Osteoporosis in Adults With Meningomyelocele: An Unrecognized Problem at Rehabilitation Clinics

Valtonen, Kirsi; Goksör, Lars-Åke; Jonsson, Olof; Mellström, Dan; Alaranta, Hannu; Viikari‐Juntura, Eira

doi:10.1016/j.apmr.2005.11.004

Cited by 34 publications

(24 citation statements)

References 28 publications

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“…There have been conflicting results in studies looking at the association of ambulatory status, neurological level of lesion, and bone mineral density [37, 43]. We cannot draw any conclusions concerning the relationship between fracture and reduced BMD because of the study design and missing data.…”

Section: Discussionmentioning

confidence: 94%

Fractures in myelomeningocele

Akbar

Bresch

Raiss

et al. 2010

J Orthopaed Traumatol

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BackgroundIn patients with myelomeningocele (MMC), a high number of fractures occur in the paralyzed extremities, affecting mobility and independence. The aims of this retrospective cross-sectional study are to determine the frequency of fractures in our patient cohort and to identify trends and risk factors relevant for such fractures.Materials and methodsBetween March 1988 and June 2005, 862 patients with MMC were treated at our hospital. The medical records, surgery reports, and X-rays from these patients were evaluated.ResultsDuring the study period, 11% of the patients (n = 92) suffered one or more fractures. Risk analysis showed that patients with MMC and thoracic-level paralysis had a sixfold higher risk of fracture compared with those with sacral-level paralysis. Femoral-neck z-scores measured by dual-energy X-ray absorptiometry (DEXA) differed significantly according to the level of neurological impairment, with lower z-scores in children with a higher level of lesion. Furthermore, the rate of epiphyseal separation increased noticeably after cast immobilization. Mainly patients who could walk relatively well were affected.ConclusionsPatients with thoracic-level paralysis represent a group with high fracture risk. According to these results, fracture and epiphyseal injury in patients with MMC should be treated by plaster immobilization. The duration of immobilization should be kept to a minimum (<4 weeks) because of increased risk of secondary fractures. Alternatively, patients with refractures can be treated by surgery, when nonoperative treatment has failed.

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Section: Discussionmentioning

confidence: 94%

Fractures in myelomeningocele

Akbar

Bresch

Raiss

et al. 2010

J Orthopaed Traumatol

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“…1 Although typically considered an adult disease, osteoporosis starts in childhood. 2,3 The age at which abnormalities in bone mineral density (BMD) first present in the population with congenital spinal dysfunction is not known.…”

Section: Discussionmentioning

confidence: 99%

Lower extremity bone mineral density in children with congenital spinal dysfunction

Haas

Kecskemethy²,

LoPiccolo

et al. 2012

Develop Med Child Neuro

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BMD Bone mineral density DXA Dual-energy X-ray absorptiometry LDF Lateral distal femur AIM To assess lower extremity bone mineral density (BMD) of children with congenital spinal dysfunction and examine factors that may influence BMD in this population.METHOD Forty-four children (25 females, 19 males) aged 6 to 18 years (mean 11y 11mo, SD 3y 6mo) with congenital spinal dysfunction (35 with myelomeningocele, seven with lipomas, one with sacral agenesis, one with caudal regression) were enrolled in the study. A health survey including ambulatory status, history of bladder augmentation, and history of fracture was administered. Each participant had a physical examination including Tanner stage and neurological level. Dual-energy X-ray absorptiometry scans of the lateral distal femur (LDF) and, when possible, lumbar spine were obtained. We reported LDF BMD results as z-scores for three regions of interest (metaphyseal, metadiaphyseal, and diaphyseal). Univariable and multivariable analyses examined relationships between LDF BMD and the other variables.RESULTS BMD was significantly related to ambulatory status (14 non-ambulatory, 15 partly ambulatory, 15 fully ambulatory) and neurological level (13 with low-level lesions, 15 mediumlevel, 16 high-level) in the univariable analysis (p<0.01 for both in all three regions). Neither history of fracture, nor Tanner stage, nor history of bladder augmentation showed a significant relationship to BMD. The significance of ambulatory status and neurological level in the univariable analysis failed to persist in the multivariable analysis of this study with a small sample size. INTERPRETATIONThe LDF measurement proved to be a viable technique for assessing BMD in children with congenital spinal dysfunction. LDF BMD was sensitive to differences in three categories of ambulation. The overall influence of neurological level was not deemed as important as ambulation.Osteoporosis has been identified as a medical problem in adults with myelomeningocele. 1 Although typically considered an adult disease, osteoporosis starts in childhood. 2,3 The age at which abnormalities in bone mineral density (BMD) first present in the population with congenital spinal dysfunction is not known. Because bone mass accrual occurs during childhood, it would be ideal to initiate assessment of BMD during this time. 4,5 Such assessment in children with congenital spinal dysfunction might reveal critical factors that influence BMD.The International Society for Clinical Densitometry recommends assessment of the lumbar spine and whole body when evaluating bone density by dual-energy X-ray absorptiometry (DXA) in children. 6 Assessment of BMD at the lumbar spine in patients with congenital spinal dysfunction can be challenging owing to bone malformations of the lumbar spine yielding uninterpretable results. The abnormal spine is also reflected in measurement of the whole body, rendering that site equally invalid. We developed a technique for assessing BMD at the lateral distal femur (LDF) and established norms f...

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“…Apkon et al [1] performed DXA of the whole body and femoral neck in 21 children with spina bifida, suggesting limitations of the technique resulting from contractures and other physical differences. Valtonen et al, evaluating DXA scans on adult rehabilitation patients with spina bifida, noted low bone density was a likely and ''unrecognized'' entity in this population [16]. There are, however, insufficient data to recommend the methods for DXA scanning in children and adolescents with spina bifida to avoid errors in diagnosis and insufficient data to determine whether fractures in spina bifida relate to low bone density or other factors such as neurosegmental level.…”

Section: Introductionmentioning

confidence: 99%

Children with Spina Bifida are at Risk for Low Bone Density

Szalay

Cheema

2011

Clinical Orthopaedics &Amp; Related Research

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Background Patients with spina bifida frequently sustain lower extremity fractures which may be difficult to diagnose because they feel little or no pain, although the relative contributions of low bone density to pain insensitivity are unclear. Routine dual-energy xray absorptiometry (DXA) scanning is unreliable because these patients lack bony elements in the spine, and many have joint contractures and/or implanted hardware. Questions/purposes We asked (1) if the lateral distal femoral scan is useful in spina bifida; (2) whether nonambulatory children with spina bifida exhibit differences in bone mineral density (BMD) compared with an age-andsex-matched population; and (3) whether Z-scores were related to extremity fracture incidence. Methods We retrospectively reviewed 37 patients with spina bifida who had DXA scans and sufficient data. Z-scores were correlated with functional level, ambulatory status, body mass index, and fracture history. Results The distal femoral scan could be performed in subjects for whom total body and/or lumbar scans could not be performed accurately. Twenty-four of 37 had Z-scores below À2 SD, defined as ''low bone density for age.'' Ten of 35 patients (29%) with fracture information had experienced one or more fractures. Our sample size was too small to correlate Z-score with fracture. Conclusion We believe BMD should be monitored in patients with spina bifida; nonambulatory patients with spina bifida and those with other risk factors are more likely to have low bone density for age than unaffected individuals. The LDF scan was useful in this population in whom lumbar and total body scans are often invalidated by contracture or artifact. Although lower extremity fractures occur regardless of ambulation or bone density, knowing an individual's bone health status may lead to interventions to improve bone health.

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Osteoporosis in Adults With Meningomyelocele: An Unrecognized Problem at Rehabilitation Clinics

Cited by 34 publications

References 28 publications

Fractures in myelomeningocele

Fractures in myelomeningocele

Lower extremity bone mineral density in children with congenital spinal dysfunction

Children with Spina Bifida are at Risk for Low Bone Density

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