2016년 10월 5일 수요일

Heterotopic ossification

A patient with complete tetraplegia feels pain on his hip joint.
Before that time, he couldn’t feel any sense below neck area.
What happened? Does the spinal cord recover?




If a patient with spinal cord injury feels sudden pain on his/her hip joint area, we have to consider about heterotopic ossification. Heterotopic ossification (HO) is a common complication occurring after traumatic brain injury, and spinal cord injury. HO has been reported to occur in 20-30% of persons with SCI.

Why does HO occur? It is poorly understood yet. Just we suggest that CNS processes facilitate HO bone formation. Bone remodeling is subject to central control through the sympathetic nervous system. Pluripotential mesenchymal cells in soft tissues differentiate into oeteoblasts and other cell lines involved with bone formation.




Plain radiography or CT scan can be helpful to evaluate HO. However, the definitive diagnostic test is a bone scan. It show HO 7-10 days earlier than a plain x-ray.



If detected, treatment of established HO should begin promptly. It is aimed at halting the ossification process. Intravenous etidronate, 300mg/day, followed by oral etidronate, 20mg/kg/d for 6 months, has been shown to be effective. However, there is no evidence that 6 months of treatment with etidronate is more effective than 3 months. Radiation therapy or surgical resection of HO can be done. Surgical resection is done only to restore joint motion and functional skills.

Pain control is also an important issue. Because, most patients with SCI already take some pain killer, just NSAIDs or acetaminophen are not useful for pain management. One of my patient who has taken Oxycodone twice a day, can relieve his pain after applying Fentanyl patch.





Gentle ROM exercise is also important physical therapy. It prevents restriction of joint ROM. I want to emphasize the word ‘gentle’. Because aggressive ROM exercise can make hematoma or soft tissue injury, so that HO can become aggravated

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