The Cleveland Clinic Spine

SUMMER 2005 Chairman’s Column By Edward C. Benzel, M.D. Chairman, Cleveland Clinic Spine Institute process by developing a multidisciorthopaedic diso...
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SUMMER 2005

Chairman’s Column By Edward C. Benzel, M.D. Chairman, Cleveland Clinic Spine Institute process by developing a multidisciorthopaedic disorders, including he Cleveland Clinic Spine plinary approach to pediatric spinal Institute (CCSI) is maturing spine disorders), sports medicine disorders. Two well-defined discirapidly as a Cleveland Clinic physicians, adult orthopaedic spine plines have emerged as a result: the department. Perhaps one of the surgeons, pediatric neurosurgeons pediatric and adolescent medical and adult neuro-spine surgeons. most telling and objective paramespine specialist and the pediatric The surgical treatment of scolters in this regard is the developand adolescent spine surgeon. The iosis has been appropriately ment and implementation of new former focuses on the diagnosis and addressed for years. However, comand innovative programs, such as medical management of all pediprehensive pediatric/adolescent the CCSI Mature Spine Clinic, atric and adolescent spine disorders, spine care, performed in concert multiple regional multidisciplinary while the latter concentrates on the with medical pediatric/adolescent spine clinics, and now the CCSI surgical management of pediatric spine specialists, surgical pediPediatric/ Adolescent Spine Proand adolescent spine disorders. atric/adolescent spine surgeons, gram. The establishment of the This distinction is CCSI Pediatric/Adovery important and lescent Spine Profollows the CCSI gram is the most The CCSI mission is to provide the best possible strategy of a multirecent CCSI foray disciplinary focus into the patient care to our patients afflicted by spinal problems, to on the medical and care and quality innovate and advance spine treatment services, surgical managecare improvement ment of the develarenas. With this and to provide a fertile environment for research, oping spine and most recent addieducation and collaborative patient care. having the right tion to the CCSI patient see the corarmamentarium, rect specialist. we now offer comEmploying medical and surgiprehensive spine care to patients of spine physical therapists, intervencal spine specialists who focus on all ages under one roof. tionalists and others is uncomdisorders of the developing spine As alluded to in this issue of monly provided. This process has in a multidisciplinary manner and often been inadequately coordinatSpinal Column, physician visits for in a multidisciplinary environment ed and, hence, confusing to referpediatric spine disorders are not is the hallmark of the CCSI proring physicians and, more uncommon, while surgery for the gram. With this in mind, enjoy this important, to the pediatric/adolessame is. Traditionally, spinal disorissue. It truly represents the introcent patients and their parents. ders have been diagnosed by school duction and, if you will, “coming Therefore, the diagnosis and mannurses, pediatricians and primary out party” of yet another innovaagement of discogenic pathologies, care physicians. Subsequent care tive CCSI and Cleveland Clinic cervical and lumbar stenosis, has been delivered by sports mediclinical care initiative. spondylolisthesis, mechanical back cine physicians, neurosurgeons and For additional information pain related to overuse, tumors and orthopaedic surgeons. Orchestrated about the Spine Institute, please other pathologies have been tradimedical management has been contact me at 216/445-5514 or our tionally suboptimal. lacking, while surgery has been disadministrator, Kathy Huffman, at The CCSI now has addressed tributed between pediatric 216/445-8442. To refer patients, the problems created by the tradiorthopaedic surgeons (surgeons call 216/4442225 or 800/553-5056, tional and somewhat disjointed with training and expertise in the ext. 42225. ■ pediatric and adolescent spine care management of pediatric

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Basic Evaluation Process for Back Pain in Children By Russell DeMicco, D.O. Cleveland Clinic Spine Institute hile back pain is perhaps the most common pain complaint of adults, and all adults have had back pain at some time in their life, back pain is much rarer in children and adolescents. In this population, back pain may be the initial symptom of an underlying disease process. This is especially true in younger children (preteenagers) who are less likely to experience an overuse injury such as those that occur during strenuous exercise. The exact incidence of back pain in children is not known, however there is a gradual increase with age. Unlike adults, children are rarely if ever disabled by back pain, and in more than half of patients, a definable cause for the back pain can be found. The cornerstone of evaluating the pediatric patient with back pain is a thorough history and physical exam, including a complete musculoskeletal and neurologic evaluation. Importance is placed on determining the nature of onset, as well as character, location, duration and radiation of symptoms. Note should be made of spinal posture (including any excessive or abnormal curves), range of motion (including any restriction), areas of tenderness, and muscle spasm. Assessment of gait, muscle strength, reflexes and sensation also are part of the initial physical. Special tests like straight leg raise and presence of pathologic reflexes like Babinski contribute more useful information. More extensive investigation may be in order if pain does not improve within several weeks or if there are objective findings on exam, pain worsens or new symptoms develop. Because effective treatment begins with an accurate diagnosis of the condition, a prompt diagnosis may increase the likelihood of a successful outcome. Important warning

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signs have been identified that if found on history and physical exam should alert the clinician that there is a high probability for a serious cause of back pain. Further evaluation and potential significant underlying etiology are suggested with: ■ persistent or increasing pain ■ pain with associated fever, malaise or weight loss ■ neurologic symptoms or exam findings

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bowel or bladder dysfunction symptom onset at young age (4 years or younger is suspicious for tumor) ■ painful left thoracic scoliosis Initial X-ray evaluation may typically include anterior-posterior and lateral views of the area involved. Oblique view X-rays often are useful to evaluate for spondylolysis. Further studies would be carried out if indicated by the previous evaluation. A CBC, sedimentation rate and urinalysis may be part of the original screening tests beyond the H&P and Xrays. An elevated CBC or sedimentation rate suggests the presence of an inflammatory or infectious process. Results of initial evaluation should be used to direct further imaging studies, which may include MRI, CT scan, tomogram or bone scan. The use of these studies is dictated by differential diagnosis. Treatment of back pain in children is diagnosis-specific. Conservative treatment (activity modification, mild analgesics) is appropriate initially if there are no neurologic signs or symptoms (radicular pain, muscle weakness, gait abnormalities, sensory changes, bowel and

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bladder abnormalities). Regardless of the cause, some form of pain reliever may be required in most cases. Treatment may begin with simple analgesics like acetaminophen (Tylenol) and ibuprofen (Advil). A targeted differential diagnosis can be generated by dividing children into two age groups: prepubertal and pubertal. In prepubertal children, the differential includes infection, in the form of diskitis or osteomyelitis, or tumor of the spinal column or spinal cord. In pubertal children, the differential includes tumor of the spinal column or spinal cord, spondylolysis or spondylolisthesis, herniated disk, lumbar strain from overuse or Scheuermann’s Disease. Specific symptom associations that are important to identify include fever and back pain (possible underlying infection, neoplasm, or inflammatory disease); neurological symptoms (may signify underlying disc herniation); excessive lordosis (possible spondylolysis or spondylolisthesis); and excessive kyphosis (possible Scheuermann’s disease). Another useful classification is the separation of back pain and its causes into one of four categories: mechanical problems, developmental abnormalities, infectious/inflammatory conditions and neoplasm. Mechanical problems include overuse injury, backpack syndrome, direct trauma and herniated discs. Mechanical problems are more common in adolescents than in pre-teens. Herniated discs are rare causes of back pain in children (especially under age 10). Although treatment is usually non-surgical, 1 percent to 2 percent of disc excisions are done on children under 16. The so-called backpack syndrome is considered in children with back pain but is still inconsistent in literature. Education on posture and proper use (potentially less than 10

percent to 15 percent of body weight carried) of backpack may be beneficial. Most overuse syndromes will respond with activity modification and mild analgesics. Developmental abnormalities include spondylolysis, spondylolisthesis and Scheuermann’s kyphosis. Spondylolysis and spondylolisthesis are among the most common causes of back pain in the lumbar and lumbosacral regions. They are most common in children 10 years and older and rarely seen in children younger than 10. Spondylolysis refers to a defect in the pars interarticularis, which occurs most commonly at the L5 vertebra. This defect is present in about 5 percent to 7 percent of the general population and may be congenital or acquired. The rate of occurrence may be 10 percent or higher in certain athletic populations (divers, hockey players, gymnasts, wrestlers and football linemen). Spondylolisthesis is the presence of a slippage of one vertebral body on another. Treatment depends on presence of symptoms. Beyond activity modification and analgesics, bracing and surgery may be considered. Diagnosis is made from X-rays (particularly oblique and lateral views). If doubt is present, SPECT bone scan or CT may provide additional information. Another developmental abnormality that results in back pain in adolescents is Scheuermann’s disease or juvenile kyphosis. Scheuermann’s disease is the most common cause of pediatric back pain in the thoracic spine or thoracolumbar spine. Although the exact cause of the disease has not been determined, researchers believe it results from an abnormality or interruption of the blood supply to key areas of the vertebral bodies, which leads to progressive fixed kyphosis of the spine. Parents may notice that their child has “poor posture” and is walking “hunched” over, while the children frequently complain of pain, espe-

cially late in the day. The diagnosis is confirmed by simple X-ray examination of the spine. Activity modification, physical therapy and analgesic medications are typical treatments. Bracing and surgery are considered in more severe cases. Inflammatory and infectious diseases including diskitis, vertebral osteomyelitis, pyelonephritis, juvenile rheumatoid arthritis (JRA), and ankylosing spondylitis (AS) may occur in younger patients (typically pre-teens) and may be associated with fever or laboratory abnormalities. Diskitis is more common in children younger than 8 to 10, while vertebral osteomyelitis is more common in children older than 8 to 10. Infection can cause fever, back pain, irritability (especially in younger children), and muscle spasms in the back. Infection may cause some children to hold their spine straight, and they may limp and/or refuse to stand or walk. The infection also may cause changes on an X-ray (narrowing of the disk space). Diagnosis is aided by bone scan and MRI. Beyond the early treatment, which usually consists of antibiotics and bed rest, surgical exploration for drainage, biopsy or fusion may considered. Kidney infections (pyelonephritis) may be causes of back or flank pain in children. Symptoms may include sharp pain on one side of the back, fever, nausea and dysuria. Treatment is antibiotics for underlying infection. JRA most often affects the cervical spine, whereas AS may present as low back pain and stiffness in boys over 8 years. Treatment consists of medication and physical therapy. Neoplastic disorders include primary and metastatic lesions. Not all tumors of

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the vertebral bodies and spine are malignant. Back pain may be caused by benign lesions such as osteoid osteoma, hemangioma and giant cell tumors. Depending on the type of tumor, treatment may include surgical removal of the tumor or radiation and/or chemotherapy. In most cases, a biopsy of the lesion is necessary to determine the type of tumor and its appropriate treatment. Primary osseous neoplasms of the lumbar spine are uncommon, with Ewing sarcoma, aneurysmal bone cyst, benign osteoblastoma and osteoid osteoma being the most common, followed by primary lymphoma. These lesions occur more often in children between the ages of 5 and 20. Osteoid osteoma is characterized by severe night pain that is relieved by salicylates. Symptoms of spinal tumors generally develop slowly and worsen over time. The main symptom is chronic back pain that may be worse at night and unaffected by rest or activity. Other symptoms may include sciatica, numbness, weakness, fever and bowel/bladder issues. Imaging (X-rays, bone scans using CT and MRI) is useful in diagnosis. Another category of consideration may be the psychosocial or psychological components or contributions to back pain. Children may mimic the behavior and symptoms of adults and older children in the family. Symptoms may indicate other problems in the home or at school. Children sometimes respond to stress with physical symptoms. There is even a population of pediatric fibromyalgia. However, these diagnoses should be made with caution after ruling out other diagnosable conditions. If a child presents with persistent back pain that is not relieved by rest, decrease in activities, and simple analgesics and anti-inflammatory drugs, consider referring the child to a spine specialist. If there are associated constitutional symptoms, referral should not be delayed. ■

Contemporary Treatment of Scoliosis By Thomas Kuivila, M.D. Cleveland Clinic Spine Institute coliosis is not yet a preventable condition. However, new treatment protocols are dramatically impacting results. A brace worn only at night has increased compliance, reducing progression of the curvature in many patients. In those requiring surgery, pedicle screw fixation techniques are proving far superior for correcting rotation in addition to lateral movement. As a result, dramatic correction is now the rule rather than the exception. The overall prevalence of scoliosis has not changed. It continues to be found in equal numbers of boys and girls, with adolescent idiopathic scoliosis accounting for about 85 percent of cases. However, curve progression is more common in girls. At The Cleveland Clinic, approximately 150 scoliosis operations are performed each year, 80 percent on girls. As a rule, curvature of less than 25 degrees requires no treatment. Regular examinations are simply performed to monitor for progression. In skeletally immature children,

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guidelines call for bracing to try to prevent further progression when the curvature progresses to 25 but not beyond 40 degrees. Bracing has no role in the skeletally mature patient. Bracing is considered less onerous than in the past. In current favor is the Providence brace, which is worn for about 10 hours at night. Its bending action maintains flexibility and produces a temporary improvement of the curve. (“Temporary” must be emphasized,

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because the goal of bracing remains control or prevention of progression, not long-term improvement.) Early results with the Providence brace are nearly as good as those achieved with the Milwaukee and Boston braces, and compliance is clearly superior. Compliance with bracing is a big issue. The majority of children needing bracing are girls aged 11 to 15, for whom wearing a large, cumbersome body brace during the day interferes with contemporary dress styles and can have an adverse psychosocial impact. We have found that most patients do not mind wearing the nighttime brace. Curves between 40 and

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50 degrees may fall into a gray zone of surgery versus conservative care. Often, an outward appearance of the curve typically affected by the degree of rotational deformity plays a role in surgical decision-making by the patient and their family. The more extensive the rotation, the more extensive the aesthetic impact. While scoliosis surgery is not done purely for cosmesis, this is the number one concern for many patients. Pain and progression issues 20 years hence are not concepts the typical teen grasps. At 50 degrees, however, surgery usually becomes a health necessity. Curves in this range will often continue to increase by one degree per year, even when the person is skeletally mature. High-magnitude curves can potentially impact lung and heart function, digestion and a host of other critical issues. Just 20 years ago, surgery for scoliosis often produced less-than-ideal results. The instrumentation used in the procedure was prone to failure, so casting or bracing was typically needed after surgery. Also, the techniques did not adequately address the 3-D component of this condition. Some patients developed secondary deformities, most notably a flat lumbar spine that can become quite problematic in the third decade and beyond. Development of the Cotrel-Dubousset instrumentation solved some of these issues by allowing better restoration of 3D alignment. However, the technique was still not optimal, as hooks attached under the spine could pull out under force. Several years ago pedicle screw fixation, which provides superior holding strength, became commonplace in the lumbar spine. More recently, we have begun using screws throughout the thoracic spine as

Upcoming Symposia Sept. 9-10 I n n ov a t i ve S p i n e C a r e : E s s e n t i a l S k i l l s fo r t h e N u r s i n g Te a m InterContinental Hotel & Conference Center Cleveland, OH Contact Bill Wick at 216/4443295 or 800/223-2273, ext. 43295, or at [email protected]

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well, resulting in extremely secure fixation. Employing the technique throughout the spine produces the force necessary to achieve outstanding correction. While dysplastic joints and vertebral asymmetry may influence the degree of correction possible, results are uniformly superior to those obtained with

earlier techniques. While we used to “promise” patients a 50 percent correction, we can now take a 60-degree curve and correct it to single digits. In some particularly flexible patients, we have obtained very nearly perfectly straight spines with this technique. ■

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July 19-25, 2006 C l ev e l a n d S p i n e R ev i ew Hands-On Cours e InterContinental Hotel & Conference Center Cleveland, OH Contact Martha Tobin at 216/445-3449 or 800/223-2273, ext. 53449, or at [email protected]

Scoliosis Schooling By Suzanne Mell, R.N., B.S.N.

chool nurses are an important link in identifying scoliosis in adolescents. During school scoliosis screenings, school nurses are the first to identify that an adolescent may have the signs of scoliosis. School nurses may be interested in the following facts:

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In 80 percent to 85 percent of adolescent scoliosis cases, the cause is unknown (called idiopathic scoliosis). Girls are at least four times more likely than boys to develop scoliosis. Most scoliosis develops gradually between the ages of 10 and 16, and usually parents and friends do not notice the gradual changes. Scoliosis is more likely to progress with the growth spurt during puberty. Scoliosis tends to run in families. If the child has a family history of scoliosis, they are more at risk to develop it and should be screened every six months. Scoliosis is usually painless in adolescents.

Scoliosis is usually discovered during a routine medical exam, school screening, sports physical or when the adolescent puts on a swimsuit at the start of summer. During a school screening, it is important to have the child remove any bulky sweaters or sweat shirts and just take a good look at their back. School nurses should look for the following signs of scoliosis: ■ ■

uneven shoulders or waistline one or both shoulder blades sticking out

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leaning slightly to one side hump on one side of the back

Have the children turn so that their back is to the screener. With chin on their chest, arms stretched out in front of them and palms together, the children should slowly bend over and touch their feet while keeping their legs straight. This maneuver often will make a slight asymmetry easier to spot. If scoliosis is suspected, it is impor-

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tant to have the adolescent evaluated further by either their family doctor or a spine expert. Cleveland Clinic adolescent spine experts offer a thorough evaluation, which includes: medical and family history; physical exam; neurological exam; and X-rays to pinpoint the location, extent and degree of the curve, alignment of the hip and pelvic bones, and the amount of spinal growth remaining. It is vital to assess skeletal maturity, because scoliosis tends to progress during spinal growth. Early detection is paramount in being able to treat scoliosis conservatively. If an adolescent presents with a curvature that is less than 20 degrees, typically the spine expert will follow the patient with spine films every four to six months to monitor the curve for signs of progression. If the adolescent presents with a curve of greater than 20 degrees but less than 40 degrees and still has skeletal growth remaining, he or she most likely will be placed in a bending brace that is worn only at night. The goal of bracing is not correction of the curve but rather to halt the progression. Once the child is

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placed in the brace, he or she will have an appointment with an X-ray in the brace to confirm brace efficacy and fit. The spine expert will follow the adolescent every four to six months with Xrays to confirm the cessation of curve progression. If the adolescent presents with a curvature greater than 40 to 45 degrees or has failed bracing and progresses to 40 to 45 degrees, the only other treatment is surgical correction. The goal of surgery is to make the spine straighter, usually by 40 percent to 80 percent, and to fuse the spine to hold the correction and prevent further progression. The surgeon fuses the vertebrae together through bone graft and uses metallic implants to hold the spine until fusion takes place, so there is no need for bracing after surgery in most cases. Usually eight to 12 months are required for the fusion to be solid enough for the adolescent to return to all activities with the exception of collision sports. Ninety-nine percent of adolescents with scoliosis continue to participate in sports, dance and similar physical activities. Spine experts at The Cleveland Clinic emphasize the importance of staying fit and active. The school nurse can play a vital role in reassuring adolescents that a mild, stable curve may never need treatment and generally will only require semi-annual checkups. It is reassuring to note that of the 2 percent to 3 percent of American 16-year-olds that have scoliosis, only 0.1 percent ever develop curves severe enough to warrant surgery. Scoliosis is best treated by a professional team, and the school nurse often is the first link in the identification and treatment of scoliosis. ■ Suzanne Mell, Nurse Manager for the Cleveland Clinic Spine Institute, can be reached at 216/445-3753.

Cleveland Clinic Spine Institute Clinical Trials

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rospective outcomes evaluation of decompression with or without instrumented fusion for lumbar stenosis with degenerative grade I spondylolisthesis. Contact Edward Benzel, M.D., at 2 16 / 4 4 5 - 5 5 14 .

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prospective, randomized clinical investigation of the Cervitech, Inc., Porous Coated Motion Artificial Disc for stabilization of the cervical spine in patients with DDD and neurological symptoms at one level between C3-C4 and C7-T1. Contact Richard Schlenk, M.D., at 216/445-4318, or Isador Lieberman, M.D., at 2 16 / 4 4 5 - 2 74 3.

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umbar spine instability study: the role of flexion/extension radiographs. Contact Russell DeMicco, D.O., at 2 16 / 4 4 4 - 0 2 2 9.

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spiration of marrow progenitor cells from the vertebral pedicle: analysis of total progenitor cell volume. Contact Rob McLain, M.D., at 2 16 / 4 4 4 - 2 74 4.

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nterior cervical fusion augmented with autologous marrow: a controlled, prospective, randomized trial. Contact Rob McLain, M.D., at 2 16 / 4 4 4 - 2 74 4.

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he precision of pain reduction in the treatment of facet joint syndrome monitored by CERSR technology.

Cleveland Clinic Spine Institute Locations The Cleveland Clinic 9500 Euclid Avenue Cleveland, OH 44195 Euclid Hospital 18901 Lake Shore Blvd. Euclid, OH 44119 Lutheran Hospital 1730 West 25th Street Cleveland, OH 44113 Beachwood Family Health & Surgery Center 26900 Cedar Road Beachwood, OH 44122 Independence Family Health Center 5001 Rockside Road Crown Centre II Independence, OH 44131

Contact Daniel Mazanec, M.D., at 2 16 / 4 4 4 - 6 19 1.

Solon Family Health Center 29800 Bainbridge Road Solon, OH 44139

2005 Spine Review Attracts Most Attendees Ever The 2005 Cleveland Spine Review course had the largest number of participants in its six-year history. More than 130 surgeons from 18 states and 12 countries spent seven days studying the fundamentals of spinal surgery, spinal fusion, instrumentation and problem-based decision-making. Each year, the hands-on course emphasizes a lecture-lab and lecture-lab practicum throughout the week to enhance the learning process. This year’s evening activities included a Cleveland Indians baseball game, touring Body Worlds 2 at the Great Lakes Science Center, and a visit to the Rock and Roll Hall of Fame and Museum

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Westlake Family Health Center 30033 Clemens Road Westlake, OH 44145 To make a referral, call 216/444-BACK (2225).

Outcomes Books Now Available The Spinal Column is published by the Cleveland Clinic Spine Institute to provide up-to-date information about the department’s research and services. The information contained in this publication is for research purposes only and should not be relied upon as medical advice. It has not been designed to replace a physician’s independent medical judgment about the appropriateness or risks of a procedure for a given patient.

The Cleveland Clinic is pleased to introduce the first edition of Outcomes booklets, summary reviews of medical and surgical trends, approaches and results. The Clinic is publishing this outcomes data by department as a quality measure. Patients and referring physicians can now have the information they need to make informed decisions when choosing or recommending a hospital or specialist for medical or surgical care. Outcomes booklets were created for more than 20 Cleveland Clinic surgical and medical areas and are currently being sent to more than 600,000 physicians across the country. View the data online at www.clevelandclinic.org/quality.

Co-Editor: Edward C. Benzel, M.D. Chairman, Cleveland Clinic Spine Institute Co-Editor: Daniel J. Mazanec, M.D., F.A.C.P. Vice Chairman, Cleveland Clinic Spine Institute Head, Section of Spine Medicine Marketing Manager: Yen Izanec Managing Editor: Laura Greenwald

For referrals to the Cleveland Clinic Spine Institute, call 216/444-BACK (2225) 9500 Euclid Avenue Cleveland, OH 44195

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