Degenerative Scoliosis: a Q & A with neurosurgeon William Taylor
More than half of all adults over the age of 70 have degenerative scoliosis – a curving of the spine that may cause pain, numbness and postural changes that result in decreased height and the appearance of shrinking.
When conservative approaches like physical therapy, steroid injections or bracing do not produce satisfying results, surgery becomes a primary option. A new minimally invasive alternative called lateral lumbar interbody fusion permits certain patients to avoid the current, typical open surgery, and return to everyday activities more quickly.
We asked William Taylor, MD, a neurosurgeon at UC San Diego Health System, to explain the nature of degenerative scoliosis and how some patients can stand a taller, faster.
Q: What causes curvature of the spine as we age?
A: Curvature of the spine may be caused by a number of factors, including fractures, congenital defects and even prior back surgery. In adults, scoliosis is usually related to degenerative disc disease, living longer and conditions such as osteoporosis and osteoarthritis. Everyone’s spine has a slight natural “S” curve, but with degenerative scoliosis, the spine is tilted more than 10 degrees in one direction. Sometimes patients may be teased about getting shorter in older age, but in reality this is a serious health condition that can cause pain and distressing neurological symptoms, such as numbness or tingling in the legs or difficulty taking deep breaths.
Q: How does the new surgical option differ from the current standard of care?
A: This new approach, which emerged about one year ago as part of a broader, on-going progression toward minimally invasive surgery, allows correction of up to 30 degrees per spinal segment in a minimally invasive procedure under general anesthesia. I’m able to make a 3-inch incision on a person’s side near their rib cage. I can then pass instruments through the incision to rebuild the defective portion of the spine with a small permanent implant. I like this approach because I can avoid all of the major organs and structures, such as muscles and ligaments.
In contrast, the other option is a major surgery in which the spine is rebuilt with long incisions in both the front and the back of the patient’s body. With this approach, there is a greater likelihood of trauma, blood loss and complications.
Eligibility for either surgery depends on the severity of the scoliosis. Both are appropriate for different types of patients.
Q: Are there age constraints to these techniques?
A: Because lateral lumbar interbody fusion is designed to be less invasive, it is appropriate for patients of all ages. I have treated patients from the ages of 25 to 80. When the quality of the patient’s life has decreased or if curvature of the spine is so severe that it displaces the internal organs, causing cardiovascular or pulmonary dysfunction, it’s time to consider treatment.
Also in older adults, if the spine is curved so much that the person’s balance is unsettled, there may be an increased risk of falls and fractures. That presents other health risks. By using a less invasive approach, patients may experience decreased pain, a shorter hospital stay, and most important, a quicker return to what was once their normal way of life. Of course there are always risks involved with any surgery. These should be discussed at length with one’s doctor.
The University of California, San Diego School of Medicine announced today that it is a Grand Challenges Explorations winner, an initiative funded by the Bill & Melinda Gates Foundation. Greg G. Goldgof, a graduate student in UC San Diego’s Biomedical Sciences Graduate Program and the Medical Science Training Program will pursue an innovative global health and development research project, titled “Outsmarting Malaria: Developing next generation anti-malarials that prevent the evolution of drug resistance.”
Grand Challenges Explorations (GCE) funds individuals worldwide to explore ideas that can break the mold in how we solve persistent global health and development challenges. Goldgof’s project is one of over 50 Grand Challenges Explorations Round 10 grants announced today by the Bill & Melinda Gates Foundation.
To receive funding, Goldgof and other Grand Challenges Explorations Round 10 winners demonstrated in a two-page online application a bold idea in one of four critical global heath and development topic areas that included agriculture development, neglected tropical diseases and communications.
“I am very appreciative that the Bill & Melinda Gates Foundation has funded my proposal to develop a new technology for drug development to treat malaria,” said Goldgof. “This information will be used to prioritize drug candidates for clinical trials and to identify new malaria drug targets for future therapies.”
Escherichia coli bacteria, magnified 10,000 times
Summer bummer
With hot days ahead, thoughts naturally turn to the cool blue of swimming pools. Alas, not everything floating in those crystalline waters these days turns out to be an inflatable toy. A new report from the Centers for Disease Control surveyed 161 heavily used pools in metro-Atlanta in 2012. They ranged from public pools to pools at private clubs and water parks.
The CDC researchers sampled the pools’ filters, looking at what they contained. Of the 161 tested pools, more than half – 93 or 58 percent – contained Escherichia coli, a bacterium that lives abundantly in the gut of humans and other warm-blooded animals.
For the most part, E. coli is harmless, but some strains are pathogenic and are culprits behind many contaminated food events and recalls. In this case, however, the presence of E. coli is particularly icky since the bacterium is a strong indicator that someone (plural?) didn’t quite make it out of the pool to the restroom.
Actually, the CDC puts an even ickier spin on it, as only science can: “Each person has an average of 0.14 grams of fecal material on their perianal surface that could rinse into the water,” the authors observed (metaphorically).
Public pools had the highest incidence at 70 percent, followed by water parks at 66 percent and private clubs at 49 percent.
On the plus side, the researchers didn’t find any evidence in the pool filters of O157:H7, the E. coli strain most associated with food contamination and illness.
While distinguished in its disgustingness, E. coli wasn’t the most abundant of the microbes found doing the backstroke next to swimmers. That claim fell appropriately to Pseudomonas aeruginosa, a bacterium that causes swimmer’s ear. It was found in 95 of the 161 filter samples, a 59 percent incidence.
The CDC scientists were quick to note their Atlanta survey can’t be generalized to pools everywhere, but they did say the rates of pool-related illnesses nationally have been rising. Part of the problem is pool maintenance, to be sure, but swimmers have to take some of the blame.
“Swimmers have the power and responsibility to decrease the risk for recreational water illnesses by practicing good hygiene,” they wrote, suggesting that people shower thoroughly before entering a pool, take regular restroom breaks followed by another quick shower rinse before re-entering a pool and if you’re suffering from a diarrheal ailment, best stick to lounging in the sun.
Just remember to use sunscreen.
Angelina Jolie and the oncogene
It’s not surprising that Angelina Jolie’s announcement that she had preventive double mastectomy is big news. You can read about it here, here, here and here – among myriad places.
The fact remains, though, that Jolie’s dilemma and decision is far from novel. It’s one faced by many women, almost all without the glare or notice of media.
With that in mind, we reprise a pair of Q&As posed to breast cancer experts at UC San Diego: Teresa Helsten, MD, assistant clinical professor in the School of Medicine’s Division of Hematology-Oncology at Moores Cancer Center and Sarah Blair, MD, associate professor of Surgery at Moores Cancer Center.
Question: Angelina Jolie opted for her surgery based on the fact she carried the BRCA1 oncogene, which reportedly boosted her risk of breast cancer to 87 percent. How can a woman know if she should be tested for this genetic mutation?
Helsten: Above all, any woman (or man, in the case of breast cancer) who is concerned about the possibility of carrying a genetic mutation for breast/ovarian cancer should consult with her physician. Physicians may provide counseling or refer patients to trained genetic counselors for evaluation.
Things that might make a woman think about her risks include the following:
- A family history of breast and other cancers: Think about both sides of the family (mother’s and father’s sides) and think about family members up to and including two generations away (up to and including grandparents or grandchildren). Any family that has two or more members with breast cancer or breast and ovarian cancer on the same side of the family, particularly if anyone has had breast cancer when younger than 50 years old, or has had two separate breast cancers. Any men with breast cancer. Breast cancer and one of the following cancers on the same side of the family: thyroid cancer, sarcoma, adrenal cancer, uterine (endometrial cancer), stomach (gastric) cancer, and leukemia/lymphoma.
- Being from a population at risk: People of Ashkenazi Jewish descent have a higher risk of carrying a BRCA1/2 mutation. Women who are Ashkenazi Jewish may not need to have as strong a family history of breast and other cancers to be considered for testing. However, women of Ashkenazi Jewish descent with no personal or family history of breast cancer are probably not at risk.
Q: Once tested and the gene is present, what are a woman’s options?
Helsten: If a woman is found to carry a genetic mutation that increases her risks of breast and ovarian cancer, there are several things to think about:
What about screening for other family members? A trained genetic counselor or physician can counsel as to who should consider testing and how. When in doubt, other family members can discuss with their own physicians.
Does she want to do anything to reduce her risks of developing breast and ovarian cancer? If so, she will need to discuss carefully with her physician to help make the right decision for her as every case is unique. Options include increased surveillance (which doesn’t lower the risk of cancer, but increases chances of detection); taking risk-reducing medications (e.g., tamoxifen); and surgical removal of breasts and/or ovaries. For example, removal of both breasts by mastectomy reduces the risk of breast cancer by approximately 90-95 percent. These decisions can be very personal and very difficult, but the good news is that they almost never need to be made in a rush. It is worth taking the time to get informed in order to make a decision that is fits the individual.
Q: Does having the genetic mutation for breast cancer mean breast cancer is inevitable?
Helsten: No, cancer is not inevitable, but the risks are usually quite high. Depending on the specific mutations discovered, the lifetime risks of breast cancer for BRCA1/2 carriers are estimated to be 56-84 percent. For ovarian cancer, the lifetime risks are a bit lower. They are estimated to be 36-46 percent for BRCA1 and 10-27 percent for BRCA2 mutation carriers.
Q: Last year, comedian and actress Wanda Sykes underwent a double mastectomy for “stage zero breast cancer.” People are fairly familiar with stages I through IV, which denote the progressive size and spread of a tumor and its likely prognosis. What is stage 0 breast cancer?
Blair: When I counsel my patients, I show them a picture to demonstrate the difference. Basically these tumors start in the duct, which is a tube that drains milk when you breast feed. Tumors that are stage 0 are confined inside the duct and cannot spread outside to other parts of the body. However, if the tumor is left alone they can eventually break through the duct and become invasive. Early treatment prevents spread of the tumor.
Q: Was Sykes’ decision to have a radical mastectomy based on her family history of breast cancer typical for a stage 0 patient?
Blair: Most women are good candidates for breast conservation, which is removal of that area of the breast or lumpectomy plus radiation. I would also recommend the drug Tamoxifen for women with estrogen sensitive tumors. This drug treats the tumor itself and helps prevent future tumors. However, some women do not want to take Tamoxifen because of its side effects. For the average woman with stage 0 their lifetime risk of developing a second cancer in either breast is 20 percent. Some women with a strong family history of breast cancer, i.e. multiple relatives with breast cancer, may have a higher risk of a second cancer, particularly if they are diagnosed at a young age. These women may consider more aggressive surgical treatment to prevent future cancers. Typically, most women do not have radical surgery but those that do have much better cosmetic outcomes than in the past.
Q: Does a diagnosis of stage 0 mean that the cancer is 100 percent curable?
Blair: Unfortunately, nothing is 100 percent in medicine but there is a high likelihood of being cured. The chance of being cured depends on the size of the tumor and its appearance under the microscope or grade. In general the chance of being cured is greater than 90 percent.
Photo courtesy of AP
Separated from its originating tumor and wandering in either the blood or lymphatic system, “circulating tumor cells” may become metastatic precursors to new tumors elsewhere in the body. In this scanning electron micrograph, a single CTC is trapped on a microchip. Image courtesy of Mehmet Toner and Daniel Haber, Massachusetts General Hospital/Cell.
Tumor-Activated Protein Promotes Cancer Spread
Researchers at the University of California, San Diego School of Medicine and UC San Diego Moores Cancer Center report that cancers physically alter cells in the lymphatic system – a network of vessels that transports and stores immune cells throughout the body – to promote the spread of disease, a process called metastasis.
The findings are published in this week’s online Early Edition of the Proceedings of the National Academy of Sciences.
Roughly 90 percent of all cancer deaths are due to metastasis – the disease spreading from the original tumor site to multiple, distant tissues and finally overwhelming the patient’s body. Lymph vessels are often the path of transmission, with circulating tumor cells lodging in the lymph nodes – organs distributed throughout the body that act as immune system garrisons and traps for pathogens and foreign particles.
The researchers, led by principal investigator Judith A. Varner, PhD, professor of medicine at UC San Diego Moores Cancer Center, found that a protein growth factor expressed by tumors called VEGF-C activates a receptor called integrin α4β1 on lymphatic vessels in lymph node tissues, making them more attractive and sticky to metastatic tumor cells.
“One of the most significant features of this work is that it highlights the way that tumors can have long-range effects on other parts of the body, which can then impact tumor metastasis or growth,” said Varner.
Varner said α4β1 could prove to be a valuable biomarker for measuring cancer risk, since increased levels of the activated protein in lymph tissues is an indirect indicator that an undetected tumor may be nearby.
She said whole-body imaging scans of the lymphatic network might identify problem areas relatively quickly and effectively. “The idea is that a radiolabeled or otherwise labeled anti-integrin α4β1 antibody could be injected into the lymphatic circulation, and it would only bind to and highlight the lymphatic vessels that have been activated by the presence of a tumor.”
Varner noted that α4β1 levels correlate with metastasis – the higher the level, the greater the chance of the cancer spreading. With additional research and clinical studies, doctors could refine treatment protocols so that patients at higher risk are treated appropriately, but patients at lower or no risk of metastasis are not over-treated.
The researchers noted in their studies that it is possible to suppress tumor metastasis by reducing growth factor levels or by blocking activation of the α4β1 receptor. Varner said an antibody to VEGF-R3 is currently in Phase 1 clinical trials. An approved humanized anti-α4β1 antibody is currently approved for the treatment of multiple sclerosis and Crohn’s disease. Varner said her lab at UC San Diego Moores Cancer Center is investigating the possibility of developing one for treating cancer.
CDC-Recommended Non-Profit Launches “MotherToBaby CA” In Time for Mother’s Day
Experts Provide Free Answers about Medications and More during Pregnancy and Breastfeeding
As Mother’s Day approaches, the University of California, San Diego School of Medicine announces MotherToBaby CA, the new name of its free, statewide counseling service that connects experts in the field of birth defects research with moms-to-be and the general public. MotherToBaby CA was formerly known as the California Teratogen Information Service (CTIS) Pregnancy Health Information Line and is housed at the Center for the Promotion of Maternal Health and Infant Development, a division of UC San Diego and Rady Children’s Hospital.
MotherToBaby CA is an affiliate of the international non-profit Organization of Teratology Information Specialists (OTIS), a prestigious professional society that supports and contributes to worldwide initiatives for teratology education and research. MotherToBaby affiliates and OTIS, which are suggested resources by many agencies including the Centers for Disease Control and Prevention (CDC), are dedicated to providing evidence-based information to mothers, health care professionals, and the general public about medications and other exposures during pregnancy and while breastfeeding.
“In addition to my primary health care provider, MotherToBaby experts offered me an added layer of support by giving me an individualized risk assessment,” said Pamela Salgado, a San Diego resident who called the service when she was thinking about getting pregnant. She had questions about the safety of a long-term medication she was taking and its potential risks during pregnancy. “Afterwards, I felt informed and empowered to make smart decisions about my health. Today, I have a healthy three-year-old boy.”
All North Americans can be connected with MotherToBaby experts toll free through its phone counseling service 866-626-6847 or online at MotherToBabyCA.org, where a private, online chat counseling service is also offered.
A prostate cancer cell
Just say nay to a PSA
Late last week, the American Urological Association announced that it no longer thinks men under the age of 55 should be routinely screened for prostate cancer with a prostate-specific antigen test or PSA.
For men between 55 and 69, it said, testing frequency should be based on a careful weighing of risks and benefits, a discussion best done with a doctor. For men over the age of 80, no testing is recommended. (Prostate cancer tends to be a slow-moving disease. After age 80, you’re more likely to die from something else.)
The AUA’s declaration, made during its annual national meeting in San Diego, marks a notable reversal of course. Two years ago, when the advisory U.S. Preventive Services Task Force released a preliminary report suggesting healthy men not be routinely screened with a PSA test, the AUA vehemently objected, and continued to do so as late as May of last year in various official statements.
Its position at that time was simple: While nobody would argue the PSA is a perfect test – misreadings can result in painful, unnecessary biopsies which may exacerbate cancer risk – it was the best test available, and had been used effectively to detect early-stage prostate cancer in thousands of men, perhaps saving their lives.
According to the AUA, the new guidelines are based upon a review of published scientific literature, rather than the Task Force’s collective medical opinion. The urology organization determined that at least for men ages 55 to 69, the test might measurably reduce their mortality rate of prostate cancer, which currently kills an estimated 30,000 American males each year. For everybody else, its efficacy is more debatable.
“There is general agreement that early detection, including prostate-specific antigen screening, has played a part in decreasing mortality from prostate cancer,” said Dr. H. Ballentine Carter, who chaired the panel that developed the guideline. “The randomized controlled trials are more mature at this point and there is more data available today than there was in 2009. It’s time to reflect on how we screen men for prostate cancer and take a more selective approach in order to maximize benefit and minimize harms.”
Listeria monocytogenes,
Killing cancer with radioactive microbes
The war on cancer is waged on many fronts, with many weapons, from chemotherapy and nanoparticles to monoclonal antibodies and targeted ultrasound.
In a new commentary published this week in PNAS, Aladar A. Szalay, PhD, in the Department of Radiation Oncology at UC San Diego Moores Cancer Center, and colleague Jochen Stritzker discuss a new (sort of) approach: Microorganisms carrying radioactive antibodies that infiltrate and kill cancer tumors and cells.
To be completely accurate, the work, described in the May 6 online issue of PNAS by Wilber Quispe-Tintaya and colleagues at Albert Einstein College of Medicine in New York City, is not entirely new. In 2009, Robert Hoffman, PhD, in the Department of Surgery at UC San Diego School of Medicine and colleagues reported on experiments with engineered salmonella bacteria, showing that it can kill mouse cancer cells, including metastases of pancreatic cancer.
But the latest Einstein College research is encouraging. It uses a different microorganism – an attenuated or weakened version of Listeria monocytogenes, a food-borne pathogen responsible for listeriosis - to which scientists attach radiolabeled antibodies, then inject the combination into mice with cancer. The reported results have been notable.
In mice injected with just the live L. monocytogenes, primary tumors were reduced in size by 20 percent and metastatic burden – the presence of cancer cells in the body – dropped by 40 percent. Mice injected with just the antibodies experienced no therapeutic effect. In combination, however, the bacteria-and-antibodies treatment reduced primary tumor size by 60 percent and detectable metastases by more than 90 percent.
Just as important, the approach showed no harmful side effects on healthy tissues or liver function. Szalay and Stritzker say the results should stimulate further experimentation, perhaps expanding to other bacteria and viruses with a particular preference and ability to infect and replicate in cancer cells, such as Escherichia coli.
UC San Diego Health System Receives National Achievement Award for Cancer Program
American College of Surgeons’ Commission on Cancer Recognizes Quality Care
UC San Diego Health System is a recipient of the 2012 Outstanding Achievement Award from the American College of Surgeons’ Commission on Cancer. Seventy-nine cancer care programs—three in California—received this national award based on excellence in providing quality care to cancer patients.
“These 79 cancer programs, surveyed in 2012, currently represent the best of the best—so to speak—when it comes to cancer care,” said Daniel P. McKellar, MD, FACS, chair of the Commission on Cancer. “Each of these facilities is not just meeting nationally recognized standards for the delivery of quality cancer care, they are exceeding them.”
Established in 2004, the honor was awarded to only 19 percent of the cancer care programs surveyed in 2012. The award is designed to recognize quality cancer care and to help patients make an informed decision on where to seek superior treatment.
UC San Diego Moores Cancer Center is recognized as an innovative leader in cancer treatment and research. Home to 413 physicians and scientists, it employs a multidisciplinary team approach to patient care that includes surgical oncology, medical oncology, gynecologic oncology, radiation oncology, pathology, diagnostic radiology, interventional radiology, palliative care, integrative medicine, psychology and nutrition.
“This award distinguishes us as part of an elite group of cancer programs in the United States that are being recognized for providing the highest quality cancer care,” said Jason Sicklick, MD, FACS, surgical oncologist and UC San Diego’s cancer liaison physician to the Commission on Cancer. “It highlights our multidisciplinary approach and allows us to share our best practices with other institutions in order to improve patient care not only in San Diego, but nationwide.”
Human lungs are composed of roughly 700 million of tiny, elastic air sacs called alveoli that pass oxygen into the body and remove carbon dioxide from it. Photo courtesy of David Gregory and Debbie Marshall, Wellcome Images
Bad fad
The “cinnamon challenge” doesn’t sound ominous: You’re supposed to attempt to swallow a tablespoon of ground cinnamon within 60 seconds without drinking any fluids. How bad can that be?
Bad enough.
In a recent paper in Pediatrics, researchers at the University of Miami describe what happens next: the ingested spice triggers a severe gag reflex, with immediate coughing, the sensation of burning in the mouth and likely vomiting.
All of which are apparently quite amusing to watch, judging from the popularity of Internet videos depicting kids (no surprise) attempting the challenge. In their paper, the University of Miami scientists reported at least 51,100 YouTube clips depicting people taking the challenge.
“One video was viewed more than 19 million times, predominantly by 13- to 24-year-olds, ages similar to people taking the Cinnamon Challenge and associated with the greatest need for conformity,” the researchers wrote.
If gagging and looking foolish were the sole results of swallowing a spoonful of cinnamon that would be one thing, but doctors say the health risks are much more serious: Inadvertently inhaling the ground cinnamon can result in choking, aspiration and pulmonary damage. Scores of challenge-takers have found themselves calling poison control centers, visiting emergency rooms - some have been hospitalized for collapsed lungs.
Cinnamon should be eaten, not inhaled. It’s a caustic power composed of cellulose fibers that do not dissolve or degrade in the lungs. The Miami scientists found no studies of cinnamon inhalation in humans, but did find one with rats. Inhaling the spice inflamed the rats’ lungs, predisposing delicate air sacs called alveoli and lung passages to lesions, thickening, loss of elasticity and scarring.
Scientists say that in people, the effects of inhaled cinnamon appear to be temporary and probably do not increase the risk of long-term damage, but in some they may trigger serious allergic reactions, including asthma, or worsen other existing lung conditions.
