Management of post-traumatic cervical spine instability: operative fusion versus halo vest immobilization. Analysis of 49 cases

A 5-year retrospective analysis was conducted for all cervical spine fractures associated with neurologic deficit initially treated at the University of Michigan Hospitals. Forty-nine cases of lower cervical spine fracture (C3-C7) were reviewed. Twenty-eight patients underwent early operative fusion followed by immobilization with either halo vests, or hard cervical collars, and 20 patients were initially immobilized in halo vests only. One patient refused treatment and was kept in a hard cervical collar. The average period of immobilization was 3 months. Eight patients in the halo vest group demonstrated radiographic evidence of spinal instability following immobilization (40%). Five of these eight patients subsequently required operative stabilization. Two of these five suffered progression of neurologic deficit secondary to loss of reduction while immobilized. Spinal instability occurred in two of the 28 patients initially fused (7%) (p less than 0.01), and in the patient treated in a collar. The findings indicate: 1) the halo vest does not protect patients with cervical instability from neurological injury, nor does it absolutely immobilize the cervical spine; 2) surgery may be required to provide spinal stability, even after a 3-month orthotic treatment period; and 3) there appears to be an increased rate of spinal stability with fusion and immobilization versus immobilization alone.     

Acute subdural hematoma following halo pin tightening in a patient with bilateral vertebral artery dissection

We report the first case of acute subdural hematoma (SDH) developing after tightening the halo of an osteoporotic 61-year-old woman on warfarin therapy for bilateral traumatic vertebral artery dissection. We discuss literature relevant to this case with an emphasis on identifying warning signs, including recurrent pin loosening, especially in patients with compromised bone structure and high risk of bleeding. Our 61-year-old patient presented to neurosurgery clinic for a 2-month follow-up of a type-III odontoid fracture sustained in a motor vehicle accident. The patient had repeatedly loosened halo pins, and shortly after the pins were tightened, the patient had a syncopal event and struck her head. An emergent computed tomography scan revealed acute SDH requiring emergent craniotomy and evacuation. SDH following pin penetration in a patient with bilateral vertebral artery dissection, osteoporosis, and anticoagulation has not been reported as a complication of the use of the halo vest for stabilization of the cervical spine. The risk of this serious complication can be minimized by giving special consideration to patients with comorbidities and by repositioning problematic pins. This case demonstrates the importance of special attention to bone strength, bleeding risk, and recurrent minor complaints with use of the halo vest.     

Cervical motion after adding a posterior pad to the halo vest

Investigators have shown that significant segmental motion occurs in patients immobilized in halo vests. One cadaver study showed that this is decreased with a posterior pad added to the construct. To improve nonoperative care of patients with cervical trauma, segmental cervical motion was evaluated in normal volunteers immobilized in a halo vest with and without a posterior pad. Two commonly used methods to measure sagittal angulation were used. Thirty normal volunteers were placed in halo vests by using positioning pins on the cranium. A sphygmomanometer attached to the posterior uprights of the vest inflated to 40 mm Hg was used as a posterior pad at the greatest visible lordosis. Lateral radiographs of the cervical spine were taken with volunteers in the upright and supine positions with and without the posterior pad inflated. Radiographs were randomly sorted and were each read twice by 3 readers. Measurements of the posterior atlantodental interval, sagittal displacement, and sagittal rotation were recorded using 2 different methods: the Buetti-Bauml method, which uses lines drawn along the posterior vertebral bodies, and the method of White and colleagues, which uses lines drawn along the inferior vertebral bodies. Inflation status of the pad showed no statistically significant difference in any of the measured variables. This was true for both methods of measurement. Application of a posterior pad to the halo vest did not show any change in the segmental motion of the cervical spine in normal volunteers.     

Differential action of pamidronate on trabecular and cortical bone in women with involutional osteoporosis

Since osteoporotic fractures are mainly related to the diminution of the bone mineral density (BMD), the effect of pamidronate (3-amino-1-hydroxy-propylidene) 1,1-bisphosphonate on the BMD of the spine, proximal femur and radius shaft was evaluated in an initial cohort of 35 postmenopausal women with at least one vertebral fracture due to involutional osteoporosis.Pamidronate was given continuously during 18 months in a daily oral dose of 4.8 to 6.0 mg/kg supplemented with calcium (1 g/day).BMD — measured by dual photon absorptiometry — increased after one year 5.3±1.0% (P<0.001) in lumbar spine and 5.3±1.5% (P<0.001) over trochanter. However no significant changes were observed in the BMD of the femoral neck, Ward's triangle or in the cortical bone of the radius shaft measured by single photon absorptiometry.Pamidronate also decreased significantly urinary hydroxyproline-creatinine excretion after 6 months and thereafter maintained a plateau. After 18 months of treatment the diminution was 42.6±4.9% (P<0.001).The differing effects of pamidronate on the BMD of lumbar spine and proximal femur might be ascribed to dissimilarities between the proportions of trabecular and cortical bone in these. These results suggest that pamidronate may be prescribed to prevent fractures in cases of involutional osteoporosis with a significant decrease of BMD in lumbar spine and/or trochanter.     

The effect of halo-vest length on stability of the cervical spine. A study in normal subjects

In order to study how the efficiency of the halo vest is affected by different lengths of the vest, an experimental headband was devised that allowed the head of a normal person to be held securely in the halo attachment. The vest was then modified to allow it to be adjusted to three different lengths (Fig. 2): a full vest extended to the iliac crests, a short vest extended to the twelfth ribs, and a half vest extended to the level of the nipples. Twenty normal, healthy adult men participated in the study. For each vest length, radiographs were made of each subject demonstrating rotation, flexion-extension, and lateral bending of the cervical spine. There was no rotation of the cervical spine, regardless of the length of the vest. There was a variable degree of motion in flexion or extension of the upper part of the cervical spine with all vest lengths, but this was not statistically significant. There was definite increase of motion caudad to the level of the fifth cervical vertebra regardless of the length of the vest. We concluded that a lesion of the upper part of the cervical spine can be treated effectively by halo traction with a half vest. This will improve the comfort and care of the patient and avoid the necessity of removing the vest if emergency cardiovascular resuscitation is needed. In the treatment of lesions of the lower part of the cervical spine (caudad to the level of the fourth cervical vertebra), the use of a halo vest that extends caudad to the level of the twelfth ribs does provide additional stability.     

Atlantoaxial rotatory subluxation, congenital absence of the posterior arch of the atlas, and cerebral palsy: an unusual triad

Posttraumatic chronic atlantoaxial rotatory subluxation and congenital absence of the posterior arch of the atlas are rare upper cervical spine abnormalities. The present case is that of a 4-year-old girl who had these two spinal disorders as well as spastic cerebral palsy. The interrelationship, if any, between these three conditions is unclear but presented an unusual diagnostic triad. A posterior spinal fusion between the occiput and third cervical vertebra was performed because of concern for upper cervical spine instability. The patient was immobilized in a halo vest, and a solid fusion occurred within 3 months. Preoperatively the child had never walked independently, but postoperatively, while wearing the halo vest, she was able to walk without external support, thus raising the suspicion of previous spinal instability. Fifteen months postoperatively she remains spastic but has a stable, orthotic-free, independent gait.     

A comparison between peripheral BMD and central BMD measurements in the prediction of spine fractures in men

Introduction: Most of the research on osteoporosis has been conducted on women. Few studies have compared central and peripheral densitometry and their association with vertebral fractures in men. The present study was designed to compare peripheral bone mineral density (BMD) measurements with central BMD measurements, and to examine their association with radiographic spine fracture in men. Methods: We studied 402 community-dwelling men aged 45–92 years (mean: 70 years) from the Rancho Bernardo Study cohort who attended a clinic visit between 1988 and 1992 when BMD measurements of the midshaft radius, ultradistal wrist, lumbar spine, and total hip were obtained, and who returned for lateral X-rays of the thoracic and lumbar spine an average of 4 years later. Logistic regression, T-scores, and quintiles were used to analyze BMD and its association with vertebral fractures. Results: The prevalence of osteoporosis defined by the National Osteoporosis Foundation criteria (for women) was 14.2% at the spine and 13% at the hip. Because there are no validated definitions of osteoporosis based on the ability to predict fracture risk for peripheral densitometry, the frequency of overlap by bone site was calculated among men in the lowest quintile of each site. Of the 402 men, 82 men (20.3%) had at least two sites with BMD measurements in the lowest quintile. After an average of 4 years, 33 (8.2%) men had at least one radiographic vertebral fracture, and ten (2.5%) men had at least two vertebral fractures. Low BMD at the spine (with and without covariate adjustment) was associated with having one or more vertebral fractures, whether using NOF T-score-defined osteoporosis [Odds ratio (OR): 3.81; confidence interval (CI): 1.52, 9.57] or the lowest quintile versus all others (OR: 2.53; CI: 1.03, 6.19). After age and/or other covariate adjustments, neither BMD at the total hip nor at the peripheral sites was associated with spine fractures using either NOF women-based criteria or male quintiles from this cohort. Conclusion: Although different men had osteoporosis defined by quintiles at different sites, only low BMD at the spine was associated with vertebral fracture.     

The effect of intravenous pamidronate versus oral alendronate on bone mineral density in patients with osteoporosis

Intravenous pamidronate is frequently used for the treatment of osteoporosis in patients who cannot tolerate oral bisphosphonates. The aim of the present study was to compare the changes in bone mineral density (BMD) after 1 year of treatment with either oral alendronate or intravenous pamidronate in patients with osteoporosis. We studied 40 consecutive patients starting treatment for osteoporosis: 20 received oral alendronate 10 mg/day and 20 received intravenous pamidronate 60 mg/3 months. Patients were started on intravenous pamidronate in the case of intolerance (within 1 month of start of treatment) of an oral bisphosphonate or in the case of contraindications for an oral bisphosphonate. BMD (spine and total hip) was measured with dual X-ray absorptiometry (DEXA) at the start of treatment and after 1 year. The BMD of the lumbar spine increased by 4.0% (P<0.05 vs baseline) in both groups, and the BMD of the hip increased by 3.3% and 2.9% (P<0.05 vs baseline) in the alendronate and pamidronate groups, respectively. The increases in BMD of the vertebral spine and the total hip after 1 year are comparable in the alendronate and pamidronate groups. We conclude that intravenous pamidronate can be used successfully as an alternative treatment in patients with gastrointestinal intolerance of an oral bisphosphonate.     

Effect of sodium fluoride on the prevention of corticosteroid-induced osteoporosis

To investigate whether sodium fluoride (NaF) is able to prevent bone loss in patients treated with corticosteroids (Cs), we performed a randomized, double-masked, placebo-controlled trial with 44 Cs-treated patients without established osteoporosis, defined as the absence of previous peripheral fractures and vertebral deformities on radiographs. The effects of NaF (25 mg twice daily) and placebo on the bone mineral density (BMD) of the lumbar spine and hips were compared at baseline and at 6, 12, 18 and 24 months. After 2 years, the BMD of the lumbar spine had decreased in the placebo group by 3.0% (95% CI: −4.9% to −1.0%;p<0.01); in the NaF group there was a statistically insignificant increase in BMD of 2.2% (95% CI: −0.8% to +5.3%). The difference in the changes in BMD between the two groups was +5.2% (95% CI: +1.8% to +8.6%;p<0.01). In the hips, BMD had decreased after 2 years in both groups: in the placebo group by −3.0% (95% CI: −5.0% to −1.0%;p<0.05) and in the NaF group by 3.8% (95% CI: −6.1% to −1.5%;p<0.01). The difference in the changes in BMD between the two groups was not significant: +0.8% (95% CI: −2.1% to +3.8%). Three vertebral deformities were observed in the placebo group and one in the NaF group (insignificant difference), while no peripheral fractures occurred during the study period. It is concluded that in Cs-treated patients without established osteoporosis NaF prevents bone loss in the lumbar spine but does not have a positive effect on the BMD of the hips.     

Influence of halo vest treatment on vital capacity

Respiratory function (vital capacity) was studied in 20 consecutive patients with unstable cervical spine injuries treated with a halo vest. Eight patients were neurologically intact. Twelve patients had incomplete spinal cord injuries that were classified on a neurologic function scale (Sunny-brook) immediately and 3 months after injury. Spirometric tests were done within 1 week of halo vest fixation, after 3 months of treatment, and 1 week after dismounting of the halo vest. The results showed that initial vital capacity was smaller than predicted normal in all patients and 30% less in neurologically impaired patients. Both groups improved during the treatment and somewhat more after removal of the halo vest. In neurologically intact patients, the halo vest caused a respiratory restriction of 10%, which was fully regained after removal of the halo vest. The difference between the groups remained throughout the study. There was no evidence that the halo vest itself affects the vital capacity more in patients with incomplete cord lesions than in neurologically intact patients. All of the cervical spine injuries healed uneventfully.     

Effects of Alendronate on Bone Density in Men with Primary and Secondary Osteoporosis

Alendronate has been reported to increase bone mineral density (BMD) and reduce fracture risk in women with osteoporosis. As there are no proven safe and effective treatments available for men with osteoporosis, we compared the effects of alendronate (10 mg/day) on BMD, measured using dual-energy X-ray absorptiometry, in a 12-month prospective, controlled, open label study involving (i) men with primary (n= 23) or secondary osteoporosis (n= 18), (ii) postmenopausal women with primary (n= 18) or secondary (n= 21) osteoporosis, and (iii) 29 male and 14 female untreated controls matched by age, height and weight. The patients had one or more vertebral fractures and ranged in age from 34.6 to 85.1 years. BMD was detectably increased relative to baseline by 6 months, and increased by comparable amounts in males and females with primary or secondary osteoporosis. At 12 months, lumbar spine BMD was 5.4%± 1.1% to 7.0%± 2.2% higher in the treated groups compared with baseline and controls (p<0.05 to 0.0001). Trochanteric BMD increased by 2.6%± 1.5% and 3.7%± 1.7% in treated men with primary and secondary osteoporosis, respectively (p = 0.06 to 0.08), and by 3.9%± 1.3% in treated women with primary osteoporosis (p<0.01) after 12 months. No significant changes were detected at the femoral neck or Ward’s triangle. BMD remained unchanged in controls. We infer that alendronate has comparable incremental effects on BMD in men and women with primary and secondary osteoporosis within 12 months of treatment. The changes are in the order of 0.5 SD – effects associated with a clinically worthwhile reduction in fracture risk. The data provide room for optimism regarding the role of alendronate in the treatment of osteoporosis in men. Randomized, double-masked and placebo-controlled trials are needed to confirm these preliminary findings and demonstrate antifracture efficacy using vertebral and nonvertebral fracture rates as the primary endpoint. Received: 23 February 1999 / Accepted: 2 June 1999     

Temporäre perkutane Spondylodese C1/2 und Halotransfixation

Dislocated combined injuries of the upper cervical spine such as C 1/2 fractures require occipitocervical fusion, especially if the dislocation can not be redressed using halo vest immobilisition. We report on the clinical course and outcome of a young woman who sustained complex cervical spine injuries. Closed reduction and a percutaneous transfixation of C 1/2 with k-wires (Magerl) and an additional halo vest immobilisition was performed to avoid permanent fusion. The 25 year old patient was involved in a motor vehicle accident that resulted in a dislocated Jefferson's fracture, an odontoid fracture type II (Anderson and d'Alonso) with protrusion into the foramen magnum, and a dislocated C 6/7 fracture. A ventral spondylodesis C6/7 was followed by temporary dorsal spondylodesis C1/2 with k-wires (Magerl) and additional halo vest immobilisition after closed reduction. The temporary percutaneous fixation C1/2 was removed after 11 weeks, as was the halo vest immobilisition. After removing the temporary percutaneous fixation (k-wires) and the halo system, the patient showed very good functional results in terms of range of motion with only minor discomfort. Complex injuries of the upper cervical spine that cannot be retained by external fixation often require an occipitocervical fusion or fixation of C1/2. In the case presented, the temporary percutaneous fixation (Magerl) with k-wires was terminated after 3 months to avoid significant functional impairment. Younger patients benefit most from temporary fusion of the upper cervical spine, which results in better functional outcome and only minor pain.     

Romosozumab Enhances Vertebral Bone Structure in Women With Low Bone Density

Romosozumab monoclonal antibody treatment works by binding sclerostin and causing rapid stimulation of bone formation while decreasing bone resorption. The location and local magnitude of vertebral bone accrual by romosozumab and how it compares to teriparatide remains to be investigated. Here we analyzed the data from a study collecting lumbar computed tomography (CT) spine scans at enrollment and 12 months post-treatment with romosozumab (210 mg sc monthly, n = 17), open-label daily teriparatide (20 μg sc, n = 19), or placebo (sc monthly, n = 20). For each of the 56 women, cortical thickness (Ct.Th), endocortical thickness (Ec.Th), cortical bone mineral density (Ct.bone mineral density (BMD)), cancellous BMD (Cn.BMD), and cortical mass surface density (CMSD) were measured across the first lumbar vertebral surface. In addition, color maps of the changes in the lumbar vertebrae structure were statistically analyzed and then visualized on the bone surface. At 12 months, romosozumab improved all parameters significantly over placebo and resulted in a mean vertebral Ct.Th increase of 10.3% versus 4.3% for teriparatide, an Ec.Th increase of 137.6% versus 47.5% for teriparatide, a Ct.BMD increase of 2.1% versus a −0.1% decrease for teriparatide, and a CMSD increase of 12.4% versus 3.8% for teriparatide. For all these measurements, the differences between romosozumab and teriparatide were statistically significant (p < 0.05). There was no significant difference between the romosozumab-associated Cn.BMD gains of 22.2% versus 18.1% for teriparatide, but both were significantly greater compared with the change in the placebo group (−4.6%, p < 0.05). Cortical maps showed the topographical locations of the increase in bone in fracture-prone areas of the vertebral shell, walls, and endplates. This study confirms widespread vertebral bone accrual with romosozumab or teriparatide treatment and provides new insights into how the rapid prevention of vertebral fractures is achieved in women with osteoporosis using these anabolic agents. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).     

Vertebral fractures and osteopenia in chronic alcoholic patients

To assess whether vertebral fractures are associated with osteopenia in chronic alcoholic patients, a transversal study was carried out in 76 chronic alcoholic males and 62 age-matched healthy males. Lumbar bone mineral density (BMD) by dual photon absorptiometry and spinal chest X-ray films were done in all patients. Twenty-seven patients (36%) had vertebral fractures, but only 5 of them had a BMD below the fracture threshold. Twenty-two patients (29%) had osteoporosis by densitometric criteria. There were no significant differences in lumbar BMD between alcoholic patients with and without vertebral fractures (1.11±0.2 versus 1.13±0.2, P=ns). Previous trauma was recorded in 24 of the 27 patients with vertebral fractures and in 28 of the 49 patients without vertebral fractures (P<0.001). Moreover, patients with vertebral fractures had more peripheral fractures than patients without vertebral fractures (81% versus 49%, P=0.01). Only one patient was aware of a previous episode of traumatic vertebral fracture. In conclusion, chronic alcoholics frequently have traumas and vertebral fractures, the latter despite having a lumbar BMD above the fracture threshold, suggesting a frequent but unrecognized association between both processes. These results suggest that both spine films and BMD measurements should be obtained for diagnosis of osteoporosis in alcoholic patients.     

Bone Changes due to Glucocorticoid Application in an Ovariectomized Animal Model for Fracture Treatment in Osteoporosis

In a pilot experiment comparing four different modalities for inducing osteoporosis in the sheep, a combination of ovariectomy, calcium/vitamin D-restricted diet and steroid administration was found to generate the highest decrease in bone mineral density (BMD). The aim of the present study was to quantify the outcome of this triple treatment in an animal model of osteoporosis in terms of alteration in bone mass, bone structure and bone mechanics. A total of 32 sheep were divided into two equal groups. Group 1 (age 3–5 years) was used as a normal control. Group 2 (age 7–9 years) was ovariectomized, fed a calcium/vitamin D-restricted diet and injected with methylprednisolone (MP) over 7 months (22 weeks MP solution, 6 weeks MP suspension). The BMD at the distal radius and tibia was determined preoperatively and at repeated intervals bilaterally using quantitative computed tomography. Steroid blood levels were determined 4 and 24 h after selected injections. BMD was measured at L3 and L4 after 7 months. Biopsies were taken from iliac crests, vertebral bodies and femoral heads, and bone structure parameters investigated by three-dimensional micro-CT. Compressive mechanical properties of cancellous bone were determined from biopsies of vertebral bodies and femoral heads. After 7 months of osteoporosis induction the BMD of cancellous bone decreased 36 ± 3% in the radius and 39 ± 4% in the tibia. Steroid blood levels 24 h after injection of MP suspension were significantly higher than after injection of MP solution. Changes in structural parameters of cancellous bone from the iliac crest, lumbar spine and femoral head in group 2 indicated osteoporosis-associated changes. In group 2 there was a significant reduction in BMD of the lumbar spine and a significant reduction in stiffness and failure load in compression testing of biopsies of lumbar vertebrae. In sheep, changes in the structural parameters of bone such as trabecular number and separation during osteoporosis induction are comparable to the human situation. The sheep model presented seems to meet the criteria for an osteoporosis model for fracture treatment with respect to mechanical and morphometric bone properties. Received: 4 May 2001 / Accepted: 6 December 2001     

Bone mineral density in patients with cervical and trochanteric fractures of the proximal femur

The bone mineral density (BMD) of the proximal femur, spine and radius shaft was determined in 75 women with atraumatic fractures of the proximal femur (FXf) (average age: 70.1±9.6 years) and 51 controls of similar age. Fractures were classified as either cervical (n=36) or trochanteric (n=39) on the basis of radiographic and surgical finding. The BMD of spine and proximal femur was determined by dual-photon absorptiometry (Lunar DP3) and the BMD of the radius shaft by single photon absorptiometry. The BMD of patients with FXf was significantly decreased over all skeletal sites compared to controls of similar age. No significant correlation was found between age and the BMD of the femoral neck in patients with FXf. Patients with trochanteric FXf were older and thinner (average: age, 72.9±9.4 years; weight, 53.1±7.8 kg) compared with patients with cervical fractures (age, 67.2±8.9 years; weight, 59.3±8.3 kg). Likewise the BMD of trochanteric FXf was lower at all measured sites: femoral neck, 0.548±0.066 g/cm² vs 0.624±0.055 g/cm² (P<0.001); L2-L4, 0.799±0.115 g/cm² vs 0.925±0.106 g/cm² (P<0.001); radius shaft, 0.454±0.057 g/cm² vs 0.502±0.083 g/cm² (P<0.05). Of the patients with trochanteric fractures 66% had concomitant vertebral fractures, while this occurred in only 28% of the patients with cervical fractures (P (Fisher)=0.0007). In summary, females with trochanteric FXf are older, thinner, have less bone mass in all measured sites and suffer with a significantly greater frequency of vertebral fractures. These patients have a generalized osteoporosis of the skeleton. Patients with cervical FXf seem to have more specific loss of the proximal femur (regional osteoporosis). The physiopathological process leading to trochanteric and cervical fractures is probably different.     

Change in lumbar spine BMD and vertebral fracture risk reduction in teriparatide-treated postmenopausal women with osteoporosis.

Increases in lumbar spine BMD account for 30-41% of the vertebral fracture risk reduction with teriparatide treatment. The remaining fracture risk reduction is caused by improvements in non-BMD determinants of bone strength. INTRODUCTION: Changes in BMD account for a small percentage of the fracture risk reduction seen in patients treated with antiresorptive drugs. The relationship between changes in lumbar spine BMD and vertebral fracture risk reduction with teriparatide treatment has not been assessed. MATERIALS AND METHODS: The relationship between spine BMD and the risk of new vertebral fractures after teriparatide treatment was assessed using data from the Fracture Prevention Trial. Postmenopausal women with osteoporosis (n = 1637) were randomized to placebo or teriparatide 20 or 40 microg/day for a median of 19 months. Spine BMD was assessed at baseline and 18 months. Vertebrae whose fracture status changed during the trial were removed from the calculation of BMD. Baseline and endpoint lateral spine radiographs were assessed using a visual semiquantitative technique. RESULTS: Both the baseline and change in spine BMD were contributors to vertebral fracture risk. The mean spine BMD increase in teriparatide-treated patients was 0.09 g/cm(2) across tertiles of baseline spine BMD. Compared with placebo, teriparatide significantly reduced the risk of new vertebral fracture for all endpoint BMD values. Teriparatide-mediated increases in spine BMD accounted for 30% (in the low baseline spine BMD tertile) to 41% (in the high baseline spine BMD tertile) of the reduction in vertebral fracture risk. CONCLUSIONS: Increases in BMD account for approximately one third of the vertebral fracture risk reduction seen with teriparatide. The majority of the risk reduction, however, results from improvements in non-BMD determinants of bone strength.     

Comparison of Bone and Total Alkaline Phosphatase and Bone Mineral Density in Postmenopausal Osteoporotic Women Treated with Alendronate

Alendronate therapy in osteoporotic women decreases bone turnover and increases bone mineral density (BMD). Optimal patient management should include verification that each patient is responding to therapy. Markers of bone turnover and BMD have both been proposed for this purpose. We have investigated changes resulting from alendronate therapy with an enzyme immunoassay for bone alkaline phosphatase (BAP) and compared it with total alkaline phosphatase (TAP) and BMD of the lumbar spine, hip, and total body. Subjects were drawn from a multicenter randomized, placebo-controlled trial of alendronate in postmenopausal women with osteoporosis. BAP and TAP levels were measured at baseline and following 3, 6 and 12 months of therapy with either placebo (n= 180) or alendronate 10 mg/day (n= 134). All subjects also received 500 mg/day supplemental calcium. BMD was measured at baseline and following 3, 6, 12, 18, 24 and 36 months of therapy. To compare BAP, TAP and BMD at each site for identifying women that experienced a skeletal effect of alendronate, we calculated least significant change (LSC) values from the long-term intraindividual variability in each placebo-treated woman. Median levels of BAP decreased by 34%, 44% and 43% at 3, 6 and 12 months, respectively, in alendronate-treated women (p<0.0001 compared with baseline and with placebo). These changes were significantly greater (p<0.0001) than changes observed for TAP. Following 6 months of alendronate therapy, 90% of the women had experienced a decrease in BAP exceeding the LSC compared with only 71% for TAP. The greatest number of women similarly identified with BMD at any site (i.e. a gain in BMD exceeding the LSC) was 81% for spinal BMD at 36 months. All other sites were less than 70% at 36 months. Short-term changes in BAP and TAP were modestly associated with subsequent changes in BMD at all sites (Spearman’s rho −0.22 to −0.52, p<0.05). Compared with TAP and BMD, BAP testing rapidly and sensitively identified skeletal effects of alendronate thus enabling appropriate drug monitoring of osteoporotic women. Though BAP and TAP changes were modestly predictive of BMD changes, the value of the bone marker tests is their ability to detect rapidly a skeletal effect of therapy. Received: 19 May 2000 / Accepted: 31 October 2000     

Zur Problematik des Halofixateurs beim alten Patienten

INTRODUCTION: The treatment of unstable cervical spine injuries with the halo vest represents an established procedure. So far no data reflecting the quality of life of patients following a halo vest treatment are available. Elderly people make up a large part of the inpatients in our hospital. Therefore special attention is payed to this group of patients in this study. METHODS: In this study 41 patients (average age of 51.8 +/- 23.5 years) with an unstable injury of the upper cervical spine were investigated. All of them underwent a halo vest therapy in our hospital during 1988-2003. The health-related quality of life was assessed in the mean 8.0 years after the trauma by using the SF-36 Health Survey. Additionally, the incidence of complications and the union rate over time were observed. RESULTS: The evaluation of the data obtained from the SF-36 revealed a reduced quality of life in the patient group in comparison to the reference population. This was particularly apparent in patients older than 60 years. The fracture healing under halo vest treatment was comparably slow. In 17% of the cases no fracture union was obtained after 12 weeks. This was only seen for patients older than 60 years. The complication rate associated to the halo vest amounted to 43% and was independent of age. CONCLUSION: The treatment of unstable fractures of the upper cervical spine with a halo vest results in a prolongated fracture healing for elderly people. Furthermore a halo vest therapy reduces the health related quality of life. Therefore, even for elderly patients an internal osteosynthetic stabilization of an unstable injury of the upper cervical spine should be considered if indicated.     

Effect of early risedronate treatment on bone mineral density and bone turnover markers after liver transplantation: a prospective single‐center study

The aim of this study was to investigate the effect of risedronate (RIS) on bone loss and bone turnover markers after liver transplantation (LT). Patients with osteopenia or osteoporosis within the first month after LT were randomized to receive RIS 35 mg/week plus calcium 1000 mg/day and vitamin D₃ 800 IU/day (n = 45) or calcium and vitamin D₃ at same dosages (n = 44). Primary endpoint was change in bone mineral density (BMD) 6 and 12 months after LT. Secondary endpoints included changes in serum β‐CrossLaps (β‐CTX) and procollagen type 1 amino‐terminal peptide (P1NP) and fracture rate. Spine X‐rays were obtained at baseline and after 12 months. There was no significant difference in BMD changes between both treatment groups at any sites; either at 6 or 12 months. Spine BMD increased in both groups at 12 months vs. baseline (P = 0.001). RIS patients had a significant increase in intertrochanteric BMD at 12 months (P < 0.05 vs. baseline). Serum β‐CTX decreased in both groups (P < 0.01), with significant differences between groups at 3 months. No significant difference in vertebral fracture incidence was found. After 12 months, BMD improved at lumbar spine and did not change at hip in both groups. Significant differences between both groups were not found. Other factors (calcium and vitamin D replacement, early prednisone withdrawal) seem to have also positive effects in BMD.