Cases reported "Osteoporosis"

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1/17. Severe progressive osteoporotic spine deformity with cardiopulmonary impairment in a young patient. A case report.

    STUDY DESIGN: This report describes a young patient with a rapidly progressive kyphosis caused by collapse of a severely osteoporotic thoracolumbar spine, which led to impairment of cardiopulmonary function. OBJECTIVES: To highlight the treatment strategy, difficulty of diagnosis, operative stabilization, and outcome. SUMMARY OF BACKGROUND DATE: Little is known about natural history, treatment options, and results of this condition. methods: The magnitude of bone loss was measured by dual-energy x-ray absorptiometry, and the deformity was visualized by computed tomography and magnetic resonance imaging. Laboratory investigations also were performed before and during halotraction in an attempt to establish a diagnosis. These data constituted the preoperation information required to assess later results of medical and surgical intervention. RESULTS: An extensive evaluation of possible underlying etiologies failed to identify a specific etiology. Before and during halotraction, bone mineral substitutes were given, partially correcting the bone mineral content as measured on repeated dual-energy x-ray absorptiometry scans. In addition, the thoracic kyphosis was partially corrected, from 100 degrees to 70 degrees Cobb's angle. Subsequently, a combined anterior and posterior stabilization was performed from C7 to S1 using a vascularized fibula graft, a double Isola rod system (AcroMed, Cleveland, OH), and a carbonate apatite cancellous bone cement to reinforce the pedicle screws. At follow-up assessment 40 months surgery, the patient was asymptomatic and fully mobilized, with radiographs showing complete incorporation of the grafts and no loosening of the fixation device. CONCLUSIONS: The diagnostic and therapeutic difficulties of progressive spine deformity caused by severe osteoporosis in young patients emphasizes the importance of a thoroughly planned treatment strategy. Halotraction is recommended to stop progression of the deformity, or even partially correct it, and to allow time to search for the diagnosis and bone mineral substitution. Surgical treatment using vascularized fibular strut grafts and a strong fixation device was successful. Biocompatible carbonated apatite cancellous bone cement was successfully used to reinforce pedicle screw fixation.
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2/17. Anterior cervical spine fusion using RABEA-Titan-Cages avoiding iliac crest spongiosa: first experiences and results.

    INTRODUCTION: In cervical discectomy using the ventral approach both, the necessity of replacement of the removed disc space itself as well as the material of the graft, if used, is still a matter of discussion. New approaches are titan-cages, usually filled with autologeous spongiosa. We present in the following study our first experiences using the hollow RABEA-Titan-Cages without filling with spongiosa to avoid the iliac crest complications. MATERIAL AND methods: 63 patients (33 male, 30 female, age 25-79 years, mean 52 years) were operated on a degenerative cervical disc herniation by ventral discectomy and replacement of the disc by the cage for fusion. The mean follow-up was 8 months. The preoperative symptoms were radiculopathies (n = 43) and myelopathies (n = 20). The diagnosis was confirmed by CT, MRI, myelography/CT and functional plain x-ray examination excluding instability. Level of the disc herniation: C3/4 n = 3, C4/5 n = 4, C5/6 n = 21, C6/7 n = 23, C7/Th1 n = 5, and 7 cases with 2 levels. In 30 cases we found hard discs, in 13 cases soft discs and in 20 patients combined lesions. All patients were intra- and postoperatively controlled by x-ray examination. RESULTS: Free of complaints were 17 patients, a marked improvement was found in 33 cases, a minor improvement in 10 cases, from those 4 patients additionally suffered from depression or alcoholism and 1 patient had a trauma in the history. 3 patients showed no change. Minor neck pain was reported in 5 cases. The mean postoperative hospitalisation was 8 days. Surgery related complications: temporary radicular palsies n = 5, hoarseness/problems with swallowing n = 5. In 2 cases (3%) with osteoporosis surgical revision of the cage was necessary (one case with ventral dislocation and one case with recurrent nerve root compression). In all other cases the x-ray control proved the correct placement of the cages intra- and postoperatively on discharge. CONCLUSION: For the anterior cervical fusion, the hollow RABEA-Titan-Cages present good clinical results and help to avoid complications from the iliac crest donor site. For long-term results, a longer follow-up and a increased number of patients is required.
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3/17. Rapid increase in bone mineral density in a child with osteoporosis and autoimmune hypoparathyroidism treated with PTH 1-34.

    We describe a 16-year-old girl with autoimmune polyglandular syndrome type 1 including hypoparathyroidism, who had osteoporosis that improved rapidly with parathyroid hormone replacement therapy. patients with hypoparathyroidism usually have high bone mass. Our patient developed vertebral compression fractures at age 10, shortly after hypoparathyroidism was diagnosed. She continued to have low lumbar bone mass until age 16, when a dual energy x-ray absorptiometry (DEXA) revealed a Z score of - 2.2 SD. Several factors including decreased physical activity, total body magnesium depletion, and intermittent ketoconazole and short-term prednisone treatment, may have contributed to the development and progression of osteoporosis. Therapy with synthetic human parathyroid hormone (PTH) 1-34 rapidly normalized lumbar bone mass, as assessed by DEXA.
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4/17. Discrepant areal and volumetric bone density measurements in a young woman with idiopathic low bone mineral density.

    OBJECTIVE: To discuss a case of idiopathic low bone density in a young woman. methods: We present a detailed report that includes clinical, laboratory, and radiologic assessment of a pre-menopausal woman with idiopathic low bone mass. RESULTS: A 34-year-old healthy woman of small body habitus was found by dual-energy x-ray absorptiometry to have bone mineral density (BMD) that was less than 2.5 standard deviations below the young and age-matched norm. After a thorough evaluation, no cause of osteoporosis was identified. Calculation of bone mineral apparent density, which minimizes the effect of small skeletal size on areal BMD, resulted in only a modest improvement in T-scores. Measurement of lumbar spine volumetric BMD by quantitative computed tomography, however, revealed a significantly improved T-score of -1.6. CONCLUSION: This report highlights the complexities of low BMD measurements in otherwise healthy young women as well as the potential application of bone mineral apparent density and quantitative computed tomography in the evaluation of low BMD in young women with small skeletal frames.
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5/17. Annual changes of bone density over 12 years in an amenorrheic athlete.

    PURPOSE: To link annual changes of bone mineral density (BMD) over 12 consecutive years to pharmacological intervention and to fluctuations of body mass and body composition in an amenorrheic athlete. methods: BMD of the lumbar spine (LS) and total proximal femur (PF) were measured using dual energy x-ray absorptiometry (DXA), every 11-13 months between ages 24.8 and 36.9 yr. body composition was assessed every 3-4 yr from a whole body DXA scan. Body mass was recorded every 3 months. For the first 5 yr of study, the subject used oral contraceptives (OC). For the subsequent 7 yr, she used estradiol skin patches (EP) with oral norethisterone. RESULTS: The first DXA scan (age 24.8 yr) revealed a low BMD at both LS and PF, with T-scores of -1.4 and -2.8, respectively. During the next 5 yr, while adhering to OC, the BMD of her LS and PF declined by 9.8% and 12.1%, respectively. Concomitantly, her body mass fell from 45.1 to 41.4 kg, her body mass index (BMI) from 16.4 to 15.0 kg.m-2, and her percent body fat from 8.3 to <4.0%. While treated with EP and norethisterone (age 29.8-33.5 yr), her LS BMD gradually increased by 9.4%, despite a further 0.8 kg decline of body mass. From age 33.8 to 36.9 yr, voluntary weight gain (2-3 kg.yr-1; total: 8.1 kg) was accompanied by an increase of her PF BMD (16.9%), with no further increase at the LS. CONCLUSION: Changes of BMD at the total proximal femur reflected changes of body mass in this subject. At the lumbar spine, BMD declined with weight loss but increased in association with transdermal estradiol treatment in the absence of weight gain.
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6/17. Vertebral reconstruction with biodegradable calcium phosphate cement in the treatment of osteoporotic vertebral compression fracture using instrumentation.

    OBJECTIVE: To assess the efficacy of posterior instrumentation and vertebral reconstruction with biodegradable calcium phosphate cement (CPC) in the treatment of osteoporotic vertebral compression fracture with neurologic deficit. BACKGROUND: vertebroplasty consists of the injection of polymethylmethacrylate (PMMA) cement into the vertebral body. While PMMA has high mechanical strength, it cures fast and thus allows only a short handling time. Other potential problems of using PMMA injection may include damage to surrounding tissues due to the high polymerization temperature or by the toxic unreacted monomer and the lack of long-term biocompatibility. Bone mineral cements such as calcium carbonate and CPCs have a longer working time and low thermal effect. They are also biodegradable while providing good mechanical strength. However, the viscosity of injectable mineral cements is high, and the infiltration of these cements into the vertebral body has been questioned. Recently, the infiltration properties of CPC have been significantly improved, making it more suitable for injection into the vertebral bodies for vertebral reconstruction. methods: Five patients were included in this open prospective study. Inclusion criteria were delayed collapsed vertebral compression fractures responsible for severe pain and neurologic dysfunction necessitating posterior decompression surgery. Of five patients, two were male and three were female with an average age at surgery of 80.4 years (71-85 years) and an average duration of follow-up of 2.5 years (2-3.5 years). Evaluation of clinical data was based on x-ray, Japanese Orthopaedic association (JOA) score for low back pain (full score is 29 points), and visual analog scale (VAS). RESULTS: The levels of the delayed collapsed vertebrae were T10, L1, and L2 (for one patient each) and L4 (two patients). All patients were in poor condition, for example, renal failure, heart failure, and chronic hepatitis. The average operative time was 2 hours (1 hour 36 minutes to 2 hours 16 minutes), and intraoperative bleeding was 181 mL (85-236 mL). As for clinical symptoms, preoperative JOA score averaged 17.8 points and was improved to 26 points postoperatively, while the preoperative VAS score of 8.6 points improved to 2 points postoperatively. Morphologic evaluation showed preoperative vertebral compression ratio averaged 41% and improved to 74% immediately after the operation and finally settled at 68%. Just one of five cases experienced late vertebral collapse 3 months after the operation. CONCLUSION: Vertebral reconstruction with biodegradable CPC in the treatment of osteoporotic vertebral compression fracture using instrumentation was a safe and useful surgical treatment.
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7/17. Normalization of bone density in a previously amenorrheic runner with osteoporosis.

    PURPOSE: To examine changes in bone mineral density (BMD) and bone mineral content (BMC) in relation to pharmacological and nutritional interventions in a distance runner diagnosed with the female athlete triad of disordered eating, amenorrhea, and osteoporosis. methods: BMD of the lumbar spine (L2-L4) and total proximal femur were measured from ages 22.9 to 30.8 yr using dual x-ray absorptiometry (DXA). RESULTS: At age 22.9, the patient presented with primary amenorrhea, low body weight (BMI: 15.8 kg.m(-2)), and low BMD in the spine (74% of normal, T score: -2.50) and hip (80% of normal, T score: -1.54). For the next 2 yr, the patient took oral contraceptives to induce menses, but continued to maintain a low weight. Her BMD remained unchanged. At age 25.1 yr, she decided to gain weight and improve her nutrition, resulting in small increases in spinal BMD ( 1.1%), hip BMD ( 1.6%), and total body BMC ( 7.6%) in 4 months. From ages 25.4 to 30.8 yr, the patient continued to gain weight, eventually reaching a healthy BMI of 21.3 kg.m(-2); correspondingly, since baseline, her BMD had increased 25.5% in the spine and 19.5% in the hip, bringing her BMD to within normal values (spine: 94% of normal, hip: 96% of normal). CONCLUSION: This case illustrates that even if skeletal development is interrupted in adolescence, there is still the potential for "catch-up" in BMD well into the third decade of life. Reversal of large bone density deficits in this patient can be attributed to improved nutrition and weight gain but not to hormone replacement.
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8/17. Regression of skeletal manifestations of hyperparathyroidism with oral vitamin d.

    CONTEXT: parathyroidectomy is the only effective therapy for osteitis fibrosa cystica in hyperparathyroidism. OBJECTIVE: The objective of this study was to describe the changes of skeletal and nonskeletal manifestations in a patient with hyperparathyroidism and renal failure after oral vitamin d therapy. DESIGN: This was a descriptive case report. SETTING: The patient was followed up in a referral center. PATIENT: A 55-yr-old male patient with moderate renal failure was referred for expansile lytic lesions affecting several ribs and the spinous process of T12. His creatinine was 1.8 mg/dl; calcium, 8.9 mg/dl; PTH, 666 pg/ml; and 1,25 dihydroxy-vitamin d, 27 pg/ml. Bone mineral density (BMD) Z-scores by dual-energy x-ray absorptiometry were -4.1 at the spine, -1.7 at the hip, and -4.3 at the forearm. MAIN OUTCOME MEASURES: The main outcome measures were the skeletal manifestations of hyperparathyroidism. RESULTS: At 10 months of therapy, calcium level was 10 mg/d, PTH level declined to 71 pg/ml, and BMD increased by 12% at the spine and 18% at the hip. Computerized tomography (CT) cuts revealed marked regression in the lytic lesions. At 2 yr, BMD increased by an additional 6% at the spine, and there were no further changes in the lytic lesions by CT. The vitamin d receptor genotype using the restriction enzymes Bsm1, Taq1, and Apa1 was Bb, tt, and AA. CONCLUSIONS: We showed regression of severe skeletal abnormalities of hyperparathyroidism documented by serial CT images in response to oral vitamin d therapy. It is possible that the vitamin d receptor genotype of the patient modulated this response.
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9/17. Vertebral compression fractures at the onset of acute lymphoblastic leukemia in a child.

    A child with acute lymphoblastic leukemia, spinal osteoporosis with vertebral compression fractures, and hypercalcemia appearing early in the course of the hematologic disease was followed for two and a half years. Bone mineral density (BMD), measured by single photon absorptiometry at the radial shaft, was within normal limits for age and sex. However, x-rays of vertebrae and vertebral BMD, measured by dual photon absorptiometry, showed marked demineralization. Despite leukemic remission, the spinal osteoporosis became worse and the patient required aggressive treatment for eight months. Treatment included 50 units of calcitonin subcutaneously every other day, 1,000 mg/day of oral calcium, and 3,000 IU/day of vitamin d. The back pain disappeared quickly, and laboratory controls showed a significant diminution of bone turnover. No new compression fractures occurred. Eighteen months later, the patient continued in remission and menarche had occurred. Dual photon absorptiometry revealed a significant "catch up" of the lumbar spine BMD. X-ray examination showed a marked remodeling of the vertebral bodies. BMD measurements in this child indicate that bone loss affected the trabecular bone compartment or occurred only at active bone marrow sites. The rapid clinical amelioration and objective biochemical, densitometric, and radiologic evidence of bone improvement warrant further clinical trials on similarly affected patients.
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10/17. The ghost joint: transient osteoporosis of the hip.

    Seven adult patients identified as having idiopathic transient osteoporosis of the hip (TOH) are reported. TOH is an uncommon entity, most often seen in women during the third trimester of pregnancy and in middle-aged men. It is characterized by groin pain, limited hip range of motion, nonspecific laboratory findings, localized radiographic evidence of osteopenia, and spontaneous recovery usually within two to nine months. diagnosis remains dependent on clinical recognition and x-ray confirmation. Radioisotope scanning aids in the diagnosis; both bone and synovial biopsies are often less productive. Treatment consists of joint protection with limited weight bearing, range of motion exercise, progressive ambulation, and analgesics. An awareness of TOH facilities appropriate diagnosis and treatment and curtails unnecessary diagnostic procedures.
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