Pathological fractures in epilepsy
Introduction
Patients with epilepsy frequently experience injuries resulting from seizure-related falls [1] or trauma occurring in the context of seizure-related impairment of consciousness [2], [3], [4], [5], [6], [7], [8]. Fractures are between two and six times more common in patients with epilepsy than in the general population, with fracture rates in the United States of 2205 per 100,000 person-years [1], [4], [9], [10], [11], [12], [13]. Additionally, antiepileptic medication-related osteopenia may increase the susceptibility to fracture, particularly in women [14], [15], [16]. Institutionalized patients treated for >10 years have a 14-fold increase in pathological fractures at the hip [17]. The relative contribution of low-intensity trauma in pathological fractures and fractures resulting from high-intensity trauma and seizure-related falls, however, remain poorly defined in noninstitutionalized patients.
Accordingly, the study described in this article examined the influence of gender and age on fractures in epilepsy. The specific issues of interest include: (1) distribution of fractures in general by age and gender, and (2) distribution of pathological and traumatic/seizure-related fractures by age and gender.
Section snippets
Study design, patients, and analysis
A retrospective analysis was performed at our tertiary care facility of all patients who had epilepsy and sustained a fracture over a 7-year period ending in 2003 using ICD-9 codes for fractures, pathological fractures, and osteoporosis or osteomalacia. The diagnosis of a bone disorder was made by the treating physician and was based on clinical and laboratory criteria supportive of the diagnosis. Clinically significant osteoporosis was defined as reduced bone density associated with either
Results
Over the 7-year period, a total of 750 patients with epilepsy sustained fractures. The majority (61%) were traumatic/seizure-related fractures (Fig. 1). The highest distribution of fractures (19%) occurred between ages 40 and 49 (Fig. 2), with a reduction in representation in subsequent age groups. However, a second lower peak (8.4%) was observed in those between ages 70 and 79.
Gender distribution in this cohort with fractures was significantly different. In those less than 50 years of age,
Discussion
Age and gender appear to exert powerful influences on the mechanism and pathogenesis of fractures in epilepsy.
References (36)
- et al.
Effect of carbamazepine and valproate on bone mineral density
J Pediatr
(1995) - et al.
Fracture risk is increased in epilepsy
Acta Neurol Scand
(1999) - et al.
Fracture incidence in Olmsted County, Minnesota: comparison of urban with rural rates and changes in urban rates over time
Osteoporos Int
(1999) - et al.
Patients’ experiences of injury as a result of epilepsy
Epilepsia
(1997) - et al.
Risk of age-related fractures in patients with unprovoked seizures
Epilepsia
(1989) - et al.
A population-based study of fracture incidence in southern Tasmania: lifetime fracture risk and evidence for geographic variations within the same country
Osteoporos Int
(2001) - et al.
Symptomatic fracture incidence in southern Tasmania: does living in the country reduce your fracture risk?
Osteoporos Int
(2002) - et al.
Symptomatic fracture incidence in those under 50 years of age in southern Tasmania
J Paediatr Child Health
(2002) Injuries and death as a consequence of seizures in people with epilepsy
Epilepsia
(1998)- et al.
Incidence of fractures among epilepsy patients: A population-based retrospective cohort study in the general practice research database
Epilepsia
(2005)
Risk of extremity fractures in adult outpatients with epilepsy
Epilepsia
Seizure-related injuries in children with newly diagnosed and untreated epilepsy
Epilepsia
Fractures, epilepsy, and antiepileptic drugs
Epilepsy Behav
Bone morphology in epileptics
Calcif Tissue Int
Menopause and bone density issues for women with epilepsy
Neurology
Bone mass and turnover in women with epilepsy on antiepileptic drug monotherapy
Ann Neurol
An analysis of lifetime fractures in women with epilepsy
Acta Neurol Scand
Bone mineral content in epileptics
Calcif Tissue Int
Cited by (64)
Relationship between bone density and levetiracetam monotherapy in epilepsy patients
2022, Clinical Neurology and NeurosurgeryAn explorative literature review of the multifactorial causes of osteoporosis in epilepsy
2019, Epilepsy and BehaviorCitation Excerpt :When epilepsy, in turn, affects between 5 and 10 per 1000 individuals in developed countries [3], the extent and consequences are great. The finding of increased fracture risk is consistent across the literature from case–control studies to meta-analyses, both when comparing patients with epilepsy to healthy control groups but also when comparing subgroups of patients with epilepsy (Table 1) [4–11]. It has been argued that patients with epilepsy have an increased risk of fractures because of an increased risk of seizure-associated falls.
Neuron subset-specific Pten deletion induces abnormal skeletal activity in mice
2017, Experimental NeurologyBone health in epilepsy
2017, International Journal of EpilepsyEnzyme-inducing antiepileptic drugs and fractures in people with epilepsy: A systematic review
2015, Epilepsy ResearchCitation Excerpt :Patients with epilepsy already must contend with significant morbidity related to their disease, including repeated bodily injury, stigma, social isolation, issues with employment, increased anxiety and depression, and even a shortened lifespan in some cases (Selassie et al., 2014; Sperling, 2004). Fractures are common in these patients, especially during seizures; however, more than 70% of fractures occurring in PWE over age 60 are thought to be simply osteoporotic in nature, unrelated to injury from seizures (Sheth et al., 2006). Such fractures can have serious consequences, including pain, disability, loss of independence, and increased mortality (Papaioannou et al., 2009; Ioannidis et al., 2009).
Survey of risk factors for osteoporosis and osteoprotective behaviors among patients with epilepsy
2015, Epilepsy and Behavior