Computerized quantitative radionuclide assessment of heterotopic ossification in spinal cord injury patients

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.

[Hip paraosteoarthropathy after sciatica nerve injury by quinine intramuscular injection]

INTRODUCTION

Often occurring in central nerve injuries, paraosteoarthropathic conditions are revealed by a stiffness or ankylosis of the joint. Their occurring during peripheral nerve injuries is rare.

OBJECTIVE

To report a case of hip paraosteoarthropathy features after sciatica nerve injury by quinine intramuscular injection.

MATERIALS AND METHOD

We report a case of a 24-year-old patient presenting with pain, oedema of the left buttock, limitation of bending of the left hip, and antalgic limping associated with a small step because of axonal left sciatic nerve injury. Initial pelvis X-ray and laboratory findings were normal. Reviewed 4 months later with important stiffness of the left hip, a second X-ray showed an atypical paraosteoarthropathy (POA). Chemotherapy and physiotherapy alleviated neurological muscle weakness but did not have any effect on the hip functionality. Surgical excision was the only treatment that improved the amplitude of movements. Evolution 7 years later showed the disappearance of the peripheral nerve-injury signs and the conservation of the movement amplitude obtained after excision, without a return to normal.

CONCLUSION-DISCUSSION

Factors pointing to this POA were initial oedema, immobilization because of pain, and trauma by quinine intramuscular injection. The interest is the exceptional occurrence of POA on a peripheral nerve injury (sciatica nerve injury by quinine injection) outside the context of length resuscitation and that sciatica nerve injury is frequent in tropical countries but anachronistic in a developed one.

[Periarticular heterotopic ossification secondary to central neurogenic dysfunction]

A case of a 48 year old woman with a medical background of tetraparesis related to a right lobectomy and periarticular ossification development (that included both knee joints) is presented. Bone scintigraphy was performed to evaluate the metabolism of the bone lesions. The scintigraphic pattern showed an important involvement of the medial and lateral left knee and medial right knee compartments, initially attributed to degenerative osteoarthritis. We believe that the presentation of this case report is interesting for two reasons: 1) the rareness of knee involvement in periarticular heterotopic ossification related to cerebral dysfunction, and 2) the possibility of a false positive diagnosis: osteoarthritic involvement versus juxta-articular ossification. This paper reviews the role of diagnostic imaging methods in the assessment of periarticular heterotopic ossification and the differential scintigraphic diagnosis regarding to osteoarticular disorders (more frequent among the general population).

Polyarticular heterotopic ossification complicating critical illness

A patient with generalized heterotopic ossification (HO) complicating critical illness due to necrotizing pancreatitis is described; data on two other cases with HO are briefly presented. The clinical features, prevention and therapy of HO are discussed. The effect of surgical therapy of the HO in our three patients was good.

Prostaglandin E2 measurements: their value in the early diagnosis of heterotopic ossification in spinal cord injury patients

OBJECTIVE

To look for a possible relation between the occurrence of heterotopic ossification (HO) and the modifications of the 24-hour prostaglandin E2 (PGE2) urinary excretion.

DESIGN

A 5-year prospective study to determine the 24-hour urinary excretion of PGE2 by radioimmunoassay with specific antisera not cross-reacting with TXA2, TXB2, 15-keto-PGE2 alpha, PGI2, 6-keto-PGF1 alpha.

SETTING

The laboratory of a division of endocrinology and diabetology of a university hospital.

PATIENTS

Of 262 acute spinal cord injury patients screened, 44 were eligible for the study.

INTERVENTIONS

Serial diagnostic quantitative bone scannings with technetium 99m Tc methylene diphosphate (99mTc-MDP) and therapeutic assessment of radiotherapy and indomethacin.

MEAN OUTCOME MEASURE

Hypothetical increase of PGE2 before and during HO formation.

RESULTS

Of 44 patients, 8 developed an HO (18.8%) with concomitant marked increase of the PGE2 excretion for as long as the HO had not reached maturity. The results of the radiotherapy were inconclusive. Indomethacin was shown to be efficacious in holding back or slowing down the HO evolution.

CONCLUSIONS

Measurement of the 24-hour PGE2 urinary excretion appears to be a valuable indicator in the early diagnosis of HO. Indomethacin should be considered as an alternative to other existing therapies.