Stem Cell Discovery Could Revolutionize Spine and Cancer Care

By Pat Anson, PNN Editor

The discovery of a new type of stem cell could revolutionize the treatment of spine disorders and slow the progression of some cancers, according to a groundbreaking study published in Nature.

Researchers from Hospital for Special Surgery (HSS) and Weill Cornell Medicine say the vertebral stem cells they found in human spines appear to play a key role in spinal health and in the metastasis of cancerous tumors as they spread through the body.

“There are two big takeaway discoveries that were made here. One is that we have discovered a stem cell that forms the spine and maintains the spine throughout life. This cell makes all the other cells that mineralize the spine,” said lead investigator Matthew Greenblatt, MD, associate professor of pathology and laboratory medicine at Weill Cornell Medicine.

“The second discovery here is that we found that this stem cell drives tumors. Breast cancer is what we focused on here, but likely also prostate cancer.”

Cancer experts have long believed that tumors metastasize to other parts of the body simply through blood flow. But Greenblat and his colleagues found that vertebral stem cells essentially attract cancer cells to the spine. That could explain why some cancers are first detected in the spine after they have metastasized from the breast, prostate and lung.

“Because we found that molecular ‘come here’ signal that's made by this spine stem cell, that gives us the ability to block that signal therapeutically. And that's something we're working on to try to prevent or treat established spine metastases,” Greenblatt told PNN.

Boosting Bone Health

Researchers say their discovery could also lead to breakthroughs in spinal health, by giving physicians a way to speed up recovery from spinal injuries and slow the progression of degenerative conditions such as osteoporosis, a disease that makes bones thinner, less dense and more likely to fracture.

For example, someone with degenerative disc disease could have their vertebral stem cells harvested, reproduced in a laboratory, and then reinjected to stimulate the growth of new bone. In animal tests, human vertebral stem cells helped laboratory mice form new bones in their spines.

“We can show that they formed basically little vertebral bones when those patient cells are put into mice, which really tells us that we found the right cell. And we can work with the cell transplant and retain stability to make new bone,” said co-author Sravisht Iyer, MD, a spine surgeon at HSS.

“I think kind of figuring out how to recruit the cells or how to how to encourage them to form more bone is going to be an important area or avenue of investigation for us, as a way to help people and protect people against what is a very morbid condition for them.”

Iyer says early treatment with vertebral stem cells could help someone with osteoporosis or a spine fracture, but wouldn’t necessarily benefit patients suffering from more advanced cases of bone loss.

“By the time people are presenting to us with spine pain, they usually have some element of compressive pathology or a degree of degeneration, which will likely require some intervention, whether that's surgery or epidural injection,” Iyer said.

“Where this work I think can really help push us forward is once you get those at-risk patients, they probably will need a surgery because a lot of degeneration is asymptomatic, and by the time they get to you they probably need something, but maybe you can prevent the second, third or fourth operation or intervention.”

More research and human studies are needed before the stem cells can be used in clinical settings to improve bone health and slow the metastasis of cancer cells. But researchers are excited by what they’ve learn so far.    

“We predict this discovery will lead to the targeting of these cells to disrupt the function and ultimately reduce the spread of cancer to the spine," said Greenblatt.

Vibrating Belt Gets FDA ‘Breakthrough Device’ Designation for Osteoporosis

By Pat Anson, PNN Editor

The U.S. Food and Drug Administration has given “Breakthrough Device” designation to a vibrating belt that lowers the risk of bone fractures caused by osteoporosis. When worn around the waist, the OsteoBoost Vibration Belt delivers gentle stimulation to the hips and spine, simulating the effects of exercise and strengthening bones.

Osteoporosis is caused by the loss of bone mineral density (BMD) and is one of the most common health conditions associated with old age. More than 10 million Americans suffer from osteoporosis and 43 million have its precursor, osteopenia.

About 1 in 2 women and 1 in 4 men over the age of 50 will suffer an osteoporosis-related fracture, usually in their hip or spine. Breaking a bone is especially traumatic for the elderly and can lead to a cascade of health problems, including chronic pain, disability and early death.

Osteoporosis is currently treated with changes in diet, exercise and bisphosphonate drugs such as Fosamax, which slow the loss of BMD. However, long term use of bisphosphonates can lead to side effects such as bone, muscle or joint pain, as well as nausea and heartburn.

“For years, I have wanted a better option for my patients with low bone density that doesn’t have the potential side effects and the inconvenience of current drug treatments. With OsteoBoost we’ve created a safe, drug-free alternative that is easy and convenient. Now my patients with osteopenia have a new way to improve their bone health and reduce their risk of fracture,” says Dr. Shane Mangrum, co-founder of San Francisco-based Bone Health Technologies, which makes the OsteoBoost belt.

OsteoBoost uses whole body vibration (WBV) technology originally developed for NASA to improve the bone health of astronauts in a weightless environment. Here on earth, WBV has been found to improve bone mineral density, but it requires users to stand on a stationary vibrating platform, which isn’t always practical.

Because OsteoBoost is wearable, users can go for a walk or perform simple household chores while getting treatment. It’s recommended the device be used in 30-minute sessions, 3 to 5 times a week.

In a small clinical trial, OsteoBoost reduced bone loss in postmenopausal women by an average of 14%, a reduction similar to bisphosphonates. The National Institutes of Health is funding a larger, $2 million study of OsteoBoost that is currently enrolling postmenopausal patients. It is scheduled to be completed in early 2022.

If that study is successful, the FDA’s Breakthrough Device designation will speed up the agency’s review of OsteoBoost and help bring it to market sooner. The belt is not currently available for purchase and will require a a prescription when it is.

A 2011 Canadian study found that WBV did not improve bone mineral density in postmenopausal women who used a vibrating platform daily for a year while also taking vitamin D and calcium supplements.

"Although commercially available WBV devices are marketed to and used by patients, the beneficial effects of WBV on fracture risk and BMD have not been established, and recent randomized, controlled trials in postmenopausal women have shown conflicting results," said lead researcher Angela Cheung, MD, at University Health Network in Toronto. "Women would be farther ahead in making sure that they are exercising regularly and eating nutritious foods."

Most Patients Say Cannabis Effective for Musculoskeletal Pain

By Pat Anson, PNN Editor

The vast majority of people with musculoskeletal pain who have tried medical cannabis say it is an effective pain reliever and over half believe it works better than other pain medications, according to a new study released by the American Academy of Orthopaedic Surgeons.  

Researchers surveyed 629 patients being treated at orthopaedic clinics to see how widely cannabis is being used for chronic muscle and joint pain that can be caused by arthritis, fibromyalgia, osteoporosis and many other conditions.

“Over time, we’ve certainly seen an increase in the use of cannabis to manage musculoskeletal (MSK) pain,” said lead author Timothy Leroux, MD, an orthopaedic surgeon and assistant professor at the University of Toronto.

“There is definite interest to see if cannabis can be used to manage chronic MSK pain, as opposed to other conventional treatments such as anti-inflammatories and opioids. With this study, we wanted to get a lay of the land as to who is using it, what proportion are using and what they perceive the efficacy to be.”

One in five of the patients surveyed said they are currently using or have tried cannabis to manage their MSK pain. Of those, 90% said cannabis was effective, 57% believe it works better than other pain medications, and 40% said it decreased their use of other drugs.

Patients who used cannabis for MSK pain were more likely to have multiple conditions, including depression, back pain, chronic pelvic pain and chronic neck pain. They were also more likely to use muscle relaxants and opioids for pain relief.

The most common form of cannabis used was cannabidiol (39%) and the most common route of ingestion was CBD oil (60%). Over a third of patients said they spent at least $200 per month on cannabis products.

Among the cannabis users, only 26% received a recommendation from a physician. Most said they tried cannabis at the urging of a friend or family member.

“Most doctors, especially orthopaedic surgeons, don’t have prescribing power for cannabis, so there is minimal physician oversight when it comes to cannabis use to manage chronic MSK pain,” said Leroux. “To complicate things, it’s a little bit of a Wild West in the cannabis industry in terms of what you get in a product, namely actual vs. labelled composition, and consistency.

“Another challenge is that we don’t fully know what products, formulations, dosages, and routes of administration are best to manage chronic MSK pain. Given the high rate of use observed in this study and little physician oversight, there’s an impetus for us as a medical community to try to understand what role, if any, cannabis may serve in the management of chronic MSK pain.”

Even among non-users, there was a fair amount of interest in cannabis. Sixty-five percent reported an interest in trying cannabis for MSK pain. Common barriers to using cannabis were stigma and lack of knowledge about its efficacy, doses and routes of administration.

“We tend to associate cannabis with a younger age due to recreational use, but in our study, age was not a significant factor influencing use for the management of chronic MSK pain,” said Leroux. “Patients reported use well into their 80’s, many whom we assumed would want to use more conventional products.

“We’d like to repeat this study in the next few years to see how use and demographics change as people become more comfortable with the idea of cannabis as the norm as well as what role state legalization plays in patients’ attitudes towards its use.”

Spinal Fusions Ineffective for Osteoporosis Patients

By Pat Anson, PNN Editor

There is little evidence that two surgical procedures commonly used to treat spinal fractures caused by osteoporosis reduce pain for patients better than pharmaceutical drugs, according to a new report by an international task force of bone health experts published in the Journal of Bone and Mineral Research..

More than 10 million Americans suffer from osteoporosis, a loss of calcium and bone density that worsens over time and significantly raises the risk of bone fractures, especially among the elderly. About 750,000 spinal fractures occur each year in the United States alone.

The task force looked at two types of spinal fusions: vertebroplasty, where medical grade cement is injected into the broken vertebrae to fuse bone fragments together; and balloon kyphoplasty, where a balloon is inserted into the compressed area of the spine to lift it and allow the cement to be inserted. Metal plates, screws and rods can also be used in spinal fusions, but were not the focus of the study.

The researchers found little to no evidence that vertebroplasty or kyphoplasty relieve pain effectively. In five clinical studies, vertebroplasty provided no significant benefit in pain control over placebo or sham procedures. There were no placebo-controlled trials for balloon kyphoplasty, leaving doctors to rely on anecdotal, low-quality evidence.

"The message for doctors and their patients suffering from painful spinal fractures is that procedures to stabilize spinal fractures should not be a first choice for treatment," said lead author Peter Ebeling, MD, Head of the Department of Medicine in the School of Clinical Sciences at Monash University in Australia.

"While patients who had these surgeries may have had a short-term reduction in pain, we found that there was no significant benefit over the long-term in improving pain, back-related disability, and quality of life when compared with those who did not have the procedures."

The task force report comes as spine surgeons increasingly market vertebroplasty and kyphoplasty as “minimally invasive" procedures that offer immediate relief from back pain without the risks of opioid medication. But there are still risks of infection, cement leakage and complications associated with elderly patients undergoing anesthesia.

Some 300,000 Medicare patients underwent vertebral augmentation between 2006-2014, with most getting the more expensive balloon kyphoplasty. The procedures have become so common they are recognized as a standard of care. The video below calls them "the most effective pain relieving treatments for elderly patients.”

"These procedures are not a magic bullet," says Bart Clarke, MD, President of the American Society for Bone and Mineral Health and a Professor of Medicine at the Mayo Clinic. “Until now, doctors have been left to sift through the data on their own to determine whether these procedures can benefit their patients. This report coalesces all that information concisely and provides recommendations to guide them."

Clarke said Mayo Clinic doctors do not typically perform vertebral augmentation procedures unless a patient's pain is unmanageable for more than 4-6 weeks. "We've seen that with analgesics and other pain relief, our patients often get better within about 6 weeks," he said.

The task force also focused on the need for osteoporosis prevention. About 25% of older men and women who have a hip fracture will have a second fracture within one year, as will around 20% of older patients who have a spinal fracture. Breaking a bone in your spine or hip may be so traumatic – especially for the elderly -- that it often leads to disability and chronic widespread body pain.

Recent studies have shown that many patients at high risk of fractures are not being diagnosed or treated for osteoporosis, even though hormones and bisphosphonate drugs can help strengthen their bones. Bisphosphonates such as Fosamax have been found to be effective at slowing the loss of bone mass and reducing fractures, but concerns about side effects made some patients reluctant to take bisphosphonates and doctors less likely to prescribe them.  

"Overall, prevention is critical. and we need to get these high-risk patients on anti-osteoporosis drugs that have proven to reduce future fractures by as much as 70 percent," Clarke said.

Early Detection and Diet May Help Prevent Osteoporosis

By Pat Anson, Editor

The key to good bone health – and preventing fractures later in life – may lie in anti-inflammatory diets and earlier detection of bone loss, according to two new studies.

Researchers at the University of Michigan are studying new ways to identify women at risk of osteoporosis, a loss in bone density that raises the risk of fractures and disability. Breaking a bone in your spine or hip doubles your chances of developing chronic widespread body pain, especially if you are older.

"It's been considered a silent disease," says Karl Jepsen, PhD, associate chair of research and professor of orthopaedic surgery at Michigan Medicine. "One of the biggest challenges when you're looking at age-related bone fragility is to identify people who will fracture."

Jepsen is the lead author of a study published in the Journal of Bone and Mineral Research, which followed nearly 200 women for 14 years as they transitioned through menopause.

"Current identification for bone fragility takes place when the patient is around 65 years of age," Jepsen explains.

"We were hopeful that this study would give us an opportunity to identify those patients as early as 30 years before they fracture based on their bone traits. That means we would have an opportunity to intervene before the fracture happens, instead of after the fact."

Jepsen and his colleagues started following the women in 1996. Participants who enrolled had to be between 42 and 52 years of age and had at least one menstrual period in the previous three months. The women had bone density scans and other tests annually to measure changes in their bone mineral density.

Researchers found that the women experienced a wide variation in bone mineral content and bone area within the hip as they went through menopause, a finding that was unexpected.

"Our results were opposite to all expectations of how we assumed this would work," Jepsen says. "We found some women appeared to have hip bones that were increasing in strength during the menopausal transition while others seemed to be losing strength."

Jepsen said his study demonstrates that bone changes can be tracked individually in women during menopause, when treatment can begin earlier to prevent bone loss. Hormones and bisphosphonate drugs are currently used to help strengthen bones.

“Our goal is to use simple bone traits to identify those women that may benefit from early intervention when it comes to bone fragility, instead of the current strategy, which treats individuals after they have lost appreciable bone mass and strength," he said.

Anti-Inflammatory Diet Improves Bone Health

Anti-inflammatory diets -- which tend to be high in vegetables, fruits, fish and whole grains -- could boost bone health and prevent fractures, according to a study at The Ohio State University.

Researchers analyzed dietary data from over 160,000 women enrolled in the landmark Women's Health Initiative by assigning inflammation scores based on 32 foods that the women reported consuming. Researchers also looked at bone-mineral-density data from over 10,000 women and collected fracture data for the entire study group.

They found a correlation between high-inflammatory diets and fractures in post-menopausal younger than 63. Women with the least-inflammatory diets also lost less bone mineral density.

"This suggests that as women age, healthy diets are impacting their bones," said Tonya Orchard, an assistant professor of human nutrition at Ohio State's Food Innovation Center. "These women with healthier diets didn't lose bone as quickly as those with high-inflammation diets, and this is important because after menopause women see a drastic loss in bone density that contributes to fractures,"

The study, which appears in the Journal of Bone and Mineral Research, was observational -- meaning it does not definitively link diet to bone health. But it adds to a growing body of evidence that inflammation can increase osteoporosis risk.

"By looking at the full diet rather than individual nutrients, these data provide a foundation for studying how components of the diet might interact to provide benefit and better inform women's health and lifestyle choices," said Rebecca Jackson, the study's senior author and director of Ohio State's Center for Clinical and Translational Science.

Previous studies have connected high levels of inflammatory markers in the blood to bone loss and fractures in older women and men. The new findings suggest that women's bone health could benefit when they choose a diet higher in beneficial fats, plants and whole grains.

Doctors Warn of Crisis in Osteoporosis Treatment

By Pat Anson, Editor

Thirty years of progress in treating osteoporosis and reducing bone fractures in the elderly is rapidly being reversed, according to two bone health experts.

In an article called A Crisis in the Treatment of Osteoporosis, published in the Journal of Bone and Mineral Research, Sundeep Khosla, MD, and Elizabeth Shane, MD, say too many patients at high risk of fractures are not being diagnosed or treated for osteoporosis, even though hormones and bisphosphonate drugs are available to help strengthen their bones.

“The field of osteoporosis may be coming full circle, and that is not good for the millions of older women and men who will suffer painful and disabling spine and hip fractures - fractures that might have been prevented,” Khosla and Shane wrote.

“As physicians, we are now watching as the fundamental progress made to reduce fractures and dramatically improve the quality of life of our patients during the past 30 years unravels.”

More than 10 million Americans suffer from osteoporosis and 44 million have its precursor, a loss in bone density that raises the risk of fractures and disability.  Breaking a bone in your spine or hip may be so traumatic – especially for the elderly -- that it doubles your chances of developing chronic widespread body pain.

Bisphosphonates such as Fosamax have been found to be effective at slowing the loss of bone mass and reducing fractures, but concerns about their use rose when patients reported side effects such as joint and musculoskeletal pain. That made some patients reluctant to take bisphosphonates and doctors less likely to prescribe them.  

Khosla and Shane cite a recent study that found only 3 percent of patients with a hip fracture in 2013 were given bisphosphonates to strengthen their bones, down from 15% of patients in 2004.

“In short, we, as physicians who care deeply about the treatment of patients with osteoporosis, find ourselves in a dire situation. At a point in time when we have developed pharmacologic tools capable of preventing enormous suffering and needless mortality, we may well be coming back full circle: the downward spiral of vertebral fracture, hip fracture, immobility, loss of independence, and premature death that we thought we had conquered may soon become the accepted norm again,” they wrote. 

“There can be no more urgent call to action for our field than we face today. We must find ways to ensure that patients who need appropriate treatment for osteoporosis are not only prescribed effective medications, but are also equipped with the information they need to make an informed choice on taking these medications.”

Khosla is an endocrinologist, research scientist, professor of medicine and director of the Clinical and Translational Science Award Program at the Mayo Clinic in Rochester, Minnesota. Shane is an endocrinologist, research scientist, professor of medicine and vice chair for clinical and epidemiological research at Columbia University in New York.

A quarter-million Americans sustain a hip fracture each year, according to the National Osteoporosis Foundation, but less than a quarter are treated for osteoporosis afterwards.

A recent survey of 42 hip fracture patients found a startling level of misinformation and mismanagement surrounding osteoporosis. A majority (57%) said their doctors did not recommend osteoporosis medication and one in four said they would reject taking the drugs.

Nearly two-thirds (64%) of those who said they were being treated for osteoporosis were taking calcium and vitamin D supplements, which researchers say are "useless" at preventing osteoporotic fractures.

Another recent study found that elderly men are far less likely to be screened for osteoporosis or to take preventive measures against the bone-thinning disease than women. The risk of death after sustaining a hip fracture is twice as high in men compared to women.

Hip Fractures Often Ignored as Sign of Osteoporosis

By Pat Anson, Editor

Most older adults who suffer hip fractures aren't told they may have osteoporosis, despite the fact that hip fractures nearly always signify the presence of the bone weakening disease and can result in serious complications, according to a small survey of patients.

More than 10 million Americans suffer from osteoporosis and 44 million have its precursor, a loss in bone density that raises the risk of fractures and disability.  Studies have found that breaking a bone in your spine or hip may be so traumatic that it doubles your chances of developing chronic widespread body pain.

"You can die after a hip fracture, and you're at great risk of prolonged complications," said Gisele Wolf-Klein, MD, director of geriatric education for Northwell Health, the largest healthcare provider in New York state.

"You can also be left as an invalid, a fear of many older adults. When we think about how preventable hip fractures are, the fact that most patients aren't told or understand they have osteoporosis - a disease that can be treated - is an enormous problem."

Wolf-Klein and her colleagues surveyed 42 hip fracture patients aged 65 and older, and found a startling level of misinformation and mismanagement surrounding osteoporosis. 

A majority (57%) of patients said their hospital physicians did not recommend osteoporosis medication after treating their hip fracture. One in four patients said they would reject taking the drugs.

Nearly two-thirds (64%) of those who said they were being treated for osteoporosis were taking calcium and vitamin D supplements, which the Northwell researchers say are "useless" at preventing osteoporotic fractures.

More effective osteoporosis medication - which maintains bone density and lower the risk of a fracture - is available in many forms, including twice-yearly infusions or weekly pills. But the researchers say they're not prescribed as often as they should be.

"There's an enormous amount of misunderstanding about osteoporosis among the public and lack of education from physicians taking care of patients,"  said Stuart Weinerman, MD, an endocrinologist at Northwell Health, "Doctors don't talk about it and the perception is that these osteoporosis drugs are dangerous or not effective. Unfortunately, these misperceptions are just incorrect. So a lot of public education needs to be done, but it should start with physicians."

Lack of effective treatment can lead to additional fractures. Over a third of the patients surveyed sustained a fall within a year, and nearly half (44%) suffered an additional fracture.

"These numbers show the need to improve our overall treatment plan for osteoporosis, which includes fall-prevention education for patients and their families," said Mia Barnett, MD, a Geriatric fellow. "We can definitely get that re-fracture number lower if patients are treated with osteoporosis medications."

A quarter-million Americans sustain a hip fracture each year, according to the National Osteoporosis Foundation, but less than a quarter are treated for osteoporosis afterwards.

A recent study found that elderly men are far less likely to be screened for osteoporosis or to take preventive measures against the bone-thinning disease than women. The risk of death after sustaining a hip fracture is twice as high in men compared to women.

A large study of over half a million adults, published in the Archives of Osteoporosis, found that men and women who had a spine fracture and women who had a hip fracture were more than twice as likely to experience long term widespread pain.

Older Men Less Likely to Be Screened for Osteoporosis

By Pat Anson, Editor

Elderly men are far less likely to be screened for osteoporosis or to take preventive measures against the bone-thinning disease than women, according to the results of a new study.

"We were surprised at how big a difference we found between men and women regarding osteoporosis," said Irina Dashkova, MD, lead author of the study, which is being presented at The American Geriatrics Society's annual meeting in Washington, DC. "In our environment, you just get this perception that osteoporosis is a women's problem. This has to be changed, and the sooner the better.

More than 10 million Americans suffer from osteoporosis, which raises their risk for serious bone fractures.  About 2 million are men -- and another 8 to 13 million men have low bone mineral density, a precursor to osteoporosis. Previous studies have found that 13% of white men over the age og 50 will experience at least one osteoporosis-related fracture during their lifetime.

“We know from research that when men suffer fractures, their mortality is higher than in women and that severe medical consequences and loss of independence are much more prevalent in men,” said Dashkova.

The risk of death after sustaining a hip fracture is twice as high in men compared to women, and loss of independence is also more common in males. Some medical conditions and drugs that can raise the risk of osteoporosis are male-specific, such as prostate cancer drugs that affect the production of testosterone.

Dashkova and her colleagues at North Shore-LIJ Health System surveyed 146 older men and women in New York and Florida and found “stunning” gender differences in attitudes and beliefs about osteoporosis:

• Women were far more likely to report a family history of osteoporosis (nearly 91% compared to 9%)
• Most women would accept osteoporosis screening, while less than 25% of men would
• Women were 4 times more likely to take preventive measures against osteoporosis, such as taking calcium and vitamin D supplements

Part of the problem may be that healthcare providers aren't encouraging men to undergo screening as often as they should.

"Our survey clearly establishes that physicians are just not thinking of screening men. It's only when older men fall and break their hip that someone thinks maybe we should do something to prevent them breaking the other hip," said Gisele Wolf-Klein, MD, director of geriatric education for the North Shore-LIJ Health System. "Not only is society in general unaware of the problem of osteoporosis in men, men are not seeking screening and diagnosis.

"The average age in my practice is in the 90s, and our patients are to be congratulated because clearly they're doing something right. But we have a duty to make sure those later years are as happy and productive as can be and not spent in a wheelchair."