Serum alkaline phosphatase and inorganic phosphorus values in spinal cord injury patients with heterotopic ossification

A Preliminary Cohort Study Assessing Routine Blood Analyte Levels and Neurological Outcome after Spinal Cord Injury

There is increasing interest in the identification of biomarkers that could predict neurological outcome following a spinal cord injury (SCI). Although initial American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade is a good indicator of neurological outcome, for the patient and clinicians, an element of uncertainty remains. This preliminary study aimed to assess the additive potential of routine blood analytes following principal component analysis (PCA) to develop prognostic models for neurological outcome following SCI. Routine blood and clinical data were collected from SCI patients (n = 82) and PCA used to reduce the number of blood analytes into related factors. Outcome neurology was obtained from AIS scores at 3 and 12 months post-injury, with motor (AIS and total including all myotomes) and sensory (AIS, touch and pain) abilities being assessed individually. Multiple regression models were created for all outcome measures. Blood analytes relating to “liver function” and “acute inflammation and liver function” factors were found to significantly increase prediction of neurological outcome at both 3 months (touch, pain, and AIS sensory) and at 1 year (pain, R² increased by 0.025 and total motor, R² increased by 0.016). For some models “liver function” and “acute inflammation and liver function” factors were both significantly predictive, with the greatest combined R² improvement of 0.043 occurring for 3 month pain prediction. These preliminary findings support ongoing research into the use of routine blood analytes in the prediction of neurological outcome in SCI patients.

The sensitivity of ultrasound screening examination in detecting heterotopic ossification following spinal cord injury

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To analyze the role of sonography in detecting heterotopic ossification (HO) following spinal cord injury (SCI).

SETTING

Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Ruhr University Bochum, Germany.

METHODS

Between January 2003 and December 2013, 217 patients with HO of the hips met the inclusion criteria and were included in the final analyses. The diagnosis of HO was carried out in all cases using our hospital protocol. Primary outcome measure was to calculate the sensitivity of ultrasound screening examination in detecting HO following SCI.

RESULTS

The diagnosis of HO was confirmed in 217 patients after a mean interval of 64.8 days (range from 8 to 295; s.d.=40.4) via computerized tomography or magnetic resonance imaging scan. In 193 out of 217 patients, suspicious HO signs were noted in the ultrasound screening examination (sensitivity=88.9%).

CONCLUSIONS

The use of ultrasound for screening for HO in SCI patients is reliable and has a high sensitivity.

Association between alendronate, serum alkaline phosphatase level, and heterotopic ossification in individuals with spinal cord injury

CONTEXT/OBJECTIVE

Only sparse evidence exists regarding the effectiveness of oral alendronate (ALN) in the prevention of heterotopic ossification (HO) in patients with spinal cord injury (SCI). The objective of this study is to investigate the protective effect of oral ALN intake on the appearance of HO in patients with SCI.

STUDY DESIGN

Retrospective database review.

SETTING

A Spinal Cord Unit at a Rehabilitation Hospital.

PARTICIPANTS

Two hundred and ninety-nine patients with SCI during acute inpatient rehabilitation.

INTERVENTIONS

Administration of oral ALN.

OUTCOME MEASURES

The incidence of HO during rehabilitation was compared between patients with SCI receiving oral ALN (n = 125) and patients with SCI not receiving oral ALN (n = 174). The association between HO and/or ALN intake with HO risk factors and biochemical markers of bone metabolism were also explored.

RESULTS

HO developed in 19 male patients (6.35%), however there was no significant difference in the incidence of HO in patients receiving oral ALN or not. The mean odds ratio of not developing versus developing HO given ALN exposure was 0.8. Significant correlation was found between abnormal serum alkaline phosphatase (ALP) levels and HO appearance (P < 0.001) as well as normal serum ALP and ALN intake (P < 0.05).

CONCLUSION

Even though there was no direct prevention of HO in patients with SCI by oral ALN intake, abnormal serum ALP was found more frequently in patients with HO development and without oral ALN intake. This evidence could suggest that ALN may play a role in preventing HO, especially in patients with acute SCI with increasing levels of serum ALP.

Development of heterotopic ossifications, blood markers and outcome after radiation therapy in spinal cord injured patients

STUDY DESIGN

Retrospective study.

OBJECTIVES

This study was implemented to detect risk factors for the developing of heterotopic ossifications (HOs) in spinal cord injury (SCI) patients.

SETTING

This study was conducted in Murnau, Germany.

METHODS

All patients from 2008-2012 with acute SCI were routinely examined by ultrasound of the hips every 2 weeks. The sub group of SCI patients suffering of HO of the hips were extracted and the incidence of developing an HO was calculated. Parameters like age, level of injury, ASIA Impairment Scale (AIS), duration time of accident until diagnosis of HO, Brooker stage, localization of HO (magnetic resonance imaging (MRI)) and symptoms like thrombosis, emboli, decrease of range of motion (ROM), dermal symptoms, swelling, increase in D-Dimere level, were evaluated. Also accompanying injuries of the brain, lung and extremities were recorded.

RESULTS

From January 2008 until January 2012, 575 patients with an acute and traumatic SCI were treated in our Department. During this period 32 HOs were detected in the muscles surrounding the hip. In 10 cases a single side and in 22 cases both sides were affected. A total of 26 patients were detected showing up a Brooker 0, two patients Brooker 1, and five patients a Brooker stage >2. The adductor muscles showed an edema in 19 cases and the quadriceps muscles were affected in 15 cases. 26% of all SCI patients showed AIS A status, but in patients who developed HO, 64% have had an AIS A status. 19% of patients with a HO were AIS B and 9.5% showed an AIS C and D. Regarding the level of injury the distribution of patients suffering of HO was comparable to the distribution of SCI patients without HO. In mean HO were detected 9 weeks after SCI and no new HO were found after the 22nd (n=1) week of injury. Clinical symptoms such as swelling, pain, redness or decrease in ROM or increase in D-Dimere levels were seen in 24 cases. Accompanying injuries like brain injury and lung contusions were found in 83% of patients developing HO. The incidence of thrombosis was comparable to SCI patients without HO. One patient with no accompanying injuries or clinical symptoms was detected by routinely performed ultrasound.

CONCLUSIONS

The risk of developing HO in patients with traumatic SCI is 5.5% but increases when accompanying injuries of the brain and lung occur. Patients with a neurological status of AIS A must also be quoted as risk patients. When considering the described risk factors and clinical symptoms, 96% of all HO can be detected.

Heterotopic ossification following traumatic brain injury and spinal cord injury

Heterotopic ossification associated with neurologic injury, or neurogenic heterotopic ossification, tends to form at major synovial joints surrounded by spastic muscles. It is commonly associated with traumatic brain or spinal cord injury and with other causes of upper motor neuron lesions. Heterotopic ossification can result in a variety of complications, including nerve impingement, joint ankylosis, complex regional pain syndrome, osteoporosis, and soft-tissue infection. The associated decline in range of motion may greatly limit activities of daily living, such as positioning and transferring and maintenance of hygiene, thereby adversely affecting quality of life. Management of heterotopic ossification is aimed at limiting its progression and maximizing function of the affected joint. Nonsurgical treatment is appropriate for early heterotopic ossification; however, surgical excision should be considered in cases of joint ankylosis or significantly decreased range of motion before complications arise. Patient selection, timing of excision, and postoperative prophylaxis are important components of proper management.

Calcium deposition with or without bone formation in the lung

Pulmonary calcification and ossification occurs with a number of systemic and pulmonary conditions. Specific symptoms are often lacking, but calcification may be a marker of disease severity and its chronicity. Pathophysiologic states predisposing to pulmonary calcification and ossification include hypercalcemia, a local alkaline environment, and previous lung injury. Factors such as enhanced alkaline phosphatase activity, active angiogenesis, and mitogenic effects of growth factors may also contribute. The clinical classification of pulmonary calcification includes both metastatic calcification, in which calcium deposits in previously normal lung or dystrophic calcification, which occurs in previously injured lung. Pulmonary ossification can be idiopathic or can result from a variety of underlying pulmonary, cardiac, or extracardiopulmonary disorders. The diagnosis of pulmonary calcification and ossification requires various imaging techniques, including chest radiography, computed tomographic scanning, and bone scintigraphy. Interpretation of the presence of and the specific pattern of calcification or ossification may obviate the need for invasive biopsy. In this review, specific conditions causing pulmonary calcification or ossification that may impact diagnostic and treatment decisions are highlighted. These include metastatic calcification caused by chronic renal failure and orthotopic liver transplantation, dystrophic calcification caused by granulomatous disorders, DNA viruses, parasitic infections, pulmonary amyloidosis, vascular calcification, the idiopathic disorder pulmonary alveolar microlithiasis, and various forms of pulmonary ossification.