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Risk factors for osteoporotic fractures in persons with spinal cord injuries and disorders

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Abstract

Summary

Clinical risk factors for fracture were explored among Veterans with a spinal cord injury. At the end of 11 years of follow-up, the absolute risk of fracture was approximately 20 %. Among the clinical and SCI-related factors explored, a prior history of fracture was strongly associated with incident fracture.

Introduction

Few studies to date have comprehensively addressed clinical risk factors for fracture in persons with spinal cord injury (SCI). The purpose of this study was to identify risk factors for incident osteoporotic fractures in persons with a SCI that can be easily determined at the point of care.

Methods

The Veteran’s Affairs Spinal Cord Dysfunction Registry, a national database of persons with a SCI, was used to examine clinical and SCI-related risk factors for fracture. Incident fractures were identified in a cohort of persons with chronic SCI, defined as SCI present for at least 2 years. Cox regression models were used to estimate the risk of incident fractures.

Results

There were 22,516 persons with chronic SCI included in the cohort with 3365 incident fractures. The mean observational follow-up time for the overall sample was 6.2 years (median 6.0, IQR 2.9–11.0). The mean observational follow-up time for the fracture group was 3.9 years (median 3.3, IQR 1.4–6.1) and 6.7 years (median 6.7, IQR 3.1–11.0) for the nonfracture group. By the end of the study, which included predominantly older Veterans with a SCI observed for a relatively short period of time, the absolute (i.e., cumulative hazard) for incident fractures was 0.17 (95%CI 0.14–0.21). In multivariable analysis, factors associated with an increased risk of fracture included White race, traumatic etiology of SCI, paraplegia, complete extent of SCI, longer duration of SCI, use of anticonvulsants and opioids, prevalent fractures, and higher Charlson Comorbidity Indices. Women aged 50 and older were also at higher risk of sustaining an incident fracture at any time during the 11-year follow-up period.

Conclusions

There are multiple clinical and SCI-related risk factors which can be used to predict fracture in persons with a SCI. Clinicians should be particularly concerned about incident fracture risk in persons with a SCI who have had a previous fracture.

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References

  1. U.S. Department of Veterans Affairs. VA/HSR&D’s Quality Enhancement Research Initiative (QUERI) works to improve the quality of healthcare for veterans by implementing research findings into routine clinical practice

  2. Smith BM et al (2010) Using VA data for research in persons with spinal cord injuries and disorders: lessons from SCI QUERI. J Rehabil Res Dev 47(8):679–688

    Article  PubMed  Google Scholar 

  3. Carbone LD et al (2013) Morbidity following lower extremity fractures in men with spinal cord injury. Osteoporos Int 24(8):2261–2267

    Article  CAS  PubMed  Google Scholar 

  4. Carbone LD et al (2014) Mortality after lower extremity fractures in men with spinal cord injury. J Bone Miner Res 29(2):432–439

    Article  PubMed  Google Scholar 

  5. Groah SL et al (2010) Intensive electrical stimulation attenuates femoral bone loss in acute spinal cord injury. PM R : J Inj, Funct, Rehabil 2(12):1080–1087

    Article  Google Scholar 

  6. Bubbear JS et al (2011) Early treatment with zoledronic acid prevents bone loss at the hip following acute spinal cord injury. Osteoporos Int 22(1):271–279

    Article  CAS  PubMed  Google Scholar 

  7. Biering-Sorensen F, Hansen B, Lee BS (2009) Non-pharmacological treatment and prevention of bone loss after spinal cord injury: a systematic review. Spinal Cord 47(7):508–518

    Article  CAS  PubMed  Google Scholar 

  8. Bauman WA et al (2005) Effect of a vitamin D analog on leg bone mineral density in patients with chronic spinal cord injury. J Rehabil Res Dev 42(5):625–634

    Article  PubMed  Google Scholar 

  9. Bauman WA et al (2005) Effect of pamidronate administration on bone in patients with acute spinal cord injury. J Rehabil Res Dev 42(3):305–313

    Article  PubMed  Google Scholar 

  10. de Brito CM M et al (2005) Effect of alendronate on bone mineral density in spinal cord injury patients: a pilot study. Spinal Cord 43(6):341–348

    Article  Google Scholar 

  11. Morse LR et al (2009) VA-based survey of osteoporosis management in spinal cord injury. PM R : J Inj, Funct, Rehabil 1(3):240–244

    Article  Google Scholar 

  12. Gadam RK, Schlauch K, Izuora KE (2013) Frax prediction without BMD for assessment of osteoporotic fracture risk. Endocr Pract 19(5):780–784

    Article  PubMed  PubMed Central  Google Scholar 

  13. Jiang SD, Jiang LS, Dai LY (2006) Mechanisms of osteoporosis in spinal cord injury. Clin Endocrinol (Oxf) 65(5):555–565

    Article  CAS  Google Scholar 

  14. Ragnarsson KT, Sell GH (1981) Lower extremity fractures after spinal cord injury: a retrospective study. Arch Phys Med Rehabil 62(9):418–423

    CAS  PubMed  Google Scholar 

  15. Zehnder Y et al (2004) Long-term changes in bone metabolism, bone mineral density, quantitative ultrasound parameters, and fracture incidence after spinal cord injury: a cross-sectional observational study in 100 paraplegic men. Osteoporos Int 15(3):180–189

    Article  PubMed  Google Scholar 

  16. Pelletier C et al (2014) Self-report of one-year fracture incidence and osteoporosis prevalence in a community cohort of Canadians with spinal cord injury. Top Spinal Cord Inj Rehabil 20(4):302–309

    Article  PubMed  PubMed Central  Google Scholar 

  17. Gifre L et al. (2015) Risk factors for the development of osteoporosis after spinal cord injury. A 12-month follow-up study. Osteoporosis International 1–8

  18. Logan WC Jr et al (2008) Incidence of fractures in a cohort of veterans with chronic multiple sclerosis or traumatic spinal cord injury. Arch Phys Med Rehabil 89(2):237–243

    Article  PubMed  Google Scholar 

  19. Carbone LD et al (2013) The association of opioid use with incident lower extremity fractures in spinal cord injury. J Spinal Cord Med 36(2):91–96

    Article  PubMed  PubMed Central  Google Scholar 

  20. Gumina S, Carbone S (2013) Reply to: “The association between hypertension and rotator cuff disease: a spurious result?”. J Should Elbow Surg 22(2), e17

    Article  Google Scholar 

  21. Wang CM et al (2001) Epidemiology of extraspinal fractures associated with acute spinal cord injury. Spinal Cord 39(11):589–594

    Article  CAS  PubMed  Google Scholar 

  22. Biering-Sorensen F, Bohr HH, Schaadt OP (1990) Longitudinal study of bone mineral content in the lumbar spine, the forearm and the lower extremities after spinal cord injury. Eur J Clin Invest 20(3):330–335

    Article  CAS  PubMed  Google Scholar 

  23. Frotzler A et al (2008) Bone steady-state is established at reduced bone strength after spinal cord injury: a longitudinal study using peripheral quantitative computed tomography (pQCT). Bone 43(3):549–555

    Article  PubMed  Google Scholar 

  24. Gehlbach S et al (2012) Previous fractures at multiple sites increase the risk for subsequent fractures: the Global Longitudinal Study of Osteoporosis in Women. J Bone Miner Res 27(3):645–653

    Article  PubMed  PubMed Central  Google Scholar 

  25. Bergstrom U et al (2008) Fracture mechanisms and fracture pattern in men and women aged 50 years and older: a study of a 12-year population-based injury register, Umea. Sweden Osteoporos Int 19(9):1267–1273

    Article  CAS  PubMed  Google Scholar 

  26. Fattal C et al (2011) Osteoporosis in persons with spinal cord injury: the need for a targeted therapeutic education. Arch Phys Med Rehabil 92(1):59–67

    Article  PubMed  Google Scholar 

  27. Gielen E et al (2011) Osteoporosis in men. Best practice & research. Clin Endocrinol Metabol 25(2):321–335

    CAS  Google Scholar 

  28. Curtis JR et al (2009) Population-based fracture risk assessment and osteoporosis treatment disparities by race and gender. J Gen Intern Med 24(8):956–962

    Article  PubMed  PubMed Central  Google Scholar 

  29. Carbone LD et al (2008) Fracture risk in men with congestive heart failure risk reduction with spironolactone. J Am Coll Cardiol 52(2):135–138

    Article  PubMed  Google Scholar 

  30. Caplan L, Saag KG (2009) Glucocorticoids and the risk of osteoporosis. Expert Opin Drug Saf 8(1):33–47

    Article  CAS  PubMed  Google Scholar 

  31. Gray SL et al (2010) Proton pump inhibitor use, hip fracture, and change in bone mineral density in postmenopausal women: results from the Women’s Health Initiative. Arch Intern Med 170(9):765–771

    Article  PubMed  PubMed Central  Google Scholar 

  32. Vestergaard P (2009) Fracture risks of antidepressants. Expert Rev Neurother 9(1):137–141

    Article  PubMed  Google Scholar 

  33. Verdel BM et al (2010) Use of antidepressant drugs and risk of osteoporotic and non-osteoporotic fractures. Bone 47(3):604–609

    Article  CAS  PubMed  Google Scholar 

  34. Bilik D et al (2010) Thiazolidinediones and fractures: evidence from translating research into action for diabetes. J Clin Endocrinol Metab 95(10):4560–4565

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Carbone LD et al (2010) Antiepileptic drug use, falls, fractures, and BMD in postmenopausal women: findings from the women’s health initiative (WHI). J Bone Miner Res 25(4):873–881

    CAS  PubMed  Google Scholar 

  36. Li L et al (2013) Opioid use for noncancer pain and risk of fracture in adults: a nested case–control study using the general practice research database. Am J Epidemiol 178(4):559–569

    Article  PubMed  Google Scholar 

  37. Xing D et al (2014) Association between use of benzodiazepines and risk of fractures: a meta-analysis. Osteoporos Int 25(1):105–120

    Article  CAS  PubMed  Google Scholar 

  38. Carbone LD et al (2014) Thiazide use is associated with reduced risk for incident lower extremity fractures in men with spinal cord injury. Arch Phys Med Rehabil 95(6):1015–1020

    Article  PubMed  Google Scholar 

  39. Uzzan B et al (1996) Effects on bone mass of long term treatment with thyroid hormones: a meta-analysis. J Clin Endocrinol Metabol 81(12):4278–4289

    CAS  Google Scholar 

  40. St Andre J, 4 et al (2011) A comparison of costs and health care utilization for veterans with traumatic and nontraumatic spinal cord injury. Top Spinal Cord Inj Rehabil 16:27–42

    Article  Google Scholar 

  41. Deyo RA, Cherkin DC, Ciol MA (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45(6):613–619

    Article  CAS  PubMed  Google Scholar 

  42. Andersen S, Laurberg P (2015) Age impact on clinical risk factors does not justify the age related change in referral pattern for osteoporosis assessment-Data from the Aalborg University Hospital Record for Osteoporosis Risk Assessment (AURORA). Maturitas 80(3):302–307

    Article  PubMed  Google Scholar 

  43. Holmberg AH et al (2006) Risk factors for fragility fracture in middle age. A prospective population-based study of 33,000 men and women. Osteoporos Int 17(7):1065–1077

    Article  CAS  PubMed  Google Scholar 

  44. Merion M (2007) Assigning E Codes for External Causes. April 13, 2007 February 20, 2014; Available from: http://health-information.advanceweb.com/Article/Assigning-E-Codes-for-External-Causes-1.aspx.

  45. Akhigbe T et al (2015) A retrospective review of lower extremity fracture care in patients with spinal cord injury. J Spinal Cord Med 38(1):2–9

    Article  PubMed  PubMed Central  Google Scholar 

  46. Hippisley-Cox J, Coupland C (2009) Predicting risk of osteoporotic fracture in men and women in England and Wales: prospective derivation and validation of QFractureScores. BMJ 339:b4229

    Article  PubMed  PubMed Central  Google Scholar 

  47. Bethel M et al (2015) Surgical compared with nonsurgical management of fractures in male veterans with chronic spinal cord injury. Spinal Cord 53(5):402–407

    Article  CAS  PubMed  Google Scholar 

  48. Hsiao P-C et al (2015) Risk factors and incidence of repeat osteoporotic fractures among the elderly in Taiwan: a population-based cohort study. Medicine 94(7), e532

    Article  PubMed  PubMed Central  Google Scholar 

  49. Reyes C et al (2014) The impact of common co-morbidities (as measured using the Charlson index) on hip fracture risk in elderly men: a population-based cohort study. Osteoporos Int 25(6):1751–1758

    Article  CAS  PubMed  Google Scholar 

  50. Klotzbuecher CM et al (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15(4):721–739

    Article  CAS  PubMed  Google Scholar 

  51. Branch NN, Obirieze A, Wilson RH (2015) Assessment of racial and sex disparities in open femoral fractures. Am J Surg 209(4):666–674

    Article  PubMed  Google Scholar 

  52. Lazo MG et al (2001) Osteoporosis and risk of fracture in men with spinal cord injury. Spinal Cord 39(4):208–214

    Article  CAS  PubMed  Google Scholar 

  53. Frisbie JH (1997) Fractures after myelopathy: the risk quantified. J Spinal Cord Med 20(1):66

    Article  CAS  PubMed  Google Scholar 

  54. Vestergaard P et al (1998) Fracture rates and risk factors for fractures in patients with spinal cord injury. Spinal Cord 36(11):790–796

    Article  CAS  PubMed  Google Scholar 

  55. Briot K, Maravic M, Roux C (2015) Changes in number and incidence of hip fractures over 12years in France. Bone 81:131–137

    Article  PubMed  Google Scholar 

  56. Gifre L et al (2014) Incidence of skeletal fractures after traumatic spinal cord injury: a 10-year follow-up study. Clin Rehabil 28(4):361

    Article  PubMed  Google Scholar 

  57. Morse LR et al (2009) Osteoporotic fractures and hospitalization risk in chronic spinal cord injury. Osteoporos Int : J Established Result Coop Between Eur Found Osteoporos Natl Osteoporos Found USA 20(3):385

    Article  CAS  Google Scholar 

  58. Bethel M et al. (2016) A historical study of appendicular fractures in veterans with traumatic chronic spinal cord injury: 2002–2007. J Spinal Cord Med 1–7.

  59. Bauman WA et al (1999) Continuous loss of bone during chronic immobilization: a monozygotic twin study. Osteoporos Int 10(2):123–127

    Article  CAS  PubMed  Google Scholar 

  60. Carbone L et al (2013) The association of anticonvulsant use with fractures in spinal cord injury. Am J Phys Med Rehabil 92(12):1037–1046, quiz 1047–50

    Article  PubMed  Google Scholar 

  61. McColl M (2002) A house of cards: women, aging and spinal cord injury. Spinal Cord 40(8):371–373

    Article  CAS  PubMed  Google Scholar 

  62. Siris ES et al (2001) Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA 286(22):2815–2822

    Article  CAS  PubMed  Google Scholar 

  63. Javidan AN et al (2014) Evaluation of bone mineral loss in patients with chronic traumatic spinal cord injury in Iran. J Spinal Cord Med 37(6):744–750

    Article  PubMed  PubMed Central  Google Scholar 

  64. U.S. Department of Veterans Affairs (2011) VHA handbook 1176.01: spinal cord injury and disorders (SCI/D) system of care, F.a.D.A

  65. Bauman WA et al (2009) Dual-energy X-ray absorptiometry overestimates bone mineral density of the lumbar spine in persons with spinal cord injury. Spinal Cord 47(8):628–633

    Article  CAS  PubMed  Google Scholar 

  66. http://whqlibdoc.who.int/trs/who_trs_916.pdf. Accessed March 1, 2014.

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Acknowledgments

This work was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development IIR 11-103-3. The contents do not represent the views of the Department of Veterans Affairs or the United States Government.

Author information

Authors and Affiliations

  1. Charlie Norwood Veterans Affairs Medical Center, Augusta, GA, USA

    M. Bethel & L. D. Carbone

  2. Department of Medicine, Medical College of Georgia, Augusta University, 1120 15th St, Augusta, GA, USA

    M. Bethel & L. D. Carbone

  3. Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL, USA

    F. M. Weaver, L. Bailey & S. Miskevics

  4. Stritch School of Medicine, Loyola University, Maywood, IL, USA

    F. M. Weaver

  5. Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA

    L. Bailey

  6. VA Puget Sound Health Care System-Seattle Division, Seattle, WA, USA

    J. N. Svircev & S. P. Burns

  7. Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA

    J. N. Svircev & S. P. Burns

  8. Durham VA Medical Center, Durham, NC, USA

    H. Hoenig

  9. Department of Medicine, Duke University, Durham, NC, USA

    K. Lyles

  10. Geriatric Research, Education, and Clinical Center, VAMC, Durham, NC, USA

    K. Lyles

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  1. M. Bethel
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  2. F. M. Weaver
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Correspondence to M. Bethel.

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This work was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development grant IIR 11-103-3. The contents do not represent the views of the Department of Veterans Affairs or the United States Government.

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Bethel, M., Weaver, F.M., Bailey, L. et al. Risk factors for osteoporotic fractures in persons with spinal cord injuries and disorders. Osteoporos Int 27, 3011–3021 (2016). https://doi.org/10.1007/s00198-016-3627-2

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