Spinal cord injury (SCI) causes rapid osteoporosis that is most severe below the level of injury. More than half of those with motor complete SCI will experience an osteoporotic fracture at some point following their injury, with most fractures occurring at the distal femur and proximal tibia. These fractures have devastating consequences, including delayed union or nonunion, cellulitis, skin breakdown, lower extremity amputation, and premature death. Maintaining skeletal integrity and preventing fractures is imperative following SCI to fully benefit from future advances in paralysis cure research and robotic-exoskeletons, brain computer interfaces and other evolving technologies. Clinical care has been previously limited by the lack of consensus derived guidelines or standards regarding dual-energy X-ray absorptiometry-based diagnosis of osteoporosis, fracture risk prediction, or monitoring response to therapies. The International Society of Clinical Densitometry convened a task force to establish Official Positions for bone density assessment by dual-energy X-ray absorptiometry in individuals with SCI of traumatic or nontraumatic etiology. This task force conducted a series of systematic reviews to guide the development of evidence-based position statements that were reviewed by an expert panel at the 2019 Position Development Conference in Kuala Lumpur, Malaysia. The resulting the International Society of Clinical Densitometry Official Positions are intended to inform clinical care and guide the diagnosis of osteoporosis as well as fracture risk management of osteoporosis following SCI.
To answer important questions in the fields of monitoring with densitometry, dual-energy X-ray absorptiometry machine cross-calibration, monitoring, spinal cord injury, periprosthetic and orthopedic bone health, transgender medicine, and pediatric bone health, the International Society for Clinical Densitometry (ISCD) held a Position Development Conference from March 20 to 23, 2019. Potential topics requiring guidance were solicited from ISCD members in 2017. Following that, a steering committee selected, prioritized, and grouped topics into Task Forces. Chairs for each Task Force were appointed and the members were co-opted from suggestions by the Steering Committee and Task Force Chairs. The Task Forces developed key questions, performed literature searches, and came up with proposed initial positions with substantiating draft publications, with support from the Steering Committee. An invited Panel of Experts first performed a review of draft positions using a modified RAND Appropriateness Method with voting for appropriateness. Draft positions deemed appropriate were further edited and presented at the Position Development Conference meeting in an open forum. A second round of voting occurred after discussions to approve or reject the positions. Finally, a face-to-face closed session with experts and Task Force Chairs, and subsequent electronic follow-up resulted in 34 Official Positions of the ISCD approved by the ISCD Board on May 28, 2019. The Official Positions and the supporting evidence were submitted for publication on July 1, 2019. This paper provides a summary of the all the ISCD Adult and Pediatric Official Positions, with the new 2019 positions highlighted in bold.