Assessment of the efficacy of teriparatide treatment for osteoporosis on lumbar fusion surgery outcomes: a systematic review and meta-analysis

Treatment of osteoporosis with medications like teriparatide, a parathyroid hormone, is known to improve bone density and reduce the risk of osteoporotic vertebral fractures. Anecdotal and limited surgical series have described the utility of this treatment for osteoporotic patients prior to spinal fusion surgery, but there is variability in adoption of this strategy as well as consensus regarding optimal treatment duration before and after surgery. In this study, the clinical results of the use of teriparatide for this application are reviewed and critically examined. We conducted a systematic review of electronic databases using different MeSH terms from 1980 to 2020. Pooled and subgroup analyses were performed using fixed and random effect models based upon the heterogeneity (I-2). The results were reported as either mean difference (MD) or odds ratio (OR) with 95% confidence interval (CI). A total of 771 patients from 12 studies were identified. Three hundred seventy-seven patients (90.8% females) were treated with teriparatide. Lumbar spinal fusion rates were significantly higher among patients who received teriparatide compared to the non-teriparatide group (OR 2.15, 95%CI 1.56-2.97,p < 0.00001). Subgroup analysis revealed that patients receiving teriparatide demonstrated 2.12-fold and 2.23-fold higher likelihood of fusion compared to those in the bisphosphonate (OR 2.12, 95%CI 1.45-3.11,p = 0.0001) and placebo (OR 2.23, 95%CI 1.22-4.08,p = 0.009) cohorts, respectively. The treatment effect of teriparatide was associated with significantly reduced subsequent vertebral fractures (OR 0.16, 95%CI 0.06-0.41,p = 0.0002), sagittal malalignment (MD - 3.85, 95%CI: -6.49 to - 1.21,p = 0.004), limb visual analogue score (VAS) (MD - 0.36, 95%CI - 0.64 to - 0.09,p = 0.008), and spinal VAS (MD - 0.24, 95%CI - 0.44 to - 0.04,p = 0.02) compared to the non-teriparatide group. Patients using teriparatide had 30% less likelihood of screw loosening at last follow-up compared to the non-teriparatide group; however, this was not statistically significant (OR 0.70, 95%CI 0.43-1.14,p = 0.15). There did not exist any statistically significant difference between the two comparative groups in terms of pseudoarthrosis (OR 0.54, 95%CI 0.24-1.21,p = 0.13), cage subsidence (OR 1.30, 95%CI 0.38-4.52,p = 0.68), and bone mineral density (MD 0.04, 95%CI - 0.19-0.29,p = 0.74) at last follow-up examination. This meta-analysis corroborates the effectiveness of teriparatide resulting in higher fusion rates. Further study is required to determine the optimal duration of treatment and timing of surgery.

Automated summary

This study confirms the efficacy of teriparatide in improving fusion rates in osteoporotic patients undergoing spinal fusion surgery. Patients treated with teriparatide had significantly higher rates of lumbar spinal fusion compared to those not receiving the treatment, with a greater likelihood of fusion compared to bisphosphonate and placebo cohorts. The treatment also showed benefits in reducing subsequent vertebral fractures, sagittal malalignment, limb VAS, and spinal VAS. Further research is needed to determine the optimal duration of treatment and timing of surgery.