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Changes in Bone Mineral Density in the Intertransverse Fusion Mass After Instrumented Single-Level Lumbar Fusion: A Prospective 1-Year Follow-up

Hagenmaier, Femke MSc*; Kok, Dennis MD*; Hol, Annemiek MSc; Rijnders, Ton MD; Oner, F. Cumhur MD, PhD§; van Susante, Job L. C. MD, PhD*

doi: 10.1097/BRS.0b013e318276fa27

Study Design. Prospective cohort.

Objective. The purpose of this study was to evaluate changes in bone mineral density (BMD) in the intertransverse fusion mass as representative for the process of bone remodeling after spinal fusion.

Summary of Background Data. Intertransverse bone graft is frequently applied to facilitate bony fusion between 2 spinal levels. The biological process of bone graft remodeling leading to eventual fusion is, however, poorly understood.

Methods. In 20 patients with a single-level instrumented posterolateral lumbar fusion for low-grade spondylolisthesis, radiographs, and clinical outcome scores (visual analogue scale for back and leg pain, Oswestry Disability Index, Short Form-36) were obtained. Locally harvested laminectomy bone was used as intertransverse bone graft. The BMD in selected “regions of interest” at both intertransverse fusion areas was assessed on days 4 and 3, after a period of 6 and 12 months after surgery using dual-energy x-ray absorptiometry scans. Eventual fusion status was assessed on computed tomographic scan at 12 months.

Results. All clinical outcome scores significantly improved at the final follow-up (P < 0.05). Baseline BMD in both paraspinal fusion areas was expressed as 100%, which significantly decreased from 81% to 75% and 77% to 70% at 3 and 6 months, for regions of interest 1 and 2, respectively (P < 0.001). From 6 to 12 months, there was an increase in BMD from 90% to 80%, for regions of interest 1 and 2 (P = 0.296). On computed tomography scan a complete fusion was noticed in 70% of the patients.

Conclusion. Repeated dual-energy x-ray absorptiometry was able to elucidate the biological process of bone graft remodeling in the intertransverse fusion mass. An active bone remodeling process was quantified with profound resorption or demineralization of the graft during the first 6 months, followed by subsequent bone apposition and restoration of BMD at the final follow-up. No difference in trend in BMD change between patients with and without fusion could be established; however, no firm conclusions can be drawn from small patient numbers.

A prospective analysis of bone mineral density (BMD) changes in the intertransverse fusion mass was performed using dual-energy x-ray absorptiometry in 20 patients after lumbar fusion. A significant BMD decrease was quantified with restoration of BMD at the final follow-up, as a representative for active bone remodeling. No difference in trend in BMD change between patients with and without fusion could be detected; however, the small number of patients did not allow firm conclusion on this matter.

Departments of *Orthopaedics

Physiotherapy, and

Nuclear Medicine, Rijnstate Hospital, Arnhem, the Netherlands; and

§Department of Orthopaedics, University Medical Center Utrecht, the Netherlands.

Address correspondence and reprint requests to Job L. C. van Susante, MD, PhD, Department of Orthopaedics, Rijnstate Hospital, Postbus 9555, 6800 TA Arnhem, the Netherlands; E-mail:

Acknowledgment date: June 13, 2012. Revision date: August 29, 2012. Acceptance date: September 26, 2012.

The manuscript submitted does not contain information about medical device(s)/drug(s).

AO Spine Europe grant funds were received in support of this work. Relevant financial activities outside the submitted work: board membership, consultancy, grants, payment for lecture.

© 2013 Lippincott Williams & Wilkins, Inc.