News Category: Thoracic Spine

Doctors are working hard to find the best treatment for each and every disease and condition. One way they do this is to compare the results of different treatment methods for a single disease or condition. Scheuermann’s disease has been studied this way.

Scheuermann’s is a back condition with excessive forward rounding or curvature of the spine, called kyphosis. It mainly occurs in the middle section of the back. The cause is unknown, but it develops when three or more vertebrae become wedge shaped. These changes result in deformity.

Treatment is usually based on age and amount of kyphosis. For example, a child or teenager who hasn’t finished growing yet is usually watched carefully and given exercises. A brace may be prescribed. It is most effective when used before the skeleton matures, at about age fourteen. The curve usually measures less than 50 degrees. Normal kyphosis is up to 40 degrees of curvature.

Surgery may be advised for patients with back pain, excessive wedging, and a curve near 70 degrees. The kind of surgery depends on the patient’s age, severity of deformity and curve, and appearance. Sometimes, a patient will be treated with all three methods as he or she grows and matures from an adolescent to an adult.

It’s not easy to compare these three treatment options. Age, severity, and symptoms change over time. The treatment selected reflects these changes. However, doctors report that it’s possible to successfully treat patients with Scheuermann’s kyphosis. The treatment matches the severity of the condition. Using this method, each patient can keep living and working at the same level, even if the back condition gets worse.

Many people are aware of scoliosis, a sideways curvature of the spine. But there is another kind of curvature called kyphosis. Kyphosis is a “C-shaped” curve as seen from the right side of the spine. The person can even look “stooped over.” This is a condition called hyperkyphosis.

The most common cause of hyperkyphosis in the upper spine is Scheuermann’s disease. This condition occurs when the front part of three or more vertebrae in a row become wedge-shaped. Doctors don’t know what causes Scheuermann’s, but the two most likely theories are genetic and mechanical factors.

A genetic or inherited cause hasn’t been proved yet. Scientists haven’t been able to find the exact gene that carries this trait. A report of identical twins with Scheuermann’s supports the idea of genetic cause. Two 14-year-old brothers who are identical twins both have all the signs of Scheuermann’s disease.

In this condition, the curve is greater than 45 degrees, with at least one vertebra wedged 5 degrees or more. One twin has a 48-degree curve. The other has a much larger curve (74 degrees). Each boy has three vertebrae in a row that are wedged. There have been no strains or mechanical loads on the spine in either boy. It’s most likely that these brothers inherited this condition.

Researchers aren’t sure why these two brothers have such different curves. It’s possible that the boy with the larger curve has a mutated or damaged Scheuermann’s gene. If scientists can find the exact gene that causes this deformity, treatment could begin earlier in life. Early treatment could help avoid the possibility of disability later in life.

If you were going to have major back surgery, wouldn’t you want to know what the result might be down the road? Patients with Scheuermann’s disease may be in for some new information on this.

Scheuermann’s disease is a forward curvature of the spine caused by wedging of three or more vertebrae. The excess forward bend is called kyphoscoliosis. The middle part of the back is affected the most, but the spine above and below the curve changes too.

Surgery to correct the curve is the most common treatment when the curve is severe and the back is painful. Doctors are studying when to do the surgery. Some doctors think the earlier, the better.

A recent study from the Netherlands has some new information about this. Based on their results with 23 cases, these doctors suggest that surgery for Scheuermann’s disease should only be done on adults. The curve should be more than 75 degrees (normal is between 20 and 40 degrees). The patient must have pain that doesn’t go away with other medical treatment.

These researchers also found that once the spine is fused, the hardware shouldn’t be removed. Metal plates, rods, and screws are used to hold the spine upright until the bone fuses solidly. When these are removed, the spine loses the correction and collapses. This happens even in patients with solid bone fusion.

Correction of a kyphoscoliosis for Scheuermann’s disease can have good results. The spine can keep its correction so long as the support implants stay in place. If the hardware pushes out and causes pain, it can be revised. The authors of this study think this is a better option than removal.

Every 45 seconds, someone has a fracture of the spine caused by osteoporosis. These are called vertebral compression fractures (VCFs). VCFs occur most often in adults over 65. About one million VCFs occur every year in the United States.

VCFs are very painful and cause spinal deformity. The patient can become stooped forward and lose height. The lungs and intestines have less room to function. Breathing and digestion can even be affected. A loss of independence and possibly even malnutrition can occur.

A new treatment for this problem is being studied. The doctor inserts a special tool called a bone tamp into the vertebra. The tamp has a balloon on the end that can be inflated. This helps pump up the bone to its original height. The bone tamp is then deflated and the cavity formed inside is filled with a bone cement. When the cement hardens, the vertebra is fixed in place. This method of treatment is called balloon kyphoplasty.

This treatment reduces pain and increases movement. The patient’s quality of life quickly improves. Height is restored, thus improving overall health. These benefits remain the same even after a year.

Balloon kyphoplasty is a new treatment for vertebral bone fractures. It’s a safe option that can quickly return older adults who’ve had a VCF from osteoporosis back to normal function.

Scoliosis is a sideways curvature of the spine. It is a condition that often affects growing children, especially teenagers. Sometimes it is caused by another problem that was present first. This is true, for example, in the case of children with muscular dystrophy or cerebral palsy who also have scoliosis.

There is one group of adolescents with scoliosis of unknown cause. This is called adolescent idiopathic scoliosis (AIS). “Idiopathic” means that the cause is unknown. Many studies have been done looking for one single cause or for two or more factors linked together. Finding this will help direct treatment. Avoiding bracing and surgery is the goal.

Researchers have looked at many factors that could cause AIS. They have studied muscles, hormones, nerves, and even the brain as the start of this problem. Genetics has always been suspected. Since AIS occurs more often in families, inheritance may be possible. New technology to study genes is part of new research efforts.

One factor is clearly a part of AIS, and that is growth. Children and teens with AIS are taller than those without AIS. Children under age 12 with AIS grow faster than children the same age but without AIS. However, there are also many children in this age group who grow fast and don’t get AIS. Something must trigger growth and other hormones in the AIS group, but no one knows what it is yet.

Despite many years of study, the cause of AIS is still unclear. Most likely, there are many factors added together that trigger this problem. Early, fast growth and genetics seem to be the most likely triggers. Abnormal brain activity is another possible cause. If doctors could predict who will get scoliosis, early and effective treatment may be possible.

Every year in the United States, nearly half a million people have compression fractures in the bones of the spine (the vertebrae). This type of fracture causes the front part of the vertebrae to break and then collapse. It is most common in people over 70 years old. Postmenopausal women who are not taking hormone replacement therapy and anyone with osteoporosis are also at risk.

When a vertebra collapses, the spine becomes more bent or flexed forward. The person starts to lose height. Until recently, treatment for a collapsed vertebra was limited to bracing, pain medications, and physical therapy. Even with these treatment methods, chronic pain and deformity are common.

Researchers are working on a cement that can be injected into the bone. This procedure is called vertebroplasty. It restores the bone’s strength, but not necessarily its former shape and size. There are some problems with the current cement available. It hardens fast, so the time the doctor has to perform the vertebroplasty is very limited. The cement may also damage nearby tissue.

A new cement made of calcium phosphate cement (CPC) is being tested. First, CPC is tested on cadaver bones, which come from human bodies preserved for study. Using cadaver bones allows researchers to inject the cement and then compress the bone until it breaks. This shows how strong the bone is and how much load can be taken using the new cement (CPC). Then CPC can be used for the actual procedure with greater understanding of its capabilities.

Vertebroplasty relieves pain and helps the patient avoid inactivity. Movement is restored quickly. New cements with fewer problems are being developed. These are more easily injected into the broken bone, restoring its strength.

Between the bones of the spine is a round cushion called the intervertebral disc. The material within the disc can rupture or herniate, putting pressure on nearby spinal nerves. The result is pain and possibly damage to the nerves. The pain may travel down the arm or leg, depending on whether the herniation is in the neck or low back.

Disc herniation usually occurs in the low back, but it can happen anywhere along the spine. Treatment depends on the location of the herniation. Treatment usually begins with anti-inflammatory medication, rest, physical therapy, and nerve blocks. Surgery is an option in some cases.

Surgery is more difficult when the herniation occurs in the middle of the back, or the thoracic spine. Various ways to reach the damaged disc have been tried. A new method called video-assisted thoracoscopic surgery (VATS) is being studied. With this procedure, the patient is positioned on his or her side, slightly tilted forward. The doctor collapses the lung and inserts a tool called an endoscope between the ribs. The endoscope is a flexible tube with a camera on the end that allows the doctor to see inside the body. Using the endoscope, the doctor can find the disc herniation and remove it. Sometimes the doctor will also fuse the bones above and below the injured disc. Finally, the collapsed lung is inflated. The VATS procedure works best for patients who have not had disc surgery before. Patients with the most severe symptoms before surgery often have the best results after surgery.

A new surgery is available for disc herniation in the mid-back area. Using video technology, this surgery only requires a few small incisions rather than fully opening the ribcage. There is less blood loss, less time in the hospital, and less pain. More research is needed to perfect this new method, but the early results are very good.

Traumatic fractures to the middle back are typically treated with surgery. Surgeons implant screws and rods (called instrumentation) to hold the spine in place. With the help of instrumentation, the space between the vertebrae–or disc space–is restored.

But what happens when the instrumentation is taken out? In some cases, the disc between the bones of the spine squeezes through the main body of the vertebrae. This causes the vertebral body to collapse, and the disc space is lost. An exaggerated forward bend of the spine, or kyphosis, results.

A group of doctors tried out a new way to maintain disc space and prevent the vertebral body from collapsing. They tested their method on cadavers (human bodies preserved for study). After doing surgery to stabilize the broken bones, the doctors inserted a balloon-like device into the vertebral body and then inflated the balloon. This created a space inside the broken bone. Calcium-based cement was injected directly into this space.

The doctors believed that once the cement dried, it would preserve the proper alignment of the spine. They had two main questions: Was this procedure possible, and was it safe?

The answers, according to this study, are “yes” and “yes.” The procedure is called vertebroplasty, and it effectively keeps the vertebral body from collapsing.

Cement injection appears to be a safe, effective way to keep the vertebral body sturdy after surgery to stabilize fractures of the middle back. The next step is to test the procedure on live human models.

Scoliosis is a side-to-side curvature of the spine. When it shows up for no aparent reason during youth, doctors call it adolescent idiopathic scoliosis. If your child has this problem, your doctor may prescribe a brace. Braces are usually suggested for people whose bones are still growing, to keep spinal curves from progressing further. While braces seem to have good results for smaller curves, the results for larger curves (greater than 35 degrees) are less predictable. How can you tell whether bracing will work?

Doctors look to X-rays for answers. From X-rays, doctors can see the pattern of the curve or curves, and monitor changes over time. These authors wanted to see whether X-rays could predict the results of bracing for teens with large spinal curves (36 to 45 degrees).

Fifty-one teens were treated with braces. Girls have scoliosis more often than boys, and this was reflected in this study, with 47 girls and four boys participating.

Sixty percent of these teens had good results from bracing. But 40 percent had curves that worsened five or more degrees even with bracing. Half of these teens went on to have surgery. Three years later, a few teens who were initially thought to have good results showed further curvature of the spine and had surgery. This reduced the overall success rate to 45 percent.

Maturity as measured by age and the timing of growth spurt or first period did not affect whether bracing worked. This suggests that bracing may be appropriate for youth at all stages of development.

Some of the teens had a single curve in their upper or low backs. Others had two curves in an S-shape. Bracing had about the same success rate for these groups. For teens with one curve, X-rays didn’t predict treatment results. But for those with double curves, there were a few interesting findings.

The exact pattern of the two curves predicted results from bracing. So did the position of the pelvis with regard to the low back. When the pelvis tilted more than 12 degrees from the low back, teens were less likely to have good results from bracing. The authors suspect that a tilted pelvis creates a poor base of support for a spine that’s already thrown off balance by curves, and this makes treatment tricky. Braces designed to correct the position of the pelvis as well as the spine may help, but more research is needed. 

Can doctors tell whether the brace will prevent further curvature of the spine when the teen is first wearing it? The authors found that, for teens with two curves, a 25 percent correction of the bigger curve during treatment predicted good results from bracing. The amount of time teens wore the brace also made a difference. Teens who wore the brace for more than 18 hours a day avoided further curvature over 80 percent of the time. When time in the brace was reduced just a few hours a day (12-18 hours total), the success rate fell to 50 percent.

The authors hope this information will help doctors decide the best course of treatment for teens with large spinal curves from scoliosis. Depending on the position of the vertebrae and pelvis, bracing may be successful about half of the time. For other patients with large curves, surgery may be necessary.

More than 24 million Americans suffer from osteoporosis. Osteoporosis results in significant bone loss, making the spine vulnerable to vertebral compression fractures, or VCFs. In patients with osteoporosis, the vertebral body can become fractured from something as simple as coughing, twisting, or lifting.

Round in shape, the vertebral body crumbles into the shape of a wedge. The spine angles forward and becomes hunched in appearance. This is called spinal kyphosis. A severe kyphosis can put pressure on the lungs and digestive system, getting in the way of breathing and appetite.

VCFs can be very painful, creating hardships with daily activities. And VCFs can produce a host of spine problems, such as pressure on the nerves or spinal cord. All of these factors point to a 30 percent higher mortality rate for patients who have VCFs.

Treatment for VCFs often includes bed rest, pain medications, and bracing. But the lack of movement that goes along with these treatments can cause even more bone loss.

In 1987, a nonsurgical treatment called vertebroplasty was introduced. In this procedure, cement is injected into the collapsed vertebral body to strengthen the broken bone. Although it effectively reduces pain, this technique doesn’t restore the original height of the vertebrae. Also, the liquid cement is injected under high pressure and commonly leaks into surrounding areas.

This study reports on a new procedure called kyphoplasty. With kyphoplasty, doctors use an instrument that inflates like a balloon to restore the broken vertebra to its original height. The balloon forms a space inside the broken vertebral body. This space is then filled with special bone cement. (The cement is allowed to thicken first, to reduce the chances that it will leak.)

In this study, the kyphoplasty procedure was done on 30 patients. Twenty-four of the patients had tried traditional treatment with no results. The other six had painful VCFs from multiple myeloma, a rare form of cancer affecting cells in the bone marrow. Patients averaged 69 years old. They’d had symptoms for about six months.

After kyphoplasty, nearly all of the patients felt better right away. None felt worse. Questionnaires completed after the procedure showed that patients improved in pain, physical functioning, social functioning, and mental health.

The procedure raised the height of the vertebral body in all cases. In 70 percent of the cases, kyphoplasty restored the vertebra to nearly half its original size. Restoring vertebral height through kyphoplasty is the main advantage over vertebroplasty, which merely fixes the broken bone in place.

During the kyphoplasty procedure, the cement leaked less than 10 percent of the time. When this happened, cement injection was stopped. No problems came from cement leakage afterward.

About seven months later, there were no major complications from the treatment. The authors feel this is a safe, effective treatment for patients with painful VCFs. The procedure seems to give immediate pain relief. It enabled some patients to move around who hadn’t been able to before.

Notably, this study followed patients for only a short time. Longer-term follow-up is needed. The procedure also needs to be tested on a larger group of patients. Because patients with VCFs may improve on their own over time, the results should be compared to those of patients who don’t have any treatment.

Osteoporosis, a problem of low bone density that commonly affects elderly women, seems to be getting a lot of press these days. Most of us know what osteoporosis is but aren’t too familiar with what it does.

Osteoporosis is life changing. It results in pain and a host of health problems. Compression fractures happen when a spine vertebra, weakened and fragile from osteoporosis, collapses on itself from the weight of the body or from minor trauma. This leads to a loss of body height and causes the lungs and intestines to be compressed into a smaller space. Squished lungs don’t work very well. And pressure on the stomach makes for a smaller appetite, resulting in poor nutrition. The pain from the fracture causes people to move less, so they end up loosing their muscle strength and their independence.

There is now a blend of news, both good and bad. The good news is that in the last few years, effective medication has become available to treat osteoporosis. However, it takes some time for the medicine to work, and it can’t completely reverse the problem. Even when the spine bone heals, the fractured vertebra will not have regained its normal height.

Two minimally invasive procedures have been designed to address vertebral compression fractures: vertebroplasty and kyphoplasty. Both involve inserting a needle into the vertebra through the back of the spinal column. Doctors place the needle off to the side to avoid the spinal cord. Using an X-ray screen to see the area, the doctor places the needle into the spot where the fracture is located. In patients treated with vertebroplasty, the surgeon injects a special bone cement directly into the fracture. This procedure holds and strengthens the broken bone. However, it does not restore the normal height of the broken vertebra.

Kyphoplasty goes one step further. It involves placing a hollow tube into the broken vertebra. Then the doctor slides a deflated balloon through the tube. Inflating the balloon helps restore the original height of the broken vertebra. Bone cement is used to fill the space formed by the balloon. When the cement hardens, it fixes the bone in its newly repaired position. By regaining the original height of the vertebra, kyphoplasty helps eliminate pain and “unsquish” the internal organs.

A neurosurgeon usually performs the surgery. Both vertebroplasty and kyphoplasty are becoming readily available around the country. Done in the office or hospital, these procedures aren’t without possible side effects. A small percentage of patients experiences side effects such as increased pain, cement leakage (in vertebroplasty, where the balloon isn’t used), and pressure against the spinal cord. Fortunately, most patients (95 percent) have less pain right away. The need for narcotic pain medication is usually less after the surgery. And people treated by kyphoplasty have improved posture, mainly because the height of the fractured vertebra is regained and kyphosis (the hunched curve of the spine) is reduced.

The Boston brace has been shown to help people with scoliosis when their spinal curve is less than 30 degrees. But most experts have felt the brace couldn’t keep curves over 35 degrees from getting worse. There is agreement that surgery should be held off until the curve reaches 40 degrees, which poses a dilemma when the curve is between 35 and 40 degrees. These curves are too small for surgery and too big to be helped by a brace.

The authors questioned whether the Boston brace could halt curves that were over 35 degrees. They also questioned if the amount of time the brace was worn each day mattered. The study included 45 girls and 5 boys averaging 13 years old. Each patient was prescribed the Boston brace to treat spine curves of 35 degrees or more. They were told to wear the brace 23 hours each day. They had appointments every four to six months to check their spine curves and to see how many hours they actually were actually wearing their braces. When they reached spinal maturity, they gradually stopped using the brace.

Results were compared an average of two years after skeletal maturity and again about 10 years later. By looking back at the patients’ records, the authors found that the Boston brace was effective in preventing large curves from getting worse. This was especially true when patients actually wore their brace for the recommended amount of time each day.
 
Those who wore their brace for more than 18 hours each day had the best results. Their curves actually improved by about 12% from the time they started using the brace. Those wearing the brace less than 12 hours per day showed an increase of almost 14% in the size of their curves.

The conclusions are clear. The Boston brace can help keep large curves from getting worse in patients with scoliosis, especially when it is worn 18 or more hours per day.