Neurosurgical Presentations of Osteomalacia: An Analysis of 100 Cases

Neurosurgical Presentations of Osteomalacia: An Analysis of 100 Cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Neurosurgical Presentations of Osteomalacia: An Analysis of 100 Cases Danyal Sadeeq Gumoriani, Kainat Bashir This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4788731/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: To assess the neurosurgical presentation of patients suffering from osteomalacia, a potentially preventable and treatable metabolic disease that can mimic neurological discogenic disorders. Study Duration: May 2023 to November 2023, covering a period of 6 months in the Department of Neurosurgery, Qazi Hussain Ahmad Medical Complex, Nowshera. Study Design: Descriptive observational study. Methodology: This review study includes 100 cases of osteomalacia presenting as discogenic disorder, collected from the Neurosurgery OPD. Data were collected using a custom 1-page form, which included age, sex, marital status, pregnancy history, educational status, main presenting complaints, history of sunlight expo- sure in urban and rural settings,primary work and working condition, duration of symptoms, and history of medical and surgical treatments. Data were sup- plemented with hematological and biochemical profiles, including hemoglobin concentration, ESR, serum calcium, phosphate, and serum alkaline phosphatase levels. Detailed radiological findings, including Looser’s zones, and CT or MRI findings were recorded to exclude other conditions. Patients with biochemical profiles and radiological evidence of osteomalacia were included, while those with other conditions not meeting the criteria were excluded. The data were analyzed according to the set parameters and used for discussion and recommendations. Results: Of the 100 patients diagnosed with osteomalacia, 57% were female and 43% were male. The age range was 14 to 50 years, with a mean age of 32 years. Educational status included 11% illiterate, 32% high school graduates, and 57% college graduates. 70% were from rural areas, and 30% were from urban locations. Among female patients, 47.37% were multiparous, 19.30% were non-multiparous, 15.79% had no children, and 17.54% were unmarried. Symptoms lasted 3 to 12 months, with a mean of 6 months. Significant past surgical history included spinal surgery in 7%, appendectomy in 5%, and C-section in 12%. Sunlight exposure was adequate in 70% and inadequate in 30%. Hemoglobin was less than 10 g/dL in 25% of cases, with normal levels in 75%. ESR was raised above 30 mm/hour in 33% of cases. Serum calcium was low in 73% and normal in 27%. Serum alkaline phosphatase was elevated above 3000 IU in 60.5% and markedly high in patients with fractures. Conclusion: Our study highlights the significant prevalence of osteomalacia in neurosurgical patients, particularly among females, rural residents, and those with lower educational levels. This underscores the need for improved primary healthcare systems and timely referrals. In neurosurgical settings, osteomalacia often presents a diagnostic challenge, as its symptoms can mimic various spinal and neurological disorders. This underscores the importance of maintaining a high index of suspicion and conducting thorough metabolic evaluations in patients presenting with chronic musculoskeletal pain. Diagnostic indicators include low hemoglobin, raised ESR, subnormal serum calcium, and radiological changes. Increased awareness and screening for osteomalacia in patients with gastroin- testinal disorders and renal issues are recommended to prevent misdiagnosis and ensure timely treatment. Osteomalacia Metabolic bone disease Chronic backache Bone pain syndrome Vitamin D deficiency Calcium metabolism Sunlight exposure Epidemiology of osteomalacia Introduction Osteomalacia represents a metabolic bone disorder characterized by impaired miner- alization of the organic matrix in the adult skeleton, leading to softening of bones and increased susceptibility to fractures. While rickets affects the growing skeleton in children, osteomalacia primarily involves the mature bones in adults. It predom- inantly affects the diaphysis of long bones and vertebrae, as the epiphyseal growth plates have already fused, resulting in distinct clinical and radiological manifestations. Osteomalacia is not a singular disease entity but rather a complex syndrome encom- passing a spectrum of radiographic, biochemical, and histopathological abnormalities affecting bone metabolism and structure. Osteomalacia can be classified into several subtypes based on etiology, including vitamin D deficiency, gastrointestinal disorders, renal tubular acidosis [1], and oncogenic osteomalacia. Each subtype presents unique challenges in diagnosis and management, requiring a tailored approach to treatment. The clinical presentation of osteomalacia is diverse, ranging from subtle bone pain and muscle weakness to more severe manifestations such as pathological fractures, skeletal deformities, and gait disturbances. Patients may also experience extraskeletal symptoms like fatigue, mood changes, and increased susceptibility to infections. These deformities may be overlooked, while diffuse skeletal pain and bony tenderness, along with hesitancy to walk due to fractures of the vertebrae and ribs, are more apparent. Radiological findings in osteomalacia include characteristic pseudofractures, typically seen in weight-bearing bones. Advanced imaging may reveal a generalized decrease in bone density, giving a ’ground glass’ appearance, and in severe cases, visible defor- mities of the pelvis and long bones. Pseudo-fractures occur due to mechanical stress from the pulsation of blood vessels over areas such as the pubic rami, femoral neck, outer edge of the scapula, upper fibula, and metatarsals. Radionuclide studies often reveal ”hot spots” over these areas. Subperiosteal erosion may sometimes be seen in cases of secondary hyperparathyroidism along the diaphyseal cortices [2]. In renal tubular acidosis, there is thickening of the cortices and trabeculae of long bones (renal osteodystrophy); however, the osteoid is weak and devoid of proper mineralization. Biochemical markers play a crucial role in diagnosis. Typical findings include low or low-normal serum calcium, decreased serum phosphate, elevated alkaline phosphatase, and low 25-hydroxyvitamin D levels. However, the pattern may vary depending on the underlying cause and disease stage. Management of osteomalacia focuses on addressing the underlying cause and restoring bone mineralization. Treatment typically involves high-dose vitamin D supplementation, with dosages ranging from 50,000 IU weekly to 800–1000 IU daily [3], depending on disease severity and patient response. Calcium supplementation and correction of any underlying metabolic abnormalities are also crucial components of the treatment plan. Methodology This is an observational descriptive study conducted over 6 months in the Neuro- surgery Department at Qazi Hussain Ahmad Medical Complex, Nowshera. The study included patients diagnosed with osteomalacia after a thorough review, who initially presented to neurosurgery OPD with backache and pain in the extremities, partic- ularly the lower limbs or generalized body aches. Only cases definitively diagnosed with osteomalacia were included, excluding cases with other diseases and conditions. These patients presented with symptoms of neurosurgical problems, and the diagno- sis of osteomalacia was achieved only after careful evaluation and medical testing. Ideally, these patients should have been assessed by primary care physicians, but the study was conducted for academic interest and to benefit the patients who missed the opportunity for early diagnosis. These patients continued to suffer due to inadequate diagnostic and treatment facilities at primary and secondary healthcare levels, with most being referred directly to neurosurgeons and general physicians at tertiary level to be treated for neurosurgical conditions. A detailed one page form was used to col- lect data on age, sex, marital status, literacy level, occupation, number of children in females, breastfeeding history, previous medical and surgical history, and drug history. Special attention was given to the main presenting symptoms, which were compared with plain radiological features. CT scans and MRI were performed in selected cases to exclude concomitant or latent neurosurgical and orthopedic diseases. Laboratory findings were recorded under headings such as hemoglobin levels, ESR, serum calcium levels, serum alkaline phosphatase levels, and serum phosphate levels. All collected data were expressed as mean ± standard deviation. A limited number of cases were followed up after appropriate treatment, with the majority not returning once their symptoms were resolved. Patients with gastrointestinal disorders and chronic renal failure were excluded from the study due to their potential confounding impact on the results. Results Out of the total 100 patients diagnosed with osteomalacia, 57% were female and 43% were male, giving a male to female ratio of approximately 1:1.3. Table 1 Male to Female Ratio These patients belonged to the adult age group with a range of 14 to 50 years, and the mean age was 32 years. Sex Number Percentage Male 43 43% Female 57 57% Total 100 100% Educational status included 11% illiterate, 32% high school graduates, and 57% college graduates. Table 2 Educational Status Education Number Percentage Illiterate 11 11% High School 32 32% College 57 57% Seventy percent were from rural areas, and 30% were from urban locations. Among the female patients, 47.37% were multiparous, 19.30% were nulliparous, 15.79% had no children despite being married, and 17.54% were unmarried. Table 3 Parity Status among Females Status Number Percentage Multiparous 27 47.37% Nulliparous 11 19.30% Married without children 9 15.79% Unmarried 10 17.54% Symptoms lasted from 3 to 12 months, with a mean duration of 6 months. Significant past surgical history included spinal surgery in 7% of cases, appendectomy in 5%, and C-section in 12%. Sunlight exposure was adequate in 70% of cases and inadequate in 30%. Hemoglobin levels were less than 10 g/dL in 25% of cases, with normal levels in 75%. ESR was raised above 30 mm/hour in 33% of cases. Serum calcium levels were low in 73% and normal in 27%. Serum alkaline phosphatase was elevated above 3000 IU in 60.5% of cases and markedly high in patients with fractures. Table 4 Laboratory Findings 4 Finding Number Percentage Hemoglobin ¡ 10 g/dL 25 25% Hemoglobin 10 g/dL 75 75% ESR ¿ 30 mm/hour 33 33% Serum Calcium (Low) 73 73% Serum Calcium (Normal) 27 27% Elevated Alkaline Phosphatase 60.5 60.5% Table 5 Presenting / Chief Complaint Complaint Number Percentage Backache 100 100% Leg Pain 43 43% Body Aches 39 39% Weakness 20 20% Discussion This study highlights the significant prevalence of osteomalacia presenting with neu- rosurgical symptoms at tertiary level in Khyber Pakhtunkhwa, Pakistan. The findings reveal important demographic and clinical patterns that have implications for both local public health strategies and broader international understanding of osteoma- lacia. Demographics and Risk Factors: The higher prevalence among females (57%) aligns with global trends, as noted in a Al-Daghri NM, Yakout S, Sabico S, et al [4]. Establishing the Prevalence of Osteomalacia in Arab Adolescents Using Biochemical Markers of Bone Health, which found girls to be at greater risk of vitamin D deficiency and osteomalacia in Saudi Arabia. The mean age of 32 years in our study population suggests that osteomalacia affects young adults in their prime productive years, potentially impacting economic productivity and quality of life. The predominance of rural residents (70%)in our study population raises concerns about healthcare access and nutritional status in rural Khyber Pakhtunkhwa. This disparity echoes findings from a similar study by Siddiqee MH, Bhattacharjee B, Sid- diqi UR, MeshbahurRahman M. High prevalence of vitamin D deficiency among the South Asian adults: a systematic review and meta-analysis [5], which reported a high prevalence of vitamin D deficiency and osteomalacia in Pakistan (73%;95% CI: 63 to 83%) followed by Bangladesh (67%; 95% CI: 50 to 83%), India (67%; 95% CI: 61 to 73%), Nepal (57%; 95% CI: 53 to 60%) and Sri Lanka (48%; 95% CI: 41 to 55%), respectively, due to limited healthcare access and nutritional deficiencies. Public Health Implications for Khyber Pakhtunkhwa: The high proportion of patients with inadequate sunlight exposure (30despite living in a sunny region suggests a need for public health education on the importance of safe sun exposure for vitamin D synthesis. Cultural practices, such as full-body coverage in traditional dress, may contribute to this issue and should be addressed sensitively in public health campaigns. The significant number of multiparous women (47.37of female patients) with osteomalacia highlights the need for improved maternal health services and nutritional support during pregnancy and lactation. A targeted intervention for this high-risk group could have substantial impact. The educational status distribution (11illiterate, 32% high school graduates, 57% college graduates) suggests that even educated individuals are at risk, indicating a need for broader public health education across all socioeconomic groups. Clinical Presentation and Diagnosis: The presentation of osteomalacia with neurosurgical symptoms underscores the impor- tance of considering metabolic bone diseases in the differential diagnosis of chronic back pain and other musculoskeletal complaints. The high rates of low serum calcium (73%) and elevated alkaline phosphatase (60.5%) in our study population support the use of these markers for screening. However, the normal calcium levels in 27% of cases highlight the need for comprehensive evaluation beyond basic serum calcium testing. International Context and Implications: Globally, osteomalacia remains a significant yet often overlooked health issue. A study by Hollick MF, Chen TC. Vitamin D deficiency, a worldwide problem with health con- sequences [6], found that vitamin D deficiency affects over 1 billion people worldwide, with particularly high rates in South Asia, the Middle East, and Africa. Our findings from Pakistan contribute to this global picture and emphasize the need for increased awareness and screening in these regions. The misdiagnosis of osteomalacia as a neu- rosurgical condition reflects a broader issue of fragmented specialty care. A study by Zimmerman L, McKeon B. et al [7]. suggested that patients with osteomalacia should be treated by any speciality that encounters and diagnoses the patient. Our study underscores the need for a more integrated approach to musculoskeletal complaints, particularly in resource-limited settings. The high prevalence of osteomalacia in our neurosurgical hospital population (100 cases in 6 months) suggests that this condi- tion may be significantly underdiagnosed in primary care settings. This aligns with a study by Salvatore Minisola et al [8]., which found that osteomalacia is often missed or misdiagnosed, leading to inappropriate treatments and poor outcomes. Recommendations: Implement widespread vitamin D screening and supplementation programs, partic- ularly targeting rural and female populations in Khyber Pakhtunkhwa. Develop culturally sensitive public health campaigns to educate the population on the importance of safe sun exposure and dietary sources of vitamin D. Enhance training for primary care physicians and specialists in recognizing and diagnosing osteomalacia, particularly when presenting with atypical symptoms. Strengthen maternal health services to include routine vitamin D supplementation and nutritional counseling during pregnancy and lactation. Conduct further research on the long-term outcomes of patients diagnosed with osteomalacia and the effectiveness of various treatment regimens in the local population. Explore the potential for fortification of staple foods with vitamin D as a public health intervention, as has been successful in other countries. Limitations: Limitations of this study include its single-center design, which may restrict the gen- eralizability of findings to other regions of Pakistan. A potential selection bias exists due to the inclusion of only neurosurgery OPD patients, without cross-collaboration with other departments such as orthopedics, possibly missing cases presenting to other specialties. Follow-up data were limited, primarily due to socioeconomic factors and patients not returning after symptom improvement, hindering the assessment of long-term treatment outcomes. The absence of a control group for comparison fur- ther constrains the interpretation of results. The study’s reliance on patient recall for sunlight exposure history is subject to bias and doesn’t account for gender-specific cultural practices (such as different clothing norms for men and women), varied work- ing conditions (indoor versus outdoor occupations), or socioeconomic factors affecting living conditions (like housing types and sunlight availability). Lastly, the exclusion of patients with gastrointestinal disorders and chronic renal failure, known risk fac- tors for osteomalacia, may have led to an underestimation of the full spectrum of the condition in this population. Conclusion In conclusion, this study highlights the significant burden of osteomalacia presenting with neurosurgical symptoms in Khyber Pakhtunkhwa, Pakistan. The findings under- score the need for improved awareness, screening, and management of this condition at both local and international levels. By addressing osteomalacia as a public health priority, we can potentially reduce the burden on specialty care and improve overall population health outcomes. Declarations Ethics approval: This study was conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. The study protocol was approved by the Ethics Committee of Qazi Hussain Ahmad Medical Complex, Nowshera. Consent to participate : Informed consent was obtained from all individual participants included in the study. Consent for publication: Patients signed informed consent regarding publishing their data. Availability of data and materials: The datasets generated and analyzed during the current study, including patient history forms, laboratory reports, X-rays, and select CT/MRI scans, are available from the corresponding author upon reasonable request, subject to appropriate data protection and confidentiality measures. Competing interests : The authors declare that they have no competing interests. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions : Danyal Sadeeq Gumoriani (D.S.G) conceived the study, collected and analyzed data, and drafted the manuscript. Kainat Bashir (K.B) contributed to data collection and analysis. Both authors read and approved the final manuscript. Acknowledgements : The authors would like to thank the staff of the Department of Neurosurgery at Qazi Hussain Ahmad Medical Complex for their support during the study period. We also express our gratitude to the patients who participated in this study. References Takedani K, Notsu M, Koike S, Yamauchi M, Mori T, Sohara E, Yamauchi A, Yoshikane K, Ito T, Kanasaki K. Osteomalacia caused by atypical renal tubular acidosis with vitamin d deficiency: a case report. CEN case Rep. 2021;10(2):294–300. https://doi.org/10.1007/s13730-020-00561-y . Gaillard F, Hacking C, Elfeky M et al. Jul. : Hyperparathyroidism. Reference arti- cle, Radiopaedia.org (Accessed on 22 2024) (2024). https://doi.org/10.53347/rID-1477 Sizar O, Khare S, Goyal A et al. Vitamin d deficiency. In: StatPearls. StatPearls Publishing, Treasure Island (FL) (2024). Updated 2023 Jul 17. https://www.ncbi.nlm.nih.gov/books/NBK532266/ Al-Daghri NM, Yakout S, Sabico S, et al. Establishing the prevalence of osteo- malacia in arab adolescents using biochemical markers of bone health. Nutrients. 2022;14(24):5354. https://doi.org/10.3390/nu14245354 7 . Siddiqee MH, Bhattacharjee B, Siddiqi UR, MeshbahurRahman M. High prevalence of vitamin d deficiency among the south asian adults: a systematic review and meta-analysis. BMC Public Health. 2021;21(1):1823. https://doi.org/10.1186/s12889-021-11888-1 . Holick MF, Chen TC. Vitamin d deficiency: a worldwide problem with health consequences. Am J Clin Nutr. 2008;87(4):1080–6. https://doi.org/10.1093/ajcn/ 87.4.1080S . Zimmerman L, McKeon B. Osteomalacia. In: StatPearls. Stat- Pearls Publishing, Treasure Island (FL) (2024). Updated 2023 Nov 12. https://www.ncbi.nlm.nih.gov/books/NBK551616/ Minisola S, Luciano. Osteomalacia and vitamin d status: A clinical update 2020 (2020) https://doi.org/10.1002/jbm4.10447 8 Additional Declarations No competing interests reported. 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While rickets affects the growing skeleton in children, osteomalacia primarily involves the mature bones in adults. It predom- inantly affects the diaphysis of long bones and vertebrae, as the epiphyseal growth plates have already fused, resulting in distinct clinical and radiological manifestations. Osteomalacia is not a singular disease entity but rather a complex syndrome encom- passing a spectrum of radiographic, biochemical, and histopathological abnormalities affecting bone metabolism and structure. Osteomalacia can be classified into several subtypes based on etiology, including vitamin D deficiency, gastrointestinal disorders, renal tubular acidosis [1], and oncogenic osteomalacia. Each subtype presents unique challenges in diagnosis and management, requiring a tailored approach to treatment. The clinical presentation of osteomalacia is diverse, ranging from subtle bone pain and muscle weakness to more severe manifestations such as pathological fractures, skeletal deformities, and gait disturbances. Patients may also experience extraskeletal symptoms like fatigue, mood changes, and increased susceptibility to infections. These deformities may be overlooked, while diffuse skeletal pain and bony tenderness, along with hesitancy to walk due to fractures of the vertebrae and ribs, are more apparent. Radiological findings in osteomalacia include characteristic pseudofractures, typically seen in weight-bearing bones. Advanced imaging may reveal a generalized decrease in bone density, giving a \u0026rsquo;ground glass\u0026rsquo; appearance, and in severe cases, visible defor- mities of the pelvis and long bones. Pseudo-fractures occur due to mechanical stress from the pulsation of blood vessels over areas such as the pubic rami, femoral neck, outer edge of the scapula, upper fibula, and metatarsals. Radionuclide studies often reveal \u0026rdquo;hot spots\u0026rdquo; over these areas. Subperiosteal erosion may sometimes be seen in cases of secondary hyperparathyroidism along the diaphyseal cortices [2]. In renal tubular acidosis, there is thickening of the cortices and trabeculae of long bones (renal osteodystrophy); however, the osteoid is weak and devoid of proper mineralization. Biochemical markers play a crucial role in diagnosis. Typical findings include low or low-normal serum calcium, decreased serum phosphate, elevated alkaline phosphatase, and low 25-hydroxyvitamin D levels. However, the pattern may vary depending on the underlying cause and disease stage. Management of osteomalacia focuses on addressing the underlying cause and restoring bone mineralization. Treatment typically involves high-dose vitamin D supplementation, with dosages ranging from 50,000 IU weekly to 800\u0026ndash;1000 IU daily [3], depending on disease severity and patient response. Calcium supplementation and correction of any underlying metabolic abnormalities are also crucial components of the treatment plan.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis is an observational descriptive study conducted over 6 months in the Neuro- surgery Department at Qazi Hussain Ahmad Medical Complex, Nowshera. The study included patients diagnosed with osteomalacia after a thorough review, who initially presented to neurosurgery OPD with backache and pain in the extremities, partic- ularly the lower limbs or generalized body aches. Only cases definitively diagnosed with osteomalacia were included, excluding cases with other diseases and conditions. These patients presented with symptoms of neurosurgical problems, and the diagno- sis of osteomalacia was achieved only after careful evaluation and medical testing. Ideally, these patients should have been assessed by primary care physicians, but the study was conducted for academic interest and to benefit the patients who missed the opportunity for early diagnosis. These patients continued to suffer due to inadequate diagnostic and treatment facilities at primary and secondary healthcare levels, with most being referred directly to neurosurgeons and general physicians at tertiary level to be treated for neurosurgical conditions. A detailed one page form was used to col- lect data on age, sex, marital status, literacy level, occupation, number of children in females, breastfeeding history, previous medical and surgical history, and drug history. Special attention was given to the main presenting symptoms, which were compared with plain radiological features. CT scans and MRI were performed in selected cases to exclude concomitant or latent neurosurgical and orthopedic diseases. Laboratory findings were recorded under headings such as hemoglobin levels, ESR, serum calcium levels, serum alkaline phosphatase levels, and serum phosphate levels. All collected data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. A limited number of cases were followed up after appropriate treatment, with the majority not returning once their symptoms were resolved. Patients with gastrointestinal disorders and chronic renal failure were excluded from the study due to their potential confounding impact on the results.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eOut of the total 100 patients diagnosed with osteomalacia, 57% were female and 43% were male, giving a male to female ratio of approximately 1:1.3.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eMale to Female Ratio\u003c/b\u003e These patients belonged to the adult age group with a range of 14 to 50 years, and the mean age was 32 years.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEducational status included 11% illiterate, 32% high school graduates, and 57% college graduates.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEducational Status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSeventy percent were from rural areas, and 30% were from urban locations. Among the female patients, 47.37% were multiparous, 19.30% were nulliparous, 15.79% had no children despite being married, and 17.54% were unmarried.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParity Status among Females\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.37%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNulliparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.30%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried without children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.79%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.54%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSymptoms lasted from 3 to 12 months, with a mean duration of 6 months. Significant past surgical history included spinal surgery in 7% of cases, appendectomy in 5%, and C-section in 12%.\u003c/p\u003e \u003cp\u003eSunlight exposure was adequate in 70% of cases and inadequate in 30%. Hemoglobin levels were less than 10 g/dL in 25% of cases, with normal levels in 75%.\u003c/p\u003e \u003cp\u003eESR was raised above 30 mm/hour in 33% of cases. Serum calcium levels were low in 73% and normal in 27%.\u003c/p\u003e \u003cp\u003eSerum alkaline phosphatase was elevated above 3000 IU in 60.5% of cases and markedly high in patients with fractures.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory Findings 4\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin \u0026iexcl; 10 g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin 10 g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESR \u0026iquest; 30 mm/hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum Calcium (Low)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum Calcium (Normal)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElevated Alkaline Phosphatase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePresenting / Chief Complaint\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplaint\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBackache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeg Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody Aches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights the significant prevalence of osteomalacia presenting with neu- rosurgical symptoms at tertiary level in Khyber Pakhtunkhwa, Pakistan. The findings reveal important demographic and clinical patterns that have implications for both local public health strategies and broader international understanding of osteoma- lacia. Demographics and Risk Factors: The higher prevalence among females (57%) aligns with global trends, as noted in a Al-Daghri NM, Yakout S, Sabico S, et al [4]. Establishing the Prevalence of Osteomalacia in Arab Adolescents Using Biochemical Markers of Bone Health, which found girls to be at greater risk of vitamin D deficiency and osteomalacia in Saudi Arabia.\u003c/p\u003e \u003cp\u003eThe mean age of 32 years in our study population suggests that osteomalacia affects young adults in their prime productive years, potentially impacting economic productivity and quality of life.\u003c/p\u003e \u003cp\u003eThe predominance of rural residents (70%)in our study population raises concerns about healthcare access and nutritional status in rural Khyber Pakhtunkhwa. This disparity echoes findings from a similar study by Siddiqee MH, Bhattacharjee B, Sid- diqi UR, MeshbahurRahman M. High prevalence of vitamin D deficiency among the South Asian adults: a systematic review and meta-analysis [5], which reported a high prevalence of vitamin D deficiency and osteomalacia in Pakistan (73%;95% CI: 63 to 83%) followed by Bangladesh (67%; 95% CI: 50 to 83%), India (67%; 95% CI: 61 to 73%), Nepal (57%; 95% CI: 53 to 60%) and Sri Lanka (48%; 95% CI: 41 to 55%), respectively, due to limited healthcare access and nutritional deficiencies.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e Public Health Implications for Khyber Pakhtunkhwa:\u003c/h2\u003e \u003cp\u003eThe high proportion of patients with inadequate sunlight exposure (30despite living in a sunny region suggests a need for public health education on the importance of safe sun exposure for vitamin D synthesis. Cultural practices, such as full-body coverage in traditional dress, may contribute to this issue and should be addressed sensitively in public health campaigns. The significant number of multiparous women (47.37of female patients) with osteomalacia highlights the need for improved maternal health services and nutritional support during pregnancy and lactation. A targeted intervention for this high-risk group could have substantial impact. The educational status distribution (11illiterate, 32% high school graduates, 57% college graduates) suggests that even educated individuals are at risk, indicating a need for broader public health education across all socioeconomic groups.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eClinical Presentation and Diagnosis:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe presentation of osteomalacia with neurosurgical symptoms underscores the impor- tance of considering metabolic bone diseases in the differential diagnosis of chronic back pain and other musculoskeletal complaints. The high rates of low serum calcium (73%) and elevated alkaline phosphatase (60.5%) in our study population support the use of these markers for screening. However, the normal calcium levels in 27% of cases highlight the need for comprehensive evaluation beyond basic serum calcium testing.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInternational Context and Implications:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eGlobally, osteomalacia remains a significant yet often overlooked health issue. A study by Hollick MF, Chen TC. Vitamin D deficiency, a worldwide problem with health con- sequences [6], found that vitamin D deficiency affects over 1\u0026nbsp;billion people worldwide, with particularly high rates in South Asia, the Middle East, and Africa. Our findings from Pakistan contribute to this global picture and emphasize the need for increased awareness and screening in these regions. The misdiagnosis of osteomalacia as a neu- rosurgical condition reflects a broader issue of fragmented specialty care. A study by Zimmerman L, McKeon B. et al [7]. suggested that patients with osteomalacia should be treated by any speciality that encounters and diagnoses the patient. Our study underscores the need for a more integrated approach to musculoskeletal complaints, particularly in resource-limited settings. The high prevalence of osteomalacia in our neurosurgical hospital population (100 cases in 6 months) suggests that this condi- tion may be significantly underdiagnosed in primary care settings. This aligns with a study by Salvatore Minisola et al [8]., which found that osteomalacia is often missed or misdiagnosed, leading to inappropriate treatments and poor outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eImplement widespread vitamin D screening and supplementation programs, partic- ularly targeting rural and female populations in Khyber Pakhtunkhwa.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDevelop culturally sensitive public health campaigns to educate the population on the importance of safe sun exposure and dietary sources of vitamin D.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEnhance training for primary care physicians and specialists in recognizing and diagnosing osteomalacia, particularly when presenting with atypical symptoms.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStrengthen maternal health services to include routine vitamin D supplementation and nutritional counseling during pregnancy and lactation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConduct further research on the long-term outcomes of patients diagnosed with osteomalacia and the effectiveness of various treatment regimens in the local population.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExplore the potential for fortification of staple foods with vitamin D as a public health intervention, as has been successful in other countries.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eLimitations of this study include its single-center design, which may restrict the gen- eralizability of findings to other regions of Pakistan. A potential selection bias exists due to the inclusion of only neurosurgery OPD patients, without cross-collaboration with other departments such as orthopedics, possibly missing cases presenting to other specialties. Follow-up data were limited, primarily due to socioeconomic factors and patients not returning after symptom improvement, hindering the assessment of long-term treatment outcomes. The absence of a control group for comparison fur- ther constrains the interpretation of results. The study\u0026rsquo;s reliance on patient recall for sunlight exposure history is subject to bias and doesn\u0026rsquo;t account for gender-specific cultural practices (such as different clothing norms for men and women), varied work- ing conditions (indoor versus outdoor occupations), or socioeconomic factors affecting living conditions (like housing types and sunlight availability). Lastly, the exclusion of patients with gastrointestinal disorders and chronic renal failure, known risk fac- tors for osteomalacia, may have led to an underestimation of the full spectrum of the condition in this population.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study highlights the significant burden of osteomalacia presenting with neurosurgical symptoms in Khyber Pakhtunkhwa, Pakistan. The findings under- score the need for improved awareness, screening, and management of this condition at both local and international levels. By addressing osteomalacia as a public health priority, we can potentially reduce the burden on specialty care and improve overall population health outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e This study was conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. The study protocol was approved by the Ethics Committee of Qazi Hussain Ahmad Medical Complex, Nowshera.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e: Informed consent was obtained from all individual participants included in the study. Consent for publication: Patients signed informed consent regarding publishing their data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets generated and analyzed during the current study, including patient history forms, laboratory reports, X-rays, and select CT/MRI scans, are available from the corresponding author upon reasonable request, subject to appropriate data protection and confidentiality measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: Danyal Sadeeq Gumoriani (D.S.G) conceived the study, collected and analyzed data, and drafted the manuscript. Kainat Bashir (K.B) contributed to data collection and analysis. Both authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: The authors would like to thank the staff of the Department of Neurosurgery at Qazi Hussain Ahmad Medical Complex for their support during the study period. We also express our gratitude to the patients who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTakedani K, Notsu M, Koike S, Yamauchi M, Mori T, Sohara E, Yamauchi A, Yoshikane K, Ito T, Kanasaki K. Osteomalacia caused by atypical renal tubular acidosis with vitamin d deficiency: a case report. CEN case Rep. 2021;10(2):294\u0026ndash;300. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s13730-020-00561-y\u003c/span\u003e\u003cspan address=\"10.1007/s13730-020-00561-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaillard F, Hacking C, Elfeky M et al. Jul. : Hyperparathyroidism. Reference arti- cle, Radiopaedia.org (Accessed on 22 2024) (2024). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.53347/rID-1477\u003c/span\u003e\u003cspan address=\"10.53347/rID-1477\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSizar O, Khare S, Goyal A et al. Vitamin d deficiency. In: StatPearls. StatPearls Publishing, Treasure Island (FL) (2024). Updated 2023 Jul 17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK532266/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK532266/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Daghri NM, Yakout S, Sabico S, et al. Establishing the prevalence of osteo- malacia in arab adolescents using biochemical markers of bone health. Nutrients. 2022;14(24):5354. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/nu14245354 7\u003c/span\u003e\u003cspan address=\"10.3390/nu14245354 7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiddiqee MH, Bhattacharjee B, Siddiqi UR, MeshbahurRahman M. High prevalence of vitamin d deficiency among the south asian adults: a systematic review and meta-analysis. BMC Public Health. 2021;21(1):1823. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-021-11888-1\u003c/span\u003e\u003cspan address=\"10.1186/s12889-021-11888-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolick MF, Chen TC. Vitamin d deficiency: a worldwide problem with health consequences. Am J Clin Nutr. 2008;87(4):1080\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ajcn/ 87.4.1080S\u003c/span\u003e\u003cspan address=\"10.1093/ajcn/ 87.4.1080S\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimmerman L, McKeon B. Osteomalacia. In: StatPearls. Stat- Pearls Publishing, Treasure Island (FL) (2024). Updated 2023 Nov 12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK551616/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK551616/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinisola S, Luciano. Osteomalacia and vitamin d status: A clinical update 2020 (2020) \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/jbm4.10447 8\u003c/span\u003e\u003cspan address=\"10.1002/jbm4.10447 8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Osteomalacia, Metabolic bone disease, Chronic backache, Bone pain syndrome, Vitamin D deficiency, Calcium metabolism, Sunlight exposure, Epidemiology of osteomalacia","lastPublishedDoi":"10.21203/rs.3.rs-4788731/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4788731/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eTo assess the neurosurgical presentation of patients suffering from osteomalacia, a potentially preventable and treatable metabolic disease that can mimic neurological discogenic disorders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Duration: \u003c/strong\u003eMay 2023 to November 2023, covering a period of 6 months in the Department of Neurosurgery, Qazi Hussain Ahmad Medical Complex, Nowshera.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design: \u003c/strong\u003eDescriptive observational study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology: \u003c/strong\u003eThis review study includes 100 cases of osteomalacia presenting as discogenic disorder, collected from the Neurosurgery OPD. Data were collected using a custom 1-page form, which included age, sex, marital status, pregnancy history, educational status, main presenting complaints, history of sunlight expo- sure in urban and rural settings,primary work and working condition, duration of symptoms, and history of medical and surgical treatments. Data were sup- plemented with hematological and biochemical profiles, including hemoglobin concentration, ESR, serum calcium, phosphate, and serum alkaline phosphatase levels. Detailed radiological findings, including Looser’s zones, and CT or MRI findings were recorded to exclude other conditions. Patients with biochemical profiles and radiological evidence of osteomalacia were included, while those with other conditions not meeting the criteria were excluded. The data were analyzed according to the set parameters and used for discussion and recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf the 100 patients diagnosed with osteomalacia, 57% were female and 43% were male. The age range was 14 to 50 years, with a mean age of 32 years. Educational status included 11% illiterate, 32% high school graduates, and 57% college graduates. 70% were from rural areas, and 30% were from urban locations. Among female patients, 47.37% were multiparous, 19.30% were non-multiparous, 15.79% had no children, and 17.54% were unmarried. Symptoms lasted 3 to 12 months, with a mean of 6 months. Significant past surgical history included spinal surgery in 7%, appendectomy in 5%, and C-section in 12%. Sunlight exposure was adequate in 70% and inadequate in 30%. Hemoglobin was less than 10 g/dL in 25% of cases, with normal levels in 75%. ESR was raised above 30 mm/hour in 33% of cases. Serum calcium was low in 73% and normal in 27%. Serum alkaline phosphatase was elevated above 3000 IU in 60.5% and markedly high in patients with fractures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eOur study highlights the significant prevalence of osteomalacia in neurosurgical patients, particularly among females, rural residents, and those with lower educational levels. This underscores the need for improved primary healthcare systems and timely referrals. In neurosurgical settings, osteomalacia often presents a diagnostic challenge, as its symptoms can mimic various spinal and neurological disorders. This underscores the importance of maintaining a high index of suspicion and conducting thorough metabolic evaluations in patients presenting with chronic musculoskeletal pain. Diagnostic indicators include low hemoglobin, raised ESR, subnormal serum calcium, and radiological changes. Increased awareness and screening for osteomalacia in patients with gastroin- testinal disorders and renal issues are recommended to prevent misdiagnosis and ensure timely treatment.\u003c/p\u003e","manuscriptTitle":"Neurosurgical Presentations of Osteomalacia: An Analysis of 100 Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-25 16:47:44","doi":"10.21203/rs.3.rs-4788731/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5d48af9-479b-406c-98ec-35d1659681bf","owner":[],"postedDate":"July 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-02T10:54:04+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-25 16:47:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4788731","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4788731","identity":"rs-4788731","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}