Protocol Proposal for Management of Neurogenic Heterotopic Ossification in Spinal Cord Injury: A Rehabilitation Center Experience
DOI :
https://doi.org/10.25759/spmfr.506Mots-clés :
Ossification, Heterotopic, Spinal Cord InjuriesRésumé
Introduction: Neurogenic heterotopic ossification (NHO) is a frequent complication of spinal cord injury (SCI). NHO poses a diagnostic challenge and can compromise patient functionality. Our aim is to characterize a case series of NHO in SCI patients, from a rehabilitation center, review the literature and propose a management protocol.Methods: A small case series is described based on medical records. A review of the literature for etiology, diagnosis and treatment of NHO in SCI was performed.
Results: A total of 5 SCI patients were included, 3 were male (median age 48.4 years). Three were traumatic SCI, 2 had concomitant traumatic brain injuryJ (TBI), all were thoracic lesions (T4-T9), 4 were complete lesions, 3 had autonomic dysreflexia. Median time from SCI to NHO was 2.1 months. All presented with swelling around the hip. Alkaline phosphatase (AP) and c-reactive protein (CRP) rises were documented. Main Protocol steps: - Calcium, phosphorus, AP, CK and CRP evaluation. - Asymptomatic patients: institute prophylaxis with Indomethacin (ER, 75 mg/day, 6 weeks) to SCI with less than 6 weeks, if risk factors for NHO are present. - If suggestive symptoms arise, first exclude DVT. After, request an x-ray, for differential diagnosis and evaluate calcifications. Repeat blood tests. Proceed to bone scintigraphy for early diagnosis. - Confirmed/strong suspicion NHO: initiate treatment with bisphosphonate, only in the absence of radiographic calcifications (etidronate 20 mg/kg/day, po, 6 months OR alendronate 70 mg/week, 9 months). Maintain an adapted rehabilitation program. - Significant limited ROM or complications with functional impact should motivate surgery consideration. After surgery, institute recurrence prophylaxis (pamidronate).
Conclusion: A management protocol is proposed for prompt and accurate diagnosis and treatment of NHO in SCI patients.
Téléchargements
Références
Alexander KA, Tseng HW, Saiga M, Genfif F, Levesque JP. When the Nervous System Turns Skeletal Muscles into Bones: How to Solve the Conundrum of Neurogenic Heterotopic Ossification. Curr Osteoporos Rep. 2020;18:666-76. doi: 10.1007/s11914-020-00836-w.
Ampadiotaki MM, Evangelopoulos DS, Pallis D, Vlachos C, Vlamis J, Evangelopoulos ME. New Strategies in Neurogenic Heterotopic Ossification. Cureus. 2021;13:e14709. doi: 10.7759/cureus.14709.
Yang K, Graf A, Sanger J. Pressure ulcer reconstruction in patients with heterotopic ossification after spinal cord injury: A case series and review of literature. J Plast Reconstr Aesthet Surg. 2017;70:518-28. doi: 10.1016/j.bjps.2016.11.026.
Wong KR, Mychasiuk R, O’Brien TJ, Shultz SR, McDonald SJ, Brady RD. Neurological heterotopic ossification: novel mechanisms, prognostic biomarkers and prophylactic therapies. Bone Res. 2020;8:42. doi: 10.1038/s41413-020-00119-9.
Legosz P, Drela K, Pulik L, Sarzyńska S, Maldyk P. Challenges of heterotopic ossification-Molecular background and current treatment strategies. Clin Exp Pharmacol Physiol. 2018;45:1229-35. doi: 10.1111/1440-1681.13025.
Aubut JA, Mehta S, Cullen N, Teasell RW. A comparison of heterotopic ossification treatment within the traumatic brain and spinal cord injured population: An evidence based systematic review. NeuroRehabilitation. 2011;28:151-60.
Sakellarou VI, Grigoriou E, Marvogenis AF, Soucaços PN, Papagelopoulos PJ. Heterotopic ossification following traumatic brain injury and spinal cord injury: Insight into the etiology and pathophysiology. J Musculoskelet Neuronal Interact. 2012;12:230-40.
Teasell RW, Mehta S, Aubut JL, Aehe MC, Sequeira K, Macaluso S, et al. A systematic review of the therapeutic interventions for heterotopic ossification after spinal cord injury. Spinal Cord. 2010;48:512-21.
van Kuijk AA, Geurts AC, van Kuppewelt HL. Neurogenic heterotopic ossification in spinal cord injury. Spinal Cord. 2002;40:313-26.
Ranganathan K, Loder S, Agarwal S, Wong VW, Forsberg J, Davis TA, et al. Heterotopic Ossification: Basic-Science Principles and Clinical Correlates. J Bone Joint Surg Am. 2015;97:1101-11. doi: 10.2166/JBJS.NJ01656.
Brady RD, Shultz SR, McDonald SJ, O’Brien TJ. Neurological heterotopic ossification: Current understanding and future directions. Bone. 2018;109:35-42. doi: 10.1016/j.bone.2017.05.015.
Cao P AF, McIntyre A, Mehta S, Loh E, Teasell R. Heterotopic Ossification Following Spinal Cord Injury. In: Eng JJ TR, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Noonan WK, Loh E, Sproule S, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence Version 8. Vancouver: SCIRE; 2022. p. 134.
Banovac K, Sherman AL, Estores IM, Banovac F. Prevention and treatment of heterotopic ossification after spinal cord injury. J Spinal Cord Med. 2004;27:376-82.
Ploumis A, Donovan JM, Olumide MO, Clark DM, Wu JC, Sohn DJ, et al. Association between alendronate, serum alkaline phosphatase level, and heterotopic ossification in individuals with spinal cord injury. J Spinal Cord Med. 2015;38:193-8. doi: 10.1179/2045772314Y0000000213.
Reznik JE, Biros E, Lamont AC, Sacher Y, Kibrik O, Milanese S, et al. A preliminary investigation on the effect of extracorporeal shock wave therapy as a treatment for neurogenic heterotopic ossification following traumatic brain injury. Part I: Effects on pain. Brain Inj. 2017;31:526-32. doi: 10.1080/02699052.2017.1283059.
Reznik JE, Biros E, Sacher Y, Kibrik O, Milanese S, Gordon S, et al. A preliminary investigation on the effect of extracorporeal shock wave therapy as a treatment for neurogenic heterotopic ossification following traumatic brain injury. Part II: Effects on function. Brain Inj. 2017;31:533-41. doi: 10.1080/02699052.2017.1283060.
Reznik JE, Gordon SJ, Barker RN, Keren O, Arama Y, Galea MP. Extracorporeal Shock Wave Therapy (ESWT) as a treatment for recurrent Neurogenic Heterotopic Ossification (NHO). Brain Inj. 2013;27:242-7.
Ryu BJ, Ha KW, Lee JY, Kim SH, Kwak HJ, Seol PH. Radial extracorporeal shock wave therapy for heterotopic ossification. J Phys Ther Sci. 2016;28:701-4. doi: 10.1588/pfsb.28.701.
Brisco R, Lassalle A, Vincendeau S, Polard JL, Fouche M, Ninubona D, et al. Treatment of heterotopic ossification by extracorporeal shock wave: 26 patients]. Ann Readapt Med Phys. 2005;48:581-9.
Jeon HM, Lee WJ, Chung HS, Yi YG, Yang S, Kim DH, et al. Extracorporeal shock wave therapy to treat neurogenic heterotopic ossification in a patient with spinal cord injury: A case report. J Spinal Cord Med. 2021;44:627-30. doi: 10.1080/10790268.2018.1632597.
Genfaff F, Ruet A, Almanpour W, Gatin L, Denomandie P, Schnitzler A. Beliefs relating to recurrence of heterotopic ossification following excision in patients with spinal cord injury: a review. Spinal Cord. 2015;53:340-4. doi: 10.1038/sc.2015.20.
Vanden Bossche L, Vanderstraeten G. Heterotopic ossification: a review. J Rehabil Med. 2005;37:129-36.
Teasell RW, Hsieh JT, Aubut JA, Eng JJ, Krassioukov A, et al; Spinal Cord Injury Rehabilitation Evidence Review Research Team. Venous thromboembolism after spinal cord injury. Arch Phys Med Rehabil. 2009;90:232-45. doi: 10.1016/j.apmr.2008.09.557.
Téléchargements
Publiée
Comment citer
Numéro
Rubrique
Licence
© Revista da Sociedade Portuguesa de Medicina Física e de Reabilitação 2025
Ce travail est disponible sous licence Creative Commons Attribution - Pas d'Utilisation Commerciale - Pas de Modification 4.0 International.
Os manuscritos devem ser acompanhados de declaração de originalidade, Autoria e de cedência dos direitos de propriedade do artigo, assinada por todos os Autores.
Quando o artigo é aceite para publicação é obrigatória a submissão de um documento digitalizado, assinado por todos os Autores, com a partilha dos direitos de Autor entre Autores e a Revista SPMFR, conforme minuta:
Declaração Copyright
Ao Editor-chefe da Revista da Sociedade Portuguesa de Medicina Física e Reabilitação
O(s) Autor(es) certifica(m) que o manuscrito intitulado:
____________________________________________________________________ (ref.Revista da SPMFR_________) é original, que todas as afirmações apresentadas como factos são baseados na investigação do(s) Autor(es), que o manuscrito, quer em parte quer no todo, não infringe nenhum copyright e não viola nenhum direito da privacidade, que não foi publicado em parte ou no todo e que não foi submetido para publicação, no todo ou em parte, noutra revista, e que os Autores têm o direito ao copyright.
Todos os Autores declaram ainda que participaram no trabalho, se responsabilizam por ele e que não existe, da parte de qualquer dos Autores conflito de interesses nas afirmações proferidas no trabalho.
Os Autores, ao submeterem o trabalho para publicação, partilham com a Revista da SPMFR todos os direitos a interesses do copyright do artigo.
Todos os Autores devem assinar
Data:
Nome(maiúsculas)
Assinatura
Relativamente à utilização por terceiros a Revista da SPMFR rege-se pelos termos da licença Creative Commons “Atribuição – uso Não-Comercial – Proibição de Realização de Obras derivadas (by-nc-nd)”.
Após publicação na Revista SPMFR, os Autores ficam autorizados a disponibilizar os seus artigos em repositórios das suas instituições de origem, desde que mencionem sempre onde foram publicados.
OS AUTORES DEVERÃO SUBMETER UMA DECLARAÇÃO DE CONTRIBUIÇÃO / CONTRIBUTORSHIP STATEMENT INDICANDO O TIPO DE PARTICIPAÇÃO DE CADA AUTOR NO ARTIGO. Mais informações: https://authors.bmj.com/policies/bmj-policy-on-authorship/
