Do you delay spinal surgery (e.g. lumbar decompression for stenosis) in men or women with newly diagnosed osteoporosis and multiple thoracic compression fractures (not involving site of potential surgery) in order to initiate anabolic or anti-resorptive therapy to potentially improve surgical healing outcomes?

This is a fairly common clinical issue. Increasingly, spine surgeons are requesting anabolic bone medications prior to the type of surgery outlined in the question. Our approach has been to use three months of such treatment prior to the surgical procedure and then to continue that treatment after the surgery. The total length of time for such treatment would depend on the patient's fracture risk. In the case described, I would likely suggest that the treatment be similar to the management of a patient with severe osteoporosis. It should be noted that the anabolic drugs do not have a specific indication as medical adjuncts to spinal surgery and insurance approval for such patients who do not have osteoporosis can be problematic. Additionally, the data on the relative efficacies of anabolic versus anti-resorptive agents in facilitating hardware fixation and superior fusion outcomes is not clear. It does seem that anabolic drugs may promote such fixation and fusion more quickly than anti-resorptive agents but the difference in outcome over longer periods of time may not be significant.

It's a good thing that orthopedic surgeons are paying attention to underlying bone health. There are a number of factors that impact the scenario you describe above. First, and most important, is whether you know how recent the fractures were. Recent fractures impart greater risk than remote fractures. Second, what else is known about the patient's bone health? If you have well-performed and interpreted DXA, that is great, but you can also use CT scans of the spine to get a bead on this. It is also important to evaluate for secondary causes of skeletal fragility. You would want to know if those compression fractures were a consequence of multiple myeloma. The International Society for Clinical Densitometry (ISCD) has published guidelines on using the CT data. Its incoming president is a spine surgeon. Perry Pickhardt and colleagues have published a number of papers on the topic. Here is a citation to one of them.

Lee et al., PMID 29314261

And here is a link to ISCD guidance. Only a subset addresses the issue you raise, and ISCD does not address pharmacological management.

https://www.iscd.org/official-positions-2023/

In return, I ask whether, and in how much depth, this and related issues are addressed in orthopedic surgery residency training?