Spine - 2026-08-17 - Journal Article
Perioperative Anabolic Osteoporosis Pharmacotherapy is Associated with Lower Rates of Proximal Junctional Kyphosis After Adult Spinal Deformity Surgery: A Systematic Review and Meta-Analysis.
Maayan O, Khattab M, Song J, Alasadi Y, Corvi JJ, Lin JD, Bronson WH, Chaudhary SB, Hecht AC, Crawford AM
Topics
Key Takeaway
Perioperative anabolic pharmacotherapy (predominantly teriparatide) is associated with a 49% reduction in odds of PJK (OR 0.51, 95% CI 0.30–0.86) and a 64% reduction in reoperation for mechanical failure (OR 0.36, 95% CI 0.14–0.88) after adult spinal deformity surgery across 2,247 patients.
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Summary
This systematic review and meta-analysis asked whether perioperative anabolic pharmacotherapy reduces PJK and reoperation for mechanical failure after ASD surgery. Random-effects pooling of 13 studies (1 RCT, 12 observational; teriparatide as primary agent in 9/13) demonstrated OR 0.51 for PJK (P=0.012, I²=0%) and OR 0.36 for reoperation for mechanical failure (P=0.025, I²=55%). Leave-one-out sensitivity analysis preserved the PJK effect direction across all iterations, and a broadened sensitivity analysis including an antiresorptive-dominant study remained directionally consistent (OR 0.63).
Key Limitation
The reoperation-for-mechanical-failure pool comprised only four studies with substantial heterogeneity (I²=55%), and 12 of 13 studies were observational, precluding definitive causal attribution and leaving confounding by indication (sicker, more osteoporotic patients selectively receiving pharmacotherapy) inadequately controlled.
Original Abstract
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
To determine whether perioperative anabolic osteoporosis pharmacotherapy is associated with lower rates of (1) proximal junctional kyphosis (PJK) and (2) reoperation for mechanical failure following adult spinal deformity surgery.
SUMMARY OF BACKGROUND DATA
Mechanical complications occur in 15 to 40 percent of patients following adult spinal deformity surgery. Although poor bone quality has been associated with mechanical failure, no quantitative synthesis has tested whether perioperative pharmacotherapy alters these outcomes.
METHODS
PubMed, Embase, Scopus, and Cochrane CENTRAL were searched through April 30, 2026 (PROSPERO CRD420261374961). Random-effects meta-analysis was performed for the primary and prespecified secondary outcomes. The primary pool comprised anabolic-exposed studies; a class-agnostic pool that additionally included a single antiresorptive-dominant, claims-based study was retained as a sensitivity analysis.
RESULTS
Thirteen studies (one randomized controlled trial, twelve observational; 2,247 patients) met inclusion criteria. Teriparatide was the primary or sole study agent in nine of thirteen studies. Anabolic pharmacotherapy was associated with reduced odds of PJK (pooled OR 0.51, 95% CI 0.30 to 0.86, P=0.012; I2=0%, k=5) and of reoperation for mechanical failure (OR 0.36, 95% CI 0.14 to 0.88, P=0.025; I2=55%, k=4). A broadened-class sensitivity analysis including the antiresorptive-dominant study was directionally consistent (OR 0.63, 95% CI 0.42 to 0.94, P=0.024). Leave-one-out sensitivity analysis preserved the direction of the PJK effect across all iterations.
CONCLUSIONS
Perioperative anabolic osteoporosis pharmacotherapy is associated with lower rates of proximal junctional kyphosis and reoperation following adult spinal deformity surgery, providing the first pooled evidence that the underlying bone-quality substrate may be pharmacologically modifiable. The certainty of this evidence is low; these findings support incorporating bone health optimization into perioperative planning as a modifiable target and prioritizing randomized trials of specific agents.
LEVEL OF EVIDENCE
IILevel of Evidence: II: Systematic review of cohort studies with one randomized controlled trial.