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Bisphosphonate and Teriparatide Use in Thoracolumbar Spinal Fusion: A Systematic Review and Meta-analysis of Comparative Studies

Study Design. Systematic review and meta-analysis. Objective. To compare the efficacy of the use of either bisphosphonates or teriparatide on radiographic and functional outcomes of patients that had thoracolumbar spinal fusion. Summary of Background Data. Controversy exists as to whether bisphosphonates interfere with successful spinal arthrodesis. An alternative osteoporosis medication is teriparatide, a synthetic parathyroid hormone that has an anabolic effect on osteoblast function. To date, there is limited comparative data on the influence of bisphosphonates or teriparatide on spinal fusion. Methods. A systematic search of medical reference databases was conducted for comparative studies on bisphosphonate or teriparatide use after thoracolumbar spinal fusion. Meta-analysis was performed using the random-effects model for heterogeneity. Radiographic outcomes assessed include fusion rates, risk of screw loosening, cage subsidence, and vertebral fracture. Results. No statistically significant differences were noted between bisphosphonates and control groups regarding fusion rate and risk of screw loosening (fusion: odds ratio [OR] = 2.2, 95% confidence interval [CI]: 0.87–5.56, P = 0.09; loosening: OR = 0.45, 95% CI: 0.14–1.48, P = 0.19). Teriparatide use was associated with higher fusion rates than bisphosphonates (OR = 2.3, 95% CI: 1.55–3.42, P < 0.0001). However, no statistically significant difference was noted between teriparatide and bisphosphonates regarding risk of screw loosening (OR = 0.37, 95% CI: 0.12–1.18, P = 0.09). Lastly, bisphosphonate use was associated with decreased odds of cage subsidence and vertebral fractures compared to controls (subsidence: OR = 0.29, 95% CI 0.11–0.75, P = 0.01; fracture: OR = 0.18, 95% CI 0.07–0.48, P = 0.0007). Conclusion. Bisphosphonates do not appear to impair successful spinal fusion compared to controls although teriparatide use is associated with higher fusion rates than bisphosphonates. In addition, bisphosphonate use is associated with decreased odds of cage subsidence and vertebral fractures compared to controls that had spinal fusion. Level of Evidence: 3