The rapid aging of the global population has transformed spine surgery. Osteoporosis and sarcopenia are now recognized not merely as comorbidities but as major biological determinants of spinal alignment, implant stability, and successful spinal fusion. Consequently, treatment strategies are evolving from purely mechanical reconstruction toward optimization of the biological environment for tissue regeneration.
In this Special Issue, the review by Lim et al [1]. provides an excellent overview of current concepts in bone health optimization for spine surgery. Their review highlights how the assessment of bone health has evolved beyond conventional bone mineral density (BMD) to incorporate bone quality, opportunistic imaging biomarkers, and individualized fracture risk, while also summarizing current pharmacological and biologic strategies for enhancing spinal fusion [2-4]. This review provides an ideal framework for understanding the studies presented in this issue.
The accompanying articles further demonstrate that bone assessment has progressed beyond BMD toward multidimensional evaluation integrating bone quality, skeletal fragility, and musculoskeletal function. More importantly, this conceptual evolution is expanding therapeutic targets for improving surgical outcomes.
One promising direction is the development of regenerative biomaterials. Rather than functioning solely as passive scaffolds, these biomaterials are designed to engineer the regenerative microenvironment by improving growth factor delivery, modulating local immune responses, and promoting endogenous tissue repair. Such strategies may be particularly valuable for maximizing the efficacy and safety of biologic therapies, including bone morphogenetic proteins (BMP) [5,6].
Another emerging therapeutic target is skeletal aging. Increasing evidence suggests that impaired bone regeneration in older individuals results not only from reduced bone mass but also from age-related biological dysfunction, including cellular senescence, stem cell exhaustion, and chronic inflammation [7]. These changes reduce the intrinsic regenerative capacity of bone and may attenuate the response to osteoanabolic therapies. Future regenerative strategies should therefore focus not only on stimulating bone formation but also on restoring the biological responsiveness of the aging skeleton [8].
Collectively, this Special Issue illustrates an important evolution in spine surgery. Our understanding of bone health has progressed from evaluating bone quantity to characterizing bone quality and, increasingly, to identifying new biological processes as therapeutic targets. The evolution from bone quantity to bone quality has ultimately led us to a new question—not only how we should assess bone, but also what aspects of bone biology should be therapeutically targeted to improve regeneration.
We hope this Special Issue not only provides readers with an up-to-date overview of osteoporosis and sarcopenia in spine surgery but also inspires new perspectives on future therapeutic strategies and further innovation in precision spine surgery.
Footnotes
Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Author Contributions
The author contributed to the writing and final approval of this Editorial Comment.
References
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