Bone Density in Myelomeningocele: The Effects of Ambulatory Status and Other Factors

Rosenstein, Byron D.; Greene, Walter B.; Herrington, Robert T.; Blum, Andrew S.

doi:10.1111/j.1469-8749.1987.tb02508.x

Cited by 52 publications

(43 citation statements)

References 23 publications

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“…Twenty-four of 37 children (64.8%) in the present study had at least one LDF Z-score less than 2 standard deviations below the age-and-sexmatched mean. Our observations confirm those of both Rosenstein et al [11] and Quan et al [10] looking at single photon absorptiometry. Apkon et al [1], using DXA as we did, classified patients not according to ISCD recommendations for children (B À2 SD is ''low bone density for age), but rather used the World Health Organization classification for postmenopausal females [2] (B À2.5 SD is ''osteoporosis'' and B À1 SD is ''osteopenia'') [7].…”

Section: Discussionsupporting

confidence: 92%

“…Rosenstein et al [11] and Quan et al [10] examined bone density in children with myelomeningocele using 125 I single photon absorptiometry. Rosenstein et al found bone density of both upper and lower extremities in patients with spina bifida related to neurologic level and ambulatory status [11].…”

Section: Introductionmentioning

confidence: 99%

“…Rosenstein et al found bone density of both upper and lower extremities in patients with spina bifida related to neurologic level and ambulatory status [11]. Quan et al found bone mineral density in the distal radius averaged 1 to 2 standard deviation units below the expected norm in patients with spina bifida who were 6 to19 years of age [10].…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Children with Spina Bifida are at Risk for Low Bone Density

Szalay

Cheema

2011

Clinical Orthopaedics &Amp; Related Research

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“…postoperatively). 1,[4][5][6] Our primary aim in this study was to examine the frequency and characteristics of fractures in paediatric patients with spina bifida. A secondary aim was to identify other variables that may contribute to the presence of fractures, such as neurological level, shunted hydrocephalus, syringomyelia, type of ambulation, mechanism of injury, and prolonged immobilization.…”

mentioning

confidence: 99%

Fractures in children and adolescents with spina bifida: the experience of a Portuguese tertiary‐care hospital

Marreiros

Monteiro

Loff

et al. 2010

Develop Med Child Neuro

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AIM The morbidity associated with osteoporosis and fractures in children and adolescents with spina bifida highlights the importance of osteoporosis prevention and treatment in these patients. The aim of this study was to examine the occurrence and pattern of bone fractures in paediatric patients with spina bifida.METHOD We reviewed the data of all paediatric patients with spina bifida who were treated in our centre between 1999 and 2008.RESULTS One hundred and thirteen patients were included in the study (63 females, 50 males; mean age 10y 8mo, SD 4y 10mo, range 6mo-18y). The motor levels were thoracic in six, upper lumbar in 22, lower lumbar in 42, and sacral in 43 patients. Of the 113 patients, 58 (51.3%) had shunted hydrocephalus. Thirty-six (31.8%) were non-ambulatory (wheelchair-dependent [unable to self-propel wheelchair] n=3, wheelchair-independent [able to self-propel wheelchair] n=33), 13 were partial ambulators, 61 were full ambulators, and three were below the age of walking. Fortyfive fractures were reported in 25 patients. The distal femur was the most common fracture site. Statistical analyses showed that patients with higher levels of involvement and in wheelchairs had a significantly increased risk of having a second fracture (p<0.001). Spontaneous fractures were the principal mechanism of injury, and an association was identified between fracture mechanism, type of ambulation, and lesion level: the fractures of patients with higher levels of motor functioning and those in wheelchairs were mainly pathological (p=0.01). We identified an association between risk of a second fracture, higher motor level lesion, and non-ambulation. There was an increased risk of having a second fracture after a previous spontaneous fracture (p=0.004).INTERPRETATION Data in this study indicate a high prevalence of fractures in patients with spina bifida.In congenital paraplegia caused by myelomeningocele, the body lacks the usual axial burden on the legs, muscular activity, and sensation. 1 There is a direct influence of working muscles on the remodelling process of the growing tibia. Postmortem studies of patients with spina bifida reveal a thin and atrophic cortex of the tibia with a diminished number of Haversian systems and large remodelling cavities. 2 In fact, patients with spina bifida have lower bone mineral density and are at risk of pathological bone fractures. 3 The clinical status of children with spina bifida can be significantly worsened by the effects of secondary osteoporosis, including fractures and subsequent further immobilization, and the leg bones of patients with spina bifida have an additional risk of fractures after inactivity (e.g. postoperatively). 1,[4][5][6] Our primary aim in this study was to examine the frequency and characteristics of fractures in paediatric patients with spina bifida. A secondary aim was to identify other variables that may contribute to the presence of fractures, such as neurological level, shunted hydrocephalus, syringomyelia, type of ambulation, mechanism of injury...

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“…In patients who are already disabled and subject to frequent surgical interventions, osteoporosis-related fractures result in a vicious cycle in which further immobilization heightens the risk of multiple fractures. [2][3][4][5][6][7] In childhood and adolescence, the formation of bone prevails; 8 consequently, childhood and adolescence constitute critical periods for the foundation of a lifetime of bone health. Failure to achieve peak bone mass has been linked to an increased risk of osteoporosis and fracture in adulthood.…”

Section: Introductionmentioning

confidence: 99%

Osteoporosis in paediatric patients with spina bifida

Marreiros

Loff

Calado

2012

The Journal of Spinal Cord Medicine

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The prevalence and morbidity associated with osteoporosis and fractures in patients with spina bifida (SB) highlight the importance of osteoporosis prevention and treatment in early childhood; however, the issue has received little attention. The method for the selection of appropriate patients for drug treatment has not been clarified. Objective: To review the literature concerning fracture risks and low bone density in paediatric patients with SB. We looked for studies describing state-of-the-art treatments and for prevention of secondary osteoporosis. Methods: Articles were identified through a search in the electronic database (PUBMED) supplemented with reviews of the reference lists of selected papers. The main outcome measures were incidence of fractures and risk factors for fracture, an association between bone mineral density (BMD) and occurrence of fracture, risk factors of low BMD, and effects of pharmacological and non-pharmacological treatments on BMD and on the incidence of fractures. We considered as a secondary outcome the occurrence of fractures in relation to the mechanism of injury. Results: Results indicated that patients with SB are at increased risk for fractures and low BMD. Risk factors that may predispose patients to fractures include higher levels of neurological involvement, non-ambulatory status, physical inactivity, hypercalciuria, higher body fat levels, contractures, and a previous spontaneous fracture. Limitations were observed in the number and quality of studies concerning osteoporosis prevention and treatment in paediatric patients with SB. The safety and efficiency of drugs to treat osteoporosis in adults have not been evaluated satisfactorily in children with SB.

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Bone Density in Myelomeningocele: The Effects of Ambulatory Status and Other Factors

Cited by 52 publications

References 23 publications

Children with Spina Bifida are at Risk for Low Bone Density

Children with Spina Bifida are at Risk for Low Bone Density

Fractures in children and adolescents with spina bifida: the experience of a Portuguese tertiary‐care hospital

Osteoporosis in paediatric patients with spina bifida

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