Whose back is it anyway? UCHealth study aims to use age as a guide to spine surgery

A database of images would guide surgeons in restoring spines to a state that reflects normal wear-and-tear
Feb. 8, 2018

Picture the spine as a piece of infrastructure we use every day – say a highway. Just as roads support transportation and commerce, the spine provides the foundation that enables the other parts of the body to move independently and in concert.

Now picture a brand-new road ready to handle traffic. The concrete is fresh, the roadway smooth and free of potholes, divots, and cracks. As the years pass, heavily loaded trucks torture the surface. Freeze-and-thaw cycles introduce cracks. Rain, snow, sun and wind assault cement and asphalt. At the side of the road, erosion changes the grade, affecting drainage.

What was new becomes worn and inevitably, the road needs repairs. But restoring it to its original condition isn’t possible, so planners and crews make fixes based on current conditions and the changed landscape – expected concessions to the passing of time.

A 20-second study

A study called the “Open Access Database of Standing Full Body Radiographs in Asymptomatic Volunteers” doesn’t sound like it would be simple for participants. Turns out that it is, though, as I found out for myself.

The study aims to build a database of images of healthy spines, grouped by age and sex. With that, surgeons planning corrective procedures could refer to pictures of spines that correspond to the ages of their patients. It seems a common-sense approach, but as principal investigator CJ Kleck, MD, noted, nobody else in the United States is doing it, as far as he knows.

I thought that alone made for a good story, but in interviewing David Calabrese, professional research assistant with the CU Department of Orthopedics Division of Spine Surgery, I decided to take it a step further.

Calabrese explained that he’d had no trouble recruiting 20- and 30-year-olds with healthy spines, but the task got tougher as he looked for older recruits – the number of people with no spine injuries or disease declines as their age increases. No surprise there.

It just so happens I’m in one of the older groups, so I volunteered. That required 15 minutes or so for Calabrese to explain the purpose and potential risks of the study – they are minimal for this one – as part of obtaining my consent, which I gave after asking a few clarifying questions. He then scheduled an appointment for me in the Spine Center at UCHealth University of Colorado Hospital.

I arrived at the center check-in area a few days later. After a few minutes, I was ushered into the clinic and answered some short questionnaires about my spine and back history and general health. I then changed into a gown and shorts and met Blane Anselmi, an X-ray tech with the Spine Center, who took me to a softly lit room where the imaging would take place.

The room holds the EOS imaging system used for the study. It takes two X-rays, front and lateral, simultaneously while the patient stands. Anselmi explained that the system produces a three-dimensional, full-body image while delivering a low radiation dose. He then invited me to step through the open entrance of the machine into a small orange and white space. To my mind, it looked like a device that might be used to disassemble my molecules for reunification in a distant time and place.

Nothing so exotic. Anselmi asked me to face left and place my feet, evenly, spaced on a line. He then instructed me to grasp a black bar, with the palms of my hands up, and stand normally. “If you usually hunch, that’s fine,” he said. Easy enough.

Once he had me positioned to his liking, Anselmi told me to breathe normally and stand as still as possible. He retreated behind glass to a control room. I heard some humming and 20 seconds later, Anselmi came back out to tell me it was all over. He led me back to the changing room, I put on my civvies and that was it.

Short, sweet and painless: a pretty good way to contribute to science and quite possibly better patient care and improved lives.

Like the roads we travel, our spines inevitably suffer wear-and-tear. Age and activity change curvature, compress vertebrae and cause stress-absorbing disks to slip. For millions of people every year, the stress produces severe pain that requires surgery. Yet spine surgeons planning procedures face a basic challenge: how to make corrections – with rods, for example – based on anatomical changes that one would expect over time, rather than a model of a spine that has endured comparatively less stress.

Select a spine

“It’s not appropriate to try to give a 50-year-old a 20-year-old back,” said David Calabrese, a professional research assistant with the Division of Spine Surgery in the Department of Orthopedics at the University of Colorado School of Medicine. “The spinal and pelvic parameters are different.”

Calabrese is part of a study funded by the Department of Orthopedics that aims to address the discrepancy. The idea is to recruit volunteers ages 20 to 80 who have no history of spine or pelvis disease or injury for full-body imaging. The results would comprise a database of images grouped by age that surgeons could use to map spine procedures more precisely. A 60-year-old man or woman with scoliosis would not get a surgery that gives them the spine of their youth but rather one comparable to the anatomy of their healthy peers.

Logical as that might sound, it’s easier said than done, at least for now. That’s because surgeons lack the age-appropriate store of images that would offer the most reliable guides in correcting spine problems, said Christopher (CJ) Kleck, MD, orthopedic spine surgeon at UCHealth University of Colorado Hospital. Kleck is principal investigator for the CU study.

Lumbar library

Kleck said the study is the first in the United States that he is aware that is attempting to create a database of full-body images grouped by age and gender. In the first phase, which is now open for enrollment (see end of story), he hopes to recruit 60 participants. That would be a springboard to phase two, in which he wants to secure additional funding to enroll a total of about 360 people, spread across age groups, with equal representation of men and women.

“We’re trying to take some of the guesswork of surgery away,” Kleck said. “During preplanning and discussing where we want to get patients to, we’ve gone to look for data and found that it’s not really out there. Orthopedic and spine surgery has developed from a mindset that everything looks the same.”

The database could be an important supplement to the UNiD system spine implant system, which Kleck and his surgical colleagues at UCH already use to customize metal rods that support the back. The rods are bent prior to surgery to conform to the patient’s anatomy and minimize the risk of breaking. Surgeons would use age as another factor in determining the ideal rod bend for an individual – another step in personalizing patient care.

Sharper, safer imagery

A key component of the new study is the system used to take images. Until recently, techs took X-rays with patients lying down, Calabrese said. They also had to take multiple images, then “stitch” them together to give surgeons a unified view of sections of the body.

Both factors presented problems for surgical planning. First, having a patient lie down changes the position of the spine and doesn’t give the surgeon a look at the weight patients bear on their knees, hips and ankles when they stand and are active. Second, multiple images stitched together must align correctly – a painstaking and time-consuming task prone to error, Kleck noted. Think splicing together tape from two audio recordings to create seamless sound. Even a slight mismatch distorts the result.

“The quality of the images isn’t good enough,” Kleck said.

To address these issues, the study uses the EOS Imaging system. The technology, available in Colorado only at UCH and Children’s Hospital Colorado, uses two scanners to take front and lateral X-rays simultaneously while the patient stands. The system’s software then converts the separate two-dimensional X-ray images to a single, rotatable, three-dimensional view of the body.

CJ Kleck, MD, orthopedic spine surgeon at UCHealth University of Colorado Hospital, is principal investigator for an ongoing study that aims to build a database of images of healthy spines in people ages 20 to 80.
CJ Kleck, MD, orthopedic spine surgeon at UCHealth University of Colorado Hospital, is principal investigator for an ongoing study that aims to build a database of images of healthy spines in people ages 20 to 80.

The result is a full picture that displays the interrelationship between the spine, hips, knees and ankles and reveals how an individual distributes weight, perhaps to compensate for pain. In addition, the EOS system delivers a low radiation dose – about half that of a standard X-ray, Kleck said.

A deepening database of full-body spine images should provide a rich resource for practice and research for the spine surgery team at UCH, Kleck noted. But he envisions a repository open to all surgeons interested in improving patient outcomes with better procedures, techniques and devices.

“The more who can take advantage of it, the better,” he said. “This study is not about us getting credit. We want to work with surgeons from across the world and be part of a global community.”

The “Open Access Database of Standing Full Body Radiographs in Asymptomatic Volunteers” study is recruiting patients now. Individuals 50 years and older are especially encouraged to participate. For more information, contact David Calabrese at david.calabrese@ucdenver.edu or 303-724-9265. Those approved for the study will receive a free copy of the radiographic report.



About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.