Focuson TotalCare of the Spine

HOSPITAL FOR SPECIAL SURGERY:SPECIALISTS IN MOBILITY

WINTER 2006 Horizon

At left: At the age of30, Cindy Sherlock’sscoliosis began toimpinge on her abilityto breathe. In May2000, Dr. OhenebaBoachie performedfusion surgery withspinal instrumentationto straighten her spine.Following surgery,Cindy went on to havetwo children, a sonLiam, and daughterRemington, and today enjoys a full and active life.

On the cover: Dr. FrankCammisa, Chief of theSpine Service, per-forms a microsurgicaldecompression of thespinal nerves on a middle-aged patientwith spinal stenosis.Inset: Dr. Cammisadescribes the compo-nents of an artificialprosthesis that canreplace a diseased vertebral disc.

perspective and have access to our full complement ofexpertise. We have imaging specialists, neurologists,physiatrists, pain management specialists, as well assurgeons – all coming together to provide the patientwith comprehensive care.”

As both physicians and the patients they treat knowwell, spine care is not an easy field to conquer. Butthat challenge is exactly what drew Dr. Cammisa to the specialty. “When I was training in the 1980s, I sawthat there was not a lot that could be done then, but Ibelieved there was a tremendous potential withupcoming technologies to improve both the surgicaland non-surgical care of the spine patient.”

“Spine care is an area for tremendous growth andinnovation,” says Thomas P. Sculco, MD, Surgeon-in-Chief, “and HSS is leading the way in terms of clinicalcare, education, and research.”

To understand the causes and conditions of thespine, a lesson in anatomy is important. The spine con-sists of vertebrae stacked one upon the other. Betweenthese vertebrae are discs that act both as cushions andstabilizers. While the vertebra is a fixed structure, thedisc allows you to move in different directions. Thespinal cord and its nerves run through a canal in the

HSS Expertise in Spine CareFrom the tip of your neck to thebase of your back, a complexconfiguration of 33 bones, interspersed with cartilage andsurrounded by a network ofnerves and soft tissue, are pro-viding you with stability, balance,and the ability to stand erect.

This elegant structure withstands phenomenalstress and yet gives us the flexibility to reach forthe stars or pick up a dime. But if the spine

becomes a source of pain and the reason for disability,the experts at Hospital for Special Surgery know precise-ly where to look and exactly what to do if necessary.

“HSS has been involved with all of the technologicalbreakthroughs that have been applied to spine,” saysFrank P. Cammisa, Jr., MD, Chief of the Spine Service.“We’re at the cutting edge of both basic scienceresearch and clinical applications in spine treatment,and we’re committed to training spine surgeons whowill contribute to improving spinal care throughout theworld. That’s what makes us stand apart from otherinstitutions.”

Beginning with advancing techniques in spine fusionfor disc herniation in the 1930s through the advent ofimage-guidance and minimally invasive surgery in themid-1990s, and most recently, performing one of the first robotic-assisted spine surgeries in the world, HSSorthopedic surgeons have continually set the pace forprogress in the diagnosis and treatment of spine disease.

The common denominator for most back problemsis pain. But the underlying pathology and treatmentsare as diverse as the individuals affected. “You have tohone in on your patient’s problem, select the righttherapeutic approach, apply it in the right way witheither rehab, surgery, or both…and then you’re goingto get a good result,” says Dr. Cammisa. “At HSS,patients are very carefully evaluated from every

1

Dr. Oheneba Boachie-Adjei reviews X-rays of a patient following scoliosis surgery in which he used a dual-rod technique that allowsan immature spine to grow.

Pinpointing the Diagnosis“We generally start with standard X-rays to evaluatethe spine. If additional diagnostic information is need-ed, we employ MRI or CT to help elucidate the precisecause of a patient’s symptoms,” says spine specialistRichard Herzog, MD, Chief of Teleradiology in theDepartment of Imaging and Radiology. “At HSS, radiol-ogists utilize the most advanced MR imaging tech-niques and the latest generation of CT scanners.”

HSS has a dedicated orthopedic MRI center that pro-vides high resolution images to evaluate the disc, spinalcord and nerve roots. CT is predominantly used toassess bony abnormalities and to determine the integri-ty of a spinal fusion. Three-dimensional CT models ofthe spine may be created for preoperative planning.

“Neurologists provide additional insight through evalu-ation of nerves emanating from the spinal cord with aclinical neurological examination that is frequently com-plimented by an electromyography study to measure theelectrical activity of peripheral nerves and muscles,” saysMoris Jak Danon, MD, Chief of Neurology. “Degenerativeconditions of the spinal canal and disc herniations canimpinge the nerves on the spinal cord. Through neuro-logical exams, we can pinpoint the origin and degree ofinjury and determine what levels of the spinal cord orperipheral nerves (at their roots) are involved.”

Physiatrist Joseph Feinberg, MD, concurs. A special-ist in electrodiagnostics, Dr. Feinberg performs nerveconduction studies that entail electrically stimulatingand activating nerves to measure their response. “Wethen use very fine needles that are ‘acupuncture like’that contain microscopic electrodes,” says Dr. Feinberg.“They can pick up electrical signals coming from muscle,which allows us to quantify the degree of nerve injury.”

Surgical Solutions for Spine ProblemsIt wasn’t so long ago that surgery on the spine was amajor and traumatic undertaking requiring a lengthyand arduous recovery. Times have changed. With thearrival of total disc replacement, minimally invasivesurgical techniques, non-fusion technologies, and newfusion procedures, physicians and patients alike areseeing dramatic improvements in spine surgery.

Orthopedic surgeon Patrick O’Leary, MD, has beenat the forefront of spinal fusion surgery since complet-ing his residency at HSS in 1975. In spinal fusion, twoor more vertebrae are permanently joined together withbone grafts and internal instrumentation to eliminate

vertebrae, with muscles and ligaments providingstrength and support. Any of the spine’s componentsare subject to trauma, wear and tear, congenital defor-mities, and inflammation.

“Rheumatologists frequently see back disease in manysettings – either as an isolated entity where back pain isa primary problem or in association with other diseases,”says HSS rheumatologist Sergio Schwartzman, MD. “One of our roles is to differentiate between the etiologiesor causes of back pain.”

Nearly 80 percent of Americans will suffer back painin their lifetime, representing some 30 million visits to physicians. Among the conditions that patients seektreatment for at HSS are herniated discs, stenosis ornarrowing of the spinal canal, spondylolisthesis (a slid-ing forward of the vertebra), fractures, scoliosis, andautoimmune diseases, such as ankylosing spondylitis.But herniated discs are considered by many to be themost painful and disabling. When a disc herniates, partof the disc material is displaced into the spinal canal.This results in pressure on the spinal nerves, which canbring pain, numbness or weakness in one or both legs.

Dr. Moris Jak Danon, a nationally recognized specialist in nerve andmuscle pathology, analyzes signals produced by electromyography todetermine the electrical activity of muscles.

2

the motion between ver-tebral segments that maybe the cause of signifi-cant pain. Fusion canalso stop the progressionof a spinal deformity suchas scoliosis. According to Dr. O’Leary, “Spine fusionis often required in thetreatment of spine frac-tures, spine tumors, scoliosis, and spondylolis-thesis. It may also be useful in reducing pain in certaindegenerative spine disorders. Spine fusion is more con-troversial in the treatment of discogenic back pain – theso-called ‘black disc’ as seen on the MRI. In this area,disc arthroplasty is currently being evaluated.”

Oheneba Boachie-Adjei, MD, Chief, Scoliosis Service,is advancing surgery for early onset scoliosis with severecurvature. Dr. Boachie is participating in a multicenter

study on a dual rod technique that achieves correctionthrough the implantation of growing rods. “We lengthenthe rods gradually, which allows the immature spine togrow and avoids the need for spinal fusion at an earlyage,” says Dr. Boachie. “This is a great advance in treat-ing early severe curves that would have required majorfusion surgery, resulting in stunted growth.”

Recently, non-fusion technology has been introducedto restore or preserve motion in the spine. Today, aselect group of patients is benefiting from spinal discreplacement in which the affected disc is removed andreplaced by a prosthesis made of metal and plastic.“Total disc replacement is a great advance for patientswith chronic, mechanical lower back pain that has notresponded to non-surgical options,” says orthopedicsurgeon Harvinder S. Sandhu, MD.

“Spine surgery at HSS is the best model for a com-prehensive team approach,” says anesthesiologist James D. Beckman, MD. “At HSS, anesthesiologists getinvolved long before the patient is brought into the OR.Communication among anesthesiologists, the surgeons,the neuro-monitoring team, and the OR nurses is crucial

Dr. Patrick O’Leary (second from left) performs a fusion to replace a damaged disc with a bone graft secured by rods to maintain proper orientation of the lumbar spine. (Below) Dr. Michael Urban, a specialist in anesthesiology for complex spine surgery, monitors the patient.

3

to ensure the best possible outcome for the patient.” Russel Huang, MD, and Andrew Sama, MD, the newer

members of the HSS spine team, bring with them expert-ise in advanced spine surgery procedures. Dr. Huanghas a keen interest in minimally disruptive decompres-sion techniques, which minimize the amount of boneand muscle removed. “These procedures are provingbeneficial to the patient with improved recovery time.”

“This is a burgeoning academic field,” says Dr. Sama.“By refining the technologies that are available, we willbe able to help many more spine patients.”

Advancing Spine Surgery through Research“Lumbar disc replacement is only the tip of the ice-berg,” says orthopedic surgeon Federico P. Girardi,MD. “Studies are underway at HSS and around theworld to evaluate cervical disc replacement, nucleusreplacement, and other non-fusion technologies.”

Dr. Frank Cammisa, Timothy M. Wright, PhD, Director,Biomedical Mechanics and Biomolecular Design, andtheir colleagues are pioneering non-fusion technologiesthat include screws to stabilize a spine without fusionand a total disc replacement made of materials thatallow for ‘normal’ motion and flexibility.

In the basic science laboratories of Chisa Hidaka,MD, researchers are looking at gene transfer strategiesthat have the potential to transform the spinal fusionprocedure. By inserting a new fusion gene constructthey have created into the intervertebral disc duringan anterior fusion procedure, they hope to induce aspinal fusion using minimally invasive techniques. “Thisshould maximize the potential for making bone in thatdisc space and avoid a bone graft, something that is nec-essary with current techniques,” says Dr. Hidaka.

Non-Surgical Approaches to Spine Care“Patients generally wish to maximize their non-surgicaltreatment options,” says HSS physiatrist Paul M. Cooke,MD, who specializes in the field of physical medicineand rehabilitation, incorporating exercise-based rehabili-tation and pain management in the non-operative treat-ment of spinal disorders. “One of the strengths of ourfield is to look at the whole patient to identify thesource of the pain as well as any contributing factors,pinpoint a precise diagnosis, and ultimately to developthe appropriate treatment plan for that individual.”

Pain management modalities include targeted epiduralsteroid injection under fluoroscopic guidance andintradiscal electrothermal therapy (IDET). “IDET workswell for properly selected patients,” says physiatristChristopher Lutz, MD. “When there is a tear in the discwall, we apply high heat directly to the inside of the discto repair the tear and promote healing.”

“Most patients will be treated with a combination ofphysical therapy, medication and injection procedures,”says Seth A. Waldman, MD, Director of Pain Medicine.“For patients who have tried these measures without suc-cess, we may recommend implanting a spinal cord stimu-lator – a permanent, implantable system that stimulatesthe part of the spinal cord where the pain is originating.Implantable infusion devices that deliver medicationdirectly into the spinal fluid may also offer relief.”

“A major strength at HSS is the close relationshipbetween surgeons and pain management doctors,” sayspain management specialist/anesthesiologist David Y.Wang, MD. “Our procedures prove valuable post-opera-tively to help patients recover from surgery as well asin addressing chronic pain.”

“Our goal is to minimize patients’ discomfort andmaximize their potential,” says Barbara Wukovits, RN,Assistant Director, Acute Pain Service. “Our staff isattuned to the nature of the patient’s pain and how itimpacts their lives. We’re not just here to treat thepain…we care about them.” n

4

To help alleviate the chronic low back pain of Robert Frigiano, Dr. PaulCooke will inject a combination of cortisone and an anesthetic underfluoroscopic guidance to reduce inflammation of the nerves.

perspective and have access to our full complement ofexpertise. We have imaging specialists, neurologists,physiatrists, pain management specialists, as well assurgeons – all coming together to provide the patientwith comprehensive care.”

As both physicians and the patients they treat knowwell, spine care is not an easy field to conquer. Butthat challenge is exactly what drew Dr. Cammisa to the specialty. “When I was training in the 1980s, I sawthat there was not a lot that could be done then, but Ibelieved there was a tremendous potential withupcoming technologies to improve both the surgicaland non-surgical care of the spine patient.”

“Spine care is an area for tremendous growth andinnovation,” says Thomas P. Sculco, MD, Surgeon-in-Chief, “and HSS is leading the way in terms of clinicalcare, education, and research.”

To understand the causes and conditions of thespine, a lesson in anatomy is important. The spine con-sists of vertebrae stacked one upon the other. Betweenthese vertebrae are discs that act both as cushions andstabilizers. While the vertebra is a fixed structure, thedisc allows you to move in different directions. Thespinal cord and its nerves run through a canal in the

HSS Expertise in Spine CareFrom the tip of your neck to thebase of your back, a complexconfiguration of 33 bones, interspersed with cartilage andsurrounded by a network ofnerves and soft tissue, are pro-viding you with stability, balance,and the ability to stand erect.

This elegant structure withstands phenomenalstress and yet gives us the flexibility to reach forthe stars or pick up a dime. But if the spine

becomes a source of pain and the reason for disability,the experts at Hospital for Special Surgery know precise-ly where to look and exactly what to do if necessary.

“HSS has been involved with all of the technologicalbreakthroughs that have been applied to spine,” saysFrank P. Cammisa, Jr., MD, Chief of the Spine Service.“We’re at the cutting edge of both basic scienceresearch and clinical applications in spine treatment,and we’re committed to training spine surgeons whowill contribute to improving spinal care throughout theworld. That’s what makes us stand apart from otherinstitutions.”

Beginning with advancing techniques in spine fusionfor disc herniation in the 1930s through the advent ofimage-guidance and minimally invasive surgery in themid-1990s, and most recently, performing one of the first robotic-assisted spine surgeries in the world, HSSorthopedic surgeons have continually set the pace forprogress in the diagnosis and treatment of spine disease.

The common denominator for most back problemsis pain. But the underlying pathology and treatmentsare as diverse as the individuals affected. “You have tohone in on your patient’s problem, select the righttherapeutic approach, apply it in the right way witheither rehab, surgery, or both…and then you’re goingto get a good result,” says Dr. Cammisa. “At HSS,patients are very carefully evaluated from every

1

Dr. Oheneba Boachie-Adjei reviews X-rays of a patient following scoliosis surgery in which he used a dual-rod technique that allowsan immature spine to grow.

Pinpointing the Diagnosis“We generally start with standard X-rays to evaluatethe spine. If additional diagnostic information is need-ed, we employ MRI or CT to help elucidate the precisecause of a patient’s symptoms,” says spine specialistRichard Herzog, MD, Chief of Teleradiology in theDepartment of Imaging and Radiology. “At HSS, radiol-ogists utilize the most advanced MR imaging tech-niques and the latest generation of CT scanners.”

HSS has a dedicated orthopedic MRI center that pro-vides high resolution images to evaluate the disc, spinalcord and nerve roots. CT is predominantly used toassess bony abnormalities and to determine the integri-ty of a spinal fusion. Three-dimensional CT models ofthe spine may be created for preoperative planning.

“Neurologists provide additional insight through evalu-ation of nerves emanating from the spinal cord with aclinical neurological examination that is frequently com-plimented by an electromyography study to measure theelectrical activity of peripheral nerves and muscles,” saysMoris Jak Danon, MD, Chief of Neurology. “Degenerativeconditions of the spinal canal and disc herniations canimpinge the nerves on the spinal cord. Through neuro-logical exams, we can pinpoint the origin and degree ofinjury and determine what levels of the spinal cord orperipheral nerves (at their roots) are involved.”

Physiatrist Joseph Feinberg, MD, concurs. A special-ist in electrodiagnostics, Dr. Feinberg performs nerveconduction studies that entail electrically stimulatingand activating nerves to measure their response. “Wethen use very fine needles that are ‘acupuncture like’that contain microscopic electrodes,” says Dr. Feinberg.“They can pick up electrical signals coming from muscle,which allows us to quantify the degree of nerve injury.”

Surgical Solutions for Spine ProblemsIt wasn’t so long ago that surgery on the spine was amajor and traumatic undertaking requiring a lengthyand arduous recovery. Times have changed. With thearrival of total disc replacement, minimally invasivesurgical techniques, non-fusion technologies, and newfusion procedures, physicians and patients alike areseeing dramatic improvements in spine surgery.

Orthopedic surgeon Patrick O’Leary, MD, has beenat the forefront of spinal fusion surgery since complet-ing his residency at HSS in 1975. In spinal fusion, twoor more vertebrae are permanently joined together withbone grafts and internal instrumentation to eliminate

vertebrae, with muscles and ligaments providingstrength and support. Any of the spine’s componentsare subject to trauma, wear and tear, congenital defor-mities, and inflammation.

“Rheumatologists frequently see back disease in manysettings – either as an isolated entity where back pain isa primary problem or in association with other diseases,”says HSS rheumatologist Sergio Schwartzman, MD. “One of our roles is to differentiate between the etiologiesor causes of back pain.”

Nearly 80 percent of Americans will suffer back painin their lifetime, representing some 30 million visits to physicians. Among the conditions that patients seektreatment for at HSS are herniated discs, stenosis ornarrowing of the spinal canal, spondylolisthesis (a slid-ing forward of the vertebra), fractures, scoliosis, andautoimmune diseases, such as ankylosing spondylitis.But herniated discs are considered by many to be themost painful and disabling. When a disc herniates, partof the disc material is displaced into the spinal canal.This results in pressure on the spinal nerves, which canbring pain, numbness or weakness in one or both legs.

Dr. Moris Jak Danon, a nationally recognized specialist in nerve andmuscle pathology, analyzes signals produced by electromyography todetermine the electrical activity of muscles.

2

the motion between ver-tebral segments that maybe the cause of signifi-cant pain. Fusion canalso stop the progressionof a spinal deformity suchas scoliosis. According to Dr. O’Leary, “Spine fusionis often required in thetreatment of spine frac-tures, spine tumors, scoliosis, and spondylolis-thesis. It may also be useful in reducing pain in certaindegenerative spine disorders. Spine fusion is more con-troversial in the treatment of discogenic back pain – theso-called ‘black disc’ as seen on the MRI. In this area,disc arthroplasty is currently being evaluated.”

Oheneba Boachie-Adjei, MD, Chief, Scoliosis Service,is advancing surgery for early onset scoliosis with severecurvature. Dr. Boachie is participating in a multicenter

study on a dual rod technique that achieves correctionthrough the implantation of growing rods. “We lengthenthe rods gradually, which allows the immature spine togrow and avoids the need for spinal fusion at an earlyage,” says Dr. Boachie. “This is a great advance in treat-ing early severe curves that would have required majorfusion surgery, resulting in stunted growth.”

Recently, non-fusion technology has been introducedto restore or preserve motion in the spine. Today, aselect group of patients is benefiting from spinal discreplacement in which the affected disc is removed andreplaced by a prosthesis made of metal and plastic.“Total disc replacement is a great advance for patientswith chronic, mechanical lower back pain that has notresponded to non-surgical options,” says orthopedicsurgeon Harvinder S. Sandhu, MD.

“Spine surgery at HSS is the best model for a com-prehensive team approach,” says anesthesiologist James D. Beckman, MD. “At HSS, anesthesiologists getinvolved long before the patient is brought into the OR.Communication among anesthesiologists, the surgeons,the neuro-monitoring team, and the OR nurses is crucial

Dr. Patrick O’Leary (second from left) performs a fusion to replace a damaged disc with a bone graft secured by rods to maintain proper orientation of the lumbar spine. (Below) Dr. Michael Urban, a specialist in anesthesiology for complex spine surgery, monitors the patient.

3

to ensure the best possible outcome for the patient.” Russel Huang, MD, and Andrew Sama, MD, the newer

members of the HSS spine team, bring with them expert-ise in advanced spine surgery procedures. Dr. Huanghas a keen interest in minimally disruptive decompres-sion techniques, which minimize the amount of boneand muscle removed. “These procedures are provingbeneficial to the patient with improved recovery time.”

“This is a burgeoning academic field,” says Dr. Sama.“By refining the technologies that are available, we willbe able to help many more spine patients.”

Advancing Spine Surgery through Research“Lumbar disc replacement is only the tip of the ice-berg,” says orthopedic surgeon Federico P. Girardi,MD. “Studies are underway at HSS and around theworld to evaluate cervical disc replacement, nucleusreplacement, and other non-fusion technologies.”

Dr. Frank Cammisa, Timothy M. Wright, PhD, Director,Biomedical Mechanics and Biomolecular Design, andtheir colleagues are pioneering non-fusion technologiesthat include screws to stabilize a spine without fusionand a total disc replacement made of materials thatallow for ‘normal’ motion and flexibility.

In the basic science laboratories of Chisa Hidaka,MD, researchers are looking at gene transfer strategiesthat have the potential to transform the spinal fusionprocedure. By inserting a new fusion gene constructthey have created into the intervertebral disc duringan anterior fusion procedure, they hope to induce aspinal fusion using minimally invasive techniques. “Thisshould maximize the potential for making bone in thatdisc space and avoid a bone graft, something that is nec-essary with current techniques,” says Dr. Hidaka.

Non-Surgical Approaches to Spine Care“Patients generally wish to maximize their non-surgicaltreatment options,” says HSS physiatrist Paul M. Cooke,MD, who specializes in the field of physical medicineand rehabilitation, incorporating exercise-based rehabili-tation and pain management in the non-operative treat-ment of spinal disorders. “One of the strengths of ourfield is to look at the whole patient to identify thesource of the pain as well as any contributing factors,pinpoint a precise diagnosis, and ultimately to developthe appropriate treatment plan for that individual.”

Pain management modalities include targeted epiduralsteroid injection under fluoroscopic guidance andintradiscal electrothermal therapy (IDET). “IDET workswell for properly selected patients,” says physiatristChristopher Lutz, MD. “When there is a tear in the discwall, we apply high heat directly to the inside of the discto repair the tear and promote healing.”

“Most patients will be treated with a combination ofphysical therapy, medication and injection procedures,”says Seth A. Waldman, MD, Director of Pain Medicine.“For patients who have tried these measures without suc-cess, we may recommend implanting a spinal cord stimu-lator – a permanent, implantable system that stimulatesthe part of the spinal cord where the pain is originating.Implantable infusion devices that deliver medicationdirectly into the spinal fluid may also offer relief.”

“A major strength at HSS is the close relationshipbetween surgeons and pain management doctors,” sayspain management specialist/anesthesiologist David Y.Wang, MD. “Our procedures prove valuable post-opera-tively to help patients recover from surgery as well asin addressing chronic pain.”

“Our goal is to minimize patients’ discomfort andmaximize their potential,” says Barbara Wukovits, RN,Assistant Director, Acute Pain Service. “Our staff isattuned to the nature of the patient’s pain and how itimpacts their lives. We’re not just here to treat thepain…we care about them.” n

4

To help alleviate the chronic low back pain of Robert Frigiano, Dr. PaulCooke will inject a combination of cortisone and an anesthetic underfluoroscopic guidance to reduce inflammation of the nerves.

perspective and have access to our full complement ofexpertise. We have imaging specialists, neurologists,physiatrists, pain management specialists, as well assurgeons – all coming together to provide the patientwith comprehensive care.”

As both physicians and the patients they treat knowwell, spine care is not an easy field to conquer. Butthat challenge is exactly what drew Dr. Cammisa to the specialty. “When I was training in the 1980s, I sawthat there was not a lot that could be done then, but Ibelieved there was a tremendous potential withupcoming technologies to improve both the surgicaland non-surgical care of the spine patient.”

“Spine care is an area for tremendous growth andinnovation,” says Thomas P. Sculco, MD, Surgeon-in-Chief, “and HSS is leading the way in terms of clinicalcare, education, and research.”

To understand the causes and conditions of thespine, a lesson in anatomy is important. The spine con-sists of vertebrae stacked one upon the other. Betweenthese vertebrae are discs that act both as cushions andstabilizers. While the vertebra is a fixed structure, thedisc allows you to move in different directions. Thespinal cord and its nerves run through a canal in the

HSS Expertise in Spine CareFrom the tip of your neck to thebase of your back, a complexconfiguration of 33 bones, interspersed with cartilage andsurrounded by a network ofnerves and soft tissue, are pro-viding you with stability, balance,and the ability to stand erect.

This elegant structure withstands phenomenalstress and yet gives us the flexibility to reach forthe stars or pick up a dime. But if the spine

becomes a source of pain and the reason for disability,the experts at Hospital for Special Surgery know precise-ly where to look and exactly what to do if necessary.

“HSS has been involved with all of the technologicalbreakthroughs that have been applied to spine,” saysFrank P. Cammisa, Jr., MD, Chief of the Spine Service.“We’re at the cutting edge of both basic scienceresearch and clinical applications in spine treatment,and we’re committed to training spine surgeons whowill contribute to improving spinal care throughout theworld. That’s what makes us stand apart from otherinstitutions.”

Beginning with advancing techniques in spine fusionfor disc herniation in the 1930s through the advent ofimage-guidance and minimally invasive surgery in themid-1990s, and most recently, performing one of the first robotic-assisted spine surgeries in the world, HSSorthopedic surgeons have continually set the pace forprogress in the diagnosis and treatment of spine disease.

The common denominator for most back problemsis pain. But the underlying pathology and treatmentsare as diverse as the individuals affected. “You have tohone in on your patient’s problem, select the righttherapeutic approach, apply it in the right way witheither rehab, surgery, or both…and then you’re goingto get a good result,” says Dr. Cammisa. “At HSS,patients are very carefully evaluated from every

1

Dr. Oheneba Boachie-Adjei reviews X-rays of a patient following scoliosis surgery in which he used a dual-rod technique that allowsan immature spine to grow.

Pinpointing the Diagnosis“We generally start with standard X-rays to evaluatethe spine. If additional diagnostic information is need-ed, we employ MRI or CT to help elucidate the precisecause of a patient’s symptoms,” says spine specialistRichard Herzog, MD, Chief of Teleradiology in theDepartment of Imaging and Radiology. “At HSS, radiol-ogists utilize the most advanced MR imaging tech-niques and the latest generation of CT scanners.”

HSS has a dedicated orthopedic MRI center that pro-vides high resolution images to evaluate the disc, spinalcord and nerve roots. CT is predominantly used toassess bony abnormalities and to determine the integri-ty of a spinal fusion. Three-dimensional CT models ofthe spine may be created for preoperative planning.

“Neurologists provide additional insight through evalu-ation of nerves emanating from the spinal cord with aclinical neurological examination that is frequently com-plimented by an electromyography study to measure theelectrical activity of peripheral nerves and muscles,” saysMoris Jak Danon, MD, Chief of Neurology. “Degenerativeconditions of the spinal canal and disc herniations canimpinge the nerves on the spinal cord. Through neuro-logical exams, we can pinpoint the origin and degree ofinjury and determine what levels of the spinal cord orperipheral nerves (at their roots) are involved.”

Physiatrist Joseph Feinberg, MD, concurs. A special-ist in electrodiagnostics, Dr. Feinberg performs nerveconduction studies that entail electrically stimulatingand activating nerves to measure their response. “Wethen use very fine needles that are ‘acupuncture like’that contain microscopic electrodes,” says Dr. Feinberg.“They can pick up electrical signals coming from muscle,which allows us to quantify the degree of nerve injury.”

Surgical Solutions for Spine ProblemsIt wasn’t so long ago that surgery on the spine was amajor and traumatic undertaking requiring a lengthyand arduous recovery. Times have changed. With thearrival of total disc replacement, minimally invasivesurgical techniques, non-fusion technologies, and newfusion procedures, physicians and patients alike areseeing dramatic improvements in spine surgery.

Orthopedic surgeon Patrick O’Leary, MD, has beenat the forefront of spinal fusion surgery since complet-ing his residency at HSS in 1975. In spinal fusion, twoor more vertebrae are permanently joined together withbone grafts and internal instrumentation to eliminate

vertebrae, with muscles and ligaments providingstrength and support. Any of the spine’s componentsare subject to trauma, wear and tear, congenital defor-mities, and inflammation.

“Rheumatologists frequently see back disease in manysettings – either as an isolated entity where back pain isa primary problem or in association with other diseases,”says HSS rheumatologist Sergio Schwartzman, MD. “One of our roles is to differentiate between the etiologiesor causes of back pain.”

Nearly 80 percent of Americans will suffer back painin their lifetime, representing some 30 million visits to physicians. Among the conditions that patients seektreatment for at HSS are herniated discs, stenosis ornarrowing of the spinal canal, spondylolisthesis (a slid-ing forward of the vertebra), fractures, scoliosis, andautoimmune diseases, such as ankylosing spondylitis.But herniated discs are considered by many to be themost painful and disabling. When a disc herniates, partof the disc material is displaced into the spinal canal.This results in pressure on the spinal nerves, which canbring pain, numbness or weakness in one or both legs.

Dr. Moris Jak Danon, a nationally recognized specialist in nerve andmuscle pathology, analyzes signals produced by electromyography todetermine the electrical activity of muscles.

2

the motion between ver-tebral segments that maybe the cause of signifi-cant pain. Fusion canalso stop the progressionof a spinal deformity suchas scoliosis. According to Dr. O’Leary, “Spine fusionis often required in thetreatment of spine frac-tures, spine tumors, scoliosis, and spondylolis-thesis. It may also be useful in reducing pain in certaindegenerative spine disorders. Spine fusion is more con-troversial in the treatment of discogenic back pain – theso-called ‘black disc’ as seen on the MRI. In this area,disc arthroplasty is currently being evaluated.”

Oheneba Boachie-Adjei, MD, Chief, Scoliosis Service,is advancing surgery for early onset scoliosis with severecurvature. Dr. Boachie is participating in a multicenter

study on a dual rod technique that achieves correctionthrough the implantation of growing rods. “We lengthenthe rods gradually, which allows the immature spine togrow and avoids the need for spinal fusion at an earlyage,” says Dr. Boachie. “This is a great advance in treat-ing early severe curves that would have required majorfusion surgery, resulting in stunted growth.”

Recently, non-fusion technology has been introducedto restore or preserve motion in the spine. Today, aselect group of patients is benefiting from spinal discreplacement in which the affected disc is removed andreplaced by a prosthesis made of metal and plastic.“Total disc replacement is a great advance for patientswith chronic, mechanical lower back pain that has notresponded to non-surgical options,” says orthopedicsurgeon Harvinder S. Sandhu, MD.

“Spine surgery at HSS is the best model for a com-prehensive team approach,” says anesthesiologist James D. Beckman, MD. “At HSS, anesthesiologists getinvolved long before the patient is brought into the OR.Communication among anesthesiologists, the surgeons,the neuro-monitoring team, and the OR nurses is crucial

Dr. Patrick O’Leary (second from left) performs a fusion to replace a damaged disc with a bone graft secured by rods to maintain proper orientation of the lumbar spine. (Below) Dr. Michael Urban, a specialist in anesthesiology for complex spine surgery, monitors the patient.

3

to ensure the best possible outcome for the patient.” Russel Huang, MD, and Andrew Sama, MD, the newer

members of the HSS spine team, bring with them expert-ise in advanced spine surgery procedures. Dr. Huanghas a keen interest in minimally disruptive decompres-sion techniques, which minimize the amount of boneand muscle removed. “These procedures are provingbeneficial to the patient with improved recovery time.”

“This is a burgeoning academic field,” says Dr. Sama.“By refining the technologies that are available, we willbe able to help many more spine patients.”

Advancing Spine Surgery through Research“Lumbar disc replacement is only the tip of the ice-berg,” says orthopedic surgeon Federico P. Girardi,MD. “Studies are underway at HSS and around theworld to evaluate cervical disc replacement, nucleusreplacement, and other non-fusion technologies.”

Dr. Frank Cammisa, Timothy M. Wright, PhD, Director,Biomedical Mechanics and Biomolecular Design, andtheir colleagues are pioneering non-fusion technologiesthat include screws to stabilize a spine without fusionand a total disc replacement made of materials thatallow for ‘normal’ motion and flexibility.

In the basic science laboratories of Chisa Hidaka,MD, researchers are looking at gene transfer strategiesthat have the potential to transform the spinal fusionprocedure. By inserting a new fusion gene constructthey have created into the intervertebral disc duringan anterior fusion procedure, they hope to induce aspinal fusion using minimally invasive techniques. “Thisshould maximize the potential for making bone in thatdisc space and avoid a bone graft, something that is nec-essary with current techniques,” says Dr. Hidaka.

Non-Surgical Approaches to Spine Care“Patients generally wish to maximize their non-surgicaltreatment options,” says HSS physiatrist Paul M. Cooke,MD, who specializes in the field of physical medicineand rehabilitation, incorporating exercise-based rehabili-tation and pain management in the non-operative treat-ment of spinal disorders. “One of the strengths of ourfield is to look at the whole patient to identify thesource of the pain as well as any contributing factors,pinpoint a precise diagnosis, and ultimately to developthe appropriate treatment plan for that individual.”

Pain management modalities include targeted epiduralsteroid injection under fluoroscopic guidance andintradiscal electrothermal therapy (IDET). “IDET workswell for properly selected patients,” says physiatristChristopher Lutz, MD. “When there is a tear in the discwall, we apply high heat directly to the inside of the discto repair the tear and promote healing.”

“Most patients will be treated with a combination ofphysical therapy, medication and injection procedures,”says Seth A. Waldman, MD, Director of Pain Medicine.“For patients who have tried these measures without suc-cess, we may recommend implanting a spinal cord stimu-lator – a permanent, implantable system that stimulatesthe part of the spinal cord where the pain is originating.Implantable infusion devices that deliver medicationdirectly into the spinal fluid may also offer relief.”

“A major strength at HSS is the close relationshipbetween surgeons and pain management doctors,” sayspain management specialist/anesthesiologist David Y.Wang, MD. “Our procedures prove valuable post-opera-tively to help patients recover from surgery as well asin addressing chronic pain.”

“Our goal is to minimize patients’ discomfort andmaximize their potential,” says Barbara Wukovits, RN,Assistant Director, Acute Pain Service. “Our staff isattuned to the nature of the patient’s pain and how itimpacts their lives. We’re not just here to treat thepain…we care about them.” n

4

To help alleviate the chronic low back pain of Robert Frigiano, Dr. PaulCooke will inject a combination of cortisone and an anesthetic underfluoroscopic guidance to reduce inflammation of the nerves.

perspective and have access to our full complement ofexpertise. We have imaging specialists, neurologists,physiatrists, pain management specialists, as well assurgeons – all coming together to provide the patientwith comprehensive care.”

As both physicians and the patients they treat knowwell, spine care is not an easy field to conquer. Butthat challenge is exactly what drew Dr. Cammisa to the specialty. “When I was training in the 1980s, I sawthat there was not a lot that could be done then, but Ibelieved there was a tremendous potential withupcoming technologies to improve both the surgicaland non-surgical care of the spine patient.”

“Spine care is an area for tremendous growth andinnovation,” says Thomas P. Sculco, MD, Surgeon-in-Chief, “and HSS is leading the way in terms of clinicalcare, education, and research.”

To understand the causes and conditions of thespine, a lesson in anatomy is important. The spine con-sists of vertebrae stacked one upon the other. Betweenthese vertebrae are discs that act both as cushions andstabilizers. While the vertebra is a fixed structure, thedisc allows you to move in different directions. Thespinal cord and its nerves run through a canal in the

HSS Expertise in Spine CareFrom the tip of your neck to thebase of your back, a complexconfiguration of 33 bones, interspersed with cartilage andsurrounded by a network ofnerves and soft tissue, are pro-viding you with stability, balance,and the ability to stand erect.

This elegant structure withstands phenomenalstress and yet gives us the flexibility to reach forthe stars or pick up a dime. But if the spine

becomes a source of pain and the reason for disability,the experts at Hospital for Special Surgery know precise-ly where to look and exactly what to do if necessary.

“HSS has been involved with all of the technologicalbreakthroughs that have been applied to spine,” saysFrank P. Cammisa, Jr., MD, Chief of the Spine Service.“We’re at the cutting edge of both basic scienceresearch and clinical applications in spine treatment,and we’re committed to training spine surgeons whowill contribute to improving spinal care throughout theworld. That’s what makes us stand apart from otherinstitutions.”

Beginning with advancing techniques in spine fusionfor disc herniation in the 1930s through the advent ofimage-guidance and minimally invasive surgery in themid-1990s, and most recently, performing one of the first robotic-assisted spine surgeries in the world, HSSorthopedic surgeons have continually set the pace forprogress in the diagnosis and treatment of spine disease.

The common denominator for most back problemsis pain. But the underlying pathology and treatmentsare as diverse as the individuals affected. “You have tohone in on your patient’s problem, select the righttherapeutic approach, apply it in the right way witheither rehab, surgery, or both…and then you’re goingto get a good result,” says Dr. Cammisa. “At HSS,patients are very carefully evaluated from every

1

Dr. Oheneba Boachie-Adjei reviews X-rays of a patient following scoliosis surgery in which he used a dual-rod technique that allowsan immature spine to grow.

Pinpointing the Diagnosis“We generally start with standard X-rays to evaluatethe spine. If additional diagnostic information is need-ed, we employ MRI or CT to help elucidate the precisecause of a patient’s symptoms,” says spine specialistRichard Herzog, MD, Chief of Teleradiology in theDepartment of Imaging and Radiology. “At HSS, radiol-ogists utilize the most advanced MR imaging tech-niques and the latest generation of CT scanners.”

HSS has a dedicated orthopedic MRI center that pro-vides high resolution images to evaluate the disc, spinalcord and nerve roots. CT is predominantly used toassess bony abnormalities and to determine the integri-ty of a spinal fusion. Three-dimensional CT models ofthe spine may be created for preoperative planning.

“Neurologists provide additional insight through evalu-ation of nerves emanating from the spinal cord with aclinical neurological examination that is frequently com-plimented by an electromyography study to measure theelectrical activity of peripheral nerves and muscles,” saysMoris Jak Danon, MD, Chief of Neurology. “Degenerativeconditions of the spinal canal and disc herniations canimpinge the nerves on the spinal cord. Through neuro-logical exams, we can pinpoint the origin and degree ofinjury and determine what levels of the spinal cord orperipheral nerves (at their roots) are involved.”

Physiatrist Joseph Feinberg, MD, concurs. A special-ist in electrodiagnostics, Dr. Feinberg performs nerveconduction studies that entail electrically stimulatingand activating nerves to measure their response. “Wethen use very fine needles that are ‘acupuncture like’that contain microscopic electrodes,” says Dr. Feinberg.“They can pick up electrical signals coming from muscle,which allows us to quantify the degree of nerve injury.”

Surgical Solutions for Spine ProblemsIt wasn’t so long ago that surgery on the spine was amajor and traumatic undertaking requiring a lengthyand arduous recovery. Times have changed. With thearrival of total disc replacement, minimally invasivesurgical techniques, non-fusion technologies, and newfusion procedures, physicians and patients alike areseeing dramatic improvements in spine surgery.

Orthopedic surgeon Patrick O’Leary, MD, has beenat the forefront of spinal fusion surgery since complet-ing his residency at HSS in 1975. In spinal fusion, twoor more vertebrae are permanently joined together withbone grafts and internal instrumentation to eliminate

vertebrae, with muscles and ligaments providingstrength and support. Any of the spine’s componentsare subject to trauma, wear and tear, congenital defor-mities, and inflammation.

“Rheumatologists frequently see back disease in manysettings – either as an isolated entity where back pain isa primary problem or in association with other diseases,”says HSS rheumatologist Sergio Schwartzman, MD. “One of our roles is to differentiate between the etiologiesor causes of back pain.”

Nearly 80 percent of Americans will suffer back painin their lifetime, representing some 30 million visits to physicians. Among the conditions that patients seektreatment for at HSS are herniated discs, stenosis ornarrowing of the spinal canal, spondylolisthesis (a slid-ing forward of the vertebra), fractures, scoliosis, andautoimmune diseases, such as ankylosing spondylitis.But herniated discs are considered by many to be themost painful and disabling. When a disc herniates, partof the disc material is displaced into the spinal canal.This results in pressure on the spinal nerves, which canbring pain, numbness or weakness in one or both legs.

Dr. Moris Jak Danon, a nationally recognized specialist in nerve andmuscle pathology, analyzes signals produced by electromyography todetermine the electrical activity of muscles.

2

the motion between ver-tebral segments that maybe the cause of signifi-cant pain. Fusion canalso stop the progressionof a spinal deformity suchas scoliosis. According to Dr. O’Leary, “Spine fusionis often required in thetreatment of spine frac-tures, spine tumors, scoliosis, and spondylolis-thesis. It may also be useful in reducing pain in certaindegenerative spine disorders. Spine fusion is more con-troversial in the treatment of discogenic back pain – theso-called ‘black disc’ as seen on the MRI. In this area,disc arthroplasty is currently being evaluated.”

Oheneba Boachie-Adjei, MD, Chief, Scoliosis Service,is advancing surgery for early onset scoliosis with severecurvature. Dr. Boachie is participating in a multicenter

study on a dual rod technique that achieves correctionthrough the implantation of growing rods. “We lengthenthe rods gradually, which allows the immature spine togrow and avoids the need for spinal fusion at an earlyage,” says Dr. Boachie. “This is a great advance in treat-ing early severe curves that would have required majorfusion surgery, resulting in stunted growth.”

Recently, non-fusion technology has been introducedto restore or preserve motion in the spine. Today, aselect group of patients is benefiting from spinal discreplacement in which the affected disc is removed andreplaced by a prosthesis made of metal and plastic.“Total disc replacement is a great advance for patientswith chronic, mechanical lower back pain that has notresponded to non-surgical options,” says orthopedicsurgeon Harvinder S. Sandhu, MD.

“Spine surgery at HSS is the best model for a com-prehensive team approach,” says anesthesiologist James D. Beckman, MD. “At HSS, anesthesiologists getinvolved long before the patient is brought into the OR.Communication among anesthesiologists, the surgeons,the neuro-monitoring team, and the OR nurses is crucial

Dr. Patrick O’Leary (second from left) performs a fusion to replace a damaged disc with a bone graft secured by rods to maintain proper orientation of the lumbar spine. (Below) Dr. Michael Urban, a specialist in anesthesiology for complex spine surgery, monitors the patient.

3

to ensure the best possible outcome for the patient.” Russel Huang, MD, and Andrew Sama, MD, the newer

members of the HSS spine team, bring with them expert-ise in advanced spine surgery procedures. Dr. Huanghas a keen interest in minimally disruptive decompres-sion techniques, which minimize the amount of boneand muscle removed. “These procedures are provingbeneficial to the patient with improved recovery time.”

“This is a burgeoning academic field,” says Dr. Sama.“By refining the technologies that are available, we willbe able to help many more spine patients.”

Advancing Spine Surgery through Research“Lumbar disc replacement is only the tip of the ice-berg,” says orthopedic surgeon Federico P. Girardi,MD. “Studies are underway at HSS and around theworld to evaluate cervical disc replacement, nucleusreplacement, and other non-fusion technologies.”

Dr. Frank Cammisa, Timothy M. Wright, PhD, Director,Biomedical Mechanics and Biomolecular Design, andtheir colleagues are pioneering non-fusion technologiesthat include screws to stabilize a spine without fusionand a total disc replacement made of materials thatallow for ‘normal’ motion and flexibility.

In the basic science laboratories of Chisa Hidaka,MD, researchers are looking at gene transfer strategiesthat have the potential to transform the spinal fusionprocedure. By inserting a new fusion gene constructthey have created into the intervertebral disc duringan anterior fusion procedure, they hope to induce aspinal fusion using minimally invasive techniques. “Thisshould maximize the potential for making bone in thatdisc space and avoid a bone graft, something that is nec-essary with current techniques,” says Dr. Hidaka.

Non-Surgical Approaches to Spine Care“Patients generally wish to maximize their non-surgicaltreatment options,” says HSS physiatrist Paul M. Cooke,MD, who specializes in the field of physical medicineand rehabilitation, incorporating exercise-based rehabili-tation and pain management in the non-operative treat-ment of spinal disorders. “One of the strengths of ourfield is to look at the whole patient to identify thesource of the pain as well as any contributing factors,pinpoint a precise diagnosis, and ultimately to developthe appropriate treatment plan for that individual.”

Pain management modalities include targeted epiduralsteroid injection under fluoroscopic guidance andintradiscal electrothermal therapy (IDET). “IDET workswell for properly selected patients,” says physiatristChristopher Lutz, MD. “When there is a tear in the discwall, we apply high heat directly to the inside of the discto repair the tear and promote healing.”

“Most patients will be treated with a combination ofphysical therapy, medication and injection procedures,”says Seth A. Waldman, MD, Director of Pain Medicine.“For patients who have tried these measures without suc-cess, we may recommend implanting a spinal cord stimu-lator – a permanent, implantable system that stimulatesthe part of the spinal cord where the pain is originating.Implantable infusion devices that deliver medicationdirectly into the spinal fluid may also offer relief.”

“A major strength at HSS is the close relationshipbetween surgeons and pain management doctors,” sayspain management specialist/anesthesiologist David Y.Wang, MD. “Our procedures prove valuable post-opera-tively to help patients recover from surgery as well asin addressing chronic pain.”

“Our goal is to minimize patients’ discomfort andmaximize their potential,” says Barbara Wukovits, RN,Assistant Director, Acute Pain Service. “Our staff isattuned to the nature of the patient’s pain and how itimpacts their lives. We’re not just here to treat thepain…we care about them.” n

4

To help alleviate the chronic low back pain of Robert Frigiano, Dr. PaulCooke will inject a combination of cortisone and an anesthetic underfluoroscopic guidance to reduce inflammation of the nerves.

Seven-year-old RyanHumphrey, gets aboost from his dad,William, who standspain-free thanks to a total disc replace-ment performed byDr. Frank Cammisa.With his diseaseddisc replaced with an artificial prosthe-sis, Mr. Humphrey,41, has also beenable to resume hislivelihood as a com-mercial painter.

Finn M.W. Caspersen knows all too wellthe toll that back pain can take onone’s life. The businessman (chairman

and CEO of Knickerbocker LLC) and philan-thropist came to Hospital for Special Surgeryseveral years ago for relief of an acute andincapacitating back pain attack. Familiarwith HSS through longtime friend Thomas P.Sculco, MD, Surgeon-in-Chief, Mr. Caspersenknew just where to go for help.

“I’ve had just about every back problemyou can have,” says Mr. Caspersen. “Not onlydo you lose flexibility, agility, strength andeven balance, but the continual pain is over-whelming. There is no escape from it.

“Having done extensive research for my own back problems, I came to the conclusionthat HSS was clearly the best spinal/orthope-dics hospital in the world, with treatmentmanaged by incredibly competent surgeonsand physiatrists working together for a com-mon goal,” he says.

Surgery with Frank P. Cammisa, MD,Chief of the Spine Service, ongoing therapywith HSS physiatrist Paul M. Cooke, MD, andhis own personal commitment to resuminghis active life, returned him to good health.“Their care has made a huge difference inmy life,” says Mr. Caspersen, who continuesto manage his condition with periodic visitswith his HSS physicians.

Pain management has also played animportant role in his care. “The great majori-ty of pain is managed incorrectly in theUnited States,” notes Mr. Caspersen. “Thepain management program at HSS is thegold standard. If I can live and work withoutpain, I’m much more productive and, ofcourse, my quality of life is much better.”

An international equestrian sportsmanand founder of the Princeton InternationalRegatta Association, Mr. Caspersen contin-ues to enjoy these pursuits, among others,while maintaining a rigorous exercise program that includes regular cardiac andstrength workouts.

While Mr. Caspersen has a deep personalinterest in spinal disorders – his son, who isin his 30s, has similar back problems – healso sees the broader impact that spine disease has on society, affecting people of allages, many in the prime of life.

“There are people in their 30s, 40s, and50s who are otherwise physically fit, at the

Editor-in-ChiefJosh FriedlandDirector of Communications

Managing EditorLinda Errante

DesignArnold Saks Associates

PhotographyRobert EsselBill Gallery (back cover)

Spine SilhouetteDK Publishing

Development DepartmentHospital for Special Surgery535 East 70th St, Suite 850WNew York, NY 10021

tel: 212.606.1196www.hss.edu/giving

Hospital for Special Surgery is anaffiliate of NewYork-PresbyterianHealthcare System and Weill MedicalCollege of Cornell University.

height of their careers, and who periodicallyare immobilized by back pain,” says Mr.Caspersen. “Back pain not only changes one’squality of life, but it also diminishes the abili-ty of individuals to function in full. It’s takingits toll – and it’s an expensive toll – on bothsides of the ledger. You have a huge loss ofproductivity of people in their peak years,and you have huge medical costs.”

The answer, he believes, lies in part infinding simpler therapeutic solutions where,he says, major back surgery isn’t alwaysrequired to repair and restore the spine. Tohelp achieve those solutions, Mr. Caspersen –a member of the HSS Board of Trusteessince 2000 – has been a major supporter ofthe Hospital’s spinal research and medicaleducation programs, including the funding ofa spinal research fellowship.

“HSS has embarked on a full-scaleresearch program with the most able peoplein the country – in the world, for that mat-ter,” he says. “Though one can’t guaranteewhere the breakthroughs will come from, Ibelieve it’s likely to be at Special Surgery ifyou look at past history, and the payback forsociety will be tremendous.

“They don’t quite have all the answersyet,” he adds, “but I hope – in some smallpart – to be of assistance in their quest.” n

Contacting Special Surgery

Finding a PhysicianOur Physician Referral Service can help find you the right doctor for your medical needs. Call 800.796.0783

Visit Our Web SiteNeed more information on musculoskeletal health and our medical services? Visit www.hss.edu

Education ProgramsFor information on classes, lec-tures, workshops, and supportgroups, call 212.606.1057

Giving to HSSTo support the Hospital’s pioneering work in research,patient care, and education, call 212.606.1196 or visitwww.hss.edu/giving

Finn M.W. Caspersen, patient and patron of HSS

Backing Spinal Research

Total SpineCare at HSS

Cervicalvertebrae(7)

Addressing InflammatoryBack DiseaseAnkylosing spondylitis is a form ofarthritis due to an inflammatoryprocess involving, most commonly,the sacroiliac joints, although it canaffect the entire spine. According toSergio Schwartzman, MD, HSSrheumatologist, “People with inflam-matory back diseases generally havepain that improves on exercise and is made worse by rest.” A systemicautoimmune illness, ankylosingspondylitis can also affect organ systems. Therapy has changed dramatically in recent years with the availability of anti-TNF (tumor necrosis factor) agents. These medications have previously provedsuccessful in halting the progressionof rheumatoid arthritis.

Patients who come toHospital for SpecialSurgery for spinal disorders find a fullarray of extraordinarycare…from specialists in imaging to physia-trists with expertise innon-operative therapiesto orthopedic surgeons who are pioneering surgical techniqueswith technologies thatare state-of-the-art.

Setting Standards forScoliosis TreatmentOheneba Boachie-Adjei, MD, Chiefof the Scoliosis Service, has beenevaluating with great success anew bracing system for adoles-cent idiopathic scoliosis that ismade up of a vest, pelvic supportand a strap – providing extra roomfor breathing and flexibility, whilecorrecting the spinal curvature. Dr. Boachie and his colleague,orthopedic surgeon Bernard A.Rawlins, MD, use sophisticatedfusion techniques and new instru-mentation to surgically correct progressive curves, enhancing therecovery of patients like 14-year-oldPaul Bailey (at right). Workingtogether with Roger F. Widmann,MD, Chief of Pediatric Orthopedics,they are also implementing newendoscopic procedures that allowthem to access the spine through thechest cavity, and perform the fusionwith three or four small incisions.

Total SpineCare at HSS

Cervicalvertebrae(7)

Lumbarvertebrae(5)

Sacrumvertebrae

(5 fusedvertebrae)

Coccyxvertebrae

(4 fusedvertebrae)

How ComplementaryMedicine Can HelpHSS spine patients can also benefitfrom a unique outpatient programoffering rehabilitation services, aswell as a number of complementaryand holistic modalities that can beused in partnership with traditionalcare for spinal disorders. At theIntegrative Care Center, an affiliate

of HSS, services include reflexology,massage therapy, a Pilates exerciseprogram, chiropractic services, andacupuncture – the practice of insert-ing very fine needles into the skin tostimulate specific anatomic points inthe body for therapeutic purposes, asdemonstrated here by anesthesiolo-gist Jeffrey Ngeow, MD, an HSS painmanagement specialist.

A Source of Care forSkeletal DysplasiaPatients with skeletal dysplasia – acondition characterized by abnormalbone growth and shortened stature –are born with smaller spinal canals.“As a result, these patients can devel-op narrowing of the space aroundthe nerves and the spinal cord at amuch earlier age,” says James C.Farmer, MD, an orthopedic surgeonwho manages the spine problems ofBryant Martin and other patients inHSS’ Center for Skeletal Dysplasias.“With surgery, we can decompressthe area around the spinal cord andnerve roots, which can be effective ineliminating symptoms.”

Addressing InflammatoryBack DiseaseAnkylosing spondylitis is a form ofarthritis due to an inflammatoryprocess involving, most commonly,the sacroiliac joints, although it canaffect the entire spine. According toSergio Schwartzman, MD, HSSrheumatologist, “People with inflam-matory back diseases generally havepain that improves on exercise and is made worse by rest.” A systemicautoimmune illness, ankylosingspondylitis can also affect organ systems. Therapy has changed dramatically in recent years with the availability of anti-TNF (tumor necrosis factor) agents. These medications have previously provedsuccessful in halting the progressionof rheumatoid arthritis.

AdvancingKnowledge in NeurologyUnder the direction ofMorris Jak Danon,

MD, Chief of Neurology,neurologists perform

electromyography andnerve conduction studies –

valuable tools to measure electricalsignals produced by peripheralnerves emanating from the spinalcord. These studies also help todetermine if the spine problem isdue to a primary muscle disease.

ReplacingDegenerative DiscsIn spinal disc replace-ment surgery, theaffected disc isremoved and replacedby a prosthesis made ofmetal and plastic (shownhere). The procedure isproving beneficial for improv-ing function and reducing pain for patients with degenerative discdisease that has not responded toother interventions.

Patients who come toHospital for SpecialSurgery for spinal disorders find a fullarray of extraordinarycare…from specialists in imaging to physia-trists with expertise innon-operative therapiesto orthopedic surgeons who are pioneering surgical techniqueswith technologies thatare state-of-the-art.

Setting Standards forScoliosis TreatmentOheneba Boachie-Adjei, MD, Chiefof the Scoliosis Service, has beenevaluating with great success anew bracing system for adoles-cent idiopathic scoliosis that ismade up of a vest, pelvic supportand a strap – providing extra roomfor breathing and flexibility, whilecorrecting the spinal curvature. Dr. Boachie and his colleague,orthopedic surgeon Bernard A.Rawlins, MD, use sophisticatedfusion techniques and new instru-mentation to surgically correct progressive curves, enhancing therecovery of patients like 14-year-oldPaul Bailey (at right). Workingtogether with Roger F. Widmann,MD, Chief of Pediatric Orthopedics,they are also implementing newendoscopic procedures that allowthem to access the spine through thechest cavity, and perform the fusionwith three or four small incisions.

Taking the Inside ViewRichard Herzog, MD, Chief ofTeleradiology, and his colleagues utilize advanced imaging techniquesto diagnose spinal disorders. InitialX-rays are useful to assess spinalalignment and to detect bony abnor-malities. When additional informa-tion is required, MRI (shown here)provides the most comprehensiveinformation concerning the condi-tion of the spine and its neural elements. CT is used to detect bonyabnormalities and to determine theintegrity of a spine fusion.

Physical Therapy FirstAccording to Holly Rudnick, PT,Rehabilitation Services, left, manypatients can benefit from exercise-based programs that combine flexibility and stretching routineswith protocols to strengthen theabdomen, back and pelvis. “Ourgoal is to improve patients’ function,decrease their pain and return themto the activities that they have beenunable to do since the onset of theirback problem,” says Ms. Rudnick.

At the Forefront of Fusion Surgery In spinal fusion (shown in the modelabove), two or more vertebrae arefused together with bone grafts andinternal devices, such as metal rods,to stabilize the spine or correct adeformity. For decades, HSS surgeonshave been involved in the develop-ment of fusion systems, materials forinstrumentation, and alternatives forbone grafts. Candidates for spinefusion may also include patients whohad recurrent disk herniations or whohave had previous back surgery.

Understanding Physiatry’s RoleRobert Watlington can continue toenjoy golf thanks to physiatrists likePaul M. Cooke, MD, who often offerthe first line of treatment for patientswith back pain. That treatment mayinclude exercise regimens supervisedby a physical therapist to restoremobility and function, as well as image-guided minimally invasive procedures such as epidural injectionsand procedures that utilize radiofre-quency waves to desensitize painfulspinal discs and joints.

Managing Chronic Back Pain “As people age, degenerative discdisease and arthritis are almost universal,” says Seth A. Waldman,MD, Director of Pain Medicine. Manywill have their pain managed with acombination of physical therapy,medication, and injection procedures.For inexorable back pain, pain management specialists apply state-of-the-art techniques, includingimplantable spinal cord stimulatorsor medication infusion pumps.

Offering Help forOsteoporosis Fractures“Nearly a million vertebral fracturesoccur in the U.S. each year,” saysJoseph M. Lane, MD, Chief of theMetabolic Bone Disease Service. Dr. Lane is able to alleviate pain fromvertebral compression fractures forpatients like Joyce Searles usingkyphoplasty. “We insert a balloon inthe affected vertebra and inflate it to create a cavity that can be filledwith bone cement, stabilizing thefracture, while improving alignmentand posture.”

Thoracicvertebrae

(12)

Total SpineCare at HSS

Cervicalvertebrae(7)

Lumbarvertebrae(5)

Sacrumvertebrae

(5 fusedvertebrae)

Coccyxvertebrae

(4 fusedvertebrae)

How ComplementaryMedicine Can HelpHSS spine patients can also benefitfrom a unique outpatient programoffering rehabilitation services, aswell as a number of complementaryand holistic modalities that can beused in partnership with traditionalcare for spinal disorders. At theIntegrative Care Center, an affiliate

of HSS, services include reflexology,massage therapy, a Pilates exerciseprogram, chiropractic services, andacupuncture – the practice of insert-ing very fine needles into the skin tostimulate specific anatomic points inthe body for therapeutic purposes, asdemonstrated here by anesthesiolo-gist Jeffrey Ngeow, MD, an HSS painmanagement specialist.

A Source of Care forSkeletal DysplasiaPatients with skeletal dysplasia – acondition characterized by abnormalbone growth and shortened stature –are born with smaller spinal canals.“As a result, these patients can devel-op narrowing of the space aroundthe nerves and the spinal cord at amuch earlier age,” says James C.Farmer, MD, an orthopedic surgeonwho manages the spine problems ofBryant Martin and other patients inHSS’ Center for Skeletal Dysplasias.“With surgery, we can decompressthe area around the spinal cord andnerve roots, which can be effective ineliminating symptoms.”

Addressing InflammatoryBack DiseaseAnkylosing spondylitis is a form ofarthritis due to an inflammatoryprocess involving, most commonly,the sacroiliac joints, although it canaffect the entire spine. According toSergio Schwartzman, MD, HSSrheumatologist, “People with inflam-matory back diseases generally havepain that improves on exercise and is made worse by rest.” A systemicautoimmune illness, ankylosingspondylitis can also affect organ systems. Therapy has changed dramatically in recent years with the availability of anti-TNF (tumor necrosis factor) agents. These medications have previously provedsuccessful in halting the progressionof rheumatoid arthritis.

AdvancingKnowledge in NeurologyUnder the direction ofMorris Jak Danon,

MD, Chief of Neurology,neurologists perform

electromyography andnerve conduction studies –

valuable tools to measure electricalsignals produced by peripheralnerves emanating from the spinalcord. These studies also help todetermine if the spine problem isdue to a primary muscle disease.

ReplacingDegenerative DiscsIn spinal disc replace-ment surgery, theaffected disc isremoved and replacedby a prosthesis made ofmetal and plastic (shownhere). The procedure isproving beneficial for improv-ing function and reducing pain for patients with degenerative discdisease that has not responded toother interventions.

Patients who come toHospital for SpecialSurgery for spinal disorders find a fullarray of extraordinarycare…from specialists in imaging to physia-trists with expertise innon-operative therapiesto orthopedic surgeons who are pioneering surgical techniqueswith technologies thatare state-of-the-art.

Setting Standards forScoliosis TreatmentOheneba Boachie-Adjei, MD, Chiefof the Scoliosis Service, has beenevaluating with great success anew bracing system for adoles-cent idiopathic scoliosis that ismade up of a vest, pelvic supportand a strap – providing extra roomfor breathing and flexibility, whilecorrecting the spinal curvature. Dr. Boachie and his colleague,orthopedic surgeon Bernard A.Rawlins, MD, use sophisticatedfusion techniques and new instru-mentation to surgically correct progressive curves, enhancing therecovery of patients like 14-year-oldPaul Bailey (at right). Workingtogether with Roger F. Widmann,MD, Chief of Pediatric Orthopedics,they are also implementing newendoscopic procedures that allowthem to access the spine through thechest cavity, and perform the fusionwith three or four small incisions.

Taking the Inside ViewRichard Herzog, MD, Chief ofTeleradiology, and his colleagues utilize advanced imaging techniquesto diagnose spinal disorders. InitialX-rays are useful to assess spinalalignment and to detect bony abnor-malities. When additional informa-tion is required, MRI (shown here)provides the most comprehensiveinformation concerning the condi-tion of the spine and its neural elements. CT is used to detect bonyabnormalities and to determine theintegrity of a spine fusion.

Physical Therapy FirstAccording to Holly Rudnick, PT,Rehabilitation Services, left, manypatients can benefit from exercise-based programs that combine flexibility and stretching routineswith protocols to strengthen theabdomen, back and pelvis. “Ourgoal is to improve patients’ function,decrease their pain and return themto the activities that they have beenunable to do since the onset of theirback problem,” says Ms. Rudnick.

At the Forefront of Fusion Surgery In spinal fusion (shown in the modelabove), two or more vertebrae arefused together with bone grafts andinternal devices, such as metal rods,to stabilize the spine or correct adeformity. For decades, HSS surgeonshave been involved in the develop-ment of fusion systems, materials forinstrumentation, and alternatives forbone grafts. Candidates for spinefusion may also include patients whohad recurrent disk herniations or whohave had previous back surgery.

Understanding Physiatry’s RoleRobert Watlington can continue toenjoy golf thanks to physiatrists likePaul M. Cooke, MD, who often offerthe first line of treatment for patientswith back pain. That treatment mayinclude exercise regimens supervisedby a physical therapist to restoremobility and function, as well as image-guided minimally invasive procedures such as epidural injectionsand procedures that utilize radiofre-quency waves to desensitize painfulspinal discs and joints.

Managing Chronic Back Pain “As people age, degenerative discdisease and arthritis are almost universal,” says Seth A. Waldman,MD, Director of Pain Medicine. Manywill have their pain managed with acombination of physical therapy,medication, and injection procedures.For inexorable back pain, pain management specialists apply state-of-the-art techniques, includingimplantable spinal cord stimulatorsor medication infusion pumps.

Offering Help forOsteoporosis Fractures“Nearly a million vertebral fracturesoccur in the U.S. each year,” saysJoseph M. Lane, MD, Chief of theMetabolic Bone Disease Service. Dr. Lane is able to alleviate pain fromvertebral compression fractures forpatients like Joyce Searles usingkyphoplasty. “We insert a balloon inthe affected vertebra and inflate it to create a cavity that can be filledwith bone cement, stabilizing thefracture, while improving alignmentand posture.”

Thoracicvertebrae

(12)

Total SpineCare at HSS

Cervicalvertebrae(7)

Lumbarvertebrae(5)

Sacrumvertebrae

(5 fusedvertebrae)

Coccyxvertebrae

(4 fusedvertebrae)

How ComplementaryMedicine Can HelpHSS spine patients can also benefitfrom a unique outpatient programoffering rehabilitation services, aswell as a number of complementaryand holistic modalities that can beused in partnership with traditionalcare for spinal disorders. At theIntegrative Care Center, an affiliate

of HSS, services include reflexology,massage therapy, a Pilates exerciseprogram, chiropractic services, andacupuncture – the practice of insert-ing very fine needles into the skin tostimulate specific anatomic points inthe body for therapeutic purposes, asdemonstrated here by anesthesiolo-gist Jeffrey Ngeow, MD, an HSS painmanagement specialist.

A Source of Care forSkeletal DysplasiaPatients with skeletal dysplasia – acondition characterized by abnormalbone growth and shortened stature –are born with smaller spinal canals.“As a result, these patients can devel-op narrowing of the space aroundthe nerves and the spinal cord at amuch earlier age,” says James C.Farmer, MD, an orthopedic surgeonwho manages the spine problems ofBryant Martin and other patients inHSS’ Center for Skeletal Dysplasias.“With surgery, we can decompressthe area around the spinal cord andnerve roots, which can be effective ineliminating symptoms.”

Addressing InflammatoryBack DiseaseAnkylosing spondylitis is a form ofarthritis due to an inflammatoryprocess involving, most commonly,the sacroiliac joints, although it canaffect the entire spine. According toSergio Schwartzman, MD, HSSrheumatologist, “People with inflam-matory back diseases generally havepain that improves on exercise and is made worse by rest.” A systemicautoimmune illness, ankylosingspondylitis can also affect organ systems. Therapy has changed dramatically in recent years with the availability of anti-TNF (tumor necrosis factor) agents. These medications have previously provedsuccessful in halting the progressionof rheumatoid arthritis.

AdvancingKnowledge in NeurologyUnder the direction ofMorris Jak Danon,

MD, Chief of Neurology,neurologists perform

electromyography andnerve conduction studies –

valuable tools to measure electricalsignals produced by peripheralnerves emanating from the spinalcord. These studies also help todetermine if the spine problem isdue to a primary muscle disease.

ReplacingDegenerative DiscsIn spinal disc replace-ment surgery, theaffected disc isremoved and replacedby a prosthesis made ofmetal and plastic (shownhere). The procedure isproving beneficial for improv-ing function and reducing pain for patients with degenerative discdisease that has not responded toother interventions.

Patients who come toHospital for SpecialSurgery for spinal disorders find a fullarray of extraordinarycare…from specialists in imaging to physia-trists with expertise innon-operative therapiesto orthopedic surgeons who are pioneering surgical techniqueswith technologies thatare state-of-the-art.

Setting Standards forScoliosis TreatmentOheneba Boachie-Adjei, MD, Chiefof the Scoliosis Service, has beenevaluating with great success anew bracing system for adoles-cent idiopathic scoliosis that ismade up of a vest, pelvic supportand a strap – providing extra roomfor breathing and flexibility, whilecorrecting the spinal curvature. Dr. Boachie and his colleague,orthopedic surgeon Bernard A.Rawlins, MD, use sophisticatedfusion techniques and new instru-mentation to surgically correct progressive curves, enhancing therecovery of patients like 14-year-oldPaul Bailey (at right). Workingtogether with Roger F. Widmann,MD, Chief of Pediatric Orthopedics,they are also implementing newendoscopic procedures that allowthem to access the spine through thechest cavity, and perform the fusionwith three or four small incisions.

Taking the Inside ViewRichard Herzog, MD, Chief ofTeleradiology, and his colleagues utilize advanced imaging techniquesto diagnose spinal disorders. InitialX-rays are useful to assess spinalalignment and to detect bony abnor-malities. When additional informa-tion is required, MRI (shown here)provides the most comprehensiveinformation concerning the condi-tion of the spine and its neural elements. CT is used to detect bonyabnormalities and to determine theintegrity of a spine fusion.

Physical Therapy FirstAccording to Holly Rudnick, PT,Rehabilitation Services, left, manypatients can benefit from exercise-based programs that combine flexibility and stretching routineswith protocols to strengthen theabdomen, back and pelvis. “Ourgoal is to improve patients’ function,decrease their pain and return themto the activities that they have beenunable to do since the onset of theirback problem,” says Ms. Rudnick.

At the Forefront of Fusion Surgery In spinal fusion (shown in the modelabove), two or more vertebrae arefused together with bone grafts andinternal devices, such as metal rods,to stabilize the spine or correct adeformity. For decades, HSS surgeonshave been involved in the develop-ment of fusion systems, materials forinstrumentation, and alternatives forbone grafts. Candidates for spinefusion may also include patients whohad recurrent disk herniations or whohave had previous back surgery.

Understanding Physiatry’s RoleRobert Watlington can continue toenjoy golf thanks to physiatrists likePaul M. Cooke, MD, who often offerthe first line of treatment for patientswith back pain. That treatment mayinclude exercise regimens supervisedby a physical therapist to restoremobility and function, as well as image-guided minimally invasive procedures such as epidural injectionsand procedures that utilize radiofre-quency waves to desensitize painfulspinal discs and joints.

Managing Chronic Back Pain “As people age, degenerative discdisease and arthritis are almost universal,” says Seth A. Waldman,MD, Director of Pain Medicine. Manywill have their pain managed with acombination of physical therapy,medication, and injection procedures.For inexorable back pain, pain management specialists apply state-of-the-art techniques, includingimplantable spinal cord stimulatorsor medication infusion pumps.

Offering Help forOsteoporosis Fractures“Nearly a million vertebral fracturesoccur in the U.S. each year,” saysJoseph M. Lane, MD, Chief of theMetabolic Bone Disease Service. Dr. Lane is able to alleviate pain fromvertebral compression fractures forpatients like Joyce Searles usingkyphoplasty. “We insert a balloon inthe affected vertebra and inflate it to create a cavity that can be filledwith bone cement, stabilizing thefracture, while improving alignmentand posture.”

Thoracicvertebrae

(12)