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Compromised bone quality is associated with hardware loosening, pseudoarthrosis, proximal junctional failure, and revision surgery. This narrative review aims to highlight the importance of preoperative bone optimization and propose a pragmatic clinical pathway for spine surgeons. Specifically, we aimed to: (1) outline risk assessment and diagnostic strategies, including clinical risk factors, laboratory testing, and imaging such as dual-energy x-ray absorptiometry (DEXA) and opportunistic CT-based Hounsfield Unit (HU) analysis; (2) evaluate therapeutic options, emphasizing pharmacologic agents (teriparatide, romosozumab, denosumab, and bisphosphonates) alongside non-pharmacologic measures including nutrition and lifestyle modification; and (3) explore future directions, including therapy duration and economic barriers to wider adoption of newer agents.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This narrative review synthesizes the current literature on preoperative bone health management in spine surgery. Risk assessment strategies were discussed including imaging, laboratory testing, and clinical picture analysis. Therapeutic options evaluated emphasize pharmacologic agents alongside non-pharmacologic measures.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Despite the clinical relevance of compromised bone quality to poor surgical outcomes, bone health assessment remains inconsistently incorporated into surgical planning. Current evidence supports a multimodal approach combining targeted assessment and timely intervention to mitigate risk of adverse bone-related events following spine surgery.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Preoperative bone health optimization is a crucial opportunity to improve long-term outcomes for patients undergoing spine surgery. Adoption of a standardized clinical pathway for risk stratification, diagnosis, and treatment may provide a valuable framework for improving fixation stability and fusion rates.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/21925682261431791","type":"journal-article","created":{"date-parts":[[2026,3,11]],"date-time":"2026-03-11T17:31:24Z","timestamp":1773250284000},"page":"3668-3682","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Pre-Operative Bone Health in Elective Spine Surgery, From Risk Assessment to Optimization Strategies: A Narrative Review"],"prefix":"10.1177","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5831-055X","authenticated-orcid":false,"given":"Mitchell K.","family":"Ng","sequence":"first","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Morgan","family":"Hitchner","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7452-2712","authenticated-orcid":false,"given":"Jonathan","family":"Dalton","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yulia","family":"Lee","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7147-0542","authenticated-orcid":false,"given":"William A.","family":"Green","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregorio","family":"Baek","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joshua","family":"Mathew","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yasmine K.","family":"Eichbaum","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8811-9687","authenticated-orcid":false,"given":"Alan S.","family":"Hilibrand","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander R.","family":"Vaccaro","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory D.","family":"Schroeder","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher K.","family":"Kepler","sequence":"additional","affiliation":[{"name":"Thomas Jefferson University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,3,6]]},"reference":[{"key":"e_1_3_7_2_2","volume-title":"Bone Health and Osteoporosis: A Report of the Surgeon General","author":"Office of the Surgeon General (US)","year":"2004","unstructured":"Office of the Surgeon General (US). 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