Background: Osteoporosis and low bone mineral density are highly prevalent among patients undergoing spinal fusion, contributing to higher rates of hardware failure, revision surgery, and poor postoperative outcomes. Despite clear risks, perioperative screening and treatment for osteoporosis remain inconsistent. Bone Health Clinics (BHCs) and Fracture Liaison Services (FLSs) have emerged as multidisciplinary models to address this care gap. We describe the implementation of a dedicated BHC at a single academic center and evaluate perioperative pharmacotherapy patterns, treatment barriers, and surgical outcomes among spine patients. Methods: We retrospectively reviewed 174 consecutive perioperative spine patients referred to our institutional BHC between October 2019 and April 2024. Demographics, surgical characteristics, bone health status, laboratory and DXA results, pharmacologic management, contraindications, insurance-related barriers, and medication sequencing were collected. Surgical outcomes included hardware failure and revision surgery. Bone health response was assessed by follow-up DXA scans. Results: The cohort was predominantly female (78.2%) with a mean age of 71.9 years. Most patients were referred by neurosurgery (53.4%) or orthopedics (41.4%). Based on DXA and fragility fracture history, 27.0% had osteopenia, 56.3% osteoporosis, and 13.8% severe osteoporosis. Pharmacotherapy was prescribed in 146 patients (83.9%), most commonly romosozumab (32.9%), denosumab (22.6%), and abaloparatide (21.2%). Twenty-eight patients (16.1%) did not receive medication, primarily due to contraindications. Insurance-related barriers disproportionately affected anabolic agents, whereas denosumab had the lowest denial rate (15.2%, p = 0.0124). Sequential therapy was common (32.1%), most frequently romosozumab followed by denosumab. Hardware failure occurred in 11.5% of patients, with 5.7% requiring revision surgery. Among the 80 patients (46.0%) with follow-up DXA, 60% demonstrated improved bone mineral density, with an average T-score gain of 0.6 ± 0.5. Conclusions: Integration of a multidisciplinary BHC into perioperative spine care was feasible, associated with high rates of pharmacotherapy initiation, and demonstrated favorable early surgical outcomes compared to published complication rates in this population. Insurance and contraindications remain key barriers to anabolic therapy access, driving prescribing toward denosumab. Prospective studies are needed to confirm the impact of perioperative bone optimization on surgical durability, cost-effectiveness, and patient-centered outcomes.
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