A comparison of heterotopic ossification treatment within the traumatic brain and spinal cord injured population: An evidence based systematic review

Background: To compare the treatment of heterotopic ossification (HO) within the traumatic brain and spinal cord injured populations. Methods: MEDLINE/Pubmed, CINAHL, EMBASE, and PsycINFO databases were searched for articles addressing treatment of HO post-injury. Articles were constrained to: English language and human subjects. Studies were included if: n >= 50% of the subjects had a spinal cord injury (SCI) or a traumatic brain injury (TBI), n >= 3 SCI or TBI subjects, and study subjects participated in a treatment or intervention. Study quality, for randomized control trials (RCTs), were assessed using the PEDro assessment scale, while non-RCTs was assessed using the Downs and Black evaluation tool. A modified Sackett scale was used to apply levels of evidence for each intervention. Results: In total 26 studies (N(TBI) = 12; N(SCI) = 14) met inclusion criteria. The majority of studies (10/12) conducted in the TBI population were surgical interventions. Studies conducted with the SCI population investigated diverse pharmacological treatments including: bisphosphonates, non-steroidal anti-inflammatory drugs (NSAIDs) and Warfarin. Non-pharmacological studies investigated the benefits of pulse low-intensity electromagnetic field therapy, surgical excision, and radiotherapy in the treatment of HO. Conclusions: Within the SCI literature, NSAIDs showed the greatest efficacy in the prevention of HO when administered early after a SCI, and biphosphonates were found to be the most effective treatment strategy. In the TBI population, surgical excision was the most effective treatment.