Bone quality, biology, and next-generation enhancers for spinal fusion in osteoporosis: a comprehensive narrative review with systematic search methodology

A multimodal approach combining comprehensive bone quality assessment, systemic anabolic optimization (moderate certainty evidence), and targeted novel biologics delivered via advanced biomaterial scaffolds (very low certainty evidence) is proposed for optimized spinal arthrodesis outcomes. However, large-scale clinical trials are required to validate these emerging biologic enhancers.