Background: Spinal fractures related to ankylosing spondylitis (AS) are often associated with serious complications. Therefore, knowledge of the incidence, best treatment, outcome, and prevention would assist in improving current guidelines. Objectives: This thesis aims at (1) analysing the complications and mortality of surgical treatment, (2) mapping the incidence and treatment modalities for these patients in Sweden, as well as (3) investigating the putative preventive effect of biological disease modifying anti-rheumatic drug (bDMARD) therapy on spinal fractures related to AS. Methods: Merged multiple national registries were used to identify predictors of mortality and spinal fractures in patients with AS. Beyond that a finite element model (FEM) was designed to simulating a cervicothoracic fracture related to AS. Results and Conclusions: During the last two decades an increase of the incidence of vertebral fractures in patients with AS was observed. With the introduction of bDMARD treatment of AS was revolutionised and quality of life and function improved.  It seems that the improved quality of life and function in these patients does not correlate with a reduced fracture risk. Still, for the first time a beneficial effect of bDMARD with regard to spinal fracture occurrence was provided. The risk of spinal fractures was not reduced, but the debut of a spinal fracture was delayed with bDMARD. Since for this study the observation interval was only a decade, a future follow-up should revisit the effect of bDMARD on spinal fractures related to AS. Furthermore, it was shown that posterior stabilisation is an effective method for restoring stability without the necessity of additional external fixation. Most likely the early rehabilitation reduced pulmonary complications, which in turn reduced early mortality of these fractures. The FEM could be used to identify the most appropriate implant configuration, since no well-established cadaver models exist. Clinical Trial Registration: ClinicalTrials.gov, Identifier NCT02840695.

Thesis (Ph. D.)--University of Washington, 2000. / Vita. Includes bibliographical references (leaves 96-103).

No description available.

Or Pui Ching. / Thesis submitted in: December 1999. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2000. / Includes bibliographical references (leaves 174-201). / Abstracts in English and Chinese. / acknowledgement --- p.i / abstract (english version) --- p.ii / abstract (chinese version) --- p.vii / table of contents --- p.xi / abbreviations --- p.xvi / list of tables --- p.xviii / list of figures --- p.xxii / Chapter chapter 1. --- introduction --- p.1 / Chapter chapter 2. --- literature review --- p.3 / Chapter 2.1. --- Bone structure --- p.3 / Chapter 2.1.1. --- Composition --- p.3 / Chapter 2.1.2. --- Cortical and Trabecular bone --- p.3 / Chapter 2.2. --- Bone Remodeling --- p.4 / Chapter 2.3. --- Bone Mass --- p.5 / Chapter 2.3.1. --- Peak Bone Mass --- p.5 / Chapter 2.3.1.1. --- Racial and Genetic Factors --- p.5 / Chapter 2.3.1.2. --- Gonadal Factors --- p.6 / Chapter 2.3.1.3. --- Nutrition Factors --- p.6 / Chapter 2.3.1.4. --- Exercise and Physical Activity --- p.7 / Chapter 2.3.2. --- Bone Loss --- p.7 / Chapter 2.3.2.1. --- Determinants of Osteoporotic Bone Loss --- p.7 / Chapter 2.3.2.2. --- Estrogen Deficiency --- p.8 / Chapter 2.3.2.3. --- Dietary Calcium deficiency and Vitamin D deficiency --- p.8 / Chapter 2.3.2.4. --- Physical Activity --- p.9 / Chapter 2.3.2.5. --- Alcoholism and Smoking --- p.9 / Chapter 2.3.2.6. --- Disease-specific Osteoporosis --- p.9 / Chapter 2.3.2.7. --- Drug-induced Osteoporosis --- p.10 / Chapter 2.3.3. --- Bone Mass and Fracture Risk --- p.11 / Chapter 2.4. --- Clinical Presentation of Osteoporosis --- p.12 / Chapter 2.4.1. --- Vertebral Fractures --- p.12 / Chapter 2.4.1.1. --- Radiological Aspects of Vertebral Fracture --- p.13 / Chapter 2.4.1.1.1. --- Changes in Trabecular Pattern --- p.13 / Chapter 2.4.1.1.2. --- Changes in Shape of the Vertebral bodies --- p.13 / Chapter 2.4.1.1.3. --- Changes of Intervertebral Discs --- p.14 / Chapter 2.4.1.2. --- Back Pain --- p.15 / Chapter 2.4.2. --- Hip Fractures --- p.15 / Chapter 2.4.3. --- Quality of Life --- p.16 / Chapter 2.5. --- Treatment of Established Osteoporosis --- p.18 / Chapter 2.5.1. --- Pain Relief --- p.18 / Chapter 2.5.2. --- Drug Therapy --- p.19 / Chapter 2.5.2.1. --- Calcium Supplement --- p.19 / Chapter 2.5.2.2. --- Vitamin D --- p.20 / Chapter 2.5.2.3. --- Estrogen --- p.21 / Chapter 2.5.2.4. --- Fluorides --- p.22 / Chapter 2.5.2.5. --- Calcitonin --- p.23 / Chapter 2.5.2.6. --- Bisphosphonates --- p.24 / Chapter 2.5.2.6.1. --- Physicochemical effects --- p.27 / Chapter 2.5.2.6.2. --- Mechanisms --- p.27 / Chapter 2.5.2.6.3. --- Therapeutic Use --- p.27 / Chapter 2.5.2.6.4. --- Side effects --- p.29 / Chapter 2.5.2.6.5. --- Alendronate --- p.30 / Chapter 2.5.2.7. --- Summary of drug treatment --- p.33 / Chapter 2.6. --- Diagnostic Methods of Osteoporosis --- p.40 / Chapter 2.6.1. --- Biochemical Markers of Bone Metabolism in Osteoporosis --- p.40 / Chapter 2.6.1.1. --- Bone Formation Markers --- p.41 / Chapter 2.6.1.1.1. --- Bone-specific Alkaline Phosphatase (bALP) --- p.41 / Chapter 2.6.1.2. --- Bone Resorption Markers --- p.42 / Chapter 2.6.1.2.1. --- Deoxypyridinoline (Dpd) --- p.43 / Chapter 2.6.2. --- Bone Densitometry --- p.45 / Chapter 2.6.2.1. --- Dual Energy X-ray Absorptiometry (DEXA) --- p.45 / Chapter 2.6.2.2. --- Peripheral Quatitative Computed Tomography (pQCT) --- p.47 / Chapter 2.6.2.3. --- Quantitative Ultrasound (QUS) --- p.48 / Chapter 2.6.3. --- Summary of Diagnostic Methods --- p.49 / Chapter chapter 3. --- methodology --- p.50 / Chapter 3.1. --- Study on Vertebral Structures --- p.51 / Chapter 3.1.1. --- Procedures --- p.51 / Chapter 3.1.2. --- Data analysis --- p.53 / Chapter 3.2. --- Alendronate Treatment --- p.54 / Chapter 3.2.1. --- Subject Selection --- p.54 / Chapter 3.2.2. --- Study design and drug administration --- p.55 / Chapter 3.2.3. --- Bone Densitometry --- p.56 / Chapter 3.2.3.1. --- Dual Energy X-ray absorptiometry --- p.56 / Chapter 3.2.3.2. --- Peripheral Quantitative Computed Tomography (pQCT) --- p.58 / Chapter 3.2.4. --- Biochemical Markers --- p.63 / Chapter 3.2.4.1. --- Bone formation marker --- p.63 / Chapter 3.2.4.2. --- Bone resorption marker --- p.64 / Chapter 3.2.5. --- Quality of Life --- p.65 / Chapter 3.2.6. --- New fracture assessment --- p.66 / Chapter 3.2.7. --- Statistical analysis --- p.67 / Chapter 3.3. --- Proximal femur fracture study --- p.68 / Chapter 3.3.1. --- Subject and study design --- p.69 / Chapter 3.3.2. --- Statistical analysis --- p.70 / Chapter chapter 4. --- results of study on vertebral structures --- p.71 / Chapter 4.1. --- Results of morphological change of vertebral bodes in osteoporotic patients --- p.71 / Chapter 4.2. --- Morphological changes of intervertebral discs --- p.71 / Chapter 4.3. --- Correlation between morphological changes of vertebrae and bulging ratio --- p.72 / Chapter chapter 5. --- results of alendronate study --- p.76 / Chapter 5.1. --- Baseline measurement --- p.76 / Chapter 5.1.1. --- Demographic characteristics --- p.76 / Chapter 5.1.2. --- Reasons for admission --- p.77 / Chapter 5.1.3. --- Social support --- p.77 / Chapter 5.1.4. --- Number of vertebral fracture(s) --- p.78 / Chapter 5.1.5. --- BMD measurement (Baseline) --- p.79 / Chapter 5.1.5.1. --- BMD of Lumbar spine and Hip (measured by DEXA) --- p.79 / Chapter 5.1.5.2. --- BMD of distal tibia and radius measured by pQCT --- p.80 / Chapter 5.1.6. --- Biochemical Markers (Bone formation and resorption) --- p.86 / Chapter 5.2. --- After treatment --- p.88 / Chapter 5.2.1. --- Bone mineral density measurement (measured by DEXA) --- p.90 / Chapter 5.2.1.1. --- Lumbar spine --- p.90 / Chapter 5.2.1.2. --- Femoral Neck --- p.93 / Chapter 5.2.1.3. --- Trochanter --- p.95 / Chapter 5.2.1.4. --- Ward's Triangle --- p.98 / Chapter 5.2.1.5. --- Summary --- p.101 / Chapter 5.2.2. --- Bone Mineral Density measured by pQCT --- p.103 / Chapter 5.2.2.1. --- Distal Radius (Program 1) --- p.103 / Chapter 5.2.2.1.1. --- BMD change of D50 --- p.103 / Chapter 5.2.2.1.2. --- BMD changes of D100 --- p.106 / Chapter 5.2.2.1.3. --- BMD change of P100 --- p.108 / Chapter 5.2.2.2. --- Distal Radius (Program 2) --- p.111 / Chapter 5.2.2.2.1. --- BMD change of pure trabecular bone --- p.112 / Chapter 5.2.2.2.2. --- BMD changes of pure cortical bone --- p.114 / Chapter 5.2.2.3. --- Distal Tibia (Program 1) --- p.118 / Chapter 5.2.2.3.1. --- BMD changes of D50 --- p.118 / Chapter 5.2.2.3.2. --- BMD changes of D100 --- p.121 / Chapter 5.2.2.3.3. --- BMD changes of P100 --- p.124 / Chapter 5.2.2.4. --- Distal Tibia (Program 2) --- p.128 / Chapter 5.2.2.4.1. --- BMD changes of pure trabecular bone --- p.128 / Chapter 5.2.2.4.2. --- BMD changes of pure cortical bone --- p.131 / Chapter 5.2.3. --- Bone turnover --- p.135 / Chapter 5.2.3.1. --- Bone Resorption Marker (urinary Deoxypyridinoline) --- p.135 / Chapter 5.2.3.2. --- Bone Formation Marker (Bone Specific Alkaline Phosphatase) --- p.137 / Chapter 5.2.4. --- Quality of Life (QOL) --- p.139 / Chapter 5.2.5. --- Oswestry Disability Index (ODI) --- p.139 / Chapter 5.2.6. --- Pain --- p.141 / Chapter 5.2.6.1. --- Pain frequency --- p.141 / Chapter 5.2.6.2. --- Night Pain --- p.142 / Chapter 5.2.6.3. --- Administration of pain relief drugs --- p.143 / Chapter 5.2.7. --- Activity of daily living --- p.144 / Chapter 5.2.8. --- Prevention of new vertebral fracture(s) --- p.146 / Chapter 5.2.9. --- Safety and Tolerability --- p.147 / Chapter chapter 6. --- results on proximal femoral fractures study --- p.149 / Chapter 6.1. --- Epidemiological study on proximal femoral fractures --- p.149 / Chapter 6.2. --- The role of ultrasound equipment in the assessment osteoporosis in patients with proximal femoral fractures --- p.154 / Chapter 6.3. --- Summary --- p.155 / Chapter chapter 7. --- discussion --- p.156 / Chapter 7.1. --- The study on vertebral structures --- p.156 / Chapter 7.1.1. --- Changes in Shape of Vertebral Bodies --- p.156 / Chapter 7.1.2. --- Changes of Interevertbral Discs --- p.157 / Chapter 7.2. --- Alendronate treatment on Chinese elderly women with Osteoporotic vertebral fracture --- p.158 / Chapter 7.2.1. --- The Effect of Alendronate on BMD of Lumbar Spine --- p.159 / Chapter 7.2.2. --- The Effects of Alendronate on BMD of Proximal Femur --- p.159 / Chapter 7.2.3. --- The Effects of Alendronate on the BMD of Trabecular and Cortical Bone in the Distal Radius and Distal Tibia --- p.160 / Chapter 7.2.4. --- The Effects of Calcium Supplementation in the study --- p.162 / Chapter 7.2.5. --- The Effect of alendronate on Biochemical Turnover --- p.162 / Chapter 7.2.6. --- The Efficacy of Alendronate on Prevention of New Fractures --- p.163 / Chapter 7.2.7. --- The Effect of Alendronate on Quality of Life --- p.164 / Chapter 7.2.8. --- Adverse Effects of Alendronate --- p.165 / Chapter 7.3. --- Proximal Femur Fracture Study --- p.165 / Chapter chapter 8. --- conclusion --- p.168 / bibliography --- p.174 / epilogue --- p.202 / appendix --- p.xxv

Foi realizado estudo prospectivo com o objetivo de se determinar a ocorrência de traumatismo raquidiano (TR) em 355 doentes em coma decorrente de traumatismo cranioencefálico (TCE) resultante de acidente de tráfego atendidos no Pronto Socorro de Neurocirurgia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (PSNCHCFMUSP) de 1° de setembro de 2003 a 31 de dezembro de 2009. Todos os doentes foram submetidos ao exame físico e neurológico e à tomografia computadorizada (TC) do corpo inteiro para diagnosticar-se e avaliar-se a gravidade das lesões traumáticas encefálicas, vertebrais ou de outras regiões no momento da admissão ao PSNCHCFMUSP. Em 69 (19,4%) doentes, foi(ram) diagnosticada(s) lesão(ões) na coluna vertebral com o exame de TC da coluna vertebral. As idades dos doentes variaram de 12 a 55 anos (média de 29,0 anos). Eram do sexo masculino 57 (82,6%) doentes. As causas do(s) traumatismo(s) foi(ram) acidente(s) envolvendo motocicleta em 28 (40,6%) casos, atropelamento em 21 (30,5%), colisão de automóvel, caminhão ou caminhonete, em 18 (26,1%) ou acidente com bicicleta em dois (2,9%). Hemorragia subaracnóidea traumática foi a anormalidade intracraniana traumática mais evidenciada no exame de TC do crânio; ocorreu em 57 (82,6%). O(s) processo(s) transverso(s) foi(ram) o(s) segmento(s) vertebral(is) mais acometido(s) pela(s) fratura(s). A sétima vértebra cervical foi a mais lesada; nela identificaram-se fraturas em 24 (34,8%) doentes. Evidenciou-se que a distribuição das fraturas foi similar ao longo das demais vértebras da coluna cervical, quatro primeiras vértebras torácicas e vértebras lombares. Em oito (11,6%) doentes a(s) lesão(ões) neurológica(s) foi(ram) classificada(s) como Frankel A, e nos demais 61(88,4%), como Frankel não-A. Houve necessidade de cirurgia espinal em 24 (34,8%) doentes e de neurocirurgia craniana em 18 (26,0%) doentes. A Escala de Recuperação de Glasgow foi aplicada para avaliar-se as condições neurológicas do doente no momento da alta hospitalar e revelou ocorrência de óbito em dois (2,9%) doentes. Concluiuse que é recomendada a avaliação clínica e também com métodos de imagem da coluna vertebral nos doentes em coma decorrente de TCE / The author presents a prospective study aiming the evaluation of coexistence of spinal injury (SI) in 355 patients presenting coma due to craniocerebral trauma assisted at the Emergency Room of the Hospital das Clínicas of the University of São Paulo Medical School, from September, 1st, 2003 to december, 31th,2009. All patients underwent physical and neurological examination and had computed tomography (CT) scanning of the entire body to diagnose and evaluate the severity of brain and spinal injury at the time of admission. Traumatic lesions of the spine were diagnosed in 69 (19.4%) patients. The ages of patients ranged from 12 to 55 years (mean = 29,0 years).The SI predominated in males, corresponding to 57 (82.6%) patients. The causes of the trauma were motorcycle accident in 28 (40.6%) cases, running over in 21(30.5%), car collision 18 (26.1%) cases and bicycle accident in two (2.9%). Traumatic subarachnoid hemorrhage was the most common traumatic intracranial abnormality in the CT images; it was identified in 57 (82.6%) patients. The transverse process was the most common vertebral part presenting fracture(s). The 7th cervical vertebra was individually the most commonly affected; traumatic lesion of this vertebra presented in 24 (34.8%) patients. The diagnosis of fracture(s) was similar in the other cervical vertebrae and occurred also in the first four thoracic and in the lumbar vertebrae. Severe neurological deficit secondary to spine fracture was diagnosed in eight (11.6%) patients, classified as Frankel A. The others 61(88.4%) patients did not present complete spinal cord or spinal roots neurological deficits were classified as Frankel non A. The Recovery Scale of Glasgow was used to evaluate the neurological status at discharge from hospital. Two (2.9%) patients died. Spinal surgery was necessary in 24 (34.8%) patients and cranial surgery in 18 (26.0%). It was concluded that in addition to clinical evaluation, the CT imaging of the spine is recommended in patients in coma due to mechanical traumatic head injury

Made available in DSpace on 2016-01-26T12:51:43Z (GMT). No. of bitstreams: 1 dioneifreitasmorais_tese.pdf: 2853152 bytes, checksum: 71afba3be408074ea20d36eb45da2d04 (MD5) Previous issue date: 2013-05-09 / Introduction: The spinal cord injury (SCI) it is any aggression that entails anatomic lesion or functional neural elements, within the spinal canal with or without fractures and / or vertebral displacement, resulting in temporary or permanent change in motor, sensory or autonomic. Objective: article 1: To investigate the epidemiological profile of victims of SCI treated at tertiary hospital. Article 2: To evaluate the clinical application of MRI in victims of SCI, considering the type, extent and severity of injury, and clinical and radiological correlation. Article 3: To evaluate complications and injuries associated with neurological severity, vertebral segment, length of stay and mortality in patients with SCI. Methods: Article 1: A descriptive, cross-sectional, prospective study, 321 patients with SCI of the Hospital de Base de São José do Rio Preto, performed January/2008 to June/2012. Analyzed the following variables: gender, age, marital status, occupation, education, religion, origin, etiology, morphology and region of the lesion; neurological status and associated injuries. Article 2: Analyzed the tests diagnostic imaging (CT and MRI), to verify the clinical value in the diagnosis of patients with SCI, by radiological findings of CT and MRI. Article 3: Analyzed the data related to the patient (age, sex), cause of the accident, anatomic distribution of injury, neurological status, associated injuries and in-hospital complications / mortality. Results: Article 1: Was found in the sample: 72% male, 28% female; prevalent age group: 21-30 years; marital most frequent: stable (46.8%), level of education: incomplete primary education (57%); most common cause: accidents automotive (38.9%); over this injury: burst fracture (23.7%); most affected region: cervical subaxial (C3-C7) (41.7%); injury associated more present: head injury trauma (TBI) (28.2%), neurological status on admission found more / High: ASIA-E. There were 25 deaths (7.8%), with 76% lesion in the cervical region were stratified with ASIA-A, and 68% had respiratory complications. Article 2: Radiological findings were best visualized on MRI, except the posterior elements (p = 0.001) were more frequently diagnosed on CT. 271 lesions were diagnosed, 271 of these by MRI, CT and 154 for 100 (36.9%) detected simultaneously, thus, MRI detected more than 117 injuries in CT. Article 3: 231 patients (72%) were male and 90 (28%) were female with a mean age of 42.68 years. 170 patients had lesions associated with SCI. The most common injury was TBI in 48 (28.2%), and 25 (8%) patients died. Conclusion: Article 1: The SCI affected more young adult males with stable relationship and low level of education. The most common cause was automobile accident, type of injury was burst fracture, and cervical region the most affected. The severity of the neurological status was related to cervical involvement and increased the risk of respiratory complications and mortality. Article 2: The MRI detected more lesions compared with CT, and is useful in diagnosing soft tissue injuries and intrathecal. Article 3: The SCI was more frequent and associated with the presence of higher TBI quantity of lesions increases the risk of death. / Introdução: O traumatismo raquimedular (TRM) trata-se de qualquer agressão que acarrete lesão anatômica ou funcional dos elementos neurais, dentro do canal vertebral com ou sem fraturas e / ou deslocamento vertebral, resultando em mudança permanente ou temporária, nas funções motora, sensitiva ou autonômica. Objetivos: artigo 1: Investigar o perfil epidemiológico de vítimas de TRM atendidos em hospital terciário. artigo 2: Avaliar a aplicação clínica da RM em vítimas de TRM, considerando-se tipo, extensão e gravidade da lesão, e correlação clínico-radiológica. artigo 3: Avaliar as complicações e lesões associadas com a gravidade neurológica, segmento vertebral, tempo de internação e mortalidade em pacientes com TRM. Métodos: artigo 1: Estudo descritivo, transversal, prospectivo, com 321 pacientes com TRM do Hospital de Base de São José do Rio Preto-SP, realizado de janeiro/2008 a junho/2012. Analisadas as variáveis: sexo; idade; estado civil; profissão; escolaridade; religião; procedência; etiologia, morfologia e região da lesão; status neurológico e lesões associadas. artigo 2: Analisados os exames de diagnóstico por imagem (TC e RM), visando verificar o valor clínico no diagnóstico do paciente com TRM, por meio dos achados radiológicos da TC e RM. artigo 3: Analisados os dados relacionados ao paciente (idade, sexo), causa do acidente, distribuição anatômica da lesão, estado neurológico, lesões associadas e complicações intra-hospitalares/mortalidade. Resultados: artigo 1: Encontrou-se na amostra: 72% sexo masculino; 28% feminino; faixa etária prevalente: 21-30 anos; estado civil mais frequente: união estável (46,8%); nível de escolaridade: ensino fundamental incompleto (57%); causa mais comum: acidente automobilísticos (38,9%); lesão mais presente: fratura explosão (23,7%); região mais afetada: cervical subaxial (C3-C7) (41,7%); lesão associada mais presente: traumatismo crâniencefálico (TCE) (28,2%); status neurológico mais encontrado na admissão/alta: ASIA E. Ocorreram 25 óbitos (7,8%), sendo 76% com lesão na região cervical, foram estratificados com ASIA-A, e 68% tiveram complicações respiratórias. artigo 2: Os achados radiológicos foram melhores visualizados na RM, exceto os elementos posteriores (p=0,001) que foram mais diagnosticados na TC. Foram diagnosticadas 271 lesões, sendo 271 pela RM, 154 pela TC e 100 (36,9%) simultaneamente detectados, assim, a RM detectou 117 lesões a mais que a TC. Artigo 3: 231 pacientes (72%) foram do sexo masculino e 90 (28%) do sexo feminino com média de idade 42,68 anos. 170 pacientes apresentaram lesões associadas ao TRM. A mais frequente lesão foi TCE em 48 (28,2%), e 25 (8%) dos pacientes foram a óbito. Conclusão: artigo 1: O TRM acometeu mais adultos jovens do sexo masculino com união estável e baixo nível de escolaridade. A causa mais comum foi acidente automobilístico, o tipo de lesão foi fratura explosão e a região cervical a mais acometida. A maior gravidade do status neurológico esteve relacionada com envolvimento cervical e aumentou o risco de complicações respiratórias e morbimortalidade. artigo 2. A RM detectou maior número de lesão comparada com a TC, sendo de grande utilidade no diagnóstico de lesões em tecidos moles e intratecal. artigo 3: O TRM foi mais frequente associado ao TCE e a presença de maior quantidade de lesões associadas aumenta o risco de morte.

Foi realizado estudo prospectivo com o objetivo de se determinar a ocorrência de traumatismo raquidiano (TR) em 355 doentes em coma decorrente de traumatismo cranioencefálico (TCE) resultante de acidente de tráfego atendidos no Pronto Socorro de Neurocirurgia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (PSNCHCFMUSP) de 1° de setembro de 2003 a 31 de dezembro de 2009. Todos os doentes foram submetidos ao exame físico e neurológico e à tomografia computadorizada (TC) do corpo inteiro para diagnosticar-se e avaliar-se a gravidade das lesões traumáticas encefálicas, vertebrais ou de outras regiões no momento da admissão ao PSNCHCFMUSP. Em 69 (19,4%) doentes, foi(ram) diagnosticada(s) lesão(ões) na coluna vertebral com o exame de TC da coluna vertebral. As idades dos doentes variaram de 12 a 55 anos (média de 29,0 anos). Eram do sexo masculino 57 (82,6%) doentes. As causas do(s) traumatismo(s) foi(ram) acidente(s) envolvendo motocicleta em 28 (40,6%) casos, atropelamento em 21 (30,5%), colisão de automóvel, caminhão ou caminhonete, em 18 (26,1%) ou acidente com bicicleta em dois (2,9%). Hemorragia subaracnóidea traumática foi a anormalidade intracraniana traumática mais evidenciada no exame de TC do crânio; ocorreu em 57 (82,6%). O(s) processo(s) transverso(s) foi(ram) o(s) segmento(s) vertebral(is) mais acometido(s) pela(s) fratura(s). A sétima vértebra cervical foi a mais lesada; nela identificaram-se fraturas em 24 (34,8%) doentes. Evidenciou-se que a distribuição das fraturas foi similar ao longo das demais vértebras da coluna cervical, quatro primeiras vértebras torácicas e vértebras lombares. Em oito (11,6%) doentes a(s) lesão(ões) neurológica(s) foi(ram) classificada(s) como Frankel A, e nos demais 61(88,4%), como Frankel não-A. Houve necessidade de cirurgia espinal em 24 (34,8%) doentes e de neurocirurgia craniana em 18 (26,0%) doentes. A Escala de Recuperação de Glasgow foi aplicada para avaliar-se as condições neurológicas do doente no momento da alta hospitalar e revelou ocorrência de óbito em dois (2,9%) doentes. Concluiuse que é recomendada a avaliação clínica e também com métodos de imagem da coluna vertebral nos doentes em coma decorrente de TCE / The author presents a prospective study aiming the evaluation of coexistence of spinal injury (SI) in 355 patients presenting coma due to craniocerebral trauma assisted at the Emergency Room of the Hospital das Clínicas of the University of São Paulo Medical School, from September, 1st, 2003 to december, 31th,2009. All patients underwent physical and neurological examination and had computed tomography (CT) scanning of the entire body to diagnose and evaluate the severity of brain and spinal injury at the time of admission. Traumatic lesions of the spine were diagnosed in 69 (19.4%) patients. The ages of patients ranged from 12 to 55 years (mean = 29,0 years).The SI predominated in males, corresponding to 57 (82.6%) patients. The causes of the trauma were motorcycle accident in 28 (40.6%) cases, running over in 21(30.5%), car collision 18 (26.1%) cases and bicycle accident in two (2.9%). Traumatic subarachnoid hemorrhage was the most common traumatic intracranial abnormality in the CT images; it was identified in 57 (82.6%) patients. The transverse process was the most common vertebral part presenting fracture(s). The 7th cervical vertebra was individually the most commonly affected; traumatic lesion of this vertebra presented in 24 (34.8%) patients. The diagnosis of fracture(s) was similar in the other cervical vertebrae and occurred also in the first four thoracic and in the lumbar vertebrae. Severe neurological deficit secondary to spine fracture was diagnosed in eight (11.6%) patients, classified as Frankel A. The others 61(88.4%) patients did not present complete spinal cord or spinal roots neurological deficits were classified as Frankel non A. The Recovery Scale of Glasgow was used to evaluate the neurological status at discharge from hospital. Two (2.9%) patients died. Spinal surgery was necessary in 24 (34.8%) patients and cranial surgery in 18 (26.0%). It was concluded that in addition to clinical evaluation, the CT imaging of the spine is recommended in patients in coma due to mechanical traumatic head injury

Introdução: O aumento da sobrevida dos pacientes com lúpus eritematoso sistêmico (LES) foi acompanhado por um aumento da frequência de comorbidades, tais como osteoporose e fraturas. Há descrições de associação de polimorfismos dos genes receptor ativador do fator nuclear kappa B (RANK), seu ligante (RANKL) e da osteoprotegerina (OPG) com alterações de densidade e fragilidade óssea, entretanto, não há estudos que avaliam estes polimorfismos em pacientes com LES. Objetivos: Avaliar polimorfismos de nucleotídeo único (SNP) dos genes RANKL, OPG e RANK em pacientes pré-menopausadas com LES e sua associação com densidade mineral óssea (DMO), fraturas vertebrais e concentrações séricas de sRANKL e OPG. Métodos: 211 mulheres com LES na pré-menopausa e 154 controles saudáveis foram avaliadas. Os seguintes SNPs foram avaliados por PCR em tempo real: RANKL [290 A > G (rs2277438)], OPG [1181 G > C (rs2073618), 245 T > G (rs3134069), 163 A>G (rs3102735)] e RANK [A > G (rs3018362)]. Concentrações séricas de OPG e sRANKL foram determinadas por ELISA, DMO e fraturas vertebrais por DXA (densitometria de dupla emissão com fonte de raios-X). Resultados: Pacientes e controles apresentaram frequência semelhante do alelo G do gene RANKL 290 A > G (41,2 vs. 40,3%, p=0,91), do alelo C do gene OPG 1181 G >C (62,6 vs. 61,0%, p=0,83), do alelo G da OPG 245 T>G (21,3 vs. 22,7%, p=0,80) do alelo G da OPG 163 A > G (96,2 vs. 87,0%, p=1,00) e do alelo G do RANK A > G (88,2 vs. 96,8%, p=0,75). Quando analisados os pacientes com LES, a frequência dos genótipos associados AG/GG do gene RANKL 290 A>G foi menos frequente em pacientes com fraturas vertebrais que em pacientes sem fraturas (28,1 vs. 46,9%, p=0,01). Com relação à densidade mineral óssea, a frequência dos genótipos associados TG/GG do polimorfismo 245 T > G da OPG foi maior em pacientes com baixa densidade mineral óssea do que em pacientes com densidade mineral óssea normal (31,4 vs. 18,1%, p=0,04). Não houve associação da DMO/fraturas com polimorfismos da OPG 1181 G > C, OPG 163 A > G e RANK A > G. Também não houve associação dos polimorfismos com as concentrações séricas de sRANKL e OPG. Conclusões: O presente trabalho demonstra pela primeira vez que variações genéticas no sistema OPG/RANKL podem desempenhar um papel importante na remodelação óssea e fratura em paciente pré-menopausadas com LES / Introduction: Survival rate improvement in systemic lupus erythematosus was accompanied by an increase in the incidence of long-term bone disorders such as osteoporosis, fractures and osteonecrosis. Polymorphisms of receptor activator of nuclear factor (NF)-kB ligand (RANKL) and osteoprotegerin (OPG) genes are known to influence bone mineral density and structure. However, there are no studies assessing these polymorphisms in SLE patients. Objective: To evaluate receptor activator of nuclear factor-kB (RANK) it ligand (RANKL) and osteoprotegerin (OPG) genes single nucleotide polymorphisms (SNP) in premenopausal SLE patients and their association with sRANKL and OPG serum levels, vertebral fractures and bone mineral density (BMD). Methods: 211 premenopausal SLE patients (ACR criteria) and 154 healthy controls were enrolled. SNPs of RANKL [290 A > G (rs2277438)], OPG [1181G > C (rs2073618), 245T>G (rs3134069), 163 A>G (rs3102735)] and RANK [A > G (rs3018362)] were obtained by real-time PCR. sRANKL/OPG serum levels were determined by ELISA. BMD and vertebral fractures were evaluated by dual energy X-ray absorptiometry. Results: SLE patients and controls had similar frequency of RANKL 290 G allele (41.2 vs. 40.3%, p=0.91), OPG 1181 C allele (62.6 vs. 61.0%, p=0.83), OPG 245 G allele (21.3 vs. 22.7%, p=0.80), OPG 163 G allele (96.2 vs. 87.0%, p=1.00) and RANK G allele (88.2 vs. 96.8%, p=0.75). Further analysis of SLE patients revealed that the frequency of RANKL 290 G allele was lower in patients with fractures than in patients without fractures (28.1 vs. 46.9%, p=0.01). In addition, the frequency of OPG 245 G allele was higher in patients with low BMD than in patients with normal BMD (31.4 vs. 18.1%, p=0.04). No association of OPG 1181 G > C, OPG 163 A > G and RANK A > G SNPs with BMD/fractures were found. Also, no association was observed between RANKL/OPG/RANK SNPs and sRANKL/OPG serum levels. Conclusions. Our study provides novel data demonstrating that RANKL/OPG genetic variations seem to play a role in bone remodeling and particularly in its main complication, fracture, in premenopausal patients with SLE

Introdução: O aumento da sobrevida dos pacientes com lúpus eritematoso sistêmico (LES) foi acompanhado por um aumento da frequência de comorbidades, tais como osteoporose e fraturas. Há descrições de associação de polimorfismos dos genes receptor ativador do fator nuclear kappa B (RANK), seu ligante (RANKL) e da osteoprotegerina (OPG) com alterações de densidade e fragilidade óssea, entretanto, não há estudos que avaliam estes polimorfismos em pacientes com LES. Objetivos: Avaliar polimorfismos de nucleotídeo único (SNP) dos genes RANKL, OPG e RANK em pacientes pré-menopausadas com LES e sua associação com densidade mineral óssea (DMO), fraturas vertebrais e concentrações séricas de sRANKL e OPG. Métodos: 211 mulheres com LES na pré-menopausa e 154 controles saudáveis foram avaliadas. Os seguintes SNPs foram avaliados por PCR em tempo real: RANKL [290 A > G (rs2277438)], OPG [1181 G > C (rs2073618), 245 T > G (rs3134069), 163 A>G (rs3102735)] e RANK [A > G (rs3018362)]. Concentrações séricas de OPG e sRANKL foram determinadas por ELISA, DMO e fraturas vertebrais por DXA (densitometria de dupla emissão com fonte de raios-X). Resultados: Pacientes e controles apresentaram frequência semelhante do alelo G do gene RANKL 290 A > G (41,2 vs. 40,3%, p=0,91), do alelo C do gene OPG 1181 G >C (62,6 vs. 61,0%, p=0,83), do alelo G da OPG 245 T>G (21,3 vs. 22,7%, p=0,80) do alelo G da OPG 163 A > G (96,2 vs. 87,0%, p=1,00) e do alelo G do RANK A > G (88,2 vs. 96,8%, p=0,75). Quando analisados os pacientes com LES, a frequência dos genótipos associados AG/GG do gene RANKL 290 A>G foi menos frequente em pacientes com fraturas vertebrais que em pacientes sem fraturas (28,1 vs. 46,9%, p=0,01). Com relação à densidade mineral óssea, a frequência dos genótipos associados TG/GG do polimorfismo 245 T > G da OPG foi maior em pacientes com baixa densidade mineral óssea do que em pacientes com densidade mineral óssea normal (31,4 vs. 18,1%, p=0,04). Não houve associação da DMO/fraturas com polimorfismos da OPG 1181 G > C, OPG 163 A > G e RANK A > G. Também não houve associação dos polimorfismos com as concentrações séricas de sRANKL e OPG. Conclusões: O presente trabalho demonstra pela primeira vez que variações genéticas no sistema OPG/RANKL podem desempenhar um papel importante na remodelação óssea e fratura em paciente pré-menopausadas com LES / Introduction: Survival rate improvement in systemic lupus erythematosus was accompanied by an increase in the incidence of long-term bone disorders such as osteoporosis, fractures and osteonecrosis. Polymorphisms of receptor activator of nuclear factor (NF)-kB ligand (RANKL) and osteoprotegerin (OPG) genes are known to influence bone mineral density and structure. However, there are no studies assessing these polymorphisms in SLE patients. Objective: To evaluate receptor activator of nuclear factor-kB (RANK) it ligand (RANKL) and osteoprotegerin (OPG) genes single nucleotide polymorphisms (SNP) in premenopausal SLE patients and their association with sRANKL and OPG serum levels, vertebral fractures and bone mineral density (BMD). Methods: 211 premenopausal SLE patients (ACR criteria) and 154 healthy controls were enrolled. SNPs of RANKL [290 A > G (rs2277438)], OPG [1181G > C (rs2073618), 245T>G (rs3134069), 163 A>G (rs3102735)] and RANK [A > G (rs3018362)] were obtained by real-time PCR. sRANKL/OPG serum levels were determined by ELISA. BMD and vertebral fractures were evaluated by dual energy X-ray absorptiometry. Results: SLE patients and controls had similar frequency of RANKL 290 G allele (41.2 vs. 40.3%, p=0.91), OPG 1181 C allele (62.6 vs. 61.0%, p=0.83), OPG 245 G allele (21.3 vs. 22.7%, p=0.80), OPG 163 G allele (96.2 vs. 87.0%, p=1.00) and RANK G allele (88.2 vs. 96.8%, p=0.75). Further analysis of SLE patients revealed that the frequency of RANKL 290 G allele was lower in patients with fractures than in patients without fractures (28.1 vs. 46.9%, p=0.01). In addition, the frequency of OPG 245 G allele was higher in patients with low BMD than in patients with normal BMD (31.4 vs. 18.1%, p=0.04). No association of OPG 1181 G > C, OPG 163 A > G and RANK A > G SNPs with BMD/fractures were found. Also, no association was observed between RANKL/OPG/RANK SNPs and sRANKL/OPG serum levels. Conclusions. Our study provides novel data demonstrating that RANKL/OPG genetic variations seem to play a role in bone remodeling and particularly in its main complication, fracture, in premenopausal patients with SLE