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Melanie Cole, MS (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole and today our discussion is going to focus on the bone-back connection, enhancing surgical success through bone health. We have a panel for you today, and joining me is Dr. Sanaa Badour. She's an Assistant Professor in the division of Endocrinology, Diabetes, and Metabolism in the Department of Internal Medicine at the University of Florida College of Medicine. And Dr. Julie Lynn Chan, she's a Neurosurgeon specializing in complex spine surgery, and she's an Assistant Professor in the Lillian S. Wells Department of Neurosurgery at the University of Florida College of Medicine.

Doctors, thank you so much for joining us today. This is such a great topic. And Dr. Chan, I'd like to start with you. Can you explain a little bit about the relationship between bone health and surgical outcomes in procedures involving the spine, some of the key factors that make bone health critical for surgical success, and how has our understanding of bone health influenced the evolution of spinal surgery techniques?

Julie Lynn Chan, MD, PhD: Thanks so much, Melanie, for having me. I think that's, first of all, it's a quite a loaded question, so I'll try to break it down. I think, first of all, the importance for me and studying this and really reaching out to see how we can improve the quality of life for our patients stems from the fact that as we know, our population is aging. We have a lot of patients who are living longer and are quite healthy and active and certainly want to remain that way, throughout the remainder of their life. And as we know, a lot of people end up with back pain, back problems, neck pain, neck problems just from living our daily life and activities and the wear and tear that our body goes through.

With that, a lot of us will end up needing a spine surgery, probably at some point in our lives. Of course we try to delay that for as long as possible, but it may come to a point where we do need a spine surgery. And a lot of times those spine surgeries do require what's called a fusion, meaning, we have to decompress the neural elements, meaning take the pressure off the nerves or help stabilize the spine, either stabilize the spine after taking the pressure off, or even stabilize the spine to help decrease or even completely alleviate the pain that patients are having. While that fusion surgery often does involve metal implants, meaning rods and screws, a lot of the strength actually, and most of the strength comes from the bone fusing essentially around or next to that hardware.

So really it's the patient's own strength and the bone that grows over that helps stabilize the spine after spine surgery. With that, as you can imagine, poorer bone quality or weaker bone, it wouldn't have as good of a chance of healing over. And one of the things, just like aging, the parts have wear and tear; the bone quality can decrease as well, and that's certainly not uncommon, as we all start to age. So with that, as you can imagine, having poor bone quality can lead to poor ability to fuse the bones and we can actually end up with a worse problem than we started with. Not only would our symptoms return, but we can have failure of our hardware, we can end up having to bring the patients back to the operating room, undergo a second surgery or even a longer surgery. I think many patients have heard, you know, spine surgery can beget spine surgery, and that's because of the pressure and the bones then take on the other levels. So really to avoid all of these, you could say, further surgery, additional surgeries and patients being in more pain after surgery, really focusing on that bone health is quite important to having a successful outcome, meaning patients feeling good, doing what we anticipated to, which is help them return back to the activities they enjoy and continue that fulfilling and enjoyable life that they once had.

So hopefully that answers in part or if not all of the questions you had. And with that, bone health, while it's something I'm very interested in, we have to work together with our partners and physicians like Dr. Sanaa Badour in building that bone health, since it really starts before the spine surgery. It starts before spine surgery and it continues after spine surgery. So really it's collectively putting all of this together to help the patients have the best outcome possible.

Host: Thank you so much, Dr. Chan, and leading right into this Dr. Badour, as we're discussing the challenges and complications that arise from poor bone health, tell us a little bit about assessments or diagnostic tools that are used to evaluate bone health. Anything exciting in the field, and are there specific interventions once you've assessed the patient and realized what's going on, to optimize the bone health preoperatively. Tell us a little bit about all of that.

Sanaa Badour, MD, MSc: Yes. So thank you, Melanie. Thank you, Dr. Julie Chan. That was an amazing introduction. And as you mentioned, bone health is very important overall. That's what I do for a living. And of course, for patients undergoing spine surgery. Once we receive the patient from the neurosurgeon, we want to do two things.

We want to assess whether they need bone health optimization, and then we risk stratify these patients as high, very high risk or even low risk, and decide accordingly, how to go around managing their bone health. First of all, when I see my patients, I try to spend some time explaining to them that bone loss is a natural part of the aging process.

It's almost inevitable in postmenopausal women and older men, and we have to treat it and we have to reduce the associated risks. And basically we're talking about fractures. In spine surgery, we want to, as Dr. Julie Chan mentioned, improve those outcomes. So we do have several tools to risk stratify patients and screen them. So preoperatively, we start by using several tools. We of course have the famous Dexascan, which measures the bone density. We also have some other tools available to us, like the opportunistic CT scan. As of 2019, it is now acceptable to use the Hounsfield units on the L1 vertebra as an indicator of the bone quality and whether there is osteoporosis or not.

And we use other tools that do not require imaging. Like Frax calculations with or without using the bone mass density in it. Of course having previous fracture or having multiple previous fractures, whether silent, like in vertebral fractures or hip fractures are all, go all into the risk assessment.

So based on whether we determine the patient is low risk, high risk, or very high risk, we proceed with the next steps, which are looking for secondary causes of bone loss. That's always very important. We check things as common as like vitamin D deficiency. And we check other less common things like multiple myeloma and thyroid or parathyroid disorders that can contribute to the bone loss we are seeing. Most of the times, workup is negative and we proceed to deciding on the treatment part.

Luckily we are in an age where there's several interventions we can do to help mitigate the bone loss and build new bone. And, based on the risk of each patient, we select the proper agent. And ideally, we want to treat for a while. And, this while remains to be explored for how much we want to treat, but the longer the better.

We take into consideration that the patient is in pain, that the patient needs to do the surgery as soon as possible, while keeping in mind that most of these agents would take at least six months or more to start working. So we do that fine balance where we go back and forth talking to the neurosurgeons about when is the best time, how long can we wait?

Do you think that waiting for three months will result in unbearable pain that will affect quality of life? Or do you think it's reasonable to wait to kind of guarantee better surgical outcomes?

Host: Dr. Chan, would you like to expand on that and speak about the surgical techniques themselves or any technologies that are so exciting that have been developed specifically to address bone health concerns during spinal procedures. As Dr. Badour was saying, wondering how long they can wait to get some of these interventions in place.

Once it's your turn to step in, what do you do to mitigate anything that happened that didn't quite make it, just how you would like it for the procedure?

Julie Lynn Chan, MD, PhD: Like Dr. Badour had said, really it's this back and forth, it's this partnership between the two, which makes the Bone Health Clinic that we've developed here at UF really unique in terms of how we interact, how it is a constant, you know, multiple crosstalk between the two of us trying to figure out, how we can optimize these patients and not just optimize the patients for today, but goals being to go forward with additional clinical trials or as you said, other technologies to really boost the bone health.

So, as Dr. Badour mentioned, I identify the patients that would be good candidates for surgery where I may have concerns for their bone health and she works them up, as she discussed. From there, the next step really is determining when is the optimal time. And many times we do have to meet in the middle. At the very least, start treatment.

Certainly if patients are having neurologic decline, we may elect to do surgery immediately, certainly if they simply, cannot walk or cannot function. Sometimes if it is pain and the patient can bear it, we will delay to optimize that surgery as we would hate for them to have a worse outcome because it couldn't be delayed.

In terms of other adjuncts, there are different types of molecules or cells that we can use during surgery to promote or improve bone health. However, some of those medications or treatments, or options that we use in the OR can have other side effects as well. So again, it's really weighing the balance of all these things.

In terms of postoperatively, as well, there are some things like bone growth stimulators that we can use that are essentially devices that the patient wears after surgery. And again, all of these things, bone growth stimulators are quite low risk, but sometimes patient can't tolerate it. They don't feel maybe comfortable wearing their brace or different things like that.

They feel like it interferes with their activity. So again, always weighing the balance of what works for the patient, how we can get their outcome to be the best possible, but really those three steps, before surgery, during surgery, after surgery, and again, all of these devices and in terms of the treatments and paradigms we're looking at, Dr. Badour and I are hoping to develop some unique protocols here at UF Shands, where we can really optimize the patient's outcomes.

Host: Dr. Badour, as we're speaking about bone health and how it impacts postoperative recovery and long-term outcomes for patients, what strategies do you employ as this multidisciplinary team to promote bone healing and prevent complications post-surgery? Speak about your team and how you all work together to promote healing for better outcomes.

Sanaa Badour, MD, MSc: First of all, I want to say that we do enjoy working with these patients because these are highly motivated patients. They are going to be adherent to the therapy we prescribe. When we optimize risk factors for bone loss, we also discuss fall preventions before and after surgery.

There is some data suggesting that 25% of patients do actually fall down in the year preceding and the year after surgery. So one in four patients is going to fall down. So we discuss full precautions extensively when we see these patients. And then, sometimes if we identify nutrition as a risk factor for bone loss, whether preoperatively or postoperatively, we also involve our nutritionist to help them identify foods that are rich in protein and calcium to help them improve their diet.

We sometimes work with physical therapists. Because, as we all know, exercise, really, helps promote bone building and muscle strengthening, which are all very important outcomes, both preoperatively and postoperatively. So, we work with these people and of course we continue to monitor their bone density by sending them to get a new bone scan.

And we, follow up on all the images they get from Dr. Julie Chan and others afterwards where we look to see if they have good fusion. We see if they have new fractures. Or if, they're healing right, if they've had previous fractures. So, we do all of this in our bone clinic.

Host: I'd love to give you each a chance for a final thought here, because this is really such an interesting topic that isn't talked about enough, because bone health certainly affects quality of life, as Dr. Chan said at the beginning. So Dr. Badour, if you were to look at areas of research to explore the intersection of bone health and patient quality of life. I'd like you to speak about what you would like to see happen in the future.

Sanaa Badour, MD, MSc: Bone loss, osteoporosis is a silent disease, unfortunately. Last thing we want to do is learn about this ongoing silent disease by having a fracture, whether at the vertebral sites or any other fracture, fragility fracture. Actually all guidelines, regarding screening and treatment of bone loss and osteoporosis, focus on maintaining independence, especially that we are treating an older adult population where independence is critical. And, people want to continue to be able to do their daily activities without assistance, without placement, without being in a nursing home. So part of prolonging that process is by maintaining healthy bones and preventing fractures.

So I always, discuss that with my patients, especially that in patients who are otherwise healthy, they perceive bone health as less critical because they feel healthy. And in patients with other comorbidities, they also kind of give priority to other ongoing, which they feel are more urgent problems.

So really, I feel that educating these patients and trying to help them estimate and learn how important managing their bone health is so important. And many times I share data with my patients from ongoing clinical trials and observational studies where I tell them in this specific topic of patients undergoing neurosurgery interventions, that while we know that globally osteoporosis patients do worse than patients without osteoporosis after these surgeries, we in fact have some data as recent as 2024 showing that patients who get treated, especially with the newer agents like teriparatide, and we don't have enough data on the also newer and stronger agents that we are now using.

We know that patients with osteoporosis, while historically had worse outcomes after surgery, tend to have similar outcomes to those without osteoporosis after treatment. Now, this is not strong data, but it's getting there and I believe that it is not as strong, it's because of the duration of treatment.

We have not yet figured for how long we need to treat the patients before and after. As I mentioned in the very beginning, we want to treat them as long as possible, but of course we have to weigh in and take in consideration that these patients are in pain, they're eager to get the surgery done and get back to having good quality of life.

But I will just end up by saying that we have ways and we have data where we can improve these outcomes and help these patients. And I think communication is key and working together back and forth as physicians results in great advantage towards the patients.

Melanie Cole, MS (Host): Thank you so much, Dr. Badour and Dr. Chan last word to you. In your opinion, what future advancements or innovations hold promise for improving surgical outcomes through better bone health management? And what would you like the key takeaways to be from today's episode for other providers?

Julie Lynn Chan, MD, PhD: Certainly, I think us working together with endocrinologists, neurosurgeons, and spine surgeons, it's really, really important for us to work together because aging, osteoporosis, they are such a common disease process that we see. And I think the one thing I'd like everyone to take away from this is it is so common, and I do see a number of patients who have been diagnosed with some sort of decreased bone density and for other factors in life, those potential side effects or maybe even the cost of medications may feel like they outweigh the benefit.

But when it comes to spine surgery, the way we evaluate the patients is quite different in the way that we look at the DEXA scores. I've heard that from many patients. So I think it's important that when it comes to spine surgery, they do come to a clinic or bone health clinic like we have that can specifically evaluate these patients regarding their osteoporosis for spine surgery. So that's the main takeaway here is that when it comes to spine surgery, the evaluation can be quite different. In terms of going forward, as Dr. Badour mentioned, there are new medications out there that a lot of people have not tried yet. And I think when it comes to spine surgery, it's really important we get these patients started on these medications early, which is another thing that Dr. Badour and I are working on, early identification before it comes to the point where the patients are so debilitated they need surgery urgently.

Host: Thank you both so much for joining us today and sharing your expertise for other providers. And to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org and to listen to more podcasts from our experts, you can always visit UFhealth.org/medmatters.

That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.