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.

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.

Nanoparticles of porous silicon, each 100 times smaller than a human hair, might be used as injectable microscopic reservoirs of therapeutic drugs. The surface of the particles can be coated with targeting molecules. Image courtesy of Chia-Chen Wu, UC San Diego. 
Small minded
DARPA, the U.S. Defense Advanced Research Projects Agency, has awarded $6 million to a multi-institutional team of researchers to develop nanotechnology therapies for the treatment of traumatic brain injury.
Led by Professor Michael J. Sailor, PhD, from the University of California San Diego, the project team seeks to use nanoparticles and similar approaches to deliver therapeutics to injured brains and reduce infections.
Ballistics injuries that penetrate the skull have amounted to 18 percent of battlefield wounds sustained by men and women who served in the campaigns in Iraq and Afghanistan, according to the most recent estimate from the Joint Theater Trauma Registry, a compilation of data collected during Operation Iraqi Freedom and Operation Enduring Freedom.
“A major contributor to the mortality associated with a penetrating brain injury is the elevated risk of intracranial infection,” said neurosurgeon  Clark C. Chen, MD, PhD, of the  UC San Diego Health System, noting that projectiles drive contaminated foreign materials into neural tissue.
Under normal conditions, the brain is protected from infection by a physiological system called the blood-brain barrier. “Unfortunately, those same natural defense mechanisms make it difficult to get antibiotics to the brain once an infection has taken hold,” said Chen. Watch a video and read the entire news release here.

Nanoparticles of porous silicon, each 100 times smaller than a human hair, might be used as injectable microscopic reservoirs of therapeutic drugs. The surface of the particles can be coated with targeting molecules. Image courtesy of Chia-Chen Wu, UC San Diego.

Small minded

DARPA, the U.S. Defense Advanced Research Projects Agency, has awarded $6 million to a multi-institutional team of researchers to develop nanotechnology therapies for the treatment of traumatic brain injury.

Led by Professor Michael J. Sailor, PhD, from the University of California San Diego, the project team seeks to use nanoparticles and similar approaches to deliver therapeutics to injured brains and reduce infections.

Ballistics injuries that penetrate the skull have amounted to 18 percent of battlefield wounds sustained by men and women who served in the campaigns in Iraq and Afghanistan, according to the most recent estimate from the Joint Theater Trauma Registry, a compilation of data collected during Operation Iraqi Freedom and Operation Enduring Freedom.

“A major contributor to the mortality associated with a penetrating brain injury is the elevated risk of intracranial infection,” said neurosurgeon Clark C. Chen, MD, PhD, of the UC San Diego Health System, noting that projectiles drive contaminated foreign materials into neural tissue.

Under normal conditions, the brain is protected from infection by a physiological system called the blood-brain barrier. “Unfortunately, those same natural defense mechanisms make it difficult to get antibiotics to the brain once an infection has taken hold,” said Chen. Watch a video and read the entire news release here.

Ithaar Derweesh, MD, urologic oncologist, UC San Diego Moores Cancer Center.
Kidney Sparing Surgery Underutilized for Patients Who Need It MostResearchers at the University of California, San Diego School of Medicine have released study results that show national treatment trends in the surgical management of patients with kidney disease. The study found that partial and complete kidney removal (total nephrectomy) and energy-based techniques to destroy tumors are all on the rise. Surprisingly, the patients most in need of kidney-sparing surgery are still more likely to undergo total nephrectomy. The findings recently published online in BJU International.“While the overall proportion of patients receiving kidney preserving treatments for localized kidney tumors continues to grow, the most significant, and perhaps unsettling finding was that patients with kidney insufficiency still undergo complete kidney removal – even though kidney preserving treatment may be indicated,” said senior author Ithaar Derweesh, MD, urologic oncologist at UC San Diego Moores Cancer Center.The kidney is a vital organ which performs a variety of functions in addition to making urine. It controls blood pressure, bone health, and also makes a hormone to tell the bone marrow to produce red blood cells. Kidney insufficiency is characterized by a progressive decline in kidney function which may affect all of these actions.“The study, which examined procedures over a 10-year period, found that patients with chronic kidney insufficiency had an almost two-fold higher probability of undergoing total nephrectomy than kidney preserving treatments, such as partial nephrectomy or tumor ablation,” said Derweesh, a pioneer in minimally invasive kidney surgery.Derweesh added that further investigation is needed to confirm these findings, and to examine what factors are responsible for patient and physician selection of treatment for kidney cancer. He noted that in the case of small renal masses less than four centimeters in size, partial nephrectomy has equivalent outcomes to total nephrectomy, and that ablation techniques, such as cryoablation or radiofrequency ablation, and observation are valid options for select patients.  
More here

Ithaar Derweesh, MD, urologic oncologist, UC San Diego Moores Cancer Center.

Kidney Sparing Surgery Underutilized for Patients Who Need It Most

Researchers at the University of California, San Diego School of Medicine have released study results that show national treatment trends in the surgical management of patients with kidney disease. The study found that partial and complete kidney removal (total nephrectomy) and energy-based techniques to destroy tumors are all on the rise. Surprisingly, the patients most in need of kidney-sparing surgery are still more likely to undergo total nephrectomy. The findings recently published online in BJU International.

“While the overall proportion of patients receiving kidney preserving treatments for localized kidney tumors continues to grow, the most significant, and perhaps unsettling finding was that patients with kidney insufficiency still undergo complete kidney removal – even though kidney preserving treatment may be indicated,” said senior author Ithaar Derweesh, MD, urologic oncologist at UC San Diego Moores Cancer Center.

The kidney is a vital organ which performs a variety of functions in addition to making urine. It controls blood pressure, bone health, and also makes a hormone to tell the bone marrow to produce red blood cells. Kidney insufficiency is characterized by a progressive decline in kidney function which may affect all of these actions.

“The study, which examined procedures over a 10-year period, found that patients with chronic kidney insufficiency had an almost two-fold higher probability of undergoing total nephrectomy than kidney preserving treatments, such as partial nephrectomy or tumor ablation,” said Derweesh, a pioneer in minimally invasive kidney surgery.

Derweesh added that further investigation is needed to confirm these findings, and to examine what factors are responsible for patient and physician selection of treatment for kidney cancer. He noted that in the case of small renal masses less than four centimeters in size, partial nephrectomy has equivalent outcomes to total nephrectomy, and that ablation techniques, such as cryoablation or radiofrequency ablation, and observation are valid options for select patients. 

More here

Man Walks Again After Surgery to Reverse Muscle Paralysis

After four years of confinement to a wheelchair, Rick Constantine, 58, is now walking again after undergoing an unconventional surgery at University of California, San Diego Heath System to restore the use of his leg. Neurosurgeon Justin Brown, MD, performed the novel 3-hour procedure.

“Following a car crash, Mr. Constantine had a brain stem stroke that caused paralysis on the right side of his body.  His leg muscles became so severely spastic that he could not walk,” said Brown, director of the Neurosurgery Peripheral Nerve Program at UC San Diego Health System. “Our team performed a delicate surgery to reduce input from the nerves that were causing the muscles to over contract to the point of disability.”

“After my injury, I was told I would never walk again. All I could to was move from my wheelchair to my bed or a chair,” said Constantine, a former NASCAR crew member. “After surgery with Dr. Brown, I could put my foot flat on the ground to walk. With physical therapy, everything just gets better and better. I’m a firm believer in never giving up.”

Prior to surgery, Constantine underwent botox treatments and physical therapy in an attempt to restore the use of his leg. The results were positive but minimal. An additional nerve conduction study, called an electromyogram (EMG), identified the muscles causing the dysfunction.

“When all other options did not produce satisfying results, we opted for surgery,” said Brown. “With the EMG, we identified the over-excited nerves that needed to be downgraded. Mr. Constantine had surgery on a Friday and within days was in physical rehabilitation. Two weeks later he was walking without a walker and has even completed a 1-mile race without assistance.”

The surgery, called a selective peripheral neurotomy, is a procedure performed under a microscope.  Brown makes an incision behind the knee to reach the tibial nerve. He then selectively trims back the troublesome nerve branches by up to 80 percent.  Cutting the nerve reduces the “noise” being relayed back to the spinal cord which causes the spasticity.

More here

Alternative Hip Replacement Technique Results in Faster RecoveryOnly 15 Percent of Joint Replacement Specialists in Nation Capable of Muscle-Sparing Approach
 University of California, San Diego Health System is one of only a few hospitals in the nation to offer computer-assisted navigation technology with the direct anterior hip replacement technique, potentially resulting in less pain, faster recovery and fewer dislocations for patients with osteoarthritis and other forms of degenerative joint disease. 
Only 15 percent of the top joint centers in the United States have the expertise and technological capability to perform an anterior hip replacement, where the incision is made in the front (anterior) of the hip as opposed to the side (lateral) or back (posterior).  The anterior approach allows the surgeon to work in between a natural muscle plane without detaching muscles or tendons from the hip or thigh bone, avoiding undue trauma to the muscle and surrounding tissue.
“With traditional hip replacements, we have to cut muscle to do the surgery, which affects the recovery process and may limit immediate hip movement in the early post-operative period,” said Francis Gonzales, MD, orthopedic surgeon specializing in adult joint reconstruction at UC San Diego Health System.  “The muscle-sparing approach is performed in between muscle groups, gently pushing the muscle aside during the hip replacement instead of cutting through it.”
UC San Diego Health System performs a high volume of anterior hip replacements annually, making it a leader in the region on the technique.
Read more

Alternative Hip Replacement Technique Results in Faster Recovery
Only 15 Percent of Joint Replacement Specialists in Nation Capable of Muscle-Sparing Approach

University of California, San Diego Health System is one of only a few hospitals in the nation to offer computer-assisted navigation technology with the direct anterior hip replacement technique, potentially resulting in less pain, faster recovery and fewer dislocations for patients with osteoarthritis and other forms of degenerative joint disease. 

Only 15 percent of the top joint centers in the United States have the expertise and technological capability to perform an anterior hip replacement, where the incision is made in the front (anterior) of the hip as opposed to the side (lateral) or back (posterior).  The anterior approach allows the surgeon to work in between a natural muscle plane without detaching muscles or tendons from the hip or thigh bone, avoiding undue trauma to the muscle and surrounding tissue.

“With traditional hip replacements, we have to cut muscle to do the surgery, which affects the recovery process and may limit immediate hip movement in the early post-operative period,” said Francis Gonzales, MD, orthopedic surgeon specializing in adult joint reconstruction at UC San Diego Health System.  “The muscle-sparing approach is performed in between muscle groups, gently pushing the muscle aside during the hip replacement instead of cutting through it.”

UC San Diego Health System performs a high volume of anterior hip replacements annually, making it a leader in the region on the technique.

Read more

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