Complication Trends and Costs of Surgical Management in 11,086 Osteoporotic Patients Receiving Lumbar Fusion

Shane Shahrestani, MS; Xiao T. Chen, BA; Alexander M. Ballatori, BA; Andy Ton, BS; Joshua Bakhsheshian, MD; Raymond J. Hah, MD; Jeffrey C. Wang, MD; Zorica Buser, PhD


Spine. 2021;46(21):1478-1484. 

In This Article

Abstract and Introduction


Study Design: Retrospective cohort study.

Objective: The aim of this study was to compare different aspects of fusion surgery in patients with osteoporosis with regard to graft subtype and surgical approach.

Summary of Background Data: Osteoporosis and chronic lower back pain are common in elderly populations and significantly increase the risk of compression fractures within the spine.

Methods: Using the 2016–2017 National Readmission Database we identified 11,086 osteoporotic patients who received lumbar fusion using ICD-10 coding. Information regarding biologic graft type and surgical approach was collected. Patients were stratified by number of levels fused. Perioperative complications were collected at 30-, 90-, and 180-day follow-up intervals. Statistical analysis included univariate testing and multivariate regression modeling, controlling for patient demographics and comorbidities.

Results: Patients receiving single-level fusion with autologous grafts had higher rates of hardware failure (P = 0.00014) at 30-day follow-up and 90-day follow-up (P < 0.0001) and higher rates of lumbar vertebral fractures at 90-day follow-up (P = 0.045) compared to those treated with nonautologous grafts. Patients receiving lumbar fusion with anterior and posterior approaches had no difference in readmission or infection rates, but the anterior approach was associated with a higher cost.

Conclusion: In this study, osteoporotic patients treated with autologous grafts had higher rates of complications compared to those treated with nonautologous grafts. Anterior and posterior approaches had similar complication rates; however, the anterior approach was associated with a higher total cost.

Level of Evidence: 4


Osteoporosis involves degradation in bone architecture, resulting in decreased bone density and increased risk of fracture.[1] Deterioration of the bone can be detected with dual-energy x-ray absorptiometry (DEXA) scanning, with the diagnostic threshold for osteoporosis set at t scores ≤−2.5.[2] Within the United States, 3% to 10% of adults older than 50 years are diagnosed with osteoporosis involving the lumbar spine, with females being affected three- to four-fold more frequently than males.[3,4] The osteoporotic burden is expected to increase as the proportion of older adults nationally continues to rise. The annual incidence of osteoporotic vertebral fractures in North American women older than 50 years is expected to reach 20% to 24%.[5]

Patients with spinal osteoporosis often report high rates of chronic lower back pain (LBP) resulting from vertebral body deformation, spinal cord compression, or fracture.[6–8] Although some individuals experiencing chronic LBP are candidates for lumbar spine fusion surgery, osteoporotic patients receive lumbar fusion procedures less frequently as a result of poor vertebral bone stock and high perioperative complication risks.[9–12] However, clear guidelines for osteoporotic patient populations aimed at optimizing surgical fusion approaches and instrumentation are lacking. Such guidelines, if developed, may improve postoperative surgical outcomes in this uniquely frail cohort of patients. In the present study, we aimed to review influence of fusion type and bone graft selection on the postsurgical complications in osteoporotic patients.