Perioperative Management of Denosumab for Arthroscopic Back Surgery

Critical Safety Concerns

• Discontinuing denosumab leads to rapid rebound bone turnover with increased risk of multiple vertebral fractures, and if denosumab must be stopped, transition to a bisphosphonate beginning 6-7 months after the last dose is mandatory to prevent rebound bone loss, as recommended by the American College of Physicians, based on evidence from clinical trials 1, 2

Perioperative Management Rationale

Potential Benefits for Spinal Surgery

• Denosumab may actually benefit surgical outcomes in osteoporotic patients undergoing spinal instrumentation, as it maintains bone quality that could support surgical hardware, similar to teriparatide, which showed a lower screw loosening rate in osteoporotic patients undergoing instrumented fusion 3

Perioperative Monitoring

• Ensure adequate calcium and vitamin D supplementation perioperatively, with a recommended daily intake of 1,000-1,200 mg of calcium and 600-800 IU of vitamin D, as suggested by clinical guidelines 4

Post-Surgical Continuation

• Resume or continue the regular 6-month Prolia injection schedule without interruption after surgery, to maintain continuous therapy and prevent rebound bone loss, as recommended by clinical guidelines 4

Common Pitfall to Avoid

• Discontinuing Prolia before surgery creates a greater harm through rebound vertebral fractures than any theoretical perioperative risk, and should be avoided unless there is a specific contraindication, as stated by the American College of Physicians 1