Top

Published in:

01-08-2018 | Review

Evidence-based prevention and treatment of osteoporosis after spinal cord injury: a systematic review

Authors: Saeed Soleyman-Jahi, Ali Yousefian, Radin Maheronnaghsh, Farhad Shokraneh, Shayan Abdollah Zadegan, Akbar Soltani, Seyed Mostafa Hosseini, Alexander R. Vaccaro, Vafa Rahimi-Movaghar

Published in: European Spine Journal | Issue 8/2018

Abstract

Purpose

Spinal cord injury (SCI) results in accelerated bone mineral density (BMD) loss and disorganization of trabecular bone architecture. The mechanisms underlying post-SCI osteoporosis are complex and different from other types of osteoporosis. Findings of studies investigating efficacy of pharmacological or rehabilitative interventions in SCI-related osteoporosis are controversial. The aim of this study was to review the literature pertaining to prevention and evidence-based treatments of SCI-related osteoporosis.

Methods

In this systematic review, MEDLINE, EMBASE, PubMed, and the Cochrane Library were used to identify papers from 1946 to December 31, 2015. The search strategy involved the following keywords: spinal cord injury, osteoporosis, and bone loss.

Results

Finally, 56 studies were included according to the inclusion criteria. Only 16 randomized controlled trials (involving 368 patients) were found. We found following evidences for effectiveness of bisphosphonates in prevention of BMD loss in acute SCI: very low-quality evidence for clodronate and etidronate, low-quality evidence for alendronate, and moderate-quality evidence for zoledronic acid. Low-quality evidence showed no effectiveness for tiludronate. In chronic SCI cases, we found low-quality evidence for effectiveness of vitamin D₃ analogs combined with 1-alpha vitamin D₂. However, low-quality inconsistent evidence exists for alendronate. For non-pharmacologic interventions, very low-quality evidence exists for effectiveness of standing with or without treadmill walking in acute SCI. Other low-quality evidences indicated that electrical stimulation, tilt-table standing, and ultrasound provide no significant effects. Very low-quality evidence did not show any benefit for low-intensity (3 days per week) cycling with functional electrical stimulator in chronic SCI.

Conclusions

No recommendations can be made from this review, regarding overall low quality of evidence as a result of high risk of bias, low sample size in most of the studies, and notable heterogeneity in type of intervention, outcome measurement, and duration of treatment. Therefore, future high-quality RCT studies with higher sample sizes and more homogeneity are strongly recommended to provide high-quality evidence and make applicable recommendations for prevention and treatment of SCI-related bone loss.

Available only for authorised users

Jazayeri SB, Beygi S, Shokraneh F, Hagen EM, Rahimi-Movaghar V (2015) Incidence of traumatic spinal cord injury worldwide: a systematic review. Eur Spine J 24:905–918. doi:10.1007/s00586-014-3424-6 CrossRefPubMed

Rahimi-Movaghar V, Sayyah MK, Akbari H, Khorramirouz R, Rasouli MR, Moradi-Lakeh M, Shokraneh F, Vaccaro AR (2013) Epidemiology of traumatic spinal cord injury in developing countries: a systematic review. Neuroepidemiology 41:65–85. doi:10.1159/000350710 CrossRefPubMed

Jazayeri SB, Ataeepour M, Rabiee H, Motevalian SA, Saadat S, Vaccaro AR, Rahimi-Movaghar V (2015) Prevalence of spinal cord injury in Iran: a 3-source capture-recapture study. Neuroepidemiology 45:28–33. doi:10.1159/000435785 CrossRefPubMed

Szollar SM, Martin EM, Sartoris DJ, Parthemore JG, Deftos LJ (1998) Bone mineral density and indexes of bone metabolism in spinal cord injury. Am J Phys Med Rehabil 77:28–35CrossRefPubMed

Wilmet E, Ismail AA, Heilporn A, Welraeds D, Bergmann P (1995) Longitudinal study of the bone mineral content and of soft tissue composition after spinal cord section. Paraplegia 33:674–677. doi:10.1038/sc.1995.141 PubMedCrossRef

Uebelhart D, Demiaux-Domenech B, Roth M, Chantraine A (1995) Bone metabolism in spinal cord injured individuals and in others who have prolonged immobilisation. A review. Paraplegia 33:669–673. doi:10.1038/sc.1995.140 PubMedCrossRef

Charmetant C, Phaner V, Condemine A, Calmels P (2010) Diagnosis and treatment of osteoporosis in spinal cord injury patients: a literature review. Ann Phys Rehabil Med 53:655–668. doi:10.1016/j.rehab.2010.10.001 CrossRefPubMed

Reiter AL, Volk A, Vollmar J, Fromm B, Gerner HJ (2007) Changes of basic bone turnover parameters in short-term and long-term patients with spinal cord injury. Eur Spine J 16:771–776. doi:10.1007/s00586-006-0163-3 CrossRefPubMed

Keating JF, Kerr M, Delargy M (1992) Minimal trauma causing fractures in patients with spinal cord injury. Disabil Rehabil 14:108–109CrossRefPubMed

10.

Morse LR, Battaglino RA, Stolzmann KL, Hallett LD, Waddimba A, Gagnon D, Lazzari AA, Garshick E (2009) Osteoporotic fractures and hospitalization risk in chronic spinal cord injury. Osteoporos Int 20:385–392. doi:10.1007/s00198-008-0671-6 CrossRefPubMed

11.

Logan WC Jr, Sloane R, Lyles KW, Goldstein B, Hoenig HM (2008) Incidence of fractures in a cohort of veterans with chronic multiple sclerosis or traumatic spinal cord injury. Arch Phys Med Rehabil 89:237–243. doi:10.1016/j.apmr.2007.08.144 CrossRefPubMed

12.

Frisbie JH (1997) Fractures after myelopathy: the risk quantified. J Spinal Cord Med 20:66–69CrossRefPubMed

13.

Zehnder Y, Luthi M, Michel D, Knecht H, Perrelet R, Neto I, Kraenzlin M, Zach G, Lippuner K (2004) Long-term changes in bone metabolism, bone mineral density, quantitative ultrasound parameters, and fracture incidence after spinal cord injury: a cross-sectional observational study in 100 paraplegic men. Osteoporos Int 15:180–189. doi:10.1007/s00198-003-1529-6 CrossRefPubMed

14.

Garland DE, Adkins RH, Kushwaha V, Stewart C (2004) Risk factors for osteoporosis at the knee in the spinal cord injury population. J Spinal Cord Med 27:202–206CrossRefPubMed

15.

Rasouli MR, Rahimi-Movaghar V, Maheronnaghsh R, Yousefian A, Vaccaro AR (2011) Preventing motor vehicle crashes related spine injuries in children. World J Pediatr 7:311–317. doi:10.1007/s12519-011-0327-z CrossRefPubMed

16.

Lazo MG, Shirazi P, Sam M, Giobbie-Hurder A, Blacconiere MJ, Muppidi M (2001) Osteoporosis and risk of fracture in men with spinal cord injury. Spinal Cord 39:208–214. doi:10.1038/sj.sc.3101139 CrossRefPubMed

17.

Bauman WA, Wecht JM, Kirshblum S, Spungen AM, Morrison N, Cirnigliaro C, Schwartz E (2005) Effect of pamidronate administration on bone in patients with acute spinal cord injury. J Rehabil Res Dev 42:305–313CrossRefPubMed

18.

Bubbear JS, Gall A, Middleton FR, Ferguson-Pell M, Swaminathan R, Keen RW (2011) Early treatment with zoledronic acid prevents bone loss at the hip following acute spinal cord injury. Osteoporos Int 22:271–279. doi:10.1007/s00198-010-1221-6 CrossRefPubMed

19.

Chappard D, Minaire P, Privat C, Berard E, Mendoza-Sarmiento J, Tournebise H, Basle MF, Audran M, Rebel A, Picot C et al (1995) Effects of tiludronate on bone loss in paraplegic patients. J Bone Miner Res 10:112–118. doi:10.1002/jbmr.5650100116 CrossRefPubMed

20.

Gilchrist NL, Frampton CM, Acland RH, Nicholls MG, March RL, Maguire P, Heard A, Reilly P, Marshall K (2007) Alendronate prevents bone loss in patients with acute spinal cord injury: a randomized, double-blind, placebo-controlled study. J Clin Endocrinol Metab 92:1385–1390. doi:10.1210/jc.2006-2013 CrossRefPubMed

21.

Minaire P, Berard E, Meunier PJ, Edouard C, Goedert G, Pilonchery G (1981) Effects of disodium dichloromethylene diphosphonate on bone loss in paraplegic patients. J Clin Invest 68:1086–1092CrossRefPubMedPubMedCentral

22.

Pearson EG, Nance PW, Leslie WD, Ludwig S (1997) Cyclical etidronate: its effect on bone density in patients with acute spinal cord injury. Arch Phys Med Rehabil 78:269–272CrossRefPubMed

23.

Shapiro J, Smith B, Beck T, Ballard P, Dapthary M, BrintzenhofeSzoc K, Caminis J (2007) Treatment with zoledronic acid ameliorates negative geometric changes in the proximal femur following acute spinal cord injury. Calcif Tissue Int 80:316–322. doi:10.1007/s00223-007-9012-6 CrossRefPubMed

24.

Bauman WA, Spungen AM, Morrison N, Zhang RL, Schwartz E (2005) Effect of a vitamin D analog on leg bone mineral density in patients with chronic spinal cord injury. J Rehabil Res Dev 42:625–634CrossRefPubMed

25.

Moran de Brito CM, Battistella LR, Saito ET, Sakamoto H (2005) Effect of alendronate on bone mineral density in spinal cord injury patients: a pilot study. Spinal Cord 43:341–348. doi:10.1038/sj.sc.3101725 CrossRefPubMed

26.

Nance PW, Schryvers O, Leslie W, Ludwig S, Krahn J, Uebelhart D (1999) Intravenous pamidronate attenuates bone density loss after acute spinal cord injury. Arch Phys Med Rehabil 80:243–251CrossRefPubMed

27.

Zehnder Y, Risi S, Michel D, Knecht H, Perrelet R, Kraenzlin M, Zach GA, Lippuner K (2004) Prevention of bone loss in paraplegics over 2 years with alendronate. J Bone Miner Res 19:1067–1074. doi:10.1359/JBMR.040313 CrossRefPubMed

28.

Schnitzer TJ, Kim K, Marks J, Yeasted R, Simonian N, Chen D (2016) Zoledronic acid treatment after acute spinal cord injury: results of a randomized, placebo-controlled pilot trial. PM R. doi:10.1016/j.pmrj.2016.01.012 CrossRefPubMed

29.

Arija-Blazquez A, Ceruelo-Abajo S, Diaz-Merino MS, Godino-Duran JA, Martinez-Dhier L, Florensa-Vila J (2013) Time-course response in serum markers of bone turnover to a single-bout of electrical stimulation in patients with recent spinal cord injury. Eur J Appl Physiol 113:89–97. doi:10.1007/s00421-012-2416-7 CrossRefPubMed

30.

Ashe MC, Eng JJ, Krassioukov AV, Warburton DE, Hung C, Tawashy A (2010) Response to functional electrical stimulation cycling in women with spinal cord injuries using dual-energy X-ray absorptiometry and peripheral quantitative computed tomography: a case series. J Spinal Cord Med 33:68–72CrossRefPubMedPubMedCentral

31.

Astorino TA, Harness ET, Witzke KA (2013) Effect of chronic activity-based therapy on bone mineral density and bone turnover in persons with spinal cord injury. Eur J Appl Physiol 113:3027–3037. doi:10.1007/s00421-013-2738-0 CrossRefPubMedPubMedCentral

32.

BeDell KK, Scremin AM, Perell KL, Kunkel CF (1996) Effects of functional electrical stimulation-induced lower extremity cycling on bone density of spinal cord-injured patients. Am J Phys Med Rehabil 75:29–34CrossRefPubMed

33.

Belanger M, Stein RB, Wheeler GD, Gordon T, Leduc B (2000) Electrical stimulation: can it increase muscle strength and reverse osteopenia in spinal cord injured individuals? Arch Phys Med Rehabil 81:1090–1098CrossRefPubMed

34.

Ben M, Harvey L, Denis S, Glinsky J, Goehl G, Chee S, Herbert RD (2005) Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries? Aust J Physiother 51:251–256CrossRefPubMed

35.

Carvalho DC, Garlipp CR, Bottini PV, Afaz SH, Moda MA, Cliquet A Jr (2006) Effect of treadmill gait on bone markers and bone mineral density of quadriplegic subjects. Braz J Med Biol Res 39:1357–1363CrossRefPubMed

36.

Chain A, Koury JC, Bezerra FF (2012) Physical activity benefits bone density and bone-related hormones in adult men with cervical spinal cord injury. Eur J Appl Physiol 112:3179–3186. doi:10.1007/s00421-011-2303-7 CrossRefPubMed

37.

Chen SC, Chen YL, Chen CJ, Lai CH, Chiang WH, Chen WL (2005) Effects of surface electrical stimulation on the muscle-tendon junction of spastic gastrocnemius in stroke patients. Disabil Rehabil 27:105–110. doi:10.1080/09638280400009022 CrossRefPubMed

38.

Clark JM, Jelbart M, Rischbieth H, Strayer J, Chatterton B, Schultz C, Marshall R (2007) Physiological effects of lower extremity functional electrical stimulation in early spinal cord injury: lack of efficacy to prevent bone loss. Spinal Cord 45:78–85. doi:10.1038/sj.sc.3101929 CrossRefPubMed

39.

de Bruin ED, Frey-Rindova P, Herzog RE, Dietz V, Dambacher MA, Stussi E (1999) Changes of tibia bone properties after spinal cord injury: effects of early intervention. Arch Phys Med Rehabil 80:214–220CrossRefPubMed

40.

Deley G, Denuziller J, Casillas JM, Babault N (2015) One year of training with FES has impressive beneficial effects in a 36-year-old woman with spinal cord injury. J Spinal Cord Med. doi:10.1080/10790268.2015.1117192 PubMedPubMedCentralCrossRef

41.

Dudley-Javoroski S, Saha PK, Liang G, Li C, Gao Z, Shields RK (2012) High dose compressive loads attenuate bone mineral loss in humans with spinal cord injury. Osteoporos Int 23:2335–2346. doi:10.1007/s00198-011-1879-4 CrossRefPubMed

42.

Dudley-Javoroski S, Shields RK (2008) Asymmetric bone adaptations to soleus mechanical loading after spinal cord injury. J Musculoskelet Neuronal Interact 8:227–238PubMedPubMedCentral

43.

Dudley-Javoroski S, Shields RK (2008) Dose estimation and surveillance of mechanical loading interventions for bone loss after spinal cord injury. Phys Ther 88:387–396. doi:10.2522/ptj.20070224 CrossRefPubMedPubMedCentral

44.

Dudley-Javoroski S, Shields RK (2013) Active-resisted stance modulates regional bone mineral density in humans with spinal cord injury. J Spinal Cord Med 36:191–199. doi:10.1179/2045772313Y.0000000092 CrossRefPubMedPubMedCentral

45.

Eser P, de Bruin ED, Telley I, Lechner HE, Knecht H, Stussi E (2003) Effect of electrical stimulation-induced cycling on bone mineral density in spinal cord-injured patients. Eur J Clin Invest 33:412–419CrossRefPubMed

46.

Frotzler A, Coupaud S, Perret C, Kakebeeke TH, Hunt KJ, Donaldson Nde N, Eser P (2008) High-volume FES-cycling partially reverses bone loss in people with chronic spinal cord injury. Bone 43:169–176. doi:10.1016/j.bone.2008.03.004 CrossRefPubMed

47.

Frotzler A, Coupaud S, Perret C, Kakebeeke TH, Hunt KJ, Eser P (2009) Effect of detraining on bone and muscle tissue in subjects with chronic spinal cord injury after a period of electrically-stimulated cycling: a small cohort study. J Rehabil Med 41:282–285. doi:10.2340/16501977-0321 CrossRefPubMed

48.

Giangregorio LM, Hicks AL, Webber CE, Phillips SM, Craven BC, Bugaresti JM, McCartney N (2005) Body weight supported treadmill training in acute spinal cord injury: impact on muscle and bone. Spinal Cord 43:649–657. doi:10.1038/sj.sc.3101774 CrossRefPubMed

49.

Giangregorio LM, Webber CE, Phillips SM, Hicks AL, Craven BC, Bugaresti JM, McCartney N (2006) Can body weight supported treadmill training increase bone mass and reverse muscle atrophy in individuals with chronic incomplete spinal cord injury? Appl Physiol Nutr Metab 31:283–291. doi:10.1139/h05-036 CrossRefPubMed

50.

Goktepe AS, Tugcu I, Yilmaz B, Alaca R, Gunduz S (2008) Does standing protect bone density in patients with chronic spinal cord injury? J Spinal Cord Med 31:197–201CrossRefPubMedPubMedCentral

51.

Gordon KE, Wald MJ, Schnitzer TJ (2013) Effect of parathyroid hormone combined with gait training on bone density and bone architecture in people with chronic spinal cord injury. PM R 5(8):663–671. doi:10.1016/j.pmrj.2013.03.032 CrossRefPubMed

52.

Groah SL, Lichy AM, Libin AV, Ljungberg I (2010) Intensive electrical stimulation attenuates femoral bone loss in acute spinal cord injury. PM R 2(12):1080–1087. doi:10.1016/j.pmrj.2010.08.003 CrossRefPubMed

53.

Hangartner TN, Rodgers MM, Glaser RM, Barre PS (1994) Tibial bone density loss in spinal cord injured patients: effects of FES exercise. J Rehabil Res Dev 31:50–61PubMed

54.

Kaplan PE, Roden W, Gilbert E, Richards L, Goldschmidt JW (1981) Reduction of hypercalciuria in tetraplegia after weight-bearing and strengthening exercises. Paraplegia 19:289–293. doi:10.1038/sc.1981.55 PubMedCrossRef

55.

Kunkel CF, Scremin AM, Eisenberg B, Garcia JF, Roberts S, Martinez S (1993) Effect of “standing” on spasticity, contracture, and osteoporosis in paralyzed males. Arch Phys Med Rehabil 74:73–78PubMed

56.

Lai CH, Chang WH, Chan WP, Peng CW, Shen LK, Chen JJ, Chen SC (2010) Effects of functional electrical stimulation cycling exercise on bone mineral density loss in the early stages of spinal cord injury. J Rehabil Med 42:150–154. doi:10.2340/16501977-0499 CrossRefPubMed

57.

Leeds EM, Klose KJ, Ganz W, Serafini A, Green BA (1990) Bone mineral density after bicycle ergometry training. Arch Phys Med Rehabil 71:207–209PubMed

58.

Melchiorri G, Andreoli A, Padua E, Sorge R, De Lorenzo A (2007) Use of vibration exercise in spinal cord injury patients who regularly practise sport. Funct Neurol 22:151–154PubMed

59.

Mohr T, Andersen JL, Biering-Sorensen F, Galbo H, Bangsbo J, Wagner A, Kjaer M (1997) Long-term adaptation to electrically induced cycle training in severe spinal cord injured individuals. Spinal Cord 35:1–16CrossRefPubMed

60.

Needham-Shropshire BM, Broton JG, Klose KJ, Lebwohl N, Guest RS, Jacobs PL (1997) Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: part 3. Lack of effect on bone mineral density. Arch Phys Med Rehabil 78:799–803CrossRefPubMed

61.

Ogilvie C, Bowker P, Rowley DI (1993) The physiological benefits of paraplegic orthotically aided walking. Paraplegia 31:111–115. doi:10.1038/sc.1993.19 PubMedCrossRef

62.

Pacy PJ, Hesp R, Halliday DA, Katz D, Cameron G, Reeve J (1988) Muscle and bone in paraplegic patients, and the effect of functional electrical stimulation. Clin Sci (Lond) 75:481–487CrossRef

63.

Rodgers MM, Glaser RM, Figoni SF, Hooker SP, Ezenwa BN, Collins SR, Mathews T, Suryaprasad AG, Gupta SC (1991) Musculoskeletal responses of spinal cord injured individuals to functional neuromuscular stimulation-induced knee extension exercise training. J Rehabil Res Dev 28:19–26CrossRefPubMed

64.

Shields RK, Dudley-Javoroski S (2006) Musculoskeletal plasticity after acute spinal cord injury: effects of long-term neuromuscular electrical stimulation training. J Neurophysiol 95:2380–2390. doi:10.1152/jn.01181.2005 CrossRefPubMedPubMedCentral

65.

Shields RK, Dudley-Javoroski S (2007) Musculoskeletal adaptations in chronic spinal cord injury: effects of long-term soleus electrical stimulation training. Neurorehabil Neural Repair 21:169–179. doi:10.1177/1545968306293447 CrossRefPubMedPubMedCentral

66.

Shields RK, Dudley-Javoroski S, Law LA (2006) Electrically induced muscle contractions influence bone density decline after spinal cord injury. Spine (Phila Pa 1976) 31:548–553. doi:10.1097/01.brs.0000201303.49308.a8 CrossRef

67.

Thoumie P, Le Claire G, Beillot J, Dassonville J, Chevalier T, Perrouin-Verbe B, Bedoiseau M, Busnel M, Cormerais A, Courtillon A et al (1995) Restoration of functional gait in paraplegic patients with the RGO-II hybrid orthosis. A multicenter controlled study. II: physiological evaluation. Paraplegia 33:654–659. doi:10.1038/sc.1995.137 PubMedCrossRef

68.

Johnston TE, Marino RJ, Oleson CV, Schmidt-Read M, Leiby BE, Sendecki J, Singh H, Modlesky CM (2016) Musculoskeletal effects of 2 functional electrical stimulation cycling paradigms conducted at different cadences for people with spinal cord injury: a pilot study. Arch Phys Med Rehabil 97:1413–1422. doi:10.1016/j.apmr.2015.11.014 CrossRefPubMed

69.

West CR, Currie KD, Gee C, Krassioukov AV, Borisoff J (2015) Active-arm passive-leg exercise improves cardiovascular function in spinal cord injury. Am J Phys Med Rehabil 94:e102–e106. doi:10.1097/PHM.0000000000000358 CrossRefPubMed

70.

Wuermser LA, Beck LA, Lamb JL, Atkinson EJ, Amin S (2015) The effect of low-magnitude whole body vibration on bone density and microstructure in men and women with chronic motor complete paraplegia. J Spinal Cord Med 38:178–186. doi:10.1179/2045772313Y.0000000191 CrossRefPubMedPubMedCentral

71.

Furlan AD, Malmivaara A, Chou R, Maher CG, Deyo RA, Schoene M, Bronfort G, van Tulder MW, Editorial Board of the Cochrane Back NG (2015) Updated method guideline for systematic reviews in the Cochrane Back and Neck Group. Spine (Phila Pa 1976) 40:1660–1673. doi:10.1097/BRS.0000000000001061 CrossRef

72.

Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of interventions. Wiley, New York

73.

Bauman WA, Cirnigliaro CM, La Fountaine MF, Martinez L, Kirshblum SC, Spungen AM (2015) Zoledronic acid administration failed to prevent bone loss at the knee in persons with acute spinal cord injury: an observational cohort study. J Bone Miner Metab 33:410–421. doi:10.1007/s00774-014-0602-x CrossRefPubMed

74.

Warden SJ, Bennell KL, Matthews B, Brown DJ, McMeeken JM, Wark JD (2001) Efficacy of low-intensity pulsed ultrasound in the prevention of osteoporosis following spinal cord injury. Bone 29:431–436CrossRefPubMed

75.

Ashe MC, Craven C, Eng JJ, Krassioukov A, the SRT (2007) Prevention and treatment of bone loss after a spinal cord injury: a systematic review. Top Spinal Cord Inj Rehabil 13:123–145. doi:10.1310/sci1301-123 CrossRefPubMedPubMedCentral

76.

Deshpande PR, Rajan S, Sudeepthi BL, Abdul Nazir CP (2011) Patient-reported outcomes: a new era in clinical research. Perspect Clin Res 2:137–144. doi:10.4103/2229-3485.86879 CrossRefPubMedPubMedCentral

Title: Evidence-based prevention and treatment of osteoporosis after spinal cord injury: a systematic review
Authors: Saeed Soleyman-Jahi
Ali Yousefian
Radin Maheronnaghsh
Farhad Shokraneh
Shayan Abdollah Zadegan
Akbar Soltani
Seyed Mostafa Hosseini
Alexander R. Vaccaro
Vafa Rahimi-Movaghar
Publication date: 01-08-2018
Publisher: Springer Berlin Heidelberg
Published in: European Spine Journal / Issue 8/2018
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI: https://doi.org/10.1007/s00586-017-5114-7

At a glance: The STEP trials

Springer Medicine

Evidence-based prevention and treatment of osteoporosis after spinal cord injury: a systematic review

Abstract

Purpose

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 8/2018

Biomechanical analysis of spino-pelvic postural configurations in spondylolysis subjected to various sport-related dynamic loading conditions

Radiation exposure to the surgeon during minimally invasive spine procedures is directly estimated by patient dose

Pedicle screw anchorage of carbon fiber-reinforced PEEK screws under cyclic loading

Reviewer’s comment concerning “Classification of normal sagittal spine alignment: refounding the Roussouly classification” by F. Laouissat et al. (2017). doi:10.1007/s00586-017-5111-x (Epub ahead of print)

Is MIS-TLIF superior to open TLIF in obese patients?: A systematic review and meta-analysis