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Thread: Scoliosis in the News

  1. #1
    Join Date
    Sep 2003
    Northern California

    Scoliosis in the News

    UCSD Patient Finds Relief with New Minimally Invasive Surgery for Back Pain

    Floyd Ross knew he had to do something about his lower back pain. It was limiting his pursuits and getting in the way of his retirement, volunteer activities and golf. Besides that, he recently married and wanted to be able to enjoy life with his new bride.

    “The pain was so bad, I had to do something, but I also knew I didn’t want to undergo traditional open-back spine surgery that can take six months for recovery. I’m 86. I don’t want to waste that much time,” Ross says.

    Instead Ross sought the help of William Taylor, M.D., a UCSD Healthcare neurosurgeon, and underwent a new minimally invasive treatment for chronic back pain at UCSD Medical Center.

    “We’re doing a few new procedures here. The one Mr. Ross had, MaXcess Transformal Lumbar Interbody Fusion (TLIF) goes through the back but uses a smaller incision than traditional back surgery and causes minimal disruption to the muscle tissue surrounding the spine,” Taylor says. “The other procedure, Extreme Lateral Interbody Infusion (XLIF), unlike traditional back surgery, accesses the spine through the patient’s side, which avoids disrupting major back muscles and tissues. In both surgeries, patients resume walking in a few days, with a typical four-six week recovery. The procedures are safe, effective and much less invasive.”

    An estimated 10 million adults annually suffer from chronic back pain, a condition that can limit activities. Most choose traditional back surgery but now patients have new options.

    Surgeons such as Taylor decide upon which procedure to use based on the patient’s case and needs. Taylor likes to use XLIF when appropriate because the novel side approach to the disc and lumbar vertebral bodies allows more direct access to the spine without causing trauma to surrounding structures.

    Both the XLIF and MaXcess TLIF procedures engage sensors that alerts Taylor if his probe is approaching one of the nerves running through the muscle, so he can steer around it. Additionally with these new procedures, the incisions are much smaller than those in traditional back surgeries. Taylor accesses the spine through two one-inch incisions compared to the five-inch incisions necessary with traditional open back surgery. This results in minimal tissue disruption and shorter hospital stays and recovery time. Patients spend only one night in the hospital compared to the five nights typical of traditional back surgery patients.

    Although there is no restriction as to age, gender or prior surgical history, Taylor advises some patients may not be appropriate for the surgery. He suggests interested patients schedule an appointment to discuss individual cases.

    Ross has no regrets he took the new minimally invasive route. He was back on his feet in days, pain-free. Although he hasn’t hit the greens yet, he plans to give his golf clubs a workout soon.

  2. #2
    Join Date
    Sep 2003
    Northern California

    Scoliosis: What treatments may lie ahead?

    They check for scoliosis in school, examining the backs of young adolescents for signs of spinal curvature. Occasionally, because the incidence is 1 percent to 2 percent of the population worldwide, they find it.
    The good news is that "the majority of scoliosis never reaches a level where it has to be treated," said Dr. John T. Braun, an orthopedic surgeon who is an assistant professor in the University of Utah School of Medicine's Department of Orthopaedics and principal Utah investigator on a number of scoliosis studies and clinical trials.
    That's good, he said, because treatment can accomplish a lot — or very little. And it's nearly impossible to predict whether the curve will get bigger, whether bracing will be effective, whether surgery may turn out to be the best option. It's a medical problem with few clear answers, and making a prognosis early is murky business indeed.
    Still, promising changes are near the horizon, he said, from a gene test to identify cases and perhaps indicate how severe the scoliosis will become as the patient grows, to better surgical techniques that still allow spine flexibility, something fusion surgery removes.
    The U. Orthopaedic Center is one of 59 institutions across the world working together to unlock mysteries of scoliosis and improve treatment. Together, they are the Spinal Deformity Study Group, which meets twice a year and collaborates in between. Besides looking at what has happened to patients who have already been treated, they're focusing on the future, based on what works best now and what can be done to improve even that.
    Do you operate on the front or the back of the spine? Do you use screws or hooks? This age or that? "Everyone has an opinion," Braun said. So researchers worldwide are entering data into a database to share and compare information. More than 50 different publications have come out of the group's work. And they're standardizing such things as how X-rays are taken or the use of force plates on the feet to see the center of body mass.
    The collaboration also means there's an international pool of talent waiting to test and validate whatever any of them find.
    One of the biggest current problems is that diagnosis is made only after scoliosis is severe enough to be seen. And no one can tell whether it will get worse. So when a child is diagnosed with scoliosis, at a minimum it will mean years of follow-up, with X-rays every six months to monitor spinal curvature.
    That's how the future looks right now for Lily Clark, who has just been fitted with a brace that covers her entire torso. Although it's cute, patterned with little elephants and lions, it's still a brace that restricts her movement and sometimes pinches.
    When she was 3 months old, her mother, Guenever Parsley, a nurse at the U., noticed the curve in her baby's spine. Subsequent tests confirmed Parsley's suspicions.
    Mild curvature, 10 degrees or less, doesn't require treatment. A brace is typically considered if the curve is 20 to 30 degrees. That's the range that Lily was in, although hers "jumped" from the low 20s to almost 35 degrees. With a 40- to 50-degree curve, surgery is likely; above that it's mandatory.
    Doctors try to keep treatment as unintrusive as possible. Frankly, Braun said, it's pretty brutal, a lot to put a child or teen through. Fortunately, it's improving. Braun did the first minimally invasive scoliosis surgery three years ago, using a small camera to see.
    It would be easier to choose a treatment if you knew what was on the line. "The diagnosis is not always clear. We follow tons who never need treatment, but we have to be diligent."
    Although a brace isn't intrusive, it's uncomfortable. And it can have psychological impact. The numbers aren't a fun sell, either.
    About half of those who wear a brace 23 hours a day, years on end, will maintain their curve so that it doesn't get worse. That's a success story. The brace doesn't permanently reshape the spine. Rather, it straightens it enough so that when it eventually is removed and the curvature begins to return, it just goes back to where it started or very slightly worse, preventing massive deformity. Another quarter will get worse, even with the brace. The final 25 percent would not have gotten worse, even without the brace.
    But who fits which category is a mystery until treatment is tried.
    Those numbers are clearly disheartening to Parsley and Bert Clark, Lily's dad, who have lots of questions. At what point, they wonder, do you consider using staples to guide the spine or surgery or some other treatment?

    see next reply for remaining text...

  3. #3
    Join Date
    Sep 2003
    Northern California
    continued from prior reply...

    Doctors used to fuse spines on very young children, who still had a lot of growing left to do. Decades ago, Braun tells Parsley and Clark, doctors didn't see the long-term ramifications. A fused spine stops lengthening as the child grows, but organs like the heart and lungs continue to grow. Surgeons years ago would fuse long sections of the spine, then congratulate themselves that they had straightened it. It was the pulmonologist who, years later, provided the follow-up. A child fused at 6 became a 16-year-old on oxygen who died in her 20s, if she lived that long.
    That's a problem well recognized and avoided nowadays, said Dr. James Ogilvie, scoliosis expert and surgeon at Shriners Hospital. "Many children have serious deformity before age 10, and those you do not want to fuse."
    Fusion also eliminates motion and function, something that discs in the spine, which have no blood supply, need. Motion signals the body to provide nutrients to the discs.
    Besides that, when part of the spine can't move, the function is transferred to another area, an adjacent segment of spine, and that degenerates.
    Not treating a severe curvature is no option, either. "A big thoracic curve can be painful. It can create trunk imbalance," a sort of listing to one side, Braun said. And it crowds the organs, reducing heart and lung function." The effect is to crowd one side of the chest with the bony curve of spine while organs on the other side gets squished.
    Braun tells Clark and Parsley to stick with the brace for now. The near future, he says, holds promise that simply isn't there today.
    He believes surgery within a year or two will allow a physician to guide growth of the spine straight without the trauma and invasiveness, using an arthroscope and devices even now in development that are fusionless, meaning the spine does not have to be made rigid. He's spent eight years testing and refining such devices, and others are also working on it.
    He often collaborates with Ogilvie, his long-time mentor. Ogilvie designed a staple for use in the spine. The latest version is made of shape-memory alloy, which returns to its original shape at a certain temperature. In its first major study in 2003 at a Shriners Hospital in Philadelphia it "showed nice results for children."
    That's still not ideal, Ogilvie and Braun agree, because a spine moves and that asks for a staple to fail, kind of like twisting a staple on a stack of papers and expecting it to hold.
    Now Braun's working on a bone anchor with hollow threads that screws into the bone, which would then grow into it and around it, making it part of the body for a very strong joining. That bone anchor has been tested in pre-human trials with a ligament loop that allows the surgeon to tether the spine to correct the curvature without taking away the spine's mobility.
    Even that's "clumsy" compared to what children need, Braun said.
    He believes the best solution will be found in genetic study. Genes make proteins that come out of cells and "if we could figure that out, we could attack this much more elegantly."
    Five years ago, Braun began a genetic study of scoliosis, and now researchers know the region of the human genome where the deformity starts.
    He and Ogilvie hope their work with a company called Axial Biotech will lead to a gene test that would tell even before symptoms appeared whether someone had the gene for scoliosis. "It would be nice to say we have a cheek swab" to test for it, Braun said. That would be a huge help to large families. If someone has a child with scoliosis, all the children are followed because of the genetic component in 80 percent of scoliosis cases. A gene test could save siblings from exams they may not need.
    The disease is five times more common in females. The fact that fewer males have it may mean that "boys have something protective" that girls lack. It appears to follow an autosomal dominant pattern of inheritance.
    Ogilvie and Braun believe a genetic test will say a lot about how severe the scoliosis will ultimately be. Perhaps, Braun speculates, something in the body that preserves symmetry goes awry with scoliosis, and that could be exploited for treatment.
    Maybe it would mean adding a dietary treatment like folate, as is done with certain metabolic diseases. Perhaps it would work like an insulin pump with diabetes, some substance added to correct something that's missing or misdirected. "It has to be some cellular and protein alteration" that could be treated, he said.
    "Scoliosis is a disease that begs to be impacted in as many ways as possible — friendlier interventions, cellular, pharmacological . . . ."
    People are taking one of two approaches to scoliosis, Ogilvie said, either "mechanical with bigger rods and hooks and screws and fusion — or genetic, and there are few people involved in the latter. Right now, mechanical is all we have."
    Still, as second, third, even fourth generations of mechanical "fixes" travel through the process of becoming marketable, Ogilvie predicts that the gene test and subsequent treatment will get there first.
    So although Lily's parents worry about a treatment plan that seems to stretch out indefinitely, with its time off for appointments and the fitting and refitting for a new brace as she grows, the expense, the sheer frustration of not knowing the outcome early, Braun encourages them to give the brace a chance to help the little girl — and to buy her time until something better comes along.
    It will come, he promises.

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