Posterior spinal fusion with pedicle screw-based constructs in osteogenesis imperfecta: a systematic review of surgical and radiographic outcomes.

Abstract

Background: Osteogenesis imperfecta (OI) is a rare genetic disorder characterized by bone fragility and severe spinal deformities, with scoliosis affecting up to 80% of patients and often progressing despite bracing. Surgical management is challenging due to poor bone quality and high complication risk. Advances in pedicle screw-based constructs and multimodal strategies, including traction and bisphosphonates, have improved outcomes and enabled the successful correction of deformities. This review analyzes radiographic and surgical results of modern posterior spinal fusion (PSF) in OI-associated spinal deformity.

Methods: A systematic search of PubMed, Scopus, Embase, Cochrane Library, and Google Scholar (inception to May 2025) was performed using search terms such as "osteogenesis imperfecta", "brittle bone disease", "posterior spinal fusion", "spinal arthrodesis", "scoliosis" and "spinal deformity". Extracted data covered demographics, OI type, traction techniques, instrumentation, radiographic and surgical outcomes, complications, and patient-reported outcome measures (PROMs). The risk of bias was assessed using the MINORS tool, and reporting followed PRISMA guidelines.

Results: The initial search identified 264 articles, of which 8 met the inclusion criteria, including 149 patients with OI (mean age 15.5 years). All studies were retrospective case series (level IV evidence). Cement augmentation was used in 31.5% of cases and apical osteotomies in 37.5%. Preoperative main curves ranged from 75.5° to 96°, with a mean correction rate of 49.5% after PSF. Both coronal and sagittal radiographic parameters improved postoperatively. The mean operative time was 410.6 minutes, blood loss averaged 1,375 mL, and hospital stay was 7.9 days. The overall complication rate was 27.5%, with 10.7% requiring unplanned reoperation.

Conclusion: Modern pedicle screw-based constructs appear to provide more consistent radiographic correction in OI-associated scoliosis compared to earlier in situ fusion techniques. Although these procedures still entail significant blood loss and long operative times, their complication rates remain acceptable given patient complexity. Future multicenter high-quality studies should focus on optimizing implant density, screw augmentation, rod material, osteotomies, and integrating navigation and new biomaterials to standardize treatment strategies.