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Bone loss at the distal femur and proximal tibia in persons with spinal cord injury: imaging approaches, risk of fracture, and potential treatment options

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Abstract

Persons with spinal cord injury (SCI) undergo immediate unloading of the skeleton and, as a result, have severe bone loss below the level of lesion associated with increased risk of long-bone fractures. The pattern of bone loss in individuals with SCI differs from other forms of secondary osteoporosis because the skeleton above the level of lesion remains unaffected, while marked bone loss occurs in the regions of neurological impairment. Striking demineralization of the trabecular epiphyses of the distal femur (supracondylar) and proximal tibia occurs, with the knee region being highly vulnerable to fracture because many accidents occur while sitting in a wheelchair, making the knee region the first point of contact to any applied force. To quantify bone mineral density (BMD) at the knee, dual energy x-ray absorptiometry (DXA) and/or computed tomography (CT) bone densitometry are routinely employed in the clinical and research settings. A detailed review of imaging methods to acquire and quantify BMD at the distal femur and proximal tibia has not been performed to date but, if available, would serve as a reference for clinicians and researchers. This article will discuss the risk of fracture at the knee in persons with SCI, imaging methods to acquire and quantify BMD at the distal femur and proximal tibia, and treatment options available for prophylaxis against or reversal of osteoporosis in individuals with SCI.

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Abbreviations

SCI:

Spinal cord injury

DXA:

Dual energy x-ray absorptiometry

CT:

Computed tomography

MRI:

Magnetic resonance imaging

QCT:

Quantitative computed tomography

MDCT:

Multidetector computed tomography

pQCT:

Peripheral quantitative computerized tomography

HR-pQCT:

High-resolution peripheral quantitative computed tomography

mSv:

Millisievert

DF:

Distal femur

PT:

Proximal tibia

LE:

Lower extremity

ROI:

Region of interest

RMS-CV%:

Root mean square coefficient of variation percent

LSC:

Least significant change

BMC:

Bone mineral content

aBMD:

Areal bone mineral density

vBMD:

Volumetric bone mineral density

vBMDTb :

Trabecular volumetric bone mineral density

vBMDCt :

Cortical volumetric bone mineral density

App:

Apparent

BV/TV:

Bone volume/tissue volume

Tb.N:

Trabecular number

Tb.Sp:

Trabecular spacing

Tb.Th:

Trabecular thickness

SSIpol :

Polar stress strain index

PI:

Polar moment of inertia

ES:

Electrical stimulation

FES:

Functional electrical stimulation

ZA:

Zoledronic acid

IOF:

International Osteoporosis Foundation

AIS:

American Spinal Injury Association Impairment Scale

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Acknowledgments

The authors would like to thank the James J. Peters Veterans Affairs Medical Center, Bronx, NY, the Department of Veterans Affairs Rehabilitation Research & Development Service, and the Kessler Institute for Rehabilitation, West Orange, NJ, for their support to perform this work. The authors would also like to thank the Department of Physical Therapy, School of Health Related Professions, Rutgers New Jersey Medical School, Newark, NJ, USA and Alex T. Lombard for his assistance completing the comprehensive literature review necessary to complete this review article.

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Authors and Affiliations

  1. Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA

    C. M. Cirnigliaro, M. F. La Fountaine & W. A. Bauman

  2. Department of Physical Therapy, School of Health Related Professions, Rutgers New Jersey Medical School, Newark, NJ, USA

    M. J. Myslinski

  3. Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, USA

    M. F. La Fountaine

  4. The Institute for Advanced Study of Rehabilitation and Sports Science, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, USA

    M. F. La Fountaine

  5. Kessler Institute for Rehabilitation, West Orange, NJ, USA

    S. C. Kirshblum

  6. Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA

    S. C. Kirshblum & G. F. Forrest

  7. Kessler Foundation, West Orange, NJ, USA

    G. F. Forrest

  8. Departments of Medicine and Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    W. A. Bauman

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  1. C. M. Cirnigliaro
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  2. M. J. Myslinski
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  3. M. F. La Fountaine
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  4. S. C. Kirshblum
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  5. G. F. Forrest
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  6. W. A. Bauman
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Correspondence to W. A. Bauman.

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Veterans Affairs Rehabilitation Research and Development Service (#B9212-C, B2020-C) and the James J. Peters VA Medical Center.

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Cirnigliaro, C.M., Myslinski, M.J., La Fountaine, M.F. et al. Bone loss at the distal femur and proximal tibia in persons with spinal cord injury: imaging approaches, risk of fracture, and potential treatment options. Osteoporos Int 28, 747–765 (2017). https://doi.org/10.1007/s00198-016-3798-x

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