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SCI Forum Report & Video

 

Osteoporosis and Fractures in Persons with SCI:
What, Why, and How to Manage

By Jelena Svircev, MD, Assistant Professor at the University of Washington in the Department of Rehabilitation Medicine and staff physician at the Spinal Cord Injury Service at the Department of Veterans Affairs at the Puget Sound Health Care System. Presented on November 13, 2012. .

If you have a spinal cord injury, you may be aware that you have a high risk of developing osteoporosis and possibly breaking a bone. This presentation will help you understand why this happens, what you can do about it and how to avoid fractures and their life-disrupting, painful and costly consequences. Watch the video or read the report.


 

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Contents

About bones

Bones are living, dynamic organs that are continuously changing and replacing cells, like any other organ in the body, although at a much slower rate.

Different parts of the long bones (Figure 1)

  1. Shaft or diaphysis.
  2. Epiphyses, or ends of the bone.
    1. Proximal epiphysis (the top end of the bone)
    2. Distal epiphysis (the bottom end of the bone).
  3. Metaphysis, the area next to the epiphysis.

Diagram of long bone showing the locations of the metaphysis, epiphysis and diaphysis.Figure 1

Many of the fractures that individuals with SCI sustain occur in the region of the metaphysis and epiphysis.

Different types of bone (Figure 2):  


 bone types Figure 2

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What is osteoporosis?

Osteoporosis, or porous bone, is a disease in which the bones lose density, become weak and brittle, and are more likely to break. In osteoporosis, the normal process of creating new cells and reabsorbing  old ones in the bones becomes imbalanced, leading to a gradual thinning of bone tissue. Osteopenia is an intermediate condition in which bone has lost density and strength but has not reached the more fragile state of osteoporosis. You can see this gradual change in Figure 3.

Images showing changes in bone from normal density to the more porous bone of severe osteoporosis.Figure 3

[Images courtesy of Susan Ott, MD, Associate Professor, Department of Medicine, University of Washington.]

Osteoporosis and bone fractures

Bone fractures in the general U.S. population, usually of the hip, are a very disabling and sometimes fatal consequence of osteoporosis;  each year, more than 300,000 people over age 65 sustain hip fractures. Of these, 30% die within one year of fracture. Those who survive experience losses in independence and function for a year or two after fracture. After that, only 40% ever regain their former mobility, and only 25% get back their pre-fracture level of independence. The majority (71%) are never able to return to their former living situation.

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How is osteoporosis diagnosed?

Bone mineral density is measured using dual-energy x-ray absorptiometry, also known as DXA scanning.  The scanner is a padded table with an x-ray tube.  The scan gives a score that is compared to that of a healthy person in their 20s. A diagnosis of osteopenia or osteoporosis is based on how far below that ideal a score falls. In the general population, osteoporosis most often shows up in the spine, hip and forearm, so those are the areas that are typically examined with DXA scanning.

Osteoporosis  in SCI

While the most common pattern of osteoporosis in the general population is in the post-menopausal female, who classically fractures in the vertebrae, the hips and the wrist, osteoporosis in SCI is quite different.

Causes

In the SCI population, osteoporosis is likely due to many different factors.

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Screening for osteoporosis in SCI

The goal of screening tests is mainly to identify “silent” disease or risk factors, and sort out the people with and without a certain disease. Screening tests should only be done if care is going to change as a result of the screening. In the able-bodied population, women do not usually start getting bone scans until well after menopause.

Using DXA scanning for people with SCI is controversial and many providers do not recommend it for a variety of reasons. First, it is often difficult to get a good quality DXA scan because of spasticity, contractures, heterotopic ossification (abnormal bone growths), hardware, and previous surgeries. Transferring onto the scanner may be difficult or impossible in some cases.

We already know that most people with SCI have bone loss, and the exposure to radiation that comes from periodic scans may pose an unnecessary risk. If individuals with SCI start on a schedule of scans every year or two starting at a relatively young age (20s or 30s in SCI versus 50s or 60s and older in the non-injured population), the cumulative radiation decades later may be dangerously high. Is it worth it? It’s important for individuals with SCI to talk through the pros and cons of DXA scanning with their physicians.

Since the rate of osteoporosis after SCI is so high, it may be safer to assume that everyone with SCI has the disease rather than doing a screening study just to confirm something that we already suspect. 

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Treatment for osteoporosis


Pharmacologic treatment

Calcium

Vitamin D 

Bisphosphonates 

Teriparatide (Forteo)

Non-pharmacologic treatment options

Standing

Functional Electrical Stimulation (FES)

Low intensity vibration

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Prevention of osteoporosis

Current state of osteoporosis prevention

Prevent treatable cause of osteoporosis and fractures

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When fractures happen

Fracture management

Even if a person doesn’t walk, it’s still important to make sure a broken bone heals properly.

Goals of fracture management:

Surgery versus conservative management

Surgery

Brace options

Fractures can be stabilized with orthotics (splints, braces or casts), but patients with SCI have unique issues to dealt with. Off-the-shelf splints may not fit or work well for SCI patients, so custom-fit devices may need to be fabricated.

Considerations when choosing orthotics:

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What is the best treatment for people with SCI who break a bone?

Which method results in fewer complications, such as wounds, infection, deep vein thrombosis or pulmonary embolism (DVT/PE), repeat interventions, non-union or poor union of the bone, and even mortality? Other considerations are length of stay in the hospital and whether the person will be able to manage back at home or might need to go to another facility for a while.

 

Treatment

Advantages

Disadvantages

Conservative/
non-surgical

 

  • Non-invasive
  • Direct cost is less

 

  • Slow
  • Skin breakdown under some braces.

 

Surgical

 

  • Hardware immediately stabilizes bone.
  • Range of motion can be started early.
  • Less shortening and/or angular deformity.

 

 

  • Standard surgical risks
  • Non-healing surgical wounds
  • Hardware loosening
  • Infection – local/systemic
  • Repeat surgeries

A recent VA study in male veterans with SCI found the following:

Goals and principles of lower limb fracture management

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References

  1. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB.  Incidence and Mortality of Hip Fractures in the United States.   JAMA. 2009 Oct 14;302(14):1573-9.
  2. Koot VC, Peeters PH, de Jong JR, Clevers GJ, van der Werken C.  Functional results after treatment of hip fracture:  a multicentre prospective study in 215 patients.  Eur J Surg. 2000 Jun;166(6):480-5.
  3. World Health Organization. Assessment of Fracture Risk and its Application to Screening for Postmenopausal Osteoporosis. WHO Technical Report Series 843. Geneva:  World Health Organization, 1994.
  4. Bauman WA, et al. An effective oral vitamin D replacement therapy in persons with spinal cord injury.  J Spinal Cord Med. 2011 September; 34(5): 455–460
  5. Shane E, et al.  Atypical subtrochanteric and diaphyseal femoral fractures:  Report  of a task force of the American Society for Bone and Mineral Research.  JBMR.  Vol 25 (11).  Nov 2010.  PP 2267-2294.  FDA safety announcement 10/13/10.
  6. Frotzler A  et al. High-volume FES-cycling partially reverses bone loss in people with chronic spinal cord injury.  Bone. 2008 Jul;43(1):169-76. Epub 2008 Mar 20.
  7. Clark JM  et al.  Physiological effects of lower extremity functional electrical stimulation in early spinal cord injury: lack of efficacy to prevent bone loss.  Spinal Cord. 2007 Jan;45(1):78-85. Epub 2006 Apr 25.
  8. Frotzler A, et al.  Effect of detraining on bone and muscle tissue in subjects with chronic spinal cord injury after a period of electrically-stimulated cycling: a small cohort study. J Rehabil Med. 2009 Mar;41(4):282-5.
  9. Freehafer AA, Mast WA.  Lower extremity fractures in patients with spinal cord injury.  Jour Bone and Joint Surg. 1965 June;47A-4:683-694.
  10. Ragnarsson KT, Sell GH.  Lower extremity fractures after spinal cord injury:  A retrospective study.  Arch Phys Med Rehabil. Sept 1981;62:418-423.
  11. Nelson A, Ahmed S, Harrow J, Fitzgerald S, Sanchez-Anguiano A, Gavin-Dreschnack D.  Fall-related fractures in persons with spinal cord impairment:  A descriptive analysis.  SCI Nursing. 2003;20(1):30-37.
  12. Canale: Campbell's Operative Orthopaedics 2003.  Mosby.  Philadelphia, PA.

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