Mortality After Lower Extremity Fractures in Men With Spinal Cord Injury

Abstract

In the United States, there are over 200,000 men with spinal cord injuries (SCIs) who are at risk for lower limb fractures. The risk of mortality after fractures in SCI is unknown. This was a population-based, cohort study of all male veterans (mean age 54.1; range, 20.3-100.5 years) with a traumatic SCI of at least 2 years' duration enrolled in the Veterans Affairs (VA) Spinal Cord Dysfunction Registry from FY2002 to FY2010 to determine the association between lower extremity fractures and mortality. Mortality for up to 5 years was determined. The lower extremity fracture rate was 2.14 per 100 patient-years at risk for at least one fracture. In unadjusted models and in models adjusted for demographic, SCI-related factors, healthcare use, and comorbidities, there was a significant association between incident lower extremity fracture and increased mortality (hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.17-1.63; HR, 1.36; 95% CI, 1.15-1.61, respectively). In complete SCI, the hazard of death after lower extremity fracture was also increased (unadjusted model: HR, 1.46; 95% CI, 1.13-1.89; adjusted model: HR, 1.32; 95% CI, 1.02-1.71). In fully-adjusted models, the association of incident lower extremity fracture with increased mortality was substantially greater in older men (age !50 years) for the entire cohort (HR, 3.42; 95% CI, 2.75-4.25) and for those with complete SCI (HR, 3.13; 95% CI, 2.19-4.45), compared to younger men (age <50 years) (entire cohort: HR, 1.42; 95% CI, 0.94-2.14; complete SCI: HR, 1.71; 95% CI, 0.98-3.01). Every additional point in the Charlson comorbidity index was associated with a 10% increase in the hazard of death in models involving the entire cohort (HR, 1.11; 95% CI, 1.09-1.13) and also in models limited to men with complete SCI (HR, 1.10; 95% CI, 1.06-1.15). These data support the concept that both the fracture itself and underlying comorbidities are drivers of death in men with SCI.

Pulsed Electromagnetic Field Regulates MicroRNA 21 Expression to Activate TGF-β Signaling in Human Bone Marrow Stromal Cells to Enhance Osteoblast Differentiation

“…The stimulation of bone at the fracture site by the introduction of electromagnetic fields may be similar to the resulting stimulation from mechanical loading [1]. The beneficial therapeutic effects of such selected low energy, time varying PEMF promote fracture healing in nonunions [3], increase lumbar spinal fusion rates [4, 5], and have been found to affect bone metabolism by decreasing bone resorption and increasing bone formation [6–8]. PEMFs have also been reported to stimulate the synthesis of extracellular matrix (ECM) proteins [9] and may also affect several membrane receptors including those for parathyroid hormone, low density lipoprotein, insulin-like growth factor-2, insulin, and calcitonin [10].…”

The Dietary Intakes of Calcium and Bone Health Related Nutrients Among Individuals with and without Spinal Cord Injury

“…Moreover, it should be noted that the percentage of participants who consumed calcium below the minimum requirement (<67% AI) was higher in SCI men compared with Non-SCI men across all age groups (Figure 2). Individuals with SCI have a much higher risk of lower extremity fragility fractures and high fracture related mortality [45]. Therefore, they require lifestyle interventions to help prevent further declines in bone mass [46].…”

Combination Therapy With Zoledronic Acid and FES‐Row Training Mitigates Bone Loss in Paralyzed Legs: Results of a Randomized Comparative Clinical Trial

“…Bone loss leads to fractures in up to 50% of individuals with SCI, with the majority of fractures occurring at the metaphyses of the proximal tibia and distal femur. Fractures are associated with prolonged immobility; worsening disability; serious medical complications, including pressure ulcer formation and amputation; and increased mortality . Despite the clinical significance of disuse osteoporosis, treatment options are limited, and there is controversy in the field regarding the efficacy of antiresorptive agents after SCI …”

“…Fractures are associated with prolonged immobility; worsening disability; serious medical complications, including pressure ulcer formation and amputation (4) ; and increased mortality. (5) Despite the clinical significance of disuse osteoporosis, treatment options are limited, and there is controversy in the field regarding the efficacy of antiresorptive agents after SCI. (6) Despite the lack of consensus regarding antiresorptive medications in SCI, bisphosphonates are the class of medication most commonly prescribed to treat SCI-induced osteoporosis.…”