JL, et al. Comparison of the effect of hydroxyapatite and allogenous bone as an adjunct to autogenous iliac bone grafting in posterolateral spinal fusion. J Korean Orthop Assoc. 2008; 43:347–52.

15. Park IH, Lee KB, Song KW, et al. Donor site pain from the ilium in spinal fusion. J Korean Soc Spine Surg. 1995; 2:90–7.

16. Hu SS. Internal fixation in the osteoporotic spine. Spine (Phila Pa 1976). 1997; 22:43–8.

17. Skripitz R, Aspenberg P. Implant fixation enhanced by intermittent treatment with parathyroid hormone. J Bone Joint Surg Br. 2001; 83:437–40.

18. Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med. 2001; 344:1434–41.

19. Lehma RA Jr, Dmitriev AE, Cardoso MJ, et al. Effect of teriparatide [rhPTH(1,34)] and calcitonin on intertransverse process fusion in a rabbit model. Spine (Phila Pa 1976). 2010; 35:146–52.

20. O'Loughlin PF, Cunningham ME, Bukata SV, et al. Paramass volume, and fusion mass quality in a rabbit spinal fusion model. Spine (Phila Pa 1976). 2009; 34:121–30.

21. Abe Y, Takahata M, Ito M, et al. Enhancement of graft bone healing by intermittent administration of human parathyroid hormone (1–34) in a rat spinal arthrodesis model. Bone. 2007; 41:775–85.

22. Brodsky AE, Kovalsky ES, Khalil MA. Correlation of radiologic assessment of lumbar spine fusions with surgical exploration. Spine (Phila Pa 1976). 1991; 16:261–5.

23. Kant AP, Daum WJ, Dean SM, et al. Evaluation of lumbar spine fusion. Plain radiographs versus direct surgical exploration and observation. Spine (Phila Pa 1976). 1995; 21:2313–7.

24. Fischgrund JS, Mackay M, Herkowitz HN, et al. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine (Phila Pa 1976). 1997; 22:2807–12.

25. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. J Bone Joint Surg Am. 1991; 73:802–7.

26. Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med. 2001; 344:1434–41.

27. Bransford R, Goergens E, Briody J, et al. Effect of zoledronic acid in an L6-L7 rabbit spine fusion model. Eur Spine J. 2007; 16:557–62.

28. Nagahama K, Kanayama M, Togawa D, et al. Does alendronate disturb the healing process of posterior lumbar interbody fusion? A prospective randomized trial. J Neurosurg Spine. 2011; 14:500–7.

29. Etah S. Kurland, Samantha L. Heller, Beverly Diamond, et al. The importance of bisphosphonate therapy in maintaining bone mass in men after therapy with teriparatide. Osteoporosis Int. 2004; 15:992–7.

Figures and Tables%

Fig. 1.

At the six month foll ow- up of the 73-year-old woman with posterior lumba r fusion for spinal stenosis L4-L5, L5-S1, dynamic flexion (A) and extension (B) radiographs show less than 2˚ angular motion on L4-L5 after instrumentation withoutscrew loosening.

Fig. 2.

CT scans 6 months after surgery from a 74-year-old woman who underwent posterolateral lumbar fusion of L3-L4, L4-L5with composite bone graft of local bone and allograft. (A) An axial CT image shows big solid trabeculated bilateral fusion massformation bilaterally on L4-L5. (B) A sagittal CT image of the same patient shows continuously sufficient trabecular bone formationin the right transverse processes of L3 to L5.

Table 1.

Demographic Characteristics of the Patients

	Group A (teriparatide)			Group B (non-teriparatide)			Total	p-value
	A-1	A-2	P-value	B-1	B-2	p-value	Total	p-value
Number of patients	13	27	-	14	32	-	86	-
Mean age (year)	73.7±6.6	73.0±6.6	0.757	72.6±4.5	74.5±6.0	0.286		0.599
NSAIDs before surgery	10	23	0.519	11	29	0.264		0.565
Smoker	0	0	-	0	1	-		-
Mean BMD (T-score)	-3.1±0.8	-3.0±0.7	0.680	-2.9±0.7	-3.1±0.6	0.321		0.963
Preoperative diagnosis			0.941			0.335		0.595
Spinal stenosis	6	13		7	14		40
Spondylo -listhesis	2	5		5	7		19
Mixed	5	9		2	11		27
Pain score before surgery
*VAS	6.85±0.99	6.52±0.89	0.300	6.57±0.76	7.00±1.02	0.165		0.233
ODI	29.30±4.03	28.50±4.26	0.580	28.80±3.31	29.90±4.01	0.365		0.360
Operation
PLF	8	5	0.007	6	6	0.011	25	0.830
§PLIF + PLF	5	22		8	26		61

*VAS: Visual Analogue Scale, ODI: Oswestry Disability Index, PLF: posterolateral fusion,

§PLIF: posterior lumbar interbody fusion, - : not applicable.

Table 2.

Clinical Pain Scores of Patients

	Group A (teriparatide)		Group B (non-teriparatide)
	A-1	A-2	B-1	B-2
Visual Analogue Scale
3 months after surgery	4.62±0.961	4.29±0.869	4.71±1.069	4.50±1.295
6 months after surgery	2.46±0.660	2.81±0.921	2.46±0.967	2.90±1.088
12 months after surgery	1.69±0.630	1.59±0.797	1.93±0.829	2.00±1.164
Oswestry Disability Index
3 months after surgery	15.85±2.410	15.30±2.462	16.00±1.617	15.59±1.915
6 months after surgery	13.07±2.139	13.52±2.408	13.29±1.978	13.72±2.317
12 months after surgery	12.31±2.175	12.19±2.573	12.50±2.442	12.69±2.533

Table 3.

Multivariate Analysis

	variables	Wilks’ Lambda	F-value	df	p-value
*VAS	Age	0.958	0.757	3.000	0.523
	Numbers of fusion level	0.966	0.612	3.000	0.610
	Fusion	0.972	0.502	3.000	0.682
	Teriparatide	0.928	1.016	3.000	0.390
	Bonegraft	0.907	1.771	3.000	0.164
	Teriparatide * bone graft	0.997	0.059	3.000	0.981
ODI	Age	0.973	0.476	3.000	0.700
	Numbers of fusion level	0.994	0.110	3.000	0.954
	Fusion	0.933	1.242	3.000	0.304
	Teriparatide	0.945	0.961	3.000	0.415
	Bonegraft	0.901	1.908	3.000	0.140
	Teriparatide * bonegraft	0.990	0.169	3.000	0.917

^∗ VAS: Visual Analogue Scale, ODI: Oswestry Disability Index.

Table 4.

Tests of Between-Subjects Effect

variables	months	*VAS			ODI
variables	months	Mean square	F	p-value	Mean square	F	p-value months
Age	3 months	1.249	1.329	0.254	0.127	0.035	0.853
	6 months	0.045	0.068	0.796	1.361	0.379	0.541
	12 months	0.452	1.111	0.296	0.532	0.136	0.714
Numbers of fusion level	3 months	0.985	1.048	0.311	0.798	0.216	0.644
	6 months	0.117	0.178	0.675	0.365	0.102	0.751
	12 months	0.517	1.271	0.265	0.088	0.023	0.881
Fusion	3 months	0.154	0.163	0.688	6.530	1.771	0.189
	6 months	0.811	1.233	0.272	9.664	2.695	0.107
	12 months	0.318	0.782	0.381	8.699	2.221	0.142
Teriparatide	3 months	1.851	1.968	0.166	6.126	1.661	0.203
	6 months	1.044	1.587	0.213	0.495	0.138	0.712
	12 months	0.286	0.702	0.406	0.642	0.164	0.687
Bonegraft	3 months	0.733	0.780	0.381	5.231	1.419	0.239
	6 months	1.223	1.860	0.178	6.352	1.771	0.189
	12 months	0.669	1.644	0.205	7.001	1.787	0.187
Teriparatide * bonegraft	3 months	0.147	0.156	0.694	0.007	0.002	0.965
	6 months	0.011	0.017	0.896	0.022	0.006	0.938
	12 months	0.017	0.041	0.840	0.492	0.126	0.725

*VAS: Visual Analogue Scale, ODI: Oswestry Disability Index.

Table 5.

Evaluation of Bone Union

	Group A (teriparatide)			Group B (non-teriparatide)			Total	p-value
	A-1	A-2	p-value	B-1	B-2	p-value	Total	p-value
Numbers of fusion level			0.015			0.229		0.619
1 level	8	5		6	6		25
2 level	5	17		6	19		47
3 level	0	5		2	7		14
Total	13	27		14	32		86
Bone union on *CT, numb ers of segm ents (%)			0.976			0.987		0.009
Bilateral fusion Mass	11 (61.1)	36 (66.7)		10 (41.7)	27 (41.5)		84
Unilateral fusion Mass	6 (33.3)	14 (25.9)		9 (37.5)	23 (35.4)		52
Insufficient fusion mass	1 (5.6)	3 (5.5)		3 (12.5)	10 (15.4)		17
No fusion mass	0(0)	1 (1.9)		2 (8.3)	5 (7.7)		8
Total	18	54		24	65		161
Bone union on flextion- extension radiography, numbers of segments (%)	-y,		> 0.999			0.868		0.095
Instability (–)	17(94.44)	51 (94.44)		21(87.50)	56 (86.15)		145
Instability (+)	1 (5.56)	3 (5.56)		3 (12.50)	9 (13.85)		16
Total	18	54		24	65		161
Average period of bone union by*CT (month)	3.25±0.87	3.65±1.27	0.332	5.67±1.00	5.65±0.99	0.962		< 0.001
Bone union rate by *CT (%)	94.44	92.59	0.784	79.17	76.92	0.821		0.009

*CT: computed tomography.

TOOLS

Similar articles