How common is osteoporosis in spine surgery patients?

It is very common. In patients over 50 having spine surgery, about 34% have osteoporosis, and nearly 80% have either osteoporosis or its milder form, osteopenia. Rates are highest in degenerative scoliosis, at about 56%. Even so, fewer than half of surgeons routinely screen for it before a fusion.

Why does bone strength matter for spine surgery?

Screws and rods are only as strong as the bone holding them. A 2024 review co-authored by Dr. Diebo found that osteoporosis increases the risk of hardware failure, non-healing, and proximal junctional kyphosis after deformity surgery. In several studies, osteoporosis raised the odds of failure at the top of a long fusion several-fold.

How is bone strength tested?

DEXA scan: This is the standard test. In people with spinal arthritis, though, bone spurs can make the spine look falsely strong. In one study, about 26% of patients rated "not osteoporotic" by lumbar DEXA had osteoporosis by CT.
CT bone density (Hounsfield units): This can be measured from a CT scan you may already have. A national neurosurgical guideline notes that values below about 98 predict more complications after surgery.
Vitamin D blood level: A level below 20 ng/mL is linked to more problems after surgery.

Which medicines help before spine surgery?

Medicine	What research shows for spine fusion
Teriparatide (daily injection, bone-building)	Strongest evidence. Higher fusion rates (about 3.5× the odds) and less screw loosening. In one study it cut 2-year reoperations from 23% to 12%.
Bisphosphonates (e.g., alendronate)	Don't harm fusion. Reduce cage sinking and fractures, but don't clearly improve fusion.
Denosumab	On its own, no clear fusion benefit. Must not be stopped without a plan , because stopping triggers rapid bone loss.
Romosozumab, abaloparatide	Promising, but little or no published data yet in spine fusion patients.

How long before surgery should treatment start?

An expert consensus recommends starting a bone-building medicine at least two months before surgery. For large, multilevel operations, the window can extend to six months. Treatment should continue at least eight months after surgery. Neurosurgical guidelines also support teriparatide before instrumented fusion in patients with osteoporosis. Our Bone Health Center provides DEXA scans, thorough evaluation and counseling, and manages bone-building medicines. Our preoperative optimization office helps with weight loss, nutrition before surgery, and conditions such as diabetes.

What can the surgeon do differently?

Surgeons can adjust the operation for weaker bone. Options include bone cement around screws, special screw designs, more fixation points, and alignment goals matched to the patient's age rather than over-correction.

When to see a specialist. If you have osteoporosis and need spine surgery, ask for a bone-health plan. Request an appointment.

Sources

Baroudi, M., et al., including Bassel G. Diebo. "Surgical Management of Adult Spinal Deformity Patients With Osteoporosis." Journal of Clinical Medicine, vol. 13, no. 23, 2024, 7173. doi:10.3390/jcm13237173. PMID 39685632.
Dimar, J., et al. "Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Osteoporosis Assessment." Neurosurgery, 2021. †
Jin, H., et al. "Anti-Osteoporosis Medication in Patients With Posterior Spine Fusion: A Systematic Review and Meta-Analysis." The Spine Journal, 2025. †
Mohanty, S., et al. "Impact of Teriparatide on Complications and Patient-Reported Outcomes of Patients Undergoing Long Spinal Fusion According to Bone Density." Journal of Bone and Joint Surgery (Am), 2024. †

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