From the Guidelines
Surgery for primary hyperparathyroidism (PHPT) is highly effective in improving bone quality, with most patients experiencing significant increases in bone mineral density (BMD) and reduced fracture risk after successful parathyroidectomy. The improvement in bone quality is a result of normalized calcium metabolism after the removal of the hypersecreting parathyroid gland, allowing for increased bone formation and reduced bone resorption 1.
Key Benefits of Surgery
- Increased bone mineral density (BMD) of 6-8% in the lumbar spine and 3-5% in the hip within the first year post-surgery
- Continued gradual improvements in BMD for 3-5 years
- Greatest BMD increases in patients with lowest pre-operative bone density and highest pre-operative parathyroid hormone (PTH) levels
- Reduced fracture risk by approximately 20-30% within 5 years after surgery
Post-Surgery Recommendations
- Adequate calcium intake (1000-1200 mg daily) to support bone health
- Vitamin D supplementation (800-1000 IU daily) to promote bone mineralization
- Consideration of additional osteoporosis medications like bisphosphonates for patients with severe pre-operative osteoporosis, but only after calcium levels have normalized and are stable following surgery 1.
Surgical Approach
The choice of surgical approach, either bilateral neck exploration (BNE) or minimally invasive parathyroidectomy (MIP), depends on various factors, including the presence of a single adenoma or multigland disease, and the accuracy of preoperative localization studies 1. MIP is often preferred for its less invasive nature, shorter operating times, and faster recovery, but BNE may be necessary in cases of discordant or nonlocalizing preoperative imaging or high suspicion for multigland disease.
From the Research
Bone Quality Improvement After Surgery for Primary Hyperparathyroidism
- Surgery for primary hyperparathyroidism (PHPT) has been shown to improve bone quality in several studies 2, 3, 4, 5, 6.
- A study published in 2004 found that about 50% of patients had increased bone mass after PHPT surgery, although the increase in bone density was difficult to predict for individual patients 2.
- Another study from 2012 found that bone metabolism normalized and bone mineral density (BMD) of the lumbar spine increased significantly within one year after surgery 3.
- A 2018 review noted that parathyroidectomy has a long-term beneficial effect on the skeleton and is probably prudent to refer PHPT patients for surgery in all cases where increased bone fragility is suspected 4.
- A 2017 study found that baseline 24-hour urinary calcium correlated directly with s-calcium, parathyroid hormone, and bone markers, and that patients with higher baseline 24-hour urinary calcium had greater increases in bone mineral density after parathyroidectomy 5.
- A 2012 study found that bone mineral density improved in up to 75% of patients after curative parathyroidectomy for PHPT, with younger patients and those with severe PHPT deriving the most skeletal benefits from parathyroidectomy 6.
Factors Associated with Bone Quality Improvement
- Younger age has been associated with greater improvement in bone mineral density after parathyroidectomy 6.
- Higher preoperative levels of parathyroid hormone, serum calcium, and urinary calcium have also been linked to greater improvement in bone mineral density 3, 5, 6.
- Baseline 24-hour urinary calcium has been identified as an independent determinant of improvement in bone mineral density 5.
- The use of bisphosphonates before surgery did not affect outcomes in one study 6.
Bone Mineral Density Changes After Surgery
- Studies have consistently shown that BMD increases after parathyroidectomy, particularly in the lumbar spine 2, 3, 5, 6.
- The hip and lumbar spine have been found to respond similarly to surgery in terms of BMD improvement 6.
- Significant improvement in BMD has been observed in up to 38% of patients, with moderate improvement in up to 31% of patients 6.