Relationships between T-scores at the hip and bone mineral density at the distal femur and proximal tibia in persons with spinal cord injury

Evaluation of the Relationship between Osteoporosis Parameters in Plain Hip Radiography and DXA Results in 156 Patients at a Single Center in Turkey

BACKGROUND

The aim of the current study is to determine the relationship between osteoporosis findings in plain X-ray and dual-energy X-ray absorptiometry (DXA) measurement results and to create an alternative diagnostic method for osteoporosis without DXA measurement when necessary.

METHODS

DXA values and hip radiographs of 156 patients were retrospectively analyzed. Singh index (SI), Dorr index (DI), cortical thickness index (CTI), and canal-to-calcar ratio (CCR) measurements from both plain hip radiographs were determined by two observers. The correlation of the DXA parameters (hip total T-score, femoral neck T-score, hip total Z-score, hip total bone mineral density [BMD], and femoral neck BMD) and osteoporosis markers on plain hip radiography (SI, DI, CTI, and CCR) was calculated. In addition, patients were evaluated by dividing them into three groups according to the level of their T-scores (normal, osteopenia, and osteoporosis). In addition, cut-off values were calculated for CTI and CCR.

RESULTS

The mean age was 68.27 ± 8.27 (50-85) years. There was a strong correlation between hip total T-score values and SI, DI, and CTI (r = 0.683, -0.667, and 0.632, respectively), and a moderate correlation (r = -0.495) with CCR. When both hips were compared, there were strong correlations between radiographic parameters (r = 0.942 for SI, 0.858 for DI, 0.957 for CTI, and 0.938 for CCR, all with p < 0.001). When patients divided into three groups according to the T-score level were compared in terms of SI, DI, CTI, and CCR, it was found to be directly related to osteoporosis level (all p < 0.001). In the differentiation of osteopenia and osteoporosis, the cut-off values were 50.4 degrees for CTI and 60.3 degrees for CCR.

CONCLUSION

Good correlations between hip total T-score values and SI, DI, CTI, and CCR (r = 0.683, -0.667, 0.632, and -0.495, respectively) indicate that the presence of osteoporosis can be detected by hip radiography findings without DXA.

Clinical Characteristics of Elderly People with Osteoporotic Vertebral Compression Fracture Based on a 12-Year Single-Center Experience in Korea

In an aging human population, osteoporotic vertebral compression fracture (OVCF) frequently occurs. We conducted this retrospective study to analyze the clinical characteristics of elderly people with OVCF who underwent percutaneous vertebroplasty or kyphoplasty over a 12-year period at a single medical center in Korea. Between 2007 and 2019, A total of 868 patients (n = 868) were treated at our institution. We assessed 600 of these patients as eligible for study purposes and divided them into three groups: Group A (spine and hip T-scores ≤-2.5; n = 332); Group B (spine T-scores ≤-2.5; n = 189); and Group C (hip T-scores ≤-2.5; n = 79). The baseline characteristics of the patients included age, sex, body mass index (BMI), past history of steroid use, alcohol consumption, use of osteoporosis therapy, smoking, and treatment for OVCF. We compared these characteristics between the three groups. We found that the mean patient age was significantly higher in Group A, compared with Group B, and significantly lower in Group B, compared with Group C. We also found significant differences in the male-to-female ratio and mean body mass index between the three groups. In conclusion, we suggest that special attention should be paid to factors closely associated with spine and hip T-scores when evaluating elderly people with OVCF and determining appropriate treatment.

Cross-Sectional Study of Knee Bone Mineral Density and Fragility Fractures in Patients with Neurological Injuries and Neuromuscular Disorders

BACKGROUND

Patients with neurological injury and neuromuscular disorders are at increased risk for osteoporosis and fragility fracture. This cross-sectional study investigated whether knee bone mineral density (BMD) correlates with fragility fracture in patients with neurological injury and neuromuscular injuries.

METHODOLOGY

In this retrospective chart review, 435 participants underwent dual-energy X-ray absorptiometry (DXA) for BMD analysis. Distal femur and proximal tibial BMD measurements were performed as per the Toronto protocol. Spine, hip, and forearm DXA was performed following the standards of the International Society of Clinical Densitometry, 2019. Blinded and independent clinical evaluations and laboratory exams were performed. Participants were divided into groups with and without fracture confirmed by clinical history and radiography.

RESULTS

Distal femur and proximal tibial BMD were measured in 288/435 (66.2%) participants. Osteoporosis was noted in 138/288 (47.9%) patients. Fractures occurred in 95/435 participants (21.8%), including one fracture in 64/435 participants (14.7%), two fractures in 24/435 participants (5.5%), and greater than two fractures in 7/435 patients (1.6%). Fractures were noted in 23/54 (42.6%) participants with post-polio syndrome, 21/66 with brain injury (31.8%), 3/10 (30%) with brain injury and spinal cord injury, 24/98 (24.5%) with neuromuscular disorders, 9/52 (17.3%) with nontraumatic spinal cord injury, and 15/155 (9.7%) with traumatic spinal cord injury. The median BMD of the knee and hip was lower in participants with fractures. Distal femur and proximal tibial BMD (odds ratio [OR] = 0.02, 95% confidence interval [CI]: 0.01-0.45) remained independently associated with fragility fracture in multivariable analysis.

CONCLUSION

Proximal tibial and distal femur BMD measurements offered additional information on neurological injury and neuromuscular disorders.

Vertebral insufficiency fractures as a cause of autonomic dysreflexia in a patient with chronic tetraplegia: A case report

Context: Osteoporosis is a known complication in spinal cord injury patients and can result in an increased risk of fractures and associated morbidity. Bone demineralization is most common in long bones below the level of injury. The pathogenesis is complex and not fully understood.Findings: We present the case of a 65-year-old male with chronic spinal cord injury who was found to have multiple vertebral compression fractures causing autonomic dysreflexia and new onset spasticity.Conclusion/Clinical Relevance: This case illustrates the need for improved awareness, diagnosis, and prevention for this disease process.

Systematic Nursing Interventions Combined with Continuity of Care in Patients with a Spinal Fracture Complicated with a Spinal Cord Injury and Its Effect on Recovery and Satisfaction

Objective. The aim of this study is to examine the application value of systematic nursing interventions combined with continuity of care in cases with a spinal fracture complicated with a spinal cord injury and its effect on recovery and satisfaction. Methods. We identified ninety cases with a spinal fracture complicated with a spinal cord injury who were admitted to local hospital from May 2019 to May 2021 as research subjects and assigned them into an experimental group (systematic nursing combined with continuity of care, n = 45) and a control group (conventional nursing, n = 45) according to their admission order. The level of life of all groups between intervention was evaluated with reference to the Generic Quality of Life Inventory-74 (GQOLI-74) Rating Scale. The Hospital Anxiety and Depression (HAD) scale was used to assess the emotional status of patients before and after intervention. The complication rates, nursing outcomes, nursing satisfaction, and rehabilitation outcomes of all cases were calculated. Results. The GQOLI-74 score of the experimental group was higher than that of another group ( $P<0.05$ ). Lower HAD scores of experimental group were observed than that of another group ( $P<0.05$ ). The experimental group obtained remarkably higher nursing effective rates and higher nursing satisfaction than another group ( $P<0.05$ ). Rehabilitation outcome of the experimental group outperformed that another group ( $P<0.05$ ). Conclusion. The use of systematic nursing intervention combined with continuity of care for cases with spinal fracture complicated with a spinal cord injury can enhance the nursing effect, effectively relieve cases’ psychological pressure, improve patients’ level of life and nursing satisfaction, and contribute to the maintenance of a good nurse-patient relationship, which merits clinical promotion.

Prediction of Distal Femur and Proximal Tibia Bone Mineral Density From Total Body Dual Energy X-Ray Absorptiometry Scans in Persons with Spinal Cord Injury

Bone density decreases rapidly after spinal cord injury (SCI), increasing fracture risk. The most common fracture sites are at the knee (i.e., distal femur or proximal tibia). Despite this high fracture incidence, knee-specific scans for bone density using dual x-ray absorptiometry (DXA) were not available until 2014 and are still not routinely used in clinical practice today. This has made it difficult to determine the rehabilitation efficacy and hindered understanding of the long-term changes in knee areal bone density. The purpose of this investigation was to compare areal bone mineral density values for the knee from both total-body and knee-specific DXA scans in persons with SCI. A total of 20 participants (16 males) >1 yr-post spinal cord injury received two DXA scans; a total-body scan and a knee-specific scan. Standardized methods were used to create regions of interest to determine bone density of four regions - the epiphysis and metaphysis of the distal femur and proximal tibia - from the total-body scan. Linear regressions and Bland-Altman analyses were conducted to determine the correlation (r²) and agreement (mean bias ± 95% level of agreement) respectively between the two scan types for each region. Linear regression analyses showed strong significant (p < 0.001) relationships between the two scan types for the distal femur epiphysis (r² = 0.88) and metaphysis (r² = 0.98) and the proximal tibia epiphysis (r² = 0.88) and metaphysis (r² = 0.99). The mean bias ± 95% level of agreement were distal femur epiphysis (0.05 ± 0.1 g/cm²) and metaphysis (0.02 ± 0.04 g/cm²); proximal tibia epiphysis (-0.02 ± 0.1 g/cm²) and metaphysis (0.02 ± 0.03 g/cm²). Results suggest knee-specific bone density can be assessed using a total-body DXA scan. This may allow for more comprehensive use of DXA scans which would reduce the burden of multiple site-specific scans for persons with SCI and enable more widespread adoption of knee bone density assessment in this population.

The Effects of Exercise and Activity-Based Physical Therapy on Bone after Spinal Cord Injury

Spinal cord injury (SCI) produces paralysis and a unique form of neurogenic disuse osteoporosis that dramatically increases fracture risk at the distal femur and proximal tibia. This bone loss is driven by heightened bone resorption and near-absent bone formation during the acute post-SCI recovery phase and by a more traditional high-turnover osteopenia that emerges more chronically, which is likely influenced by the continual neural impairment and musculoskeletal unloading. These observations have stimulated interest in specialized exercise or activity-based physical therapy (ABPT) modalities (e.g., neuromuscular or functional electrical stimulation cycling, rowing, or resistance training, as well as other standing, walking, or partial weight-bearing interventions) that reload the paralyzed limbs and promote muscle recovery and use-dependent neuroplasticity. However, only sparse and relatively inconsistent evidence supports the ability of these physical rehabilitation regimens to influence bone metabolism or to increase bone mineral density (BMD) at the most fracture-prone sites in persons with severe SCI. This review discusses the pathophysiology and cellular/molecular mechanisms that influence bone loss after SCI, describes studies evaluating bone turnover and BMD responses to ABPTs during acute versus chronic SCI, identifies factors that may impact the bone responses to ABPT, and provides recommendations to optimize ABPTs for bone recovery.

The design of a randomized control trial of exoskeletal-assisted walking in the home and community on quality of life in persons with chronic spinal cord injury

There are more than 300,000 estimated cases of spinal cord injury (SCI) in the United States, and approximately 27,000 of these are Veterans. Immobilization from SCI results in adverse secondary medical conditions and reduced quality of life. Veterans with SCI who have completed rehabilitation after injury and are unable to ambulate receive a wheelchair as standard of care. Powered exoskeletons are a technology that offers an alternative form of limited mobility by enabling over-ground walking through an external framework for support and computer-controlled motorized hip and knee joints. Few studies have reported the safety and efficacy for use of these devices in the home and community environments, and none evaluated their impact on patient-centered outcomes through a randomized clinical trial (RCT). Absence of reported RCTs for powered exoskeletons may be due to a range of challenges, including designing, statistically powering, and conducting such a trial within an appropriate experimental framework. An RCT for the study of exoskeletal-assisted walking in the home and community environments also requires the need to address key factors such as: avoiding selection bias, participant recruitment and retention, training, and safety concerns, particularly in the home environment. These points are described here in the context of a national, multisite Department of Veterans Affairs Cooperative Studies Program-sponsored trial. The rationale and methods for the study design were focused on providing a template for future studies that use powered exoskeletons or other strategies for walking and mobility in people with immobilization due to SCI.