Defining the three-column spine [letters; see comments]

              Letters JAOA • Vol 102 • No 4 • April 2002 • 203
LETTERS
Follow-up on “Symptoms
associated with anthrax
exposure: Suspected
‘aborted’ anthrax”
To the Editor:
Case reports are the front line of evidence
in the evolution of medical practice. Despite
the obvious weakness of case reports (ie,
they deal with a small number of patients,
even as low as a single person), they have
great value as the starting point of discov-ery.
1
Although we cannot predict whether
the ideas presented in our January 2002
case report (JAOA 2002;102:41-43) will be
sustained after further study—or after addi-tional
evidence is revealed—the clinical
observations included in that case report
continue to be of interest.
The patient we presented, a 37-year-old
man with a high level of exposure to the
spores of Bacillus anthracis, has improved
since publication of the report. On presen-tation,
he had a low PO2 level, pleural effu-sions,
and abnormal lesions on imaging of
the chest. Blood culture results and anti-body
tests for exposure to anthrax were
negative. After 3 months of triple antibiot-ic
treatment, the patient’s PO2 level is now
108; his fevers have subsided, but his
strength has not returned. The patient was
noted to be anergic to measles and Candida
albicans, and the results of histo titers whole
complement test have also come back neg-ative.
We have received many questions about
our decision to relate the patient’s illness
to anthrax exposure. Our intention was to
present a single case for primary care clin-icians
that would begin to explore the expe-riences
of clinicians who have patients with
similar findings. None of the clinicians at
our facility has seen a case of anthrax dis-ease.
This patient was cultured for anthrax
and tested for antispore antibody and anti-toxin
antibody by the Centers for Disease
Control and Prevention, and all results were
negative. Therefore, the patient presented in
the case report does not have anthrax dis-ease.
But there should be an explanation as
to why a healthy 37-year-old male with no
medical problems suddenly has fevers,
shortness of breath with a PO2 of 67, pleural
effusions, and abnormal lymph nodes. The
fact is, thus far, we have failed to produce an
explanation for the distress occurring in this
patient. The temporal relationship between
his exposure to B anthracis and his symp-toms—
and the fact that the symptoms were
relieved with antibiotic treatment—make
an infectious etiology high on our list of
possible causes.
If anthrax exposure does prove to be the
cause of this patient’s distress, our patient
would not be the first to have symptoms
from an anthrax exposure without being
culture- or antibody-positive. A fact sheet on
three laboratory occupational deaths includ-ed
in a government report, “Report of
Demilitarization of Fort Detrick,”2 includes
the 1951 case of William Allen Boyles, whose
death was classified as caused by anthrax,
despite the fact that “the microorganism
could not be (and never was) cultivated
from blood, sputum, nose and throat, or
skin taken at any time during the illness,
nor from tissue and fluids taken at autopsy.”
The diagnosis was made postmortem be-cause
of a small number of gram-positive
bacilli resembling B anthracis found only in
the pacconian granulations of the brain.
Arthur M. Friedlander et al3 reported
the findings of a study of 60 rhesus monkeys
exposed to B anthracis to test the effectiveness
of antibiotics. In that study, one animal given
ciprofloxacin died 5 days after exposure,
presumably from an aspiration pneumonia
diagnosed because of negative blood cul-tures
for anthrax. Another monkey died 73
days after antibiotics were stopped; this time
the death was attributed to urethral obstruc-tion—
again because blood samples were
culture-negative for anthrax. A third mon-key
died 5 days after antibiotics were dis-continued.
Similarly, no cause could be
found for that animal’s death.3
The anthrax bacterium causes damage
through extensive replication in the blood.
Its ability to expand so successfully is helped
by proteins it secretes that “intoxicate” the
cells it is invading. The proteins are benign
until they bind to the surface of the cell
where an enzyme trims off its outermost
tip. Protective antigen, edema factor, and
lethal factor are the proteins involved in cel-lular
damage, allowing the spores to enter
the cytosol of the cells.4
Without knowing what caused our pa-tient’s
illness, we have to take care of him.
Granted, the temporal relationship to the
exposure does not automatically mean there
is a causal relationship. The patient’s con-dition
has improved while on triple intra-venous
antibiotic therapy and became worse
when intravenous antibiotics were discon-tinued.
This report gives clinicians an indication
as to treatment options. Limited experience
with anthrax disease makes all clinical infor-mation,
including our patient’s presenta-tion,
important to share.
TYLER C. CYMET, DO
Section Head
Department of Family Medicine
Sinai Hospital
Baltimore, Maryland
Assistant Professor
Internal Medicine
The Johns Hopkins University School of
Medicine
Baltimore, Maryland
GARY J. KERKVLIET, MD
Director
Residence Practice Office
Program of Internal Medicine
Sinai Hospital
Baltimore, Maryland
Assistant Professor
Associate Program Director
Internal Medicine
The Johns Hopkins University School of
Medicine
Baltimore, Maryland
References
1. Vandenbroucke JP. In defense of case reports
and case series. Ann Intern Med. 2001;134:330-
334.
2. Report on the Demilitarization of Fort Detrick
(MD), including case report of the death of William
Boyles. Document of US Government 1977.
3. Friedlander AM, Welkos SL, Pitt ML, Ezzell JW,
Worsham PL, Rose KJ, et al. Postexposure pro-phylaxis
against experimental inhalation anthrax.
J Infect Dis. 1993;167:1239-1243.
4. Young AT, Collier RJ. Attacking anthrax. Sci
Am. 2002;286:48-50, 54-59.
204 • JAOA • Vol 102 • No 4 • April 2002
LETTERS
Letters
Unity between osteopathic
and allopathic medicine
only answer to preserving
osteopathic uniqueness
To the Editor:
This letter is an addition to the ongoing
dialog regarding the uniqueness of osteo-pathic
medicine and addresses, in particu-lar,
the comments of Brent Hutson, MSII,
“DOs must preserve their uniqueness” (The
DO 2001;42:15-16). I will discuss the effects
of disturbing trends in the current health-care
environment that certainly challenge
the DO “uniqueness.”
Mr. Hutson, while passionate and well-meaning,
emphasizes the differences be-tween
allopathic and osteopathic medicine,
rather than finding their commonalities.
He implies that it is impossible to unite the
two professions under a single representa-tive
body or to test the two professions with
a unified testing structure. His arguments
on both accounts are neither convincing
nor unique.
Let us first examine the elements that
create the need for unity. Medicine today is
under assault on many fronts. Frivolous
lawsuits led by lawyers wishing to cash in
on the current litigious trend in American
culture are driving the cost of malpractice
insurance upward, making it nearly impos-sible
for small groups of physicians to afford
group insurance at reasonable rates. One
terrible result of this trend is that a portion
of students no longer wish to practice
obstetrics-gynecology because of the cost
of malpractice insurance. It is unimagin-able
that the choice of one’s profession is
dictated by insurance malpractice rates,
rather than sincere desire!
On another front are the problems of
insurance reimbursement and Medicare
and Medicaid cost cutting. This is our bread
and butter, folks; this is how we survive.
Reimbursement is guided by Medicare,
which is, in turn, set by the government.
When the government, in its infinite wis-dom,
cuts Medicare reimbursement, pri-vate
insurance cuts reimbursement as well.
Not only do reimbursement cuts affect pay
but affect how a hospital staffs each depart-ment.
If General Medical Center receives a
cut in Medicare reimbursement, it can no
longer fully staff the emergency depart-ment
with an adequate number of aides to
transport patients to other floors or to the x-ray
department in a timely manner. The
poor distribution of patients to their next
step in care creates a glut in an already-overcrowded
department. This is just one
example of the effect of reimbursement cuts
that occurs every day!
A more dangerous example of the
effects of reimbursement cuts is the virtual
unchecked growth of mid-level practition-ers,
so-called “physician extenders.” While
Mr. Hutson and others are busy arguing
that “OMT [osteopathic manipulative treat-ment]
is an art” and “rational treatment is
based on an understanding of the basic
principles of body unity...,” nurse practi-tioners
(NPs) are practicing medicine in
primary care offices! To add insult to injury,
many nurse practitioners work in the offices
of osteopathic physicians. The harm appar-ent
in this scenario is that a patient deemed
by an NP to have otitis media will not
understand the benefit that is possible from
receiving lymphatic treatment. Lost also is
the possibility of a patient presenting with
congestion and cough who is triaged to an
NP, who does not see the benefit of thera-py
that includes rib-raising. These are the
diagnoses that have made osteopathic
medicine unique, yet reimbursement drives
the diagnosis and treatment of these types
of problems. It takes more physician visits
to maintain the same income, resulting in
health maintenance organizations pushing
for the cheaper alternative of physician-extenders.
This is what strips osteopathic
physicians of their unique identity.
So how can we fight back? How can the
battle be won? Unity is the answer—the
unity of a combined representative body
speaking to legislatures demonstrating the
strength that can be found when two
groups with common issues put aside their
differences and acknowledge what really
matters to the practice of medicine. Will it
be difficult? Yes. Must it occur? Absolutely.
Putting together a winning plan is not
easy, so it is imperative that we begin by
solidifying our common interests and goals.
Sharing and teaching OMT to our allopathic
peers is only the start. Combining the Unit-ed
States Medical Licensing Examination
and the Comprehensive Osteopathic Med-ical
Licensing Examination is certainly pos-sible.
Moreover, the addition of an OMT
section to the current USMLE format would
further demonstrate that osteopathic physi-cians
have treatment options in addition to
allopathic medicine, rather than care that is
viewed as different.
It is my view, and certainly the view of
others, that for all branches of medicine to
survive in today’s threatening environment,
we must unify our voices so they can be
heard louder than they have ever been
heard before.
ETHAN E. WAGNER, MSIV
University of Health Services College of
Medicine
Kansas City, Missouri
Herbal medications
should undergo rigorous
evaluation
To the Editor:
In his case report, “Digoxin toxicity in a 26-
year-old woman taking a herbal dietary
supplement” (JAOA 2001;101:444-446),
Michael E. Scheinost, DO, points out some
of the often-overlooked risks associated
with herbal supplements and should be
commended for addressing this important
public health issue. The following are relat-ed
issues that we believe warrant further
attention.
One of the dangers associated with
herbal products is their classification as
dietary supplements. Since the Dietary Sup-plement
Health and Education Act of 1994
was passed, herbal products (medications)
have been exempt from the regulatory over-sight
and the safety and efficacy regula-tions
established for other biologically active
products used in healthcare, namely pre-scription
and over-the-counter medica-tions.
1,2 As a result, the public, and to a less-er
degree, clinicians view herbal med-ications
as relatively harmless and may not
be aware of their biologic activity. This may
explain why patients frequently attribute
their physicians’ concerns to anti-herbal
sentiments. Herbal medications, similar to
some foods and traditional medications,
can trigger interactions and allergic reac-tions
and should be taken with caution by
certain populations. Unknown cardiac gly-coside
activity in herbal medications is only
JAOA • Vol 102 • No 4 • April 2002 • 205
LETTERS
Letters
one example of the potential risks and bio-logic
activity of these products.
The public may not be aware that some
herbal companies do not use good manu-facturing
practices. As a result, contaminants
and unsafe adulterants such as mercury and
arsenic may be in some of these products.
Although many physicians are inade-quately
educated about herbal products and
nutritional supplements, it still remains wor-risome
that patients follow the “medical”
advice of a health store clerk over that of a
clinician. Our poison control center held an
herbal information day and invited the pub-lic
to ask related questions. A random survey
of a portion of the callers indicated that fewer
than 20% volunteered their use of herbal
medications to their clinicians, and fewer
than 33% were asked by their clinicians
about taking such products.
As professionals, we need to become
educated about nutriceuticals and under-stand
why patients turn to herbal medica-tions
and to alternative medicine, then pro-vide
a nonjudgmental atmosphere for
patients so they feel comfortable discussing
their healthcare choices. As there are still rel-atively
few well-designed, randomized, con-trolled
clinical trials establishing the safety,
clinical benefit, or effectiveness of many
herbal products, we need to promote rigor-ous
evaluation of such products, as well as
communicate the message to patients that
herbal supplements are not inert, but rather
biologically active chemicals that should be
considered medications.
As osteopathic physicians and students,
we may be tempted to automatically accept
the use of herbal medicines, as our profession
is often considered a complementary modal-ity.
This is, however, exactly what we should
avoid. It was, in fact, concern about the safe-ty
and effectiveness of medications and med-ical
practices that served as a major impetus
for Andrew Taylor Still, MD, DO, to devel-op
osteopathic medicine.
ANDREW FARBER, MSII
New York College of Osteopathic Medicine
Old Westbury, New York
ROBIN B. MCFEE, DO
Clinical Assistant Professor of Medicine
New York College of Osteopathic Medicine
Consultant to the LI Regional Poison Control
Center
Winthrop University Hospital
Mineola, New York
References
1. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines
and perioperative care. JAMA. 2001;286:208-216.
2. Dietary Supplement Health and Education Act,
Public Law No. 103-417 (1994). Available at
http://www.fda.gov/opacom/laws/dshea.html.
To kill, or not to kill...
To the Editor:
When a physician considers the issue of
physician-assisted suicide (PAS), the under-lying
question if whether to end another’s
life. To many lay people, the question may
not seem so difficult to answer. Is the
patient’s prognosis “terminal”? Is this per-son’s
quality of life unbearable? Is the
patient so depressed that he or she has lost
the will to live? These questions might seem
straightforward, cut-and-dried, or black-and-
white, but this could not be farther
from the truth. Physicians, patients, and
their loved ones know the agony in at-tempting
to cope with PAS. Therefore,
physicians need to take a stand and be
heard as experts on the issue. Medicine is an
art, not an exact science—yet lawmakers
set exact criteria that enable patients to kill
themselves. This demonstrates the degree to
which we have allowed our society to dete-riorate.
Physician-assisted suicide is an emo-tionally
charged, subjective issue that can-not
be converted into an objective, exact
referendum to be decided at the voting
booth.
How did we get to this point? What
happened to place us in such a difficult sit-uation?
The issue of PAS first appeared on
the Washington ballot in 1991 and was
defeated. California voters considered the
issue in 1992, and it was again defeated. In
1994, Oregon’s Death with Dignity Act
passed despite the fact that the Oregon
Medical Association and the Oregon Osteo-pathic
Association were strongly opposed
to PAS. The American Medical Associa-tion,
the American Osteopathic Associa-tion,
and the American Nursing Association
continue to maintain strong opposition to
PAS. Is anybody listening out there? Osteo-pathic
physicians have taken an oath to
“first do no harm” and to “give no drugs for
deadly purposes.” But these patients are
voluntary, terminal patients, right? In 1996,
Lee et al1 found that 50% of physicians
could not predict confidently that a patient’s
condition was terminal. Further, surveyed
physicians were unable to definitively rec-ognize
depression 33% of the time. So much
for the objective criteria to qualify for PAS.
The voting public is unaware of that side of
the story.
To date, only one state—Oregon— has
legalized PAS. Michigan and California
have had the issue on the ballot, only to be
defeated. A poll of California citizens
showed that most were in favor of volun-tary
PAS for terminally-ill patients. Cali-fornia
is expected to again ask its voters to
decide this issue, styling the proposed law
after the Oregon statute. California’s law
would allow the physician to provide, but
not administer, the lethal drugs to the ter-minal
patient—a hair-splitting point but
critical for passage of the proposal. This is,
after all, the technicality that got renegade
pathologist, [Jack] Kevorkian, convicted of
murder in Michigan after he successfully
assisted in the killing of nearly 130 human
beings.
In 1992, D.C. Clark of the Center for Sui-cide
Research and Prevention2 stated that
patients with terminal illness and intractable
pain are usually grateful that no one facil-itated
their suicide while they were tem-porarily
depressed or having difficulties
with pain. Clark also stated that 95% of sui-cide
patients suffered from depression, yet
only 2% to 4% of suicides were in termi-nally-
ill patients.
We must concentrate on effectively treat-ing
pain and depression in terminally-ill
patients. Hospice can provide this service.
The suicide rate among hospice patients is
generally less than one tenth of 1%. That
is because hospice manages pain and pro-vides
emotional and spiritual support for
the patient and family. Rather than help-ing
to facilitate the suicides of terminally-ill
patients who are desperate and afraid, we
should support the peaceful completion of
their journey.
JOHN G. HORTON, DO
Director of Medical Education
Selby General Hospital
Marietta, Ohio
206 • JAOA • Vol 102 • No 4 • April 2002
LETTERS
Letters
References
1. Lee MA, Nelson HD, Tilden VP, Ganzini L,
Schmidt TA, et al. Legalizing assisted suicide–views
of physicians in Oregon. N Engl J Med. 1996; 334:
310-315.
2. Clark DC. “Rational” suicide and people with
terminal conditions or disabilities. Issues Law Med.
1192;8:147-66.
Defining the three-column
spine
To the Editor:
The article by Maurizio A. Miglietta, DO, et
al, “Evaluation of spine injury in blunt trau-ma”
(JAOA 2002;102:87-91) is an excellent
discussion of the difficulties physicians face
trying to “clear” the spine. In the “Indica-tions
for subspecialty consultation” section
of the article, however, the authors define
the three-column theory as consisting of (1)
the anterior half of the vertebral body and
anterior longitudinal ligament; (2) the pos-terior
half of the vertebral body, posterior
longitudinal ligament and facets; and (3)
the spinous processes, lamina arcus verte-brae,
and interspinous ligaments. The three-column
spine theory1 proposed by Francis
Denis, MD, which expanded on the
Holdsworth two-column theory,2 actually
defines the column differently. The correct
three-column spine consists of (1) the ante-rior
two thirds of the vertebral body, the
anterior longitudinal ligament, and the ante-rior
annulus fibrosis; (2) posterior third of
the vertebral body, posterior longitudinal
ligament, and the posterior annulus; and
(3) posterior bony complex and ligamen-tous
structures. The facet joints are includ-ed
in the posterior column of both the two-and
three-column theories.
ANDREW D. MULLINS, DO
Bay St.Louis, Mississippi
References
1. Denis F. The three column spine and its signif-icance
in the classification of acute thoracolumbar
spinal injuries. Spine. 1983;8:817-831.
2. Holdsworth F. Fractures, dislocations, and frac-ture-
dislocations of the spine. J Bone Joint Surg
Am. 1970;52:1534-1551.
Response
To the Editor:
The comments offered by Andrew D.
Mullins, DO, indicate that he thoroughly
reviewed our article regarding spine clear-ance
in trauma. As Mullin states, Francis
Denis, MD, first introduced the three-col-umn
theory, which is an expansion of Sir
Frank Holdsworth’s initial work.1,2 Denis’
analysis of 412 thoracolumbar injuries in
1983 systematically classified the major
types of spinal injuries radiographically
and biomechanically. The Denis theory
remains the accepted classification.
To address Mullin’s point regarding the
distinction of halves versus thirds of the
vertebral body in delineating columns, I
have reviewed several sources. Denis2
describes the three columns as follows: (1)
anterior column consists of “anterior lon-gitudinal
ligament, anterior annulus fibro-sus,
and the anterior part of the vertebral
body”; (2) middle column consists of the
“posterior longitudinal ligament, posteri-or
annulus fibrosus, and the posterior wall
of the vertebral body”; and (3) posterior
column consists of “posterior bony com-plex
(posterior arch) alternating with pos-terior
ligaments complex (supraspinous,
interspinous, capsule, and ligamentum
flavum).” The illustration included with
Denis’ article, however, seems to agree with
the halves versus thirds breakdown of the
vertebral body. The two interpretations of
the three-column theory appear in other
texts as well. 3,4
I believe the millimeters of difference in
anatomic distinction of the three-column
theory is less important than the overall
concept of three columns and spine insta-bility.
However, I appreciate Mullin’s atten-tion
to this discrepancy in the literature.
MAURIZIO A. MIGLIETTA, DO
R Adams Cowley Shock Trauma Center
Baltimore, Maryland
References
1. Denis F. Spinal instability as defined by the
three-column spine concept in acute spinal trau-ma.
Clin Orthop. 1984;189:65-76.
2. Denis F. The three-column spine and its signif-icance
in the classification of acute thoracolumbar
spinal injuries. Spine. 1983;8:817-831.
3. Harris JH Jr, Harris WH, Navelline RA. The Radi-ology
of Emergency Medicine, 3rd ed. Baltimore,
Md: Williams & Wilkins; 1993;141-142.
4. Vollmer DG, Gegg C. Classification and acute
management of thoracolumbar fractures. Neu-rosurg
Clin N Am. 1997;8:499-507.