Heterotopic Ossification After Spinal Cord Injury: Current Clinical Approaches
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SPINAL CORD INJURY REHABILITATION (J DONOVAN, SECTION EDITOR)
Heterotopic Ossification After Spinal Cord Injury: Current Clinical Approaches Juliet C. Zakel 1,2 & Amanda L. Harrington 1,2
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review Heterotopic ossification (HO) is a frequent complication after spinal cord injury (SCI). This review article critically analyzes the scientific literature of HO after SCI and offers expert opinion on how past research translates to clinical practice. Recent Findings Triple-phase bone scintigraphy has been the gold standard for diagnosing HO; however, recent research suggests diagnostic ultrasound may be more convenient, cost-effective, and safe. Currently, routine pharmaceutical prophylaxis for HO after SCI is not recommended. Range of motion exercises are advised to prevent and treat HO. Etidronate was approved for HO treatment, but it is no longer available in the USA. Evidence to support the use of alternate bisphosphonates is lacking. Surgical resection is reserved for select cases where the primary goal is improving function. Summary HO is a common complication after SCI, and continued research is needed to improve diagnosis, prevention, and treatment. Keywords Heterotopic ossification . Spinal cord injury
Introduction Heterotopic ossification (HO) is defined as the abnormal formation of bone outside the skeletal system most often in the soft tissues surrounding joints. HO has been associated with genetic conditions such as progressive osseous heteroplasia and fibrodysplasia ossificans progressiva, but is also a possible sequelae of acquired conditions including bone fracture, hip arthroplasty, burn, amputation, traumatic brain injury (TBI), and spinal cord injury (SCI). Although the reported incidence of HO after SCI ranges from 10 to 78% in the literature, the clinical relevance depends on the location and
This article is part of the Topical Collection on Spinal Cord Injury Rehabilitation * Amanda L. Harrington [email protected] 1
UPMC Rehabilitation Institute at UPMC Mercy, University of Pittsburgh Medical Center, 1400 Locust St. Building D, Suite G103, PM&R Office, Pittsburgh, PA 15219, USA
2
Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Kaufmann Medical Building, Suite 910, 3471 Fifth Ave, Pittsburgh, PA 15213, USA
extent of ossification [1••, 2–4]. In some cases, HO is more of an incidental finding, but in other cases, it may be a source of significant pathology. Clinically significant HO after SCI is estimated at 10–20% [4–7]. The pathophysiology of HO is not well understood; however, the proposed mechanism is a traumatic event that causes local inflammation, which in turn signals nearby mesenchymal cells to differentiate into osteoblasts that lay down a bony matrix [1••, 2, 4, 8–11].
Clinical Presentation The early phase of HO, which typically presents between 3 and 12 weeks post injury, is characterized by inflammation, pain, warmth, tenderness, and swelling
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