From the Guidelines
For a patient with osteopenia who is scheduled for spinal fusion surgery, I recommend postponing the Reclast (zoledronic acid) infusion until at least 3 months after the surgery. Reclast is a potent bisphosphonate that inhibits bone resorption and could potentially interfere with the bone healing and fusion process following spinal surgery. While Reclast is effective for treating osteopenia and reducing fracture risk, the timing of administration relative to surgery is critical. After the fusion has adequately healed (typically 3-6 months post-surgery, depending on the patient's healing progress), Reclast can be safely administered as a once-yearly 5mg intravenous infusion over at least 15 minutes. Prior to administration, the patient should have normal renal function (creatinine clearance >35 mL/min), adequate vitamin D levels, and normal calcium levels. The patient should be instructed to take supplemental calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) both before and after Reclast administration. Common side effects include post-infusion flu-like symptoms, which can be mitigated by pre-medicating with acetaminophen. The rationale for delaying Reclast is that bisphosphonates alter bone remodeling, which is essential for successful spinal fusion, and premature administration could potentially increase the risk of pseudarthrosis or failed fusion 1.
Some key points to consider:
- Reclast is effective for treating osteopenia and reducing fracture risk, but its use should be carefully timed in relation to spinal fusion surgery.
- The optimal duration of Reclast therapy is not well established, but it is generally recommended to continue treatment for up to 2 years, with the option to extend based on clinical judgment 1.
- Patients should be monitored for renal dysfunction and osteonecrosis of the jaw (ONJ) while receiving Reclast, and should undergo regular dental examinations and maintain good oral hygiene to minimize the risk of ONJ 1.
- Reclast should be administered at a reduced dose in patients with impaired renal function, and is not recommended for patients with severe renal impairment (creatinine clearance <30 mL/min) 1.
Overall, the use of Reclast in patients with osteopenia undergoing spinal fusion surgery requires careful consideration of the potential benefits and risks, and should be individualized based on the patient's specific clinical circumstances.
From the Research
Efficacy of Reclast (Zoledronic Acid) for Osteopenia in Spinal Fusion Surgery
- Reclast (zoledronic acid) has been shown to be effective in improving bone fusion in osteoporotic patients after lumbar fusion surgery 2.
- Treatment with zoledronic acid shortens the duration of time to fusion, improves the fusion rate, prevents subsequent adjacent vertebral compression fractures, and improves clinical outcomes 2.
- Zoledronic acid also prevents immobilization-induced bone loss in the hip and increases bone mineral density (BMD) 2.
Comparison with Other Studies
- A review of zoledronic acid for osteoporosis found that it improves BMD, reduces fracture risk, and preserves bone structure and mass 3.
- However, another study found that patients with osteopenia or osteoporosis who undergo single-level lumbar fusion have higher rates of postoperative pseudarthrosis and revision surgery 4.
- Pretreatment with medications to prevent bone loss, such as zoledronic acid, may decrease these complication rates, although the differences did not reach statistical significance 4.
Specific Studies on Zoledronic Acid and Spinal Fusion
- A retrospective study found that a single dose of zoledronic acid does not decrease the volume of the fusion-mass in patients undergoing spinal fusion with osteoporosis 5.
- Another study found that zoledronic acid accelerates spinal fusion, shortens the time of fusion, and decreases the risk of adjacent vertebral compressing fracture and pedicle screw loosening 6.
- The study also found that zoledronic acid improves clinical outcomes and quality of life, with significant differences in SF-36 scores between the zoledronic acid group and the control group at 12 months 6.