Trends and attitudes of spine surgeons regarding osteoporosis

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As a consequence, spinal fusion surgery is becoming increasingly common and necessary.<a class="elsevierStyleCrossRef" href="#bib0215">1</a>In Spain, approximately 2 million women suffer from osteoporosis (OP) according to the densitometry criteria proposed by the World Health Organisation. The prevalence of OP in women over 50 is 26%<a class="elsevierStyleCrossRef" href="#bib0220">2</a> and it is 44% in women operated on for degenerative spine disease (Chin et al.)<a class="elsevierStyleCrossRef" href="#bib0225">3</a>.In patients who have undergone spinal fusion surgery, the decrease in bone mineral density (BMD) affects both the clinical and radiological outcomes. OP can lead to poor bone fusion, a reduction in the pull-out force of pedicle screws and increased subsidence of the prosthetic material; and it is also a risk factor for pseudarthrosis.<a class="elsevierStyleCrossRefs" href="#bib0215">1,4</a>Despite effective pharmacological treatments and innovations in surgical techniques for OP, studies have revealed inadequate preoperative assessment and a lack of participation from spine surgeons with respect to this type of patient.<a class="elsevierStyleCrossRef" href="#bib0235">5</a> Moreover, low referral rates to OP specialists after vertebral compression fracture (VCF) have been reported.<a class="elsevierStyleCrossRefs" href="#bib0240">6,7</a>Although trends and attitudes of spinal surgeons with respect to OP have been studied, mainly in North America,<a class="elsevierStyleCrossRef" href="#bib0235">5</a> no such assessments have been carried out in our area, and nor have the specific surgical strategies most commonly used in spine surgery been investigated.The aim of this study was to assess the patterns and trends in the diagnosis and treatment of OP by spine surgeons in Spain, and to inquire about the spine surgery techniques most commonly used in patients with osteoporosis.Material and methodsSurvey type study using a questionnaire with 10 self-administered questions directed at specialists who are members of the Sociedad Española de Neurocirugía (SENEC) [Spanish Neurosurgery Society].Contents and sections of the questionnaireQuestions were asked about the speciality (1) and the workplace (2). The questionnaire was then divided into 3 parts (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>):<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Role of the spine surgeon in dealing with OP in spinal fusion (4 questions): assessed the trends and role of the neurosurgeon in terms of the diagnostic approach in patients with suspected OP and untreated OP. Changes to the surgical strategy and the specific surgery techniques most used in patients with OP were also assessed.</li><li class="elsevierStyleListItem" id="lsti0010">2.Perception of the influence of OP in the development of pseudarthrosis (2 questions): addressed the surgeon's perception of and opinion on what influence OP has on the development of pseudarthrosis.</li><li class="elsevierStyleListItem" id="lsti0015">3.Assessment of treatment trends and patterns of referral among surgeons with respect to osteoporotic VCF (2 questions).</li></ul><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Question designThe questions were written avoiding redundancies, errors and ambiguities in the text. The answers were multiple-choice, with the possibility of additional comments to avoid information gaps.Administration of the questionnaireThe questionnaire questions were integrated into the Survey Monkey online survey platform and sent with an email message to the SENEC members through the Technical Secretariat. A total of 3 emails were sent: an invitation to take part in the survey and 2 reminders.Data collection processThe answers were collected through Survey Monkey and the data were then transferred to a database (Excel spreadsheet).This study was authorised by our hospital's Ethics Committee for Research with Medicinal Products and the Board of Directors of SENEC.ResultsOut of 480 surveys sent out, we obtained a total of 77 answered questionnaires, with the participation of specialists at the different hospitals around Spain listed in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Role of the spine surgeon in dealing with osteoporosis in spinal fusionQ1. With regard to the specialist's trends and attitudes in patients with suspected OP, the most common approaches were to refer to the specialist for diagnosis and treatment of OP before surgery in 32.5%, and in another third, carrying out the surgery routinely without further consultations or tests (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Q2. For patients with untreated OP programmed for a spinal fusion, 33.8% answered that they would refer to the OP specialist before surgery, 26% would refer after the intervention and 11.7% would go ahead with the surgery as routine.Q3. In patients with OP on treatment, the tendency in almost half of the respondents (48.7%) was to alter the surgical strategy and in another 47.4%, to operate as routine without changes.Q4. The alternatives in terms of the surgical approaches most commonly used for patients with OP (one or more options) were: cement-augmented screws (70.1%); modification of the surgical technique (example: bicortical screws, minimise the tapping) in 31.2% and long assemblies in 29.9% (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Perception of the influence osteoporosis has on the development of pseudarthrosisQ5. In the case of patients who develop pseudarthrosis, 46.1% do not consider additional investigations for the diagnosis of OP, even when planning a re-intervention. However, 27.6% refer to the OP specialist for diagnosis and treatment optimisation (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Q6. Regarding their perception of the influence OP has on the development of pseudarthrosis, 35.1% consider that it has quite a lot of influence and 23.4%, a certain amount.Trends in treatment and referral by surgeons in the case of osteoporotic vertebral compression fractureQ7. In the case of osteoporotic VCF, it was found that 59.7% of surgeons prefer to refer the patient to the specialist and that 10.4% would request a bone density scan and a bone metabolic profile.Q8. As far as the surgical treatment of these fractures was concerned, the majority (66.2%) would opt for conservative treatment for 4–6 weeks and, in case of refractoriness, opt for some vertebral augmentation technique (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia>DiscussionSpine surgery and osteoporosisA growing number of patients with some type of spinal disease requiring surgery also have undiagnosed or untreated OP.<a class="elsevierStyleCrossRefs" href="#bib0230">4,8</a>Early identification of the most relevant risk factors for OP is therefore important. The main risk factors are: postmenopausal women; early menopause; family member with hip fracture; metabolic bone disease, BMI of less than 20kg/m2; prolonged oral corticosteroid therapy, with the assurance that the outcome of this will influence the decision on treatment.<a class="elsevierStyleCrossRef" href="#bib0255">9</a>That last criterion is particularly relevant, as de novo diagnosis of OP prior to spinal surgery should stimulate action in terms of timely therapy and lead to the surgical plan being modified. In addition to the bone density scan, or dual-energy x-ray absorptiometry (DXA), the consensus is that the incidental radiological finding of vertebral fractures with an osteoporosis profile is also diagnostic of OP.<a class="elsevierStyleCrossRef" href="#bib0260">10</a>A significant proportion of patients with surgical spine disease are at risk for OP. Chin et al. estimated the prevalence of OP in subjects over 50 having spinal surgery and found that 46.7% of women had osteopenia and 44.1% OP; 45.9% of men had osteopenia and 12.5% had OP.<a class="elsevierStyleCrossRefs" href="#bib0225">3,4</a> In other words, it is very likely that the prevalence of OP in patients over 50 having spinal surgery is higher than that in the general population.<a class="elsevierStyleCrossRef" href="#bib0220">2</a>In our questionnaire, in cases of suspected OP, 61.1% of surgeons considered some measure that would help diagnose OP and a third of responders did not consider it necessary to make any effort to confirm the diagnosis. The latter attitude is probably a reflection of the little influence attributed to OP in the outcomes of spinal fusion surgery. In line with our study, Dipaola et al. reported that 46% of surgeons would request a DXA in patients with suspected OP prior to performing spinal fusion.<a class="elsevierStyleCrossRef" href="#bib0235">5</a>As regards the importance of the bone metabolic profile, it is estimated that anywhere from 40% to 90% of adults have low serum vitamin D levels.<a class="elsevierStyleCrossRefs" href="#bib0265">11–13</a> Ravindra et al. studied the postoperative serum vitamin D levels of 230 consecutive patients who had elective spinal fusion for degenerative spondylosis; 30% had vitamin D deficiency and 68.9% had insufficiency.<a class="elsevierStyleCrossRef" href="#bib0280">14</a> Current evidence shows that patients with spine disease have a high prevalence of hypovitaminosis D,<a class="elsevierStyleCrossRef" href="#bib0230">4</a> which could influence the clinical and radiological outcomes of fusion surgery.<a class="elsevierStyleCrossRef" href="#bib0275">13</a>Although the evidence on the benefits of preoperative treatment with vitamin D and calcium is still limited<a class="elsevierStyleCrossRef" href="#bib0250">8</a> (Lehman), the 9% in this study who would possibly request a metabolic profile is very low, considering the high prevalence of hypovitaminosis D and the fact that it can be relatively rapid to correct preoperatively.For patients with untreated osteoporosis who are candidates for spinal surgery, almost half of the respondents said they would take some measure towards treating the OP preoperatively, either referring to the specialist or starting treatment. However, 37.7% go ahead with the surgery and do not consider referring or treating the OP, or treat postoperatively; a proportion where we understand there is room for improvement.Considerable advances have been made in understanding the physiopathology and in the treatment of OP over recent decades.<a class="elsevierStyleCrossRef" href="#bib0250">8</a> A number of recently published clinical trials assessed the impact of various pharmacological treatments on bone fusion in spinal surgery. In the main, beneficial effects were found with alendronate,<a class="elsevierStyleCrossRef" href="#bib0285">15</a> zolendronic acid<a class="elsevierStyleCrossRef" href="#bib0290">16</a> and teriparatide.<a class="elsevierStyleCrossRef" href="#bib0295">17</a>Pre-treatment with antiresorptive medication modifies bone remodelling and improves graft integration and bone fusion.<a class="elsevierStyleCrossRefs" href="#bib0285">15–18</a> Consequently, although always according to the clinical context, some authors recommend deferring surgery to allow suitable optimisation of the OP.<a class="elsevierStyleCrossRef" href="#bib0230">4</a> Although there is no clear consensus, it is recommended that OP treatment be started at least 4–6 weeks before surgery and continued in the postoperative period under specialised supervision.<a class="elsevierStyleCrossRef" href="#bib0250">8</a>For the planning of surgery in patients with OP, in our study almost half of the respondents would not modify the surgical technique. The Dipaola et al. survey shows that 74% of the specialists would modify their treatment or their surgical plan according to the result of the DXA.<a class="elsevierStyleCrossRef" href="#bib0235">5</a>Preoperative diagnosis of OP and the appropriate surgical strategy can improve bone fusion rates and decrease the number of complications.<a class="elsevierStyleCrossRef" href="#bib0215">1</a> Some of the best-known surgical techniques which can increase clinical success and vertebral fusion rates<a class="elsevierStyleCrossRefs" href="#bib0250">8,19</a> are instrumentation with long assemblies, the use of transverse connectors,<a class="elsevierStyleCrossRef" href="#bib0310">20</a> and selection of long and conical pedicle screws; 29% of the respondents would apply these options. Modifying the surgical technique was a valid option for 30% of the responders and included minimising tapping<a class="elsevierStyleCrossRef" href="#bib0315">21</a> and bicortical clamping of pedicle screws at the level of S1.<a class="elsevierStyleCrossRef" href="#bib0320">22</a> It is important to avoid mismatch by properly selecting the size of the interbody implants and so prevent subsidence.<a class="elsevierStyleCrossRef" href="#bib0325">23</a>Other useful tools are the cement-augmented, expandable pedicle screws.<a class="elsevierStyleCrossRef" href="#bib0330">24</a> In our respondents there was a clear preference for the use of cement-augmented screws (70%).The fusion rate in patients with OP treated by instrumented posterior lumbar fusion with conventional technique is 89.7%.<a class="elsevierStyleCrossRef" href="#bib0335">25</a> Retrospective studies on fusion with cement-augmented pedicle screw demonstrate a fusion rate close to 100%.<a class="elsevierStyleCrossRefs" href="#bib0340">26–29</a> However, the reports on expandable pedicle screws describe a fusion rate of 86–100%.<a class="elsevierStyleCrossRefs" href="#bib0355">29–32</a> Therefore, these techniques, despite not being free of complications, can be a valid alternative in patients with OP and should ideally be part of the surgical arsenal of spine surgeons.<a class="elsevierStyleCrossRef" href="#bib0355">29</a>Pseudarthrosis and osteoporosisWith reference to pseudarthrosis, almost half of the respondents do not consider conducting additional studies for the diagnosis of OP, even with the threat of need for re-intervention. Dipaola et al. found that only 19% of surgeons requested a DXA and 20% a bone metabolic profile for the study of pseudarthrosis.<a class="elsevierStyleCrossRef" href="#bib0235">5</a>In our case, 61% of the respondents perceive that OP has quite a lot or a lot of influence on the development of pseudarthrosis. However, this does not translate into them taking action to diagnose it.Our results and those of Dipoala et al.<a class="elsevierStyleCrossRef" href="#bib0235">5</a> suggest that a considerable proportion of surgeons do not perceive that OP has a significant influence on the development of pseudarthrosis.Development of pseudarthrosis is multifactorial and requires a preoperative assessment of risk factors such as advanced age, alcoholism, malnutrition and smoking, as well as OP.A decrease in BMD is an independent risk factor related to the failure of instrumentation in lumbar vertebral fusion.<a class="elsevierStyleCrossRef" href="#bib0230">4</a> It has been reported that adequate BMD achieves higher rates of bone fusion in patients after vertebral spine fusion and that patients with low BMD have a higher risk of pseudoarthrosis.<a class="elsevierStyleCrossRefs" href="#bib0375">33,34</a>If revision surgery becomes necessary for established pseudarthrosis, it is recommended to rule out disorders that may deteriorate bone quality, such as OP, malnutrition, hyperparathyroidism, rheumatoid arthritis and other systemic inflammatory diseases.<a class="elsevierStyleCrossRef" href="#bib0375">33</a>It would therefore seem reasonable that in the case of pseudarthrosis, efforts should be made to diagnose and treat OP before revision surgery.Osteoporosis-related vertebral fracturesWith reference to OP-related vertebral fractures, we found a greater awareness and active participation of the spine surgeon, either referring the patient to a specialist for medical management (59%) or performing some type of diagnostic test (24%). Dipaola et al. also found that 60% of spine surgeons request a DXA and 39%, bone metabolic profile.<a class="elsevierStyleCrossRef" href="#bib0235">5</a>A primary care study which reviewed more than 4 million medical records in Spain found that, after a first hip fracture, de novo treatment was started in only a minority of patients, whether with bisphosphonates (13.6%) or calcium and vitamin D (21.8%).<a class="elsevierStyleCrossRef" href="#bib0385">35</a>A correlation has been found between orthopaedic surgeons requesting a DXA after distal radius fractures and an increase in the chances of treatment, both of OP and of vertebral fractures.<a class="elsevierStyleCrossRef" href="#bib0240">6</a>In terms of the trends in treatment of OP-related vertebral fractures, the majority (66%) considered the most appropriate treatment to be vertebral augmentation after a 4–6 week period of conservative treatment with no improvement.<a class="elsevierStyleCrossRef" href="#bib0390">36</a> 22.4% opted for some vertebral augmentation technique (vertebroplasty or kyphoplasty) at the time of diagnosis.Several clinical trials, such as the VERTOS II,<a class="elsevierStyleCrossRef" href="#bib0395">37</a> the FREE study,<a class="elsevierStyleCrossRef" href="#bib0400">38</a> and the Farrokhi et al. trial,<a class="elsevierStyleCrossRef" href="#bib0405">39</a> show beneficial results in terms of improvement in pain and quality of life with the use of vertebroplasty or kyphoplasty. However, the VERTOS IV study,<a class="elsevierStyleCrossRef" href="#bib0410">40</a> which compared a group of patients with percutaneous vertebroplasty and a control group with injection of local anaesthetic in pedicles, found no significant differences in the improvement of pain until the one-year follow-up. A recent review by the Cochrane Foundation of 21 clinical trials, 5 of which studied vertebroplasty versus placebo (VERTOS IV being one), concludes that vertebroplasty has little clinical benefit (pain relief in only 7%).<a class="elsevierStyleCrossRef" href="#bib0415">41</a>In general, there is consensus in waiting 4–6 weeks in patients with a VCF before considering vertebroplasty, as in most patients the pain subsides after a period of observation. However, some neurosurgery and interventional medicine scientific societies in the United States have extended the definition of failure of medical treatment to patients with disabling pain in the area of the fracture that prevents them from walking or performing physiotherapy after 24h of an adequate analgesic treatment, or in the case of having intolerable adverse effects from the medication.<a class="elsevierStyleCrossRef" href="#bib0390">36</a> In line with this criterion, the results of the multicentre VAPOUR trial, which compared vertebroplasty to placebo in patients with VCF less than 6 weeks old, found a significant improvement in pain (difference of 23%).<a class="elsevierStyleCrossRef" href="#bib0420">42</a>Gathering the best available scientific evidence,<a class="elsevierStyleCrossRef" href="#bib0415">41</a> for the time being, it is not possible to recommend vertebroplasty in OP-related VCF, as it has little clinical beneficial effect.In short, this study is pioneering in the analysis of trends and attitudes among the spinal surgery community in terms of OP. We emphasise the need to establish and standardise the diagnostic and preoperative treatment criteria for OP.One limitation of our research was the relatively low participation of specialists in the survey. This is a known drawback of survey studies sent electronically and may possibly make the study less representative. The trends in behaviour we found are representative of the neurosurgical community, which leads us to suggest that these patterns should be measured in traumatologists.Our results show the need to encourage the active participation of the spine surgeon, referring patients with OP for treatment at an early stage. Ideally, efforts should be made to develop consensual and multidisciplinary management guidelines for diagnosis and treatment of patients with OP in the preoperative period before spinal surgery.ConclusionsGreater involvement of the spine surgeon could improve the referral intention rate and preoperative treatment of OP in spinal fusion surgery and pseudarthrosis. In vertebral fractures there is better awareness about optimising the treatment and follow-up of OP.FundingThis work was funded by the 22nd Research Grant awarded by the Colegio de Médicos de Las Palmas de Gran Canaria [College of Physicians of Las Palmas, Gran Canaria].Conflicts of interestWe declare that we have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1261128" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1167943" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1261129" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1167942" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Contents and sections of the questionnaire" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Question design" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Administration of the questionnaire" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Data collection process" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Role of the spine surgeon in dealing with osteoporosis in spinal fusion" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Perception of the influence osteoporosis has on the development of pseudarthrosis" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Trends in treatment and referral by surgeons in the case of osteoporotic vertebral compression fracture" ] ] ] 7 => array:3 [ "identificador" => "sec0055" "titulo" => "Discussion" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Spine surgery and osteoporosis" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Pseudarthrosis and osteoporosis" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Osteoporosis-related vertebral fractures" ] ] ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-11-22" "fechaAceptado" => "2019-04-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1167943" "palabras" => array:6 [ 0 => "Osteoporosis" 1 => "Arthrodesis" 2 => "Spine" 3 => "Pseudarthrosis" 4 => "Fracture" 5 => "Vertebral" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1167942" "palabras" => array:6 [ 0 => "Osteoporosis" 1 => "Artrodesis" 2 => "Columna vertebral" 3 => "Seudoartrosis" 4 => "Fractura" 5 => "Vertebral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Background and objectivesNeurosurgeons and other specialists are increasingly having to treat patients with osteoporosis who require spinal fusion surgery.Although there are effective pharmacological treatments and innovations in surgical techniques that can benefit these patients, low rates of diagnosis and preoperative treatment of osteoporosis have been reported, in addition to the limited participation of spine surgeons in this area.The objective of this study was to evaluate trends in diagnosis and treatment of osteoporosis with regard to spine surgeons of the neurosurgical community. Material and methodsAn electronic survey with 10 multiple-choice questions was issued to Spanish Neurosurgery Society (SENEC) members. The following were evaluated: (1) the surgeon's role regarding osteoporosis in spinal arthrodesis, (2) the influence of osteoporosis in pseudarthrosis, and (3) treatment trends in relation to osteoporotic vertebral fractures. ResultsA total of 77 completed questionnaires were obtained. In patients with suspected osteoporosis, 32.5% of respondents did not consider any measure to diagnose it before spinal arthrodesis. In osteoporosis without treatment, 37.7% would proceed with surgery without treatment or would do so after surgery. A total of 48% of respondents would choose to modify their surgical strategy in patients with osteoporosis. The preferred surgical technique was the placement of augmentation screws (70%). In pseudarthrosis, 46.1% did not consider an osteoporosis diagnosis to be necessary for a reoperation. In osteoporotic vertebral fractures, 80.5% of surgeons considered some measure that would facilitate the treatment of osteoporosis. ConclusionsGreater participation of the spine surgeon could improve the diagnosis and preoperative treatment of osteoporosis in spinal arthrodesis surgery and pseudarthrosis. In vertebral fractures, there is greater awareness of the optimisation of treatment and monitoring of osteoporosis." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Antecedentes y objetivosCon cada vez mayor frecuencia neurocirujanos y otros especialistas nos vemos afrontados al tratamiento de pacientes con osteoporosis que requieren una cirugía de fusión de columna.Pese a existir tratamientos farmacológicos efectivos e innovaciones en las técnicas quirúrgicas que pueden beneficiar a estos pacientes, se han reportado tasas bajas de diagnóstico y tratamiento preoperatorio de osteoporosis, además de una escasa participación de los cirujanos de columna en este ámbito.El objetivo de este estudio fue evaluar las tendencias en el diagnóstico y tratamiento respecto a la osteoporosis en los cirujanos de raquis de la comunidad neuroquirúrgica. Material y métodosSe realizó una encuesta electrónica con 10 preguntas de opción múltiple a los miembros de la Sociedad Española de Neurocirugía (SENEC). Se valoraron: 1) papel del cirujano de columna frente a la osteoporosis en la artrodesis de raquis, 2) la influencia de osteoporosis en la seudoartrosis y 3) tendencias de tratamiento respecto a las fracturas vertebrales osteoporóticas. ResultadosObtuvimos un total de 77 cuestionarios respondidos. En los pacientes con sospecha de osteoporosis, un 32,5% de los encuestados no se plantea ninguna medida para diagnosticarla antes de una artrodesis vertebral. En osteoporóticos sin tratamiento, un 37,7% procedería con la cirugía sin tratamiento o lo haría después de la cirugía. El 48% de los respondedores optaría por modificar su estrategia quirúrgica en los pacientes con osteoporosis. La técnica quirúrgica preferida fue la colocación de tornillos cementados (70%). En la seudoartrosis, el 46,1% no considera necesario el diagnóstico de osteoporosis para una reintervención. En las fracturas vertebrales osteoporóticas, el 80,5% de los cirujanos se plantea alguna medida que facilitara el tratamiento de la osteoporosis. ConclusionesUna mayor participación del cirujano de columna mejoraría el diagnóstico y tratamiento preoperatorio de la osteoporosis en las cirugías de artrodesis vertebral y seudoartrosis. En las fracturas vertebrales existe una mejor concienciación para optimizar el tratamiento y el seguimiento de la osteoporosis." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Díaz-Romero Paz R, Sosa Henríquez M, Armas Melián K, Coloma Valverde G. Tendencias de actuación de los cirujanos de columna respecto a la osteoporosis. Neurocirugía. 2019;30:268–277." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2682 "Ancho" => 3169 "Tamanyo" => 691764 ] ] "descripcion" => array:1 [ "en" => "List of participation of the different hospital centres around Spain." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1441 "Ancho" => 2091 "Tamanyo" => 150176 ] ] "descripcion" => array:1 [ "en" => "Approach taken by spine surgeons in cases of suspected osteoporosis who are to have spinal fusion." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1349 "Ancho" => 2360 "Tamanyo" => 152770 ] ] "descripcion" => array:1 [ "en" => "Strategies most used to improve surgical outcomes in patients with osteoporosis undergoing spinal surgery." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1235 "Ancho" => 2241 "Tamanyo" => 166725 ] ] "descripcion" => array:1 [ "en" => "Approach taken by the surgeons surveyed in cases of pseudarthrosis after spine surgery." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1466 "Ancho" => 2304 "Tamanyo" => 126155 ] ] "descripcion" => array:1 [ "en" => "Therapeutic approach to osteoporosis-related vertebral fractures." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "The questions (Q) as they were sent in the questionnaire." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Q1. What is your usual approach in patients with SUSPECTED osteoporosis who are to have spinal fusion?</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I request bone density scan as routine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I request a metabolic profile as routine (vitamin D, parathyroid hormone, calcium) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I request both tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I refer to the specialist for diagnosis and treatment of the osteoporosis prior to surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I go ahead with the surgery as routine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other (specify) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Q2. What is your usual approach in patients with untreated osteoporosis who are to have spinal fusion?</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I go ahead with the surgery as routine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I go ahead with the surgery and then refer the patient for osteoporosis treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26.0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I refer to the specialist for treatment of the osteoporosis prior to surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I start treatment for the osteoporosis and then go ahead with the surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I opt for conservative treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other (specify) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Q3. What is your usual approach in patients with osteoporosis on treatment who are to have spinal fusion?</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I would alter my planning and surgical strategy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I go ahead with the surgery as routine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other (specify) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Q4. From a surgical point of view, what strategy do you use to improve surgical outcomes in patients with osteoporosis undergoing spinal surgery? (You may select 1 or more options)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Long instrumentation assemblies extending the fixation points \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cement-augmented cannulated screws \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expandable screws \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Modification of the technique; pedicular screws with bicortal fixation, minimise the tapping \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I don’t generally alter my surgical strategy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other (specify) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2157211.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Role of the spine surgeon in dealing with OP in spinal fusion." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "The questions (Q) as they were sent in the questionnaire." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Q5. What approach do you take in patients who develop pseudoarthrosis after spine surgery?</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I request bone density scan as routine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I request a metabolic profile as routine (vitamin D, parathyroid hormone, calcium) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I request both tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I refer to the specialist for diagnosis and, where necessary, treatment of the osteoporosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">When re-intervention is indicated, I go ahead with the surgery without any additional investigations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other (specify) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Q6. What influence do you think osteoporosis has on the development of pseudoarthrosis?</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Very little \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A certain amount \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Quite a lot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A lot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26.0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other (specify) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Q7. What is your approach in terms of diagnosis in patients who develop a low-energy vertebral compression fracture?</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I request bone density scan as routine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I request a metabolic profile as routine (vitamin D, parathyroid hormone, calcium) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I request both tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I refer to the specialist for confirmation of osteoporosis diagnosis and treatment if appropriate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I don’t consider any specific diagnostic test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other (specify) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Q8. What do you think is the best therapeutic approach in patients who develop a painful low-energy acute vertebral compression fracture?</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conservative treatment only \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conservative treatment for 4–6 weeks and, if no improvement, vertebroplasty or balloon kyphoplasty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertebroplasty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Balloon kyphoplasty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percutaneous fixation with pedicle screws+vertebral augmentation techniques \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other (specify) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2157210.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Trends in approach and treatment in relation to pseudarthrosis and vertebral fragility fractures." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0215" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical management of spinal conditions in the elderly osteoporotic spine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.L. Goldstein" 1 => "D.S. Brodke" 2 => "T.J. Choma" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1227/NEU.0000000000000948" "Revista" => array:6 [ "tituloSerie" => "Neurosurgery" "fecha" => "2015" "volumen" => "77" "paginaInicial" => "S98" "paginaFinal" => "S107" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26378363" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0220" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalencia de osteoporosis determinada por densitometría en la población femenina española" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.D. Curiel" 1 => "J.J. García" 2 => "J.L. Carrasco" 3 => "J. Honorato" 4 => "R.P. Cano" 5 => "A. Rapado" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clín (Barc)" "fecha" => "2001" "volumen" => "116" "paginaInicial" => "86" "paginaFinal" => "88" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0225" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.K. Chin" 1 => "J.Y. Park" 2 => "Y.S. Yoon" 3 => "S.U. Kuh" 4 => "B.H. Jin" 5 => "K.S. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Osteoporosis Int" "fecha" => "2007" "volumen" => "18" "paginaInicial" => "1219" "paginaFinal" => "1224" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0230" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative medical management of spine surgery patients with osteoporosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D. Lubelski" 1 => "T.J. Choma" 2 => "M.P. Steinmetz" 3 => "J.S. Harrop" 4 => "T.E. 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Trends and attitudes of spine surgeons regarding osteoporosis

Tendencias de actuación de los cirujanos de columna respecto a la osteoporosis

Ricardo Díaz-Romero Paza,

Corresponding author

ricdrp@yahoo.com

Corresponding author.

, Manuel Sosa Henríquezb, Kevin Armas Meliána, Gustavo Coloma Valverdea

a Servicio de Neurocirugía, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas, Las Palmas de Gran Canaria, Spain

b Unidad Metabolismo Mineral y Osteoporosis, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas, Las Palmas de Gran Canaria, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The progressive increase in the life expectancy of the population here in Spain and worldwide has led to a significant increase in patients with spinal disorders&#44; whether degenerative or caused by deformity&#46; As a consequence&#44; spinal fusion surgery is becoming increasingly common and necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In Spain&#44; approximately 2 million women suffer from osteoporosis &#40;OP&#41; according to the densitometry criteria proposed by the World Health Organisation&#46; The prevalence of OP in women over 50 is 26&#37;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a> and it is 44&#37; in women operated on for degenerative spine disease &#40;Chin et al&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In patients who have undergone spinal fusion surgery&#44; the decrease in bone mineral density &#40;BMD&#41; affects both the clinical and radiological outcomes&#46; OP can lead to poor bone fusion&#44; a reduction in the pull-out force of pedicle screws and increased subsidence of the prosthetic material&#59; and it is also a risk factor for pseudarthrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">1&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite effective pharmacological treatments and innovations in surgical techniques for OP&#44; studies have revealed inadequate preoperative assessment and a lack of participation from spine surgeons with respect to this type of patient&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a> Moreover&#44; low referral rates to OP specialists after vertebral compression fracture &#40;VCF&#41; have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Although trends and attitudes of spinal surgeons with respect to OP have been studied&#44; mainly in North America&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a> no such assessments have been carried out in our area&#44; and nor have the specific surgical strategies most commonly used in spine surgery been investigated&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The aim of this study was to assess the patterns and trends in the diagnosis and treatment of OP by spine surgeons in Spain&#44; and to inquire about the spine surgery techniques most commonly used in patients with osteoporosis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Survey type study using a questionnaire with 10 self-administered questions directed at specialists who are members of the <span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Neurocirug&#237;a</span> &#40;SENEC&#41; &#91;Spanish Neurosurgery Society&#93;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Contents and sections of the questionnaire</span><p id="par0040" class="elsevierStylePara elsevierViewall">Questions were asked about the speciality &#40;1&#41; and the workplace &#40;2&#41;&#46; The questionnaire was then divided into 3 parts &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Role of the spine surgeon in dealing with OP in spinal fusion &#40;4 questions&#41;&#58; assessed the trends and role of the neurosurgeon in terms of the diagnostic approach in patients with suspected OP and untreated OP&#46; Changes to the surgical strategy and the specific surgery techniques most used in patients with OP were also assessed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Perception of the influence of OP in the development of pseudarthrosis &#40;2 questions&#41;&#58; addressed the surgeon&#39;s perception of and opinion on what influence OP has on the development of pseudarthrosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Assessment of treatment trends and patterns of referral among surgeons with respect to osteoporotic VCF &#40;2 questions&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Question design</span><p id="par0060" class="elsevierStylePara elsevierViewall">The questions were written avoiding redundancies&#44; errors and ambiguities in the text&#46; The answers were multiple-choice&#44; with the possibility of additional comments to avoid information gaps&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Administration of the questionnaire</span><p id="par0065" class="elsevierStylePara elsevierViewall">The questionnaire questions were integrated into the Survey Monkey online survey platform and sent with an email message to the SENEC members through the Technical Secretariat&#46; A total of 3 emails were sent&#58; an invitation to take part in the survey and 2 reminders&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data collection process</span><p id="par0070" class="elsevierStylePara elsevierViewall">The answers were collected through Survey Monkey and the data were then transferred to a database &#40;Excel spreadsheet&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">This study was authorised by our hospital&#39;s Ethics Committee for Research with Medicinal Products and the Board of Directors of SENEC&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">Out of 480 surveys sent out&#44; we obtained a total of 77 answered questionnaires&#44; with the participation of specialists at the different hospitals around Spain listed in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Role of the spine surgeon in dealing with osteoporosis in spinal fusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Q1&#46; With regard to the specialist&#39;s trends and attitudes in patients with suspected OP&#44; the most common approaches were to refer to the specialist for diagnosis and treatment of OP before surgery in 32&#46;5&#37;&#44; and in another third&#44; carrying out the surgery routinely without further consultations or tests &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Q2&#46; For patients with untreated OP programmed for a spinal fusion&#44; 33&#46;8&#37; answered that they would refer to the OP specialist before surgery&#44; 26&#37; would refer after the intervention and 11&#46;7&#37; would go ahead with the surgery as routine&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Q3&#46; In patients with OP on treatment&#44; the tendency in almost half of the respondents &#40;48&#46;7&#37;&#41; was to alter the surgical strategy and in another 47&#46;4&#37;&#44; to operate as routine without changes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Q4&#46; The alternatives in terms of the surgical approaches most commonly used for patients with OP &#40;one or more options&#41; were&#58; cement-augmented screws &#40;70&#46;1&#37;&#41;&#59; modification of the surgical technique &#40;example&#58; bicortical screws&#44; minimise the tapping&#41; in 31&#46;2&#37; and long assemblies in 29&#46;9&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Perception of the influence osteoporosis has on the development of pseudarthrosis</span><p id="par0105" class="elsevierStylePara elsevierViewall">Q5&#46; In the case of patients who develop pseudarthrosis&#44; 46&#46;1&#37; do not consider additional investigations for the diagnosis of OP&#44; even when planning a re-intervention&#46; However&#44; 27&#46;6&#37; refer to the OP specialist for diagnosis and treatment optimisation &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Q6&#46; Regarding their perception of the influence OP has on the development of pseudarthrosis&#44; 35&#46;1&#37; consider that it has quite a lot of influence and 23&#46;4&#37;&#44; a certain amount&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Trends in treatment and referral by surgeons in the case of osteoporotic vertebral compression fracture</span><p id="par0115" class="elsevierStylePara elsevierViewall">Q7&#46; In the case of osteoporotic VCF&#44; it was found that 59&#46;7&#37; of surgeons prefer to refer the patient to the specialist and that 10&#46;4&#37; would request a bone density scan and a bone metabolic profile&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Q8&#46; As far as the surgical treatment of these fractures was concerned&#44; the majority &#40;66&#46;2&#37;&#41; would opt for conservative treatment for 4&#8211;6 weeks and&#44; in case of refractoriness&#44; opt for some vertebral augmentation technique &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Spine surgery and osteoporosis</span><p id="par0125" class="elsevierStylePara elsevierViewall">A growing number of patients with some type of spinal disease requiring surgery also have undiagnosed or untreated OP&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">4&#44;8</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Early identification of the most relevant risk factors for OP is therefore important&#46; The main risk factors are&#58; postmenopausal women&#59; early menopause&#59; family member with hip fracture&#59; metabolic bone disease&#44; BMI of less than 20<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#59; prolonged oral corticosteroid therapy&#44; with the assurance that the outcome of this will influence the decision on treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">That last criterion is particularly relevant&#44; as de novo diagnosis of OP prior to spinal surgery should stimulate action in terms of timely therapy and lead to the surgical plan being modified&#46; In addition to the bone density scan&#44; or dual-energy x-ray absorptiometry &#40;DXA&#41;&#44; the consensus is that the incidental radiological finding of vertebral fractures with an osteoporosis profile is also diagnostic of OP&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">A significant proportion of patients with surgical spine disease are at risk for OP&#46; Chin et al&#46; estimated the prevalence of OP in subjects over 50 having spinal surgery and found that 46&#46;7&#37; of women had osteopenia and 44&#46;1&#37; OP&#59; 45&#46;9&#37; of men had osteopenia and 12&#46;5&#37; had OP&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">3&#44;4</span></a> In other words&#44; it is very likely that the prevalence of OP in patients over 50 having spinal surgery is higher than that in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In our questionnaire&#44; in cases of suspected OP&#44; 61&#46;1&#37; of surgeons considered some measure that would help diagnose OP and a third of responders did not consider it necessary to make any effort to confirm the diagnosis&#46; The latter attitude is probably a reflection of the little influence attributed to OP in the outcomes of spinal fusion surgery&#46; In line with our study&#44; Dipaola et al&#46; reported that 46&#37; of surgeons would request a DXA in patients with suspected OP prior to performing spinal fusion&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">As regards the importance of the bone metabolic profile&#44; it is estimated that anywhere from 40&#37; to 90&#37; of adults have low serum vitamin D levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">11&#8211;13</span></a> Ravindra et al&#46; studied the postoperative serum vitamin D levels of 230 consecutive patients who had elective spinal fusion for degenerative spondylosis&#59; 30&#37; had vitamin D deficiency and 68&#46;9&#37; had insufficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">14</span></a> Current evidence shows that patients with spine disease have a high prevalence of hypovitaminosis D&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a> which could influence the clinical and radiological outcomes of fusion surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">13</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Although the evidence on the benefits of preoperative treatment with vitamin D and calcium is still limited<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> &#40;Lehman&#41;&#44; the 9&#37; in this study who would possibly request a metabolic profile is very low&#44; considering the high prevalence of hypovitaminosis D and the fact that it can be relatively rapid to correct preoperatively&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">For patients with untreated osteoporosis who are candidates for spinal surgery&#44; almost half of the respondents said they would take some measure towards treating the OP preoperatively&#44; either referring to the specialist or starting treatment&#46; However&#44; 37&#46;7&#37; go ahead with the surgery and do not consider referring or treating the OP&#44; or treat postoperatively&#59; a proportion where we understand there is room for improvement&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Considerable advances have been made in understanding the physiopathology and in the treatment of OP over recent decades&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> A number of recently published clinical trials assessed the impact of various pharmacological treatments on bone fusion in spinal surgery&#46; In the main&#44; beneficial effects were found with alendronate&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">15</span></a> zolendronic acid<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">16</span></a> and teriparatide&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Pre-treatment with antiresorptive medication modifies bone remodelling and improves graft integration and bone fusion&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">15&#8211;18</span></a> Consequently&#44; although always according to the clinical context&#44; some authors recommend deferring surgery to allow suitable optimisation of the OP&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a> Although there is no clear consensus&#44; it is recommended that OP treatment be started at least 4&#8211;6 weeks before surgery and continued in the postoperative period under specialised supervision&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">For the planning of surgery in patients with OP&#44; in our study almost half of the respondents would not modify the surgical technique&#46; The Dipaola et al&#46; survey shows that 74&#37; of the specialists would modify their treatment or their surgical plan according to the result of the DXA&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Preoperative diagnosis of OP and the appropriate surgical strategy can improve bone fusion rates and decrease the number of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a> Some of the best-known surgical techniques which can increase clinical success and vertebral fusion rates<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">8&#44;19</span></a> are instrumentation with long assemblies&#44; the use of transverse connectors&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a> and selection of long and conical pedicle screws&#59; 29&#37; of the respondents would apply these options&#46; Modifying the surgical technique was a valid option for 30&#37; of the responders and included minimising tapping<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">21</span></a> and bicortical clamping of pedicle screws at the level of S1&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">22</span></a> It is important to avoid mismatch by properly selecting the size of the interbody implants and so prevent subsidence&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">23</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Other useful tools are the cement-augmented&#44; expandable pedicle screws&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a> In our respondents there was a clear preference for the use of cement-augmented screws &#40;70&#37;&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The fusion rate in patients with OP treated by instrumented posterior lumbar fusion with conventional technique is 89&#46;7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">25</span></a> Retrospective studies on fusion with cement-augmented pedicle screw demonstrate a fusion rate close to 100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">26&#8211;29</span></a> However&#44; the reports on expandable pedicle screws describe a fusion rate of 86&#8211;100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">29&#8211;32</span></a> Therefore&#44; these techniques&#44; despite not being free of complications&#44; can be a valid alternative in patients with OP and should ideally be part of the surgical arsenal of spine surgeons&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Pseudarthrosis and osteoporosis</span><p id="par0195" class="elsevierStylePara elsevierViewall">With reference to pseudarthrosis&#44; almost half of the respondents do not consider conducting additional studies for the diagnosis of OP&#44; even with the threat of need for re-intervention&#46; Dipaola et al&#46; found that only 19&#37; of surgeons requested a DXA and 20&#37; a bone metabolic profile for the study of pseudarthrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">In our case&#44; 61&#37; of the respondents perceive that OP has quite a lot or a lot of influence on the development of pseudarthrosis&#46; However&#44; this does not translate into them taking action to diagnose it&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Our results and those of Dipoala et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a> suggest that a considerable proportion of surgeons do not perceive that OP has a significant influence on the development of pseudarthrosis&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Development of pseudarthrosis is multifactorial and requires a preoperative assessment of risk factors such as advanced age&#44; alcoholism&#44; malnutrition and smoking&#44; as well as OP&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">A decrease in BMD is an independent risk factor related to the failure of instrumentation in lumbar vertebral fusion&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a> It has been reported that adequate BMD achieves higher rates of bone fusion in patients after vertebral spine fusion and that patients with low BMD have a higher risk of pseudoarthrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">33&#44;34</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">If revision surgery becomes necessary for established pseudarthrosis&#44; it is recommended to rule out disorders that may deteriorate bone quality&#44; such as OP&#44; malnutrition&#44; hyperparathyroidism&#44; rheumatoid arthritis and other systemic inflammatory diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">It would therefore seem reasonable that in the case of pseudarthrosis&#44; efforts should be made to diagnose and treat OP before revision surgery&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Osteoporosis-related vertebral fractures</span><p id="par0230" class="elsevierStylePara elsevierViewall">With reference to OP-related vertebral fractures&#44; we found a greater awareness and active participation of the spine surgeon&#44; either referring the patient to a specialist for medical management &#40;59&#37;&#41; or performing some type of diagnostic test &#40;24&#37;&#41;&#46; Dipaola et al&#46; also found that 60&#37; of spine surgeons request a DXA and 39&#37;&#44; bone metabolic profile&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">A primary care study which reviewed more than 4 million medical records in Spain found that&#44; after a first hip fracture&#44; de novo treatment was started in only a minority of patients&#44; whether with bisphosphonates &#40;13&#46;6&#37;&#41; or calcium and vitamin D &#40;21&#46;8&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">35</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">A correlation has been found between orthopaedic surgeons requesting a DXA after distal radius fractures and an increase in the chances of treatment&#44; both of OP and of vertebral fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">6</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">In terms of the trends in treatment of OP-related vertebral fractures&#44; the majority &#40;66&#37;&#41; considered the most appropriate treatment to be vertebral augmentation after a 4&#8211;6 week period of conservative treatment with no improvement&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">36</span></a> 22&#46;4&#37; opted for some vertebral augmentation technique &#40;vertebroplasty or kyphoplasty&#41; at the time of diagnosis&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Several clinical trials&#44; such as the VERTOS II&#44;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">37</span></a> the FREE study&#44;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">38</span></a> and the Farrokhi et al&#46; trial&#44;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">39</span></a> show beneficial results in terms of improvement in pain and quality of life with the use of vertebroplasty or kyphoplasty&#46; However&#44; the VERTOS IV study&#44;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">40</span></a> which compared a group of patients with percutaneous vertebroplasty and a control group with injection of local anaesthetic in pedicles&#44; found no significant differences in the improvement of pain until the one-year follow-up&#46; A recent review by the Cochrane Foundation of 21 clinical trials&#44; 5 of which studied vertebroplasty versus placebo &#40;VERTOS <span class="elsevierStyleSmallCaps">IV</span> being one&#41;&#44; concludes that vertebroplasty has little clinical benefit &#40;pain relief in only 7&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">In general&#44; there is consensus in waiting 4&#8211;6 weeks in patients with a VCF before considering vertebroplasty&#44; as in most patients the pain subsides after a period of observation&#46; However&#44; some neurosurgery and interventional medicine scientific societies in the United States have extended the definition of failure of medical treatment to patients with disabling pain in the area of the fracture that prevents them from walking or performing physiotherapy after 24<span class="elsevierStyleHsp" style=""></span>h of an adequate analgesic treatment&#44; or in the case of having intolerable adverse effects from the medication&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">36</span></a> In line with this criterion&#44; the results of the multicentre VAPOUR trial&#44; which compared vertebroplasty to placebo in patients with VCF less than 6 weeks old&#44; found a significant improvement in pain &#40;difference of 23&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">42</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Gathering the best available scientific evidence&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a> for the time being&#44; it is not possible to recommend vertebroplasty in OP-related VCF&#44; as it has little clinical beneficial effect&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">In short&#44; this study is pioneering in the analysis of trends and attitudes among the spinal surgery community in terms of OP&#46; We emphasise the need to establish and standardise the diagnostic and preoperative treatment criteria for OP&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">One limitation of our research was the relatively low participation of specialists in the survey&#46; This is a known drawback of survey studies sent electronically and may possibly make the study less representative&#46; The trends in behaviour we found are representative of the neurosurgical community&#44; which leads us to suggest that these patterns should be measured in traumatologists&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Our results show the need to encourage the active participation of the spine surgeon&#44; referring patients with OP for treatment at an early stage&#46; Ideally&#44; efforts should be made to develop consensual and multidisciplinary management guidelines for diagnosis and treatment of patients with OP in the preoperative period before spinal surgery&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusions</span><p id="par0280" class="elsevierStylePara elsevierViewall">Greater involvement of the spine surgeon could improve the referral intention rate and preoperative treatment of OP in spinal fusion surgery and pseudarthrosis&#46; In vertebral fractures there is better awareness about optimising the treatment and follow-up of OP&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Funding</span><p id="par0285" class="elsevierStylePara elsevierViewall">This work was funded by the <span class="elsevierStyleSmallCaps">22nd</span> Research Grant awarded by the <span class="elsevierStyleGrantSponsor" id="gs1"><span class="elsevierStyleItalic">Colegio de M&#233;dicos de Las Palmas de Gran Canaria</span></span> &#91;College of Physicians of Las Palmas&#44; Gran Canaria&#93;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0290" class="elsevierStylePara elsevierViewall">We declare that we have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Abstract"
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          "titulo" => "Introduction"
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          "titulo" => "Material and methods"
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              "titulo" => "Question design"
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          "titulo" => "Results"
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              "titulo" => "Role of the spine surgeon in dealing with osteoporosis in spinal fusion"
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              "titulo" => "Perception of the influence osteoporosis has on the development of pseudarthrosis"
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              "identificador" => "sec0050"
              "titulo" => "Trends in treatment and referral by surgeons in the case of osteoporotic vertebral compression fracture"
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          "titulo" => "Discussion"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Spine surgery and osteoporosis"
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            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Pseudarthrosis and osteoporosis"
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            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Osteoporosis-related vertebral fractures"
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          ]
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          "titulo" => "Conclusions"
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          "titulo" => "References"
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    "fechaRecibido" => "2018-11-22"
    "fechaAceptado" => "2019-04-17"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1167943"
          "palabras" => array:6 [
            0 => "Osteoporosis"
            1 => "Arthrodesis"
            2 => "Spine"
            3 => "Pseudarthrosis"
            4 => "Fracture"
            5 => "Vertebral"
          ]
        ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:6 [
            0 => "Osteoporosis"
            1 => "Artrodesis"
            2 => "Columna vertebral"
            3 => "Seudoartrosis"
            4 => "Fractura"
            5 => "Vertebral"
          ]
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Neurosurgeons and other specialists are increasingly having to treat patients with osteoporosis who require spinal fusion surgery&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Although there are effective pharmacological treatments and innovations in surgical techniques that can benefit these patients&#44; low rates of diagnosis and preoperative treatment of osteoporosis have been reported&#44; in addition to the limited participation of spine surgeons in this area&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The objective of this study was to evaluate trends in diagnosis and treatment of osteoporosis with regard to spine surgeons of the neurosurgical community&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">An electronic survey with 10 multiple-choice questions was issued to Spanish Neurosurgery Society &#40;SENEC&#41; members&#46; The following were evaluated&#58; &#40;1&#41; the surgeon&#39;s role regarding osteoporosis in spinal arthrodesis&#44; &#40;2&#41; the influence of osteoporosis in pseudarthrosis&#44; and &#40;3&#41; treatment trends in relation to osteoporotic vertebral fractures&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A total of 77 completed questionnaires were obtained&#46; In patients with suspected osteoporosis&#44; 32&#46;5&#37; of respondents did not consider any measure to diagnose it before spinal arthrodesis&#46; In osteoporosis without treatment&#44; 37&#46;7&#37; would proceed with surgery without treatment or would do so after surgery&#46; A total of 48&#37; of respondents would choose to modify their surgical strategy in patients with osteoporosis&#46; The preferred surgical technique was the placement of augmentation screws &#40;70&#37;&#41;&#46; In pseudarthrosis&#44; 46&#46;1&#37; did not consider an osteoporosis diagnosis to be necessary for a reoperation&#46; In osteoporotic vertebral fractures&#44; 80&#46;5&#37; of surgeons considered some measure that would facilitate the treatment of osteoporosis&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Greater participation of the spine surgeon could improve the diagnosis and preoperative treatment of osteoporosis in spinal arthrodesis surgery and pseudarthrosis&#46; In vertebral fractures&#44; there is greater awareness of the optimisation of treatment and monitoring of osteoporosis&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Con cada vez mayor frecuencia neurocirujanos y otros especialistas nos vemos afrontados al tratamiento de pacientes con osteoporosis que requieren una cirug&#237;a de fusi&#243;n de columna&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Pese a existir tratamientos farmacol&#243;gicos efectivos e innovaciones en las t&#233;cnicas quir&#250;rgicas que pueden beneficiar a estos pacientes&#44; se han reportado tasas bajas de diagn&#243;stico y tratamiento preoperatorio de osteoporosis&#44; adem&#225;s de una escasa participaci&#243;n de los cirujanos de columna en este &#225;mbito&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio fue evaluar las tendencias en el diagn&#243;stico y tratamiento respecto a la osteoporosis en los cirujanos de raquis de la comunidad neuroquir&#250;rgica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; una encuesta electr&#243;nica con 10 preguntas de opci&#243;n m&#250;ltiple a los miembros de la Sociedad Espa&#241;ola de Neurocirug&#237;a &#40;SENEC&#41;&#46; Se valoraron&#58; 1&#41; papel del cirujano de columna frente a la osteoporosis en la artrodesis de raquis&#44; 2&#41; la influencia de osteoporosis en la seudoartrosis y 3&#41; tendencias de tratamiento respecto a las fracturas vertebrales osteopor&#243;ticas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Obtuvimos un total de 77 cuestionarios respondidos&#46; En los pacientes con sospecha de osteoporosis&#44; un 32&#44;5&#37; de los encuestados no se plantea ninguna medida para diagnosticarla antes de una artrodesis vertebral&#46; En osteopor&#243;ticos sin tratamiento&#44; un 37&#44;7&#37; proceder&#237;a con la cirug&#237;a sin tratamiento o lo har&#237;a despu&#233;s de la cirug&#237;a&#46; El 48&#37; de los respondedores optar&#237;a por modificar su estrategia quir&#250;rgica en los pacientes con osteoporosis&#46; La t&#233;cnica quir&#250;rgica preferida fue la colocaci&#243;n de tornillos cementados &#40;70&#37;&#41;&#46; En la seudoartrosis&#44; el 46&#44;1&#37; no considera necesario el diagn&#243;stico de osteoporosis para una reintervenci&#243;n&#46; En las fracturas vertebrales osteopor&#243;ticas&#44; el 80&#44;5&#37; de los cirujanos se plantea alguna medida que facilitara el tratamiento de la osteoporosis&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Una mayor participaci&#243;n del cirujano de columna mejorar&#237;a el diagn&#243;stico y tratamiento preoperatorio de la osteoporosis en las cirug&#237;as de artrodesis vertebral y seudoartrosis&#46; En las fracturas vertebrales existe una mejor concienciaci&#243;n para optimizar el tratamiento y el seguimiento de la osteoporosis&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; D&#237;az-Romero Paz R&#44; Sosa Henr&#237;quez M&#44; Armas Meli&#225;n K&#44; Coloma Valverde G&#46; Tendencias de actuaci&#243;n de los cirujanos de columna respecto a la osteoporosis&#46; Neurocirug&#237;a&#46; 2019&#59;30&#58;268&#8211;277&#46;</p>"
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Strategies most used to improve surgical outcomes in patients with osteoporosis undergoing spinal surgery&#46;</p>"
        ]
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Approach taken by the surgeons surveyed in cases of pseudarthrosis after spine surgery&#46;</p>"
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      4 => array:7 [
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        "etiqueta" => "Fig&#46; 5"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Therapeutic approach to osteoporosis-related vertebral fractures&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">The questions &#40;Q&#41; as they were sent in the questionnaire&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Q1&#46; What is your usual approach in patients with SUSPECTED osteoporosis who are to have spinal fusion&#63;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I request bone density scan as routine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I request a metabolic profile as routine &#40;vitamin D&#44; parathyroid hormone&#44; calcium&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I request both tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I refer to the specialist for diagnosis and treatment of the osteoporosis prior to surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I go ahead with the surgery as routine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other &#40;specify&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Q2&#46; What is your usual approach in patients with untreated osteoporosis who are to have spinal fusion&#63;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I go ahead with the surgery as routine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I go ahead with the surgery and then refer the patient for osteoporosis treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I refer to the specialist for treatment of the osteoporosis prior to surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I start treatment for the osteoporosis and then go ahead with the surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I opt for conservative treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other &#40;specify&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Q3&#46; What is your usual approach in patients with osteoporosis on treatment who are to have spinal fusion&#63;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I would alter my planning and surgical strategy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I go ahead with the surgery as routine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other &#40;specify&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Q4&#46; From a surgical point of view&#44; what strategy do you use to improve surgical outcomes in patients with osteoporosis undergoing spinal surgery&#63; &#40;You may select 1 or more options&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Long instrumentation assemblies extending the fixation points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cement-augmented cannulated screws&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Expandable screws&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Modification of the technique&#59; pedicular screws with bicortal fixation&#44; minimise the tapping&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I don&#8217;t generally alter my surgical strategy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other &#40;specify&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">The questions &#40;Q&#41; as they were sent in the questionnaire&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Q5&#46; What approach do you take in patients who develop pseudoarthrosis after spine surgery&#63;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I request bone density scan as routine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I request a metabolic profile as routine &#40;vitamin D&#44; parathyroid hormone&#44; calcium&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I request both tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I refer to the specialist for diagnosis and&#44; where necessary&#44; treatment of the osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>When re-intervention is indicated&#44; I go ahead with the surgery without any additional investigations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other &#40;specify&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Q6&#46; What influence do you think osteoporosis has on the development of pseudoarthrosis&#63;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Very little&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>A certain amount&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Quite a lot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>A lot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other &#40;specify&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q7&#46; <span class="elsevierStyleItalic">What is your approach in terms of diagnosis in patients who develop a low-energy vertebral compression fracture&#63;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I request bone density scan as routine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I request a metabolic profile as routine &#40;vitamin D&#44; parathyroid hormone&#44; calcium&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I request both tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I refer to the specialist for confirmation of osteoporosis diagnosis and treatment if appropriate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I don&#8217;t consider any specific diagnostic test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other &#40;specify&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Q8&#46; What do you think is the best therapeutic approach in patients who develop a painful low-energy acute vertebral compression fracture&#63;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Conservative treatment only&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Conservative treatment for 4&#8211;6 weeks and&#44; if no improvement&#44; vertebroplasty or balloon kyphoplasty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vertebroplasty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Balloon kyphoplasty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Percutaneous fixation with pedicle screws<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>vertebral augmentation techniques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other &#40;specify&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Trends in approach and treatment in relation to pseudarthrosis and vertebral fragility fractures&#46;</p>"
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                        0 => array:2 [
                          "etal" => true
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                      "titulo" => "Survey of spine surgeons on attitudes regarding osteoporosis and osteomalacia screening and treatment for fractures&#44; fusion surgery&#44; and pseudoarthrosis"
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                            4 => "J&#46;N&#46; Grauer"
                            5 => "G&#46;R&#46; Rechtine"
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                        "volumen" => "9"
                        "paginaInicial" => "537"
                        "paginaFinal" => "544"
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                      "titulo" => "Improving evaluation and treatment for osteoporosis following distal radial fractures"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "T&#46;D&#46; Rozental"
                            1 => "E&#46;C&#46; Makhni"
                            2 => "C&#46;S&#46; Day"
                            3 => "M&#46;L&#46; Bouxsein"
                          ]
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Article information

ISSN: 25298496
Original language: English

DOI:10.1016/j.neucie.2019.06.001

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