Perioperative disease activity and metabolic optimization in spinal Paget's disease

Dear Editor,

The article by Eissa et al. reports a rare juxtafacet synovial cyst occurring in the context of spinal Paget's disease of bone (PDB), treated with decompression, cyst excision, and instrumented fusion (Eissa et al., 2025). The report highlights important surgical challenges associated with pagetic bone and appropriately emphasizes hypervascularity as a key intraoperative concern. A central scientific issue with direct relevance to surgical risk stratification and reproducibility warrants further clarification: the lack of documented disease activity status and perioperative antiresorptive optimization, despite the report of considerable intraoperative bleeding. Paget's disease is characterized by focal increases in bone turnover and vascularity during its active phase, features that may significantly influence intraoperative blood loss and technical complexity. Contemporary evidence-based guidelines stress that assessment of disease activity—typically using serum alkaline phosphatase or other markers of bone turnover—is fundamental to management decisions (Ralston et al., 2019; Ralston, 2013; Singer et al., 2014). Importantly, these guidelines explicitly recognize elective surgery involving pagetic bone as a clinical context in which medical treatment with potent bisphosphonates, particularly intravenous zoledronic acid, may be desirable to suppress disease activity and potentially reduce bone hypervascularity (Ralston et al., 2019; Singer et al., 2014). In the present case, while hypervascular bleeding is described and the role of bisphosphonates is correctly acknowledged (Eissa et al., 2025), the report does not specify whether the patient demonstrated biochemical evidence of active Paget's disease or whether antiresorptive therapy was administered preoperatively. From a spine surgeon's perspective, this information is not ancillary; rather, it directly informs operative planning, blood conservation strategies, and interpretation of surgical risk. Without documentation of metabolic disease status and its management, it remains unclear whether the observed bleeding reflects unavoidable disease biology or a potentially modifiable factor. Although high-level randomized surgical data addressing perioperative bisphosphonate use in Paget's disease are limited, expert consensus and guideline-based recommendations consistently emphasize disease suppression in active PDB, particularly when major orthopedic or spinal procedures are anticipated (Ralston et al., 2019; Ralston, 2013; Singer et al., 2014). Routine reporting of disease activity markers and perioperative metabolic optimization would therefore strengthen the translational value of case-based literature and facilitate comparison across centers. It is suggested that future reports of spinal surgery in Paget's disease systematically include: (1) biochemical markers of disease activity, (2) details regarding antiresorptive therapy and its timing relative to surgery, and (3) whether neurological urgency precluded preoperative metabolic control. Such reporting would align surgical practice with established principles of metabolic bone disease management and enhance the scientific rigor of publications addressing rare spinal manifestations of PDB. The authors are to be congratulated on documenting an uncommon and challenging clinical entity. Clarifying the metabolic context in which surgery was undertaken would further enhance the clinical and scientific impact of this valuable contribution.

Funding

None.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.