Spinal Cord Injury Induced Osteoporosis: Case Report and Current Literature
Keywords:Spinal Cord Injury, Osteoporosis, Teriparatide, Bone Density, SOST protein, human
Background: Among the various etiologies of osteoporosis, spinal cord injury has a drastic progression of the disease, causing weekly bone loss. There is no definitive treatment for the prevention of osteoporosis in these individuals. This review illustrates the recent findings on the pathophysiology, treatment, and management of spinal cord injury-induced osteoporosis. Furthermore, we cover a case of a male patient who experienced severe bone loss after a spinal cord injury at the age of 21 years.
The Case: We have a 57-year-old man with a history of AIS grade A spinal cord injury, level T11 with rod fixation from a motorcycle collision at age 21. His fracture history following the injury includes tibia, femur, and vertebral fractures. Bone mineral density imaging revealed notable T-scores ranging from -3.1 to -3.4 at the hip and femurs. Treatment plan consisted of teriparatide, dietary supplements, and physical therapy. Biomarkers from baseline to post one month of treatment revealed the following: procollagen type 1 N-terminal propeptide from 38 mcg/L to 70 mcg/L and C-terminal telopeptide from 209 pg/mL to 88 pg/mL, representing an increased bone formation and decreased bone resorption, respectively. After two years, bone mineral density T-scores improved to -2.7 on the left and the patient was capable of standing for the first time with the assistance of a standing frame.
Conclusion: Our case exemplified the progression of the disease and treatment options. A basis for the derivation of future innovative therapies has been covered. Favorable treatments and management are described in the review.
Bauman WA, Cardozo CP. Osteoporosis in Individuals with Spinal Cord Injury. PM&R. 2014 Aug 27;7(2):188–201.
Dobbs NB, Buckwalter J, Saltzman C. Osteoporosis: The Increasing Role of the Orthopaedist. Iowa Orthop J. 1999; 19:43-52.
Battaglino RA, Lazzari AA, Garshick E, Morse LR. Spinal Cord Injury-Induced Osteoporosis: Pathogenesis and Emerging Therapies. Curr Osteoporos Rep. 2012 Dec;10(4):278–85.
Tan CO. Spinal Cord Injury and Osteoporosis: Causes, Mechanisms, and Rehabilitation Strategies.Int J Phys Med Rehabil. 2013;1(4):127.
National Spinal Cord Injury Statistical Center. Spinal Cord Injury Facts and Figueres at a Glance. Available from https://www.nscisc.uab.edu/Public/Facts%20and%20Figures%20-%202018.pdf. Last updated 2021; cited Jun 22, 2020.
National Spinal Cord Injury Statistical Center. Spinal Cord Injury Facts and Figures at a Glance. Available from: https://www.nscisc.uab.edu/Public/Facts%20and%20Figures%202020.pdf. Last updated 2021; cited Jun 22, 2020.
Li X, Ominsky MS, Niu Q-T, Sun N, Daugherty B, Dagostin D, et al. Targeted Deletion of the Sclerostin Gene in Mice Results in Increased Bone Formation and Bone Strength. J Bone Miner Res. 2008 Jun 11;23(6):860–9.
Morse LR, Sudhakar S, Danilack V, Tun C, Lazzari A, Gagnon DR, et al. Association between sclerostin and bone density in chronic spinal cord injury. J Bone Miner Res. 2012 Feb;27(2):352–9.
Wu J, Ma L, Wu L, Jin Q. Wnt-β-catenin signaling pathway inhibition by sclerostin may protect against degradation in healthy but not osteoarthritic cartilage. Mol Med Rep. 2017 May;15(5):2423–32.
Wijenayaka AR, Kogawa M, Lim HP, Bonewald LF, Findlay DM, Atkins GJ. Sclerostin Stimulates Osteocyte Support of Osteoclast Activity by a RANKL-Dependent Pathway. PLoS ONE. 2011 Oct;6(10):E25900.
Battaglino RA, Sudhakar S, Lazzari AA, Garshick E, Zafonte R, Morse LR. Circulating sclerostin is elevated in short-term and reduced in long-term SCI. Bone. 2012 Sept;51(3):600–5.
Morse LR, Sudhakar S, Lazzari AA, Tun C, Garshick E, Zafonte R, et al. Sclerostin: a candidate biomarker of SCI-induced osteoporosis. Osteoporos Int. 2013 Mar;24(3):961–8.
Lamarche J, Mailhot G. Vitamin D and spinal cord injury: should we care? Spinal Cord. 2016 Dec;54(12):1060–75.
Mechanick JL, Pomerantz F, Flanagan S, Stein A, Gordon WA, Ragnarsson KT. Parathyroid hormone suppression in spinal cord injury patients is associated with the degree of neurologic impairment and not the level of injury. Arch Phys Med Rehabil. 1997 Jul;78(7):692–6.
Drake M, Srinivasan B, Mödder U, Peterson J, McCready L, Riggs B, et al. Effects of Parathyroid Hormone Treatment on Circulating Sclerostin Levels in Postmenopausal Women. J Clin Endocrinol Metab. 2010 Nov;95(11):5056–62.
Yu EW, Kumbhani R, Siwila-Sackman E, Leder BZ. Acute Decline in Serum Sclerostin in Response to PTH Infusion in Healthy Men. J Clin Endorcinol Metab. 2011 Nov;96(11):E1848-51.
Savvidis C, Tournis S, Dede AD. Obesity and bone metabolism. Hormones. 2018 Apr;17(2):205–17.
Zhou Y, Rui L. Leptin signaling and leptin resistance. Front Med. 2013 Jun;7(2):207–22.
Jeon JY, Steadward RD, Wheeler GD, Bell G, Mccargar L, Harber V. Intact Sympathetic Nervous System Is Required for Leptin Effects on Resting Metabolic Rate in People with Spinal Cord Injury. J Clin Endocrinol Metab. 2003 Jan;88(1):402–7.
Doherty AL, Battaglino RA, Donovan J, Gagnon D, Lazzari AA, Garshick E, et al. Adiponectin Is a Candidate Biomarker of Lower Extremity Bone Density in Men With Chronic Spinal Cord Injury. J Bone Miner Res. 2014 Jan;29(1):251–9.
Leder BZ, Tsai JN, Uihlein AV, Wallace PM, Lee H, Neer RM, et al. Denosumab and teriparatide transitions in post-menopausal osteoporosis (the DATA-switch study): extension of a randomized control trial. Lancet. 2015 Sept 19;386(9999):1147-1155
Morse L. Osteoporosis prophylaxis in acute SCI. Spinal Cord Ser Cases. 2019 Apr;5(1).
Goenka S, Sethi S, Pandey N, Joshi M, Jindal Rajeswari. Effect of Early Treatment with Zoledronic Acid on Prevention of Bone Loss in Patients with Acute Spinal Cord Injury: A Randomized Controlled Trial. Spinal Cord. 2018 Sept 26; 56:1207-1211.
Lindsay R, Krege JH, Marin F, Jin L, Stepan JJ. Teriparatide for osteoporosis: importance of the full course. Osteoporos Int. 2016 Aug;27(8):2395–410.
Edwards WB, Simonian N, Haider IT, Anschel AS, Chen D, Gordon KE, et al. Effects of Teriparatide and Vibration on Bone Mass and Bone Strength in People with Bone Loss and Spinal Cord Injury: A Randomized, Controlled Trial. J Bone Miner Res. 2018 Oct;33(10):1729–40.
StatPearls Publishing. Osteoporosis in Spinal Cord Injuries. Available from https://www.ncbi.nlm.nih.gov/books/NBK526109/. Last updated Dec 2, 2020; cited Apr 23, 2020.
Wirth F, Schempf G, Stein G, Wellmann K, Manthou M, Scholl C, et al. Whole-Body Vibration Improves Functional Recovery in Spinal Cord Injured Rats. J Neurotrauma. 2013 Mar 15;30(6):453–68.
Ness LL, Field-Fote EC. Whole-body vibration improves walking function in individuals with spinal cord injury: A pilot study. Gait Posture. 2009 Nov;30(4):436–40.
Mcclung MR. Romosozumab for the treatment of osteoporosis. Osteoporos Sarcopenia. 2018 Mar;4(1):11–5.
Lewiecki EM, Blicharski T, Goemaere S, Lippuner K, Meisner PD, Miller PD, et al. A Phase III Randomized Placebo-Controlled Trial to Evaluate Efficacy and Safety of Romosozumab in Men With Osteoporosis. J Clin Endocrinol Metab. 2018 Sept 1;103(9):3183–93.
Merlotti D, Falchetti A, Chiodini I, Gennari L. Efficacy and safety of abaloparatide for the treatment of post-menopausal osteoporosis. Expert Opin on Pharmacother. 2019 Mar 11;20(7):805–11.
McClung M, O'Donoghue M, Papapoulos S, Bone H, Langdahl B, Saag K. Odanacatib for the treatment of postmenopausal osteoporosis: results of the LOFT multicentre, randomised, double-blind, placebo-controlled trial and LOFT Extension study. Lancet Diabetes Endocrinol. 2019 Dec 1;7(12):899–911.
Morse LR, Biering-Soerensen F, Carbone LD, Cervinka T, Cirnigliaro CM, Johnston TE, et al. Bone Mineral Density Testing in Spinal Cord Injury: 2019 ISCD Official Position. J Clinical Densitom. 2019 Oct-Dec;22(4):554–66.
Shetty S, Kapoor N, Bondu JD, Thomas N, Paul TV. Bone Turnover Markers: Emerging Tool in the Management of Osteoporosis. Indian J Endocrinol Metab. 2016 Nov-Dec; 20(6):846-853.
Tsujimoto M, Chen P, Miyauchi A, Sowa H, Krege JH. PINP as and Aid for Monitoring Patients Treated with Teriparatide. Bone. 2011 Apr 1; 48(4): 798-803.
How to Cite
Authors who publish with this journal agree to the following terms:
- The Author retains copyright in the Work, where the term “Work” shall include all digital objects that may result in subsequent electronic publication or distribution.
- Upon acceptance of the Work, the author shall grant to the Publisher the right of first publication of the Work.
- The Author shall grant to the Publisher and its agents the nonexclusive perpetual right and license to publish, archive, and make accessible the Work in whole or in part in all forms of media now or hereafter known under a Creative Commons Attribution 4.0 International License or its equivalent, which, for the avoidance of doubt, allows others to copy, distribute, and transmit the Work under the following conditions:
- Attribution—other users must attribute the Work in the manner specified by the author as indicated on the journal Web site; with the understanding that the above condition can be waived with permission from the Author and that where the Work or any of its elements is in the public domain under applicable law, that status is in no way affected by the license.
- The Author is able to enter into separate, additional contractual arrangements for the nonexclusive distribution of the journal's published version of the Work (e.g., post it to an institutional repository or publish it in a book), as long as there is provided in the document an acknowledgment of its initial publication in this journal.
- Authors are permitted and encouraged to post online a prepublication manuscript (but not the Publisher’s final formatted PDF version of the Work) in institutional repositories or on their Websites prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work. Any such posting made before acceptance and publication of the Work shall be updated upon publication to include a reference to the Publisher-assigned DOI (Digital Object Identifier) and a link to the online abstract for the final published Work in the Journal.
- Upon Publisher’s request, the Author agrees to furnish promptly to Publisher, at the Author’s own expense, written evidence of the permissions, licenses, and consents for use of third-party material included within the Work, except as determined by Publisher to be covered by the principles of Fair Use.
- The Author represents and warrants that:
- the Work is the Author’s original work;
- the Author has not transferred, and will not transfer, exclusive rights in the Work to any third party;
- the Work is not pending review or under consideration by another publisher;
- the Work has not previously been published;
- the Work contains no misrepresentation or infringement of the Work or property of other authors or third parties; and
- the Work contains no libel, invasion of privacy, or other unlawful matter.
- The Author agrees to indemnify and hold Publisher harmless from the Author’s breach of the representations and warranties contained in Paragraph 6 above, as well as any claim or proceeding relating to Publisher’s use and publication of any content contained in the Work, including third-party content.
Enforcement of copyright
The IJMS takes the protection of copyright very seriously.
If the IJMS discovers that you have used its copyright materials in contravention of the license above, the IJMS may bring legal proceedings against you seeking reparation and an injunction to stop you using those materials. You could also be ordered to pay legal costs.
If you become aware of any use of the IJMS' copyright materials that contravenes or may contravene the license above, please report this by email to firstname.lastname@example.org
If you become aware of any material on the website that you believe infringes your or any other person's copyright, please report this by email to email@example.com