Neurogenic Heterotopic Ossification Research Articles

Non-Traumatic Intracranial Heterotopic Ossification: A Case from Turkey

Heterotopic ossification (HO) is the abnormal, non-neoplastic presence of lamellar bone in soft tissue. The ectopic formation of lamellar bone in non-osseus tissues secondary to traumatic injuries of the spinal cord or the brain is defined as Neurogenic HO. The pathophysiology of HO is not clear. But several theories like overactive humoral mechanisms after fracture healing, imbalance of pro-osteoinductive and anti-osteoinductive mediators located on the soft tissues and gene mutations in such as bone morphogenetic proteins-4 (BMP-4) are proposed. Casualty factors leading to increased risk of HO include older age, blast mechanism of injury, location of injury and traumatic brain injury. The aim of this paper is to demonstrate a case of HO located in the brain without history of trauma or any other risk factors.

Bone graft of a femoral head by fragments of neurogenic heterotopic ossification

Neurogenic heterotopic ossification (NHO) are a common complication after lesions of the central nervous system (10–23% after head injury). The late removal of hip NHOs sometimes causes the risk of femoral head and femoral neck fracture per or postoperatively. Indeed ankylosis of a joint eventually induces bone loss and joint destruction. A 23-year-old patient who suffered a severe TBI in 2012 in a military context presents multiple NHOs, which especially affects both hips. On the right side, CT of the pelvis shows a circumferential NHO that ankyloses the joint. The NHO therefore absorbs the stresses on the femoral head which is thus off-loaded. This causes bone loss quantified by CT. A surgical indication for excision is established for functional reasons and because of the risks of the sciatic nerve compression. A soft femoral neck is found during the procedure. A bone graft using the fragments of the NHO is attempted by internal drilling. The procedure ends with a sciatic nerve release. The rehabilitation program started after two weeks of strict bed rest in order to consolidate the bone graft. A passive mobilization program in flexion-extension is started afterward, with a gain of 10° every two weeks. Rotations and abductions-adductions are strictly prohibited during the first 6 weeks. Progressive verticalization is started after 2 months. A radiography of the pelvis shows the integrity of the femoral head 6 weeks after surgery. The patient is then placed in a wheelchair. The NHOs must be removed as soon as they are troublesome. Late surgery is exposing the patient to a joint ankylosis which complicates the surgical procedure and its aftermath. In this case, bone grafting the femoral head with fragments of NHOs seems to be an alternative to explore in order to avoid head-neck resection or the implantation of a hip replacement. However, an extremely cautious rehabilitation seems to be necessary.

Functional Outcomes of the Surgery and Rehabilitation in a Challenging Case of Heterotopic Ossification after Encephalitis.

Heterotopic ossification is the formation of the lamellar bone where normally osseous tissue does not exist. Since heterotopic ossification can cause severe functional loss, it is a challenging condition for both clinicians and patients. Neurogenic heterotopic ossification is a rare condition after encephalitis. Likewise, in this paper, we have presented a challenging case of heterotopic ossification after viral encephalitis and functional outcomes after the management of heterotopic ossification.

Prevalence of neurogenic heterotopic ossification in traumatic head- and spinal-injured patients admitted to a tertiary referral hospital in Australia.

A study was undertaken to investigate the prevalence of neurogenic heterotopic ossification (NHO) in patients with traumatic brain injury (TBI) or traumatic spinal cord injury (TSCI) admitted to nonspecialized units. Methods consisted of a retrospective audit of patients, using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM) coding system, admitted to The Townsville Hospital with TBI/TSCI between July 1, 2006, and December 31, 2012. Fifty-eight patients with length of stay of 60 days or longer were admitted to The Townsville Hospital with TBI/TSCI over this period with mean age of 60 years (range, 31-87 years); 55 were TBI and 3 were TSCI patients. Three thousand one hundred fourteen TBI/TSCI patients with length of stay of less than 60 days and mean age of 43 years (range, 18-93 years) were also identified (2903 were TBI and 211 were TSCI patients). Overall, none had a diagnosis of NHO; 6 patients, identified by the ICD-10-AM codes, with a diagnosis of heterotopic ossification did not have an associated TBI/TSCI. Findings of 0% of NHO prevalence in TSCI/TBI patients admitted to the large tertiary referral hospital suggest that NHO may have been missed, possibly because of the TSCI/TBI ICD-10-AM codes, not being specifically designed for documentation of the TBI/TSCI complications. If NHO remains undiagnosed in nonspecialized units because of the method of coding, it may increase functional limitation in already compromised individuals.

Extracorporeal shock wave therapy for painful chronic neurogenic heterotopic ossification after traumatic brain injury: a case report.

Neurogenic heterotopic ossification (NHO) is a process of benign bone formation and growth in soft tissues surrounding major synovial joints and is associated with central nervous system (CNS) injuries. It is a common complication in major CNS injuries, such as traumatic brain injury, spinal cord injury, and stroke. Here, we report the case of a 72-year-old male, who experienced a traumatic brain injury and painful chronic NHO around the left hip joint. Three applications of extracorporeal shock wave therapy (ESWT) were administered to the area of NHO, which resulted in pain relief and an improvement in the loss of motion in the left hip joint. Improvements were also noted in walking performance and activities of daily living, although the size of NHO remained unchanged. Therapeutic effects of ESWT lasted for 12 weeks.

Authors’ reply

Dear Sir, We have considered Ekiz et al’s(1) kind comments made with regard to our article, “Neurogenic heterotopic ossification after a stroke: diagnostic and radiological challenges”.(2) We acknowledge that ultrasonography is a useful tool for the evaluation of musculoskeletal lesions. Ultrasonography is widely available, is generally cheaper than computed tomography (CT) and magnetic resonance (MR) imaging, and has no ionising radiation, and the advantages of this imaging technique are widely known. However, ultrasonographic evaluation is essentially operator dependent, and often, misdiagnosis may result from inexperience. In our institution, cross-sectional imaging (i.e. CT or MR imaging) is the next intuitive step of evaluation upon encountering an ossifying lesion of the hip on plain radiography. Moreover, the often equivocal findings of ultrasonography would eventually lead the clinician to order CT or MR imaging for further diagnostic clarity. From a technical standpoint regarding ultrasonography, the acoustic shadowing encountered when imaging bony lesions often does not allow one to determine the amount of ossification of the lesion, and detailed evaluation is deferred to further CT or MR imaging. Further imaging allows for confident exclusion of other differential diagnoses such as bone tumours, which are often not well appreciated on ultrasonographic evaluation.(3,4) In summary, we feel that the role of ultrasonography in identifying cases of neurogenic heterotopic ossification is limited by the level of operator experience with regard to the imaging technique. Ultrasonography is superior in the evaluation of soft tissue lesions, but we feel that CT and/or MR imaging are often more reproducible, and these two imaging techniques have superior specificity when evaluating bony lesions.(3,4) Yours sincerely,

Sciatic nerve compression by neurogenic heterotopic ossification: use of CT to determine surgical indications

To describe the characteristics of neurogenic heterotopic ossification (NHO) based on clinical tests, electroneuromyography (ENMG) and CT in a database of patients with lesions of the central nervous system who required sciatic nerve neurolysis along with posterior hip NHO resection, and to determine the respective roles of ENMG and CT in the management of posterior hip NHOs in patients who are unable to communicate or express pain. The consistency of the ENMG results with clinical findings, CT results and macroscopic signs of lesions was retrospectively assessed after sciatic nerve neurolysis and ablation of 55 posterior hip NHOs. Sciatic nerve neurolysis was necessary in 55 cases (47.4%; 55 out of 116). CT showed contact of the NHO with the nerve in all cases: 5 in contact with no deflection, 3 in contact with deflection, 21 moulded into a gutter and 26 entrapped in the NHO. There were clinical signs of sciatic nerve lesion in 21.8% of cases (12 out of 55). ENMG showed signs of sciatic nerve lesions in only 55.6% (10 out of 18), only 4 of whom presented with clinical signs of a nerve lesion. No significant relationship was found between clinical symptoms and ENMG findings of sciatic nerve compression (n = 13, p = 0.77). Nerve compression by NHO is likely an underdiagnosed condition, particularly in patients who are unable to communicate. Diagnosis of sciatic compression by NHO should be based on regular clinical examinations and CT. ENMG is not sufficiently sensitive to be used alone for surgical decision-making.

Chiropractic Care of a Patient With Neurogenic Heterotopic Ossification of the Anterior Longitudinal Ligament After Traumatic Brain Injury: A Case Report

ObjectiveThe purpose of this case report is to describe the use of chiropractic care for a patient with neurogenic heterotopic ossification of the anterior longitudinal ligament in the cervical spine and soft tissues of the right hip after a traumatic brain injury and right femur fracture. Clinical FeaturesA 25-year-old military officer was referred to a hospital-based chiropractic clinic with complaints of pain and stiffness of the neck and back along with reduced respiratory excursions that began several months after a motor vehicle accident in which he had a traumatic brain injury. The patient had a fractured right femur from the accident, which had since been treated surgically, but had complications of heterotopic ossification in the soft tissues of the hip. His overall pain level was 3 of 10 on a verbal pain scale during use of oxycodone HCL/acetaminophen. Chest excursion was initially measured at .5 cm. Intervention and OutcomeWith the intent to restore respiratory chest motion and to reduce the patient's back and neck pain, the patient was placed on a program of chiropractic and myofascial manipulation, exercise therapy, and respiratory therapy. After a year of care, the patient rated overall pain at 3 of 10 verbal pain scale level but was no longer taking medications for pain and an increase in respiratory chest excursions measured at 3.5 cm. ConclusionThis case demonstrated that chiropractic treatment provided benefit to a patient with heterotopic ossification concurrent with musculoskeletal pain.

Anatomical details of neurogenic heterotopic ossification anterior to the ankylotic hip

Neurogenic heterotopic ossification (NHO) is a common complication in patients with spinal cord injury (SCI) and traumatic brain injury (TBI). Although there are many reports regarding the etiology, pathophysiology, and medical management, few studies elaborate the anatomical details of NHO, which leads to ankylosis of the hip joint. A prospective study on surgical resection of NHO in patients with hip ankylosis was conducted. Radiography and magnetic resonance imaging (MRI) were used to assess the relationship of the NHO block with the blood vessels, peripheral nerve, and surrounding muscles and bones. The anatomical relationships were also assessed and documented during the surgical procedures. NHO, which is anterior to the hip and causes hip ankylosis, settles into tissue planes without involving the tissue itself and does not disrupt the femoral neurovascular structures. The NHO bone block can then fuse to the cortex of adjacent bone. During resection, the normal bony contour should be exposed as a marker to guide the resection in order to avoid iatrogenic fracture.

The use of spect/ct in the evaluation of heterotopic ossification in para/tetraplegics

Objective: To evaluate the stage of maturation and the metabolism of neurogenic heterotopic ossification by using SPECT/CT. Methods: A total of 12 medical records of patients with spinal cord injury, all of them classified according to the ASIA protocol (disability scale from the American Spinal Injury Association) in complete lesion (A) and partial lesions (B, C and D) and registered at the Laboratory of Biomechanics and Rehabilitation of the Locomotor System, were submitted to SPECT/CT evaluation. Results: Sixteen hips with heterotopic ossification observed in X-ray were studied and only two (12.5%) had high osteoblastic activity. Five hips showed medium activity, three (18.75%) low activity and six (37.5%) did not present any activity detected by SPECT/CT. Conclusion: SPECT/CT helps to determinate which patients have a greater risk of relapse after surgical resection, proving to be a useful imaging study in preoperative evaluation that can be used to determinate the postoperative prognosis of these patients. Level of Evidence III, Investigating a Diagnostic Test.

Slipped capital femoral epiphysis caused by neurogenic heterotopic ossification

Slipped capital femoral epiphysis (SCFE) is rare in nonambulatory patients, as mechanical factors play important roles in the development of the disease. We report a case of SCFE, which occurred in a 12-year-old girl with a nonambulatory status after cerebral infarction. SCFE occurred after she received passive range of motion exercise and extracorporeal shock wave treatment for neurogenic heterotopic ossification around the hip joint. The patient was successfully managed by a stepwise approach, with radiological and clinical improvements.

Functional results of surgery neurogenic heterotopic ossification in patients with severe traumatic brain injury: About 19 cases

Functional results of surgery neurogenic heterotopic ossification in patients with severe traumatic brain injury: About 19 cases

Functional results of surgery neurogenic heterotopic ossification at the elbow cerebro injured: About nine cases

Functional results of surgery neurogenic heterotopic ossification at the elbow cerebro injured: About nine cases

Functional results of surgery neurogenic heterotopic ossification in patients with severe traumatic brain injury: About 19 cases

Functional results of surgery neurogenic heterotopic ossification in patients with severe traumatic brain injury: About 19 cases

Heterotopic ossification after central nervous system trauma

Neurogenic heterotopic ossification (NHO) is a disorder of aberrant bone formation affecting one in five patients sustaining a spinal cord injury or traumatic brain injury. Ectopic bone forms around joints in characteristic patterns, causing pain and limiting movement especially around the hip and elbow. Clinical sequelae of neurogenic heterotopic ossification include urinary tract infection, pressure injuries, pneumonia and poor hygiene, making early diagnosis and treatment clinically compelling. However, diagnosis remains difficult with more investigation needed. Our pathophysiological understanding stems from mechanisms of basic bone formation enhanced by evidence of systemic influences from circulating humor factors and perhaps neurological ones. This increasing understanding guides our implementation of current prophylaxis and treatment including the use of non-steroidal anti-inflammatory drugs, bisphosphonates, radiation therapy and surgery and, importantly, should direct future, more effective ones.

Extracorporeal Shock Wave Therapy (ESWT) as a treatment for recurrent Neurogenic Heterotopic Ossification (NHO)

Primary objective: To describe the effects of extracorporeal shock wave therapy (ESWT) on neurogenic heterotopic ossification (NHO).Research design: A single case study was considered the most appropriate methodology in this situation.Methods and procedures: The subject was a 43 year old female 10 years post-traumatic brain injury with recurring NHO around the hip joint. Baseline assessments of pain using a 10-point VAS, range of motion of the hip using a goniometer and walking ability (number of steps over a standard distance) were conducted. Four applications of ESWT using a Minispec™ Extracorporeal Shock Wave Lithotripsy machine (Medispec Int. USA) administered over 6 weeks to the anterolateral aspect of the right hip. Follow-up assessments were conducted weekly over the period of intervention and then monthly for 5 months.Main outcomes and results: Immediately following treatment, pain was reduced to 0 on the VAS scale; hip range of motion increased and the number of steps over a standard distance reduced, indicating increased step length. At 5-month follow-up, without further ESWT intervention, these results were maintained.Conclusion: This case study suggests that ESWT may be a non-invasive, low risk intervention for the management of NHO.

Osificación heterotópica neurógena. Veinte años después de una lesión medular traumática

The case of a patient with a post-traumatic C8-D1 spinal cord ASIA B injury that occurred 22 years ago is presented. The patient initiated with acute erythema and induration at the anteromedial aspect of the right thigh. Examination and complementary tests confirmed the diagnosis of neurogenic heterotopic ossification (NHO). However, the patient did not have risk factors for NHO development. Treatment was started with prednisone and etidronate disodium with clinical and radiological improvement. Nonetheless, calcification persisted in the last imaging control.NHO is a common complication in the acute or subacute phase of post-traumatic spinal cord injuries. However, cases have been rarely reported in the years following the injury. Those found in the literature include predisposing risk factors. In our case, the difficulty to reach a correct diagnosis led to late treatment. Even so, the outcome was favorable.

Neurogenic heterotopic ossification (NHO) and nerve compression: Example of the hip posterior HO and sciatic compression

Neurogenic heterotopic ossification (NHO) and nerve compression: Example of the hip posterior HO and sciatic compression

Neurogenic heterotopic ossification: From laboratory to patient and vice versa

Neurogenic heterotopic ossification: From laboratory to patient and vice versa

Neurogenic heterotopic ossification of the hip complicated by rupture of an arterial pseudo-aneurysm, a case report

Neurogenic heterotopic ossification of the hip complicated by rupture of an arterial pseudo-aneurysm, a case report