Regional osteoporosis in women who have a complete spinal cord injury.

BACKGROUND: Regional bone loss in patients who have a spinal cord injury has been evaluated in males. In addition, there have been reports on groups of patients of both genders who had an acute or chronic complete or incomplete spinal cord injury. Regional bone loss in females who have a complete spinal cord injury has not been reported, to our knowledge. METHODS: In a study of thirty-one women who had a chronic, complete spinal cord injury, we assessed bone mineral density in relation to age, weight, and time since the injury. The results were compared with the bone mineral density in seventeen healthy, able-bodied women who had been age-matched by group (thirty years old and less, thirty-one to fifty years old, and more than fifty years old). Dual-energy x-ray absorptiometry was used to measure the bone mineral density of the lumbar spine, hip, and knee; Z-scores for the hip and spine were calculated. RESULTS: The mean bone mineral density in the spine in the youngest, middle, and oldest spinal-cord-injury groups was 98%, 108%, and 115% of the densities in the respective age-matched control groups (p < 0.0001), and the mean bone mineral density in the oldest spinal-cord-injury group was equal to that in the youngest control group. This gain in bone mineral density in the spine was reflected by the spine Z-scores, as the mean score in the oldest injured group averaged more than one standard deviation above both the norm and the mean score in the control group. The mean loss of bone mineral density in the knee in the youngest, middle, and oldest spinal-cord-injury groups was 38%, 41%, and 47% compared with the densities in the corresponding control age-groups (p < 0.0001). Furthermore, the oldest injured group had a mean reduction of knee bone mineral density of 54% compared with the youngest control group. The mean loss of bone mineral density in the hips of the injured patients was 18%, 25%, and 25% compared with the densities in the control subjects in the respective age-groups (p < 0.0001). CONCLUSIONS: The bone mineral density in the spine either was maintained or was increased in relation to the time since the injury. This finding is unlike that seen in healthy women, in whom bone mineral density decreases with age. The bone mineral density in the hips of the injured patients initially decreased approximately 25%; thereafter, the rate of loss was similar to that in the control group. The bone mineral density in the knees of the injured patients rapidly decreased 40% to 45% and then further decreased only minimally.

The effect of pulsed electromagnetic fields on osteoporosis at the knee in individuals with spinal cord injury.

The purpose of this study was to determine the effects of pulsed electromagnetic fields on osteoporotic bone at the knee in individuals with chronic spinal injury. The study consisted of 6 males with complete spinal cord injury at a minimum of 2 years duration. Bone mineral density (BMD) was obtained at both knees at initiation, 3 months, 6 months, and 12 months using dual energy X-ray absorptiometry. In each case, 1 knee was stimulated using The Bone Growth Stimulator Model 3005 from American Medical Electronics, Incorporated and the opposite knee served as the control. Stimulation ceased at 6 months. At 3 months BMD increased in the stimulated knees 5.1% and declined in the control knees 6.6% (p < .05 and p < .02, respectively). By 6 months the BMD returned to near baseline values and at 12 months both knees had lost bone at a similar rate to 2.4% below baseline for the stimulated knee and 3.6% below baseline for the control. There were larger effects closer to the site of stimulation. While the stimulation appeared useful in retarding osteoporosis, the unexpected exaggerated decline in the control knees and reversal at 6 months suggests underlying mechanisms are more complex than originally anticipated. The authors believe a local as well as a systemic response was created.

Cost of medical care for postoperative spinal infections.

The movement towards managed care has raised the awareness of health care costs in today's society. The additional expense involved in treating patients with deep postoperative spinal infections after lower back fusion increases the total cost of care more than four times. Three areas of greatest increase in cost are room and board, pharmacy and laboratory charges. Decreasing the expense of this complication can best be effected through use of home nursing care, choice, and duration of antibiotic treatment and prudent laboratory testing.

Spinal infections in the immunocompromised host.

There is an increasing population of immunocompromised patients with HIV, IV drug abuse, organ transplantation, and long-term steroid treatment developing spinal infections. Delayed diagnosis because of blunted host immune response and lack of outward signs and symptoms places the treating physician at a disadvantage in the treatment of this type of disease, which presents at a later stage of development. Immunocompromised patients are infected by a different group of pathogens than their healthier cohorts (e.g., Pseudomonas, gram-negative bacteria and fungal infections) because their host defenses are diminished. Osteomyelitis with or with out pyomyositis and epidural abscess may occur. The overriding symptom is back pain. Radiculopathy, myelopathy, and sensory loss may accompany local pain and tenderness. Plain film radiography, CT scan, MR image, and bone scan is invaluable in the diagnosis of these infections. The cornerstone of treatment is identification of the responsible pathogen, appropriate medical therapy, immobilization of the affected segment of the spine, and physical therapy to combat physical deconditioning. Psoas abscesses may require surgical debridement if they cannot be adequately drained by CT-guided percutaneous catheterization. Epidural abscesses with neurologic compromise require surgical drainage. Impingement of the spinal cord or cauda equina by collapsed osteomyelitic vertebral bodies requires surgical debridement by anterior vertebrectomy, with an autologous tricortical iliac crest strut and immobilization of the spine using external bracing or posterior instrumentation as dictated by the disease.

Nonoperative management of upper thoracic spine fractures.

We attempted to determine if nonsurgical treatment could be successful in treating instability of upper thoracic spine fractures, which may receive some stabilization and splinting from the ribs. From 1966 to 1989, the records of all patients treated at Rancho Los Amigos Medical Center for fractures from T-1 to T-8 were reviewed. Penetrating injuries and malignant lesions were excluded. A total of 118 patients were admitted during this period; 49 patients had nonsurgical treatment. Complications included 1 patient with neurologic worsening, brace-related skin necrosis in 8 cases, and deep venous thrombosis in 12 patients. No failure of arthrodesis was noted. Rib fractures did not adversely affect late stability. We conclude that orthotic treatment of thoracic spine instability from T-1 to T-8 can be successful, especially in cases where early surgery is not possible.

Visual versus quantified digital radiographic determination of bone density.

Quantitative digital radiography (QDR) was used to assess the ability of physicians to determine bone mineral density (BMD) loss from a series of plain radiographs. Twenty-four spinal cord injured patients underwent QDR of the left knee. Seven of the 24 were selected, each of whom had bone mineral loss from 10-70% in 10% increments as assessed by comparison to average BMD of age-matched controls, and a standardized AP radiograph of the left knee was performed. Twenty-five independent examiners (orthopaedic surgeons and residents) were then asked to view the randomly arranged radiographs and visually determine the amount of BMD loss for each radiograph as compared to a control radiograph at 100%. Chi square analysis of the data revealed that the distribution of responses was significantly different than expected at the p less than .01 level. Taking into account that responses may have erred by +/-10%, the distribution of responses was again found to be significant at the p less than .01 level. An accurate determination of BMD loss was achieved only at 10% bone loss and 70% bone loss. The results of this study suggest that the visual determination of bone loss based on plain radiographs is accurate only at very low or very high levels of bone loss. Using standardized techniques, only near normal radiographs or radiographs with at least 70% BMD loss can be assessed accurately.

Intraarticular morphine, bupivacaine, and morphine/bupivacaine for pain control after knee videoarthroscopy.

Evidence has accumulated that opioids can produce potent antinociceptive effects by interacting with opioid receptors in peripheral tissues. This study sought to compare the effects of morphine with those of bupivacaine administered intraarticularly upon pain following arthroscopic knee surgery. In a double-blind, randomized manner, 33 patients received either morphine (1 mg in 20 ml NaCl; n = 11), bupivacaine (20 ml, 0.25%; n = 11), or a combination of the two (n = 11) intraarticularly at the completion of surgery. After 1, 2, 3, and 4 h and at the end of the 1st and 2nd postoperative days, pain was assessed by a visual analogue scale, and supplemental analgesic requirements were recorded. Pain scores were significantly greater in the morphine group than in the other two groups at 1 h. There were no significant differences at 2 and 3 h. From 4 h until the end of the study period, pain scores were significantly greater in the bupivacaine group than in the other two groups. Analgesic requirements were significantly greater in the morphine group than in the other groups at 1 h but were significantly greater in the bupivacaine group than in the other groups throughout the remainder of the study period. We conclude that intraarticular morphine produces an analgesic effect of delayed onset but of remarkably long duration. The combination of these two drugs results in satisfactory analgesia throughout the entire observation period.

Heterotopic ossification as a complication of the staged total thigh muscles flap in spinal cord injury patients.

Between 1980 and 1990, 24 total thigh flap procedures were performed at Rancho Los Amigos Medical Center (Downey, CA) by the Pressure Ulcer Management Service. An unexpected occurrence was identified, that is, the rapid development of heterotopic ossification (HO) occurring in the exposed muscle flap between the first and second stages. There were 15 two-stage total thigh flap procedures on 14 patients performed between 1980 and 1990. Of these 15 flap procedures, 11 in 10 patients were found to have HO evident at the second-stage debridement/closure. In comparing our findings with those in other studies (earliest evidence of HO at 19 days), the initial presentation of HO in affected tissues might be even earlier than previously detected. The risks and technical difficulties due to development of HO associated with the two-stage total thigh flap procedure point toward future modifications in preoperative planning that may prove beneficial. Therefore, if the two-stage total thigh flap procedure is necessary, the interval between initial debridement/disarticulation (stage 1) and definitive flap closure (stage 2) should be kept to an absolute minimum. Additionally, HO medicinal prophylaxis (that is, indomethacin or diphosphonates) or radiation after the first stage of the total thigh flap procedure should be considered. Our final conclusion is that the total thigh flap procedure should be done as a one-stage procedure if possible.

Osteoporosis after spinal cord injury.

Dual-photon absorptiometry characterized bone loss in males aged less than 40 years after complete traumatic paraplegic and quadriplegic spinal cord injury. Total bone mass of various regions and bone mineral density (BMD) of the knee were measured in 55 subjects. Three different populations were partitioned into four groups: 10 controls (healthy, age matched); 25 acutely injured (114 days after injury), with 12 reexamined 16 months after injury; and 20 chronic (greater than 5 years after injury). Significant differences (p less than 0.0001) in bone mass mineral between groups at the arms, pelvis, legs, distal femur, and proximal tibia were found, with no differences for the head or trunk. Post hoc analyses indicated no differences between the acutely injured at 16 months and the chronically injured. Paraplegic and quadriplegic subjects were significantly different only at the arms and trunk, but were highly similar at the pelvis and below. In the acutely injured, a slight but statistically insignificant rebound was noted above the pelvis. Regression techniques demonstrated early, rapid, linear (p less than 0.0001) decline of bone below the pelvis. Bone mineral loss occurs throughout the entire skeleton, except the skull. Most bone loss occurs rapidly and below the pelvis. Homeostasis is reached by 16 months at two thirds of original bone mass, near fracture threshold.

A clinical perspective on common forms of acquired heterotopic ossification.

The clinical courses of heterotopic ossification (HO) as a consequence of trauma and central nervous system insults have many similarities as well as dissimilarities. Detection is commonly noted at two months. The incidence of clinically significant HO is 10%-20%. Approximately 10% of the HO is massive and causes severe restriction in joint motion or ankylosis. The most common sign and symptom are decreased range of motion and pain. The locations are the proximal limbs and joints. Sites of HO about a joint may vary according to the etiology of the HO. Roentgenographic evolution of HO occurs during a six-month period in the majority of patients. Treatment modalities include diphosphonates, indomethacin, radiation, range of motion exercises, and surgical excision. Surgical timing differs according to etiology: traumatic HO may be resected at six months; spinal cord injury HO is excised at one year; and traumatic brain injury HO is removed at 1.5 years. A small number of patients have progression of HO with medicinal treatment and recurrence after resection. The patients seem recalcitrant to present treatment methods regardless of the HO etiology.

Surgical approaches for resection of heterotopic ossification in traumatic brain-injured adults.

The site of heterotopic ossification (HO) at the elbow or the hip dictates the surgical approach for resection. Three approaches are used for HO resection at the elbow: (1) a posterolateral approach for posterolateral HO; (2) an anterolateral approach for anterior HO; and (3) a medical approach for medial or posteromedial HO or anterior transfer of the ulnar nerve. Two approaches are recommended for resection of HO at the hip: (1) an anterior approach for anterior or inferomedial HO and (2) a posterior approach for posterior HO. Posterior HO is often associated with a hip-flexion contracture, and an anterior soft-tissue release may be necessary as well. Physical examination indicates the prognosis for functional improvement as well as recurrence. Patients with a near normal neurologic recovery have minimal to no HO recurrence with improved limb function and increased joint motion, whereas a poor neurologic recovery and persistent spasticity are associated with recurrence of HO and no functional limb improvement. Standard roentgenograms aid in selecting the appropriate surgical approach. Radiation, indomethacin, and diphosphonates have been administered for prophylaxis. Physical therapy is necessary until range of motion stabilizes.

Long-term follow-up of fracture nonunions treated with PEMFs.

One hundred thirty-nine established fracture nonunions were treated using a pulsed electromagnetic field (PEMF) device that also recorded patient usage. Patients who used the device less than an average of three hours a day had a success rate of 35.7% (5/14), while those who used the device in excess of three hours daily had an 80% success rate (108/135). The difference in the success rate was statistically significant at p less than .05. Treatment success was unaffected by long versus short bone, open versus closed fractures, nonunion of nine to 12 months duration compared to one to ten years, age of patient (whether less than or greater than age 60), gender, recalcitrant versus first time treatment, infected versus noninfected nonunions, fracture gaps up to 1cm, or weightbearing versus nonweightbearing. Ninety-seven fractures in 90 patients (90% follow-up) who averaged more than three hours of PEMF treatment daily and were originally classified as healed were reevaluated clinically and radiographically at four years following treatment (range: 3.6-5.4 years; mean: 4.1 years). Eighty-nine (92%) maintained a solid union. The success rate of PEMF treatment for nonunion repair demonstrated no statistically significant change over long-term follow-up.

Heterotopic ossification. Effect on dual-photon absorptiometry of the hip.

Dual-photon absorptiometry (DPA) is now widely used to determine bone mineral density of the lumbar spine and hips. Because the resulting images are often not of sufficient resolution to identify many bone or soft tissue abnormalities that may influence results, clinical and radiographic correlation is necessary. Presented are two cases in which results of DPA of the hips were elevated because of the presence of heterotopic ossification.

Management of fractures of the humerus in patients who have an injury of the ipsilateral brachial plexus.

Twenty-one adults who had a fracture of the middle of the humeral shaft and an injury of the ipsilateral brachial plexus were followed for an average of twenty-eight months. Only two of these patients showed evidence of neurological improvement. Of the eleven patients who had an associated traumatic injury to the brain, eight were treated non-operatively and three, operatively. The presence of a fracture of the humerus in a flail extremity has been found to delay rehabilitation markedly and to result in prolonged hospitalization. Eleven fractures were treated non-operatively with a brace or cast, and there were five non-unions, two delayed unions, and two malunions. Of the ten fractures that were treated operatively, three that were treated by compression-plating all united. Two fractures were treated by external fixation; one had a delayed union and one, a malunion. In the remaining five patients, who were treated with an intramedullary rod, there were two non-unions, one delayed union, and one malunion.