Nonsteroidal anti-inflammatory drugs and bone metabolism in spinal fusion surgery - A pharmacological quandary

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is ubiquitous in c ontemporary medical practice and these agents are efficacious in a number o f clinical contexts. In particular, NSAIDs have proven to be highly effecti ve adjuncts in the amelioration of postoperative pain in the subset of pati ents undergoing spinal surgery requiring fusion. NSAIDs act through inhibit ion of cyclooxygenase enzymes and therefore diminish prostaglandin producti on. However, prostaglandins are intimately involved in the modulation of bo ne metabolism and the balance of data, from both clinical and I;laboratory contexts, indicate that prostaglandins preferentially favor bone anabolism. Most recently, limited emerging evidence suggests that NSAID administratio n in patients undergoing spinal fusion surgery may increase nonunion rates, which in turn, has important ramifications to the patient, their family an d the entire medical system. Hence, disparate views have evolved regarding the use of NSAIDs in postoperative pain control in patients undergoing spin al surgery requiring fusion. NSAIDs have proven efficacy in the management of postoperative pain in these patients, however, this must be weighed agai nst the risk of nonunion and its associated consequences. In this review, t he role of prostaglandins in bone metabolism, the pharmacology of NSAIDs an d the modulation of bone metabolism by NSAIDs are discussed. Additionally, the current evidence examining the use of NSAIDs in spinal surgery is prese nted. As rates of spinal surgery continue to rise, it is imperative that th e apparent pharmacological quandary surrounding the administration of NSAID s in patients undergoing spinal surgery requiring fusion be addressed, both to guide present clinical practice and to outline further directions for i nvestigation. (C) 2000 Elsevier Science Inc. All rights reserved.