In this month’s issue:

1. Seniors with Severe Back and Leg Pain Have New Treatment Option at Jefferson Hospital
2. HUP Offers Vertebroplasty -- A Minimally Invasive Procedure to Stabilize Compression Fractures of the Spine
3. Telemedicine Brings the World to Crozer-Keystone Health System
4. MossRehab Presents Diabetic Foot and Wound Education

Orthopaedic surgeons at the Rothman Institute of Thomas Jefferson University Hospital, a Philadelphia International Medicine (PIM) member, are offering as part of a new study a new treatment that uses a synthetic bone protein to a select group of patients with a common spinal problem that causes severe back and leg pain.

About 5 percent of older people have a painful back and leg problem called degenerative spondylolisthesis. Degenerative spondylolisthesis is an age-related problem that is caused when there is forward slippage of one vertebra (one of the 33 bones, which in a series make up the spine) over another. Women are four times more likely to suffer from this condition than men.

Degenerative spondylolisthesis keeps many older adults from participating in the activities they enjoy. At its worst, degenerative spondylolisthesis causes older patients to become severely compromised in their daily activities.

The new procedure being studied by Rothman orthopaedic surgeons offers the best hope ever to affected patients. By using a synthetic version of human bone morphogenetic protein– a protein that is made in small amounts by our bodies to help bone grow– a patient’s potential to heal their bony fusion should improve beyond the 70 percent success rate experienced with traditional spinal fusion surgery without instrumentation that requires a graft from the patient’s own hip bone. The new technique also reduces a patient’s hospital stay by several days.

Alexander R. Vaccaro, M.D., co-director of Reconstruction Spine Services at the Rothman Institute at Jefferson, and the first surgeon to conduct the special surgery, said Jefferson is one of only four medical centers nationwide taking part in the study.

"The surgery we are doing has only recently been used in the laboratory," says Dr. Vaccaro, a professor of Orthopaedic Surgery, Jefferson Medical College of Thomas Jefferson University. "In the future, if recombinant bone morphogenetic protein gets approved for general use, anytime you want to do a bone fusion anywhere in the body, in the spine, in the arm, tibia, it will be phenomenal because it will reduce significantly the potential for non-healing."

Dr. Vaccaro’s research on the synthetic bone protein is featured in this month’s issue of the Journal of the American Academy of Orthopaedic Surgeons.

The Rothman Institute holds the unique distinction of being the first center to perform this special surgery in the United States in posterior lumbar surgery without instrumentation.

Traditional spinal fusion surgery for degenerative spondylolisthesis, Dr. Vaccaro says, involved the use of metal screws to hold parts of the vertebrae together. "There are many problems with this," the Jefferson orthopaedic surgeon says. "For one, metal is expensive. It can also increase the risk of infection due to prolonged operating time, and it is a technically demanding procedure.

"However, if we did not use metal with our fusions, they didn't heal as predictably. Instead of fusing 85 percent of the time, they would fuse only 70 percent of the time. The new type of surgery minimizes the use of metal screws."

The Hospital of the University of Pennsylvania is one of only a few around the nation using a novel procedure called vertebroplasty that gives patients relief from painful compressed spinal fractures. Using sophisticated imaging technology, highly-skilled radiologists inject medicinal liquid cement into the compressed fracture stabilizing the brittle bone, preventing further compression, and alleviating back pain.

Compression fractures of the spine can be caused by traumas such as car accidents or falls. Likewise, compression fractures are often the result of severe osteoporosis, which can cause such debilitating pain that walking, eating and even breathing becomes labored and difficult. Some women with extreme cases even become bedridden or wheelchair bound and conventional methods of relieving this pain include wearing uncomfortable back braces or taking oral pain medications.

"Vertebroplasty is an exciting new technique that will help many individuals return to their normal daily living activities," says Steven G. Imbesi, MD, assistant professor of radiology. "Studies have shown that 90 percent of patients who undergo this procedure experience immediate pain relief."

Prior to the procedure, the physician reviews the patient's spinal X-ray, MRI, and bone scan to pinpoint the exact location of the compressed vertebra. These images help determine if the compression fracture is the primary cause of pain and whether any nerve damage is involved. During the surgery, which takes a few hours, the patient lies on his/her stomach while the radiologist uses a fluoroscope-- an active X-ray machine-- to get a detailed image of the skeletal spine.

Under general anesthesia, the patient is injected with a contrast dye to insure proper localization of the needle and solution. With accurate precision using sophisticated imaging technology, the radiologist injects liquid cement, clinically called methyl methacrylate, directly into the patient's brittle bone stabilizing the fracture and preventing further compression.

The medical cement fills in the brittle areas of the bone and solidifies in about 20 minutes. Patients are hospitalized overnight and experience pain relief as early as the next day. "Patients feel so much better after surgery that it is necessary to remind them to take it easy and gradually get back into their normal living activities," explains Dr. Imbesi.

This technique is only applicable for individuals who have had their diagnosis within three to 12 months of the compression fracture and for those whose compression fracture is specifically located within the T5 (thoracic or mid-back) through L5 (lumbar region or lower back) vertebrae. In addition, patients must first try conventional therapy for at least two months before being eligible for vertebroplasty.

Over the past decade, there have been many dynamic innovations in computer technology that have revolutionized healthcare delivery. Crozer-Keystone Health System, a PIM member, has consistently been at the forefront of computer and telecommunications technology, particularly in the areas of digital imaging and video compression. This is especially true in the creation of an interactive medical network that provides visual, as well as audio communications, between a health provider and a patient in different locations.

"Simply stated, telemedicine provides medical information or clinical assessment to patients and medical practitioners electronically that would otherwise be unavailable or would require the physical transport of people or information," explains Joshua Snow, director of telemedicine services for Crozer-Keystone.

He notes that this easy-to-use technology enables physicians to consult with patients and specialists in two ways:

• In non-emergency situations, store-and-forward technology is used: images taken with a digital camera are electronically transferred to other locations. Physicians can then diagnose conditions and evaluate at their convenience, even across time zones.
• When an immediate consultation is needed, two-way interactive television (IATV) is used. This is "real time" technology, with a physician at one end and a patient, healthcare provider, and/or specialist at the other. Sophisticated tools send high-resolution images and audio.

"We use standards-based video-conferencing technology, which is compatible with any leading video-conference technology available today," explains Snow.

"The minimum hardware configuration for a remote site is basic: P233 with 32MG of memory and a 2 gig hard drive. In addition, for video-conferencing, a remote site will need a communications board, a network terminator (digital modem), and a camera with a microphone." Diagnostic applications for this technology include: psychiatry, dermatology, maternal fetal medicine, cardiology, radiology, ophthalmology, orthopedics, burn care, and wound care.

Telemedicine can bring the world-renowned expertise of the Burn Treatment Center at Crozer-Chester Medical Center to the bedside of a critically burned patient anywhere in the world. Or, in the recovery phase, the burn patient can be assessed for reconstructive plastic surgery using this image transmission.

At Crozer-Keystone, additional opportunities have been realized for emergency medicine, correctional healthcare, long-term care, home health care and continuing medical education.

Ophthalmologist Christopher Williams, MD, the first Crozer-Keystone physician to use telemedicine to consult with sub-specialists within and outside the system, believes its potential uses are far-reaching. Dr. Williams last year was a participant in the PIM visiting physician program and spent time at Saudi German Hospital in Jeddah.

"Telemedicine is an efficient way to consult with sub-specialists. The software programs and advanced technology allow us to see and talk to one another while viewing video segments at the same time. This is especially beneficial when consulting with colleagues concerning very complex medical problems."

Telemedicine has enabled Williams to consult colleagues at other institutions, as well as receive telemedicine consults from one of Crozer-Keystone’s Centers for Family Health.

Interactive technology gives the consultant a pair of eyes in the primary care physician’s office. Seeing the problem, rather than only hearing about it, significantly improves the specialist’s assessment and results in better decisions.

Dr. Taweel discussed the factors contributing to foot dysfunction and ulceration in the diabetic population. He reviewed how neuropathy (diseased nerves) in the lower extremities causes diabetics to experience numbness in their feet. Neuropathy, in conjunction with areas of high pressure on the bottom of the foot, can result in breakdown of the skin. If left untreated, these areas can then become infected, leading to amputation. According to Dr. Taweel, current treatment strategies include casting, bracing and specialized footwear.

MossRehab is one of the Philadelphia region’s leading providers of medical rehabilitation services, with programs designed for those who have experienced brain injury, stroke, amputation and other physical disabilities. MossRehab also offers 22 outpatient sites through MossCare Network.

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