Osteoporosis International

, Volume 28, Issue 3, pp 747–765 | Cite as

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

  • C. M. Cirnigliaro
  • M. J. Myslinski
  • M. F. La Fountaine
  • S. C. Kirshblum
  • G. F. Forrest
  • W. A. Bauman
Review

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.

Keywords

Distal femur Dual energy x-ray absorptiometry Peripheral quantitative computed tomography Proximal tibia Quantitative computed tomography Spinal cord injury 

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

Notes

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.

Compliance with ethical standards

Grant sources

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

Conflicts of interest

None.

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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2016

Authors and Affiliations

  • C. M. Cirnigliaro
    • 1
  • M. J. Myslinski
    • 2
  • M. F. La Fountaine
    • 1
    • 3
    • 4
  • S. C. Kirshblum
    • 5
    • 6
  • G. F. Forrest
    • 6
    • 7
  • W. A. Bauman
    • 1
    • 8
  1. 1.Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord InjuryJames J. Peters Veterans Affairs Medical CenterBronxUSA
  2. 2.Department of Physical Therapy, School of Health Related ProfessionsRutgers New Jersey Medical SchoolNewarkUSA
  3. 3.Department of Physical Therapy, School of Health and Medical SciencesSeton Hall UniversitySouth OrangeUSA
  4. 4.The Institute for Advanced Study of Rehabilitation and Sports Science, School of Health and Medical SciencesSeton Hall UniversitySouth OrangeUSA
  5. 5.Kessler Institute for RehabilitationWest OrangeUSA
  6. 6.Department of Physical Medicine and RehabilitationRutgers New Jersey Medical SchoolNewarkUSA
  7. 7.Kessler FoundationWest OrangeUSA
  8. 8.Departments of Medicine and Rehabilitation MedicineIcahn School of Medicine at Mount SinaiNew YorkUSA

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