Spring 2010 HSS Pediatric Connection, Vol. 2 Issue 3

Pediatric Connection A PUBLICATION OF THE PEDIATRIC MUSCULOSKELETAL DEPARTMENT OF HOSPITAL FOR SPECIAL SURGERY VOLUME 2 – ISSUE 3 SPRING 2010

MEDICAL STAFF Pediatric Orthopedists John S. Blanco, MD Shevaun M. Doyle, MD Daniel W. Green, MD Cathleen L. Raggio, MD Leon Root, MD David M. Scher, MD Roger F. Widmann, MD Pediatricians H. Susan Cha, MD Lisa S. Ipp, MD Stephanie L. Perlman, MD Pediatric Rheumatologists Alexa B. Adams, MD Thomas J.A. Lehman, MD Emma Jane MacDermott, MD Pediatric Anesthesiologists Victor M. Zayas, MD Chris R. Edmonds, MD Andrew C. Lee, MD Kathryn (Kate) DelPizzo, MD

The Connection Inspection: Teen from China Finds Help and Hope at HSS

by Adrienne Stoller, MA

“Dear Dr. Blanco: Do you remember me? I am your patient Xiu Qin Chen. I did my scoliosis surgery in June.

Today is Thanksgiving. For this special day, I want say ‘thank you’ to you. Thank you for giving me a new life.”

John Blanco, MD, Associate Attending Orthopaedic Surgeon at Hospital for Special Surgery, received Xiu Qin’s email message (excerpt above) at a time that not only underscored the meaning of Thanksgiving, but also emphasized the impact of modern medical technology. “Her message reinforced how we, as physicians and surgeons, can make a tremendous difference in the lives of our patients,” noted Dr. Blanco.

PRE-SURGERY

POST-SURGERY

A Long Journey

have a healthy and happy life.” In 2008, this mother’s hope for her child became possible, when the Chen family immigrated to New York City and learned of the expertise at HSS.

Diagnosed in China with scoliosis at age 14 years, Xiu Qin suffered from impaired mobility and constant pain. For Xiu Qin, regular activities of daily living, such as lifting, bathing, sitting and walking, became more difficult over time.

She was unable to stand erect and depended on others for mobility. Compromised healthcare resources in her region of China precluded Xiu Qin from appropriate medical care.

Referred to the Hospital by her family physician, Xiu Qin received a thorough evaluation by a multidisciplinary team, including orthopedics, genetics, and rheumatology. “She came to us complaining of chronic back pain, but it was much more complicated,” recalls Dr. Blanco.

“Xiu Qin presented with a severe scoliosis that we do not commonly see, requiring a comprehensive team approach to her care.”

“We were told that Xiu Qin should have surgery, but that it was too risky,” explains Xiu Qin’s mother. “I wished so much for my daughter to

Scoliosis is a progressive curvature of the spine seen in both children and adults. The condition is considered severe, and surgical intervention (Continued on page 3)

Hospital for Special Surgery is an affiliate of NewYork-Presbyterian Healthcare System and Weill Cornell Medical College.

For more information about HSS Pediatrics, visit http://www.hss.edu The Pediatric Orthopedic Service provides coverage to the Phyllis & David Komansky Center for Children’s Health at NewYork-Presbyterian Hospital.

For more information about the Komansky Center, visit http://www.cornellpediatrics.org

Getting back in action: Xiu Qin Chen at work with HSS physical therapist, Lisa Cannegieter.

Why sedate children for MRI examinations?

Non-Surgical Treatment for Spinal Deformities: Scoliosis Bracing

by Li Foong Foo, MD, MRCP, FRCR

by Andrew Tse, CO

Magnetic Resonance Imaging (MRI) is an ideal diagnostic imaging test in the pediatric age group. It has the advantages of improved inherent tissue contrast, absence of ionizing radiation, and direct multiplanar capabilities.

Scoliosis braces are designed to stop the progression of side bending spinal deformities in growing children. Patients who have curves measuring between 20 and 40 degrees with growth remaining may require a scoliosis brace also known as a thoracolumbosacral orthosis (TLSO).

The goal of bracing is to prevent further curve progression while the patient grows, avoiding the need for surgical correction.

Once skeletally mature, patients no longer require brace treatment.

However, MRI is also a long examination.

Any movement during MRI will degrade image quality and often require repeated image acquisitions, thereby prolonging the examination.

At HSS, we have found that adequate sedation minimizes the motion degradation of images and need for image re-acquisition, allowing for shorter imaging time. Sedation of pediatric patients is performed by a speciality-trained pediatric anesthesiologist-led team at HSS, with strict attention to safe practice, routines, and procedure.

Prior to MRI, parents and/or caregivers of pediatric patients who will undergo image testing are given complete information about the exam, including reasons for recommended sedation.

Save the Date!

Pediatric Orthopaedics for the Primary Care Provider 2010 November 19, 2010

Boston Brace The Boston brace is a full-time TLSO for non-operative treatment of idiopathic scoliosis that is made using a custom-made plastic module fitted with foam pads and trimmed asymmetrically with relief windows, an armpit extension, as well as hip extensions to counter specific curves and to set the spine in a balanced position. Developed in the 1970s, this therapeutic approach was an answer to the difficulties patients had with wearing a Milwaukee brace. The difference is in the design.

The Boston brace is an underarm plastic brace worn under clothing, while the Milwaukee brace is fabricated with a neck ring and vertical metal struts attached to a pelvic girdle and could not be concealed under clothes. Since its introduction, the Boston brace has been found to be just as effective as an underarm brace to control curve patterns below the shoulder blades when compared with the Milwaukee brace. It manages single as well as double curve patterns effectively and is currently the gold standard in full-time scoliosis braces.

Charleston Bending Brace

LOCATION

Hospital for Special Surgery Richard L. Menschel Education Center, 2nd Floor 535 East 70th Street | New York City INFORMATION

www.hss.edu/cme | 212.606.1613

Programs Promoting Musculoskeletal Health

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Depending on the curve pattern, the physician may prescribe a full-time brace (e.g., Boston brace) or a night-time brace (e.g., Charleston bending brace). As a result of extensive study, these two types of braces have been shown to be an effective and conservative means to halt progression of the spinal deformity.

The Charleston bending brace is a part-time TLSO worn at night during sleep. It is as effective on lower single curves as the Boston brace.

Essentially, the brace holds the torso in an overcorrected bending position directly opposing the scoliosis curve. The patient sleeps on the back or the belly while bending to their left or right side. Many patients may find this brace more appealing because they spend less time in it and, more importantly, it does not need to be worn to school.

No matter the chosen method, successful bracing is best achieved by a team approach. The physician, orthotist, patient, and family all play an important role in treatment. The physician will monitor the patient’s progress throughout the treatment and the orthotist will make periodic adjustments to the brace due to growth or increased flexibility. Moreover, the patient should understand the process and the importance of wearing the brace to maximize compliance and minimize anxiety. Good family support is also essential to the physical as well as the emotional well-being of the patient to achieve optimal results.

Teen from China Finds Help and Hope at HSS (Continued) is recommended, when a spinal curve is greater than 50 degrees.

In Xiu Qin’s case, the curvature was over 90 degrees.

Dr. Blanco recommended surgery for Xiu Qin as the best option for correcting her spine and alleviating pain. “Traditionally, the goal of Xiu Qin Chen scoliosis surgery was to prevent the curve from getting worse, but now we can dramatically improve the spinal deformity during surgical correction,” explains Dr. Blanco. Dr. Blanco also points out that in patients like Xiu Qin, in which scoliosis measures more than 80 degrees, lung and heart function also may be compromised. For this reason, spine correction not only can improve a patient’s quality of life, but also preserve it.

Extremely frail and underweight, Xiu Qin began a year-long process of preparing for surgery, with the assistance of many HSS patient services, including language services, food and nutrition, patient education, and social work. “What comes to mind is the dedication of Xiu Qin’s family and their endless cooperation,” says Amy Silverman, LCSW, ACC Social Worker in Pediatrics. “In particular, I was struck by their level of patience with all the steps needed to make sure that Xiu Qin had her surgery.”

Formula for Success Although anterior and posterior surgery of the spine is often performed simultaneously, Xiu Qin’s scoliosis condition and her weakened constitution required two operations which included nearly 10 days of recovery time in between procedures.

“Same-day front and back operations are long, about 14 hours, but lead to less overall time spent in the hospital,” explains Dr. Blanco. “For Xiu Qin, however, the magnitude and duration of the operation, the amount of blood loss anticipated, combined with her still frail medical condition presented too great a risk.”

At 16 years of age, Xiu Qin underwent her first operation on June 3, 2009. The procedure consisted of releasing the ligaments and discs in the front of the spine to increase the flexibility of her curve. During the second operation, on June 12, Dr. Blanco attached two metal rods to Xiu Qin’s spine, using hooks and screws attached to the vertebral bodies. Rods attached to the spine ensure that the backbone remains corrected while the spinal fusion takes place. Bone graft material is used to solidly fuse the spine. The rods remain attached to the spine for the rest of a patient’s life.

operations, Xiu Qin was transported next door to the Pediatric ICU at NewYork Presbyterian Hospital-Weill Cornell Medical Center for intensive monitoring.

“From initial evaluation to post-operative management, cases like Xiu Qin’s truly speak to the multidisciplinary, cross-institutional approach to patient care at HSS,” says Dr. Blanco. “It is extremely important that we share expertise and resources to achieve the best possible outcomes for our patients.”

Rehab and Recovery Xiu Qin was on her feet and taking the first steps toward rehabilitation the day after her second surgery. With a height gain of three inches (from 5 ft 3 to 5 ft 6), she was among the few patients who required temporary post-operative bracing to provide extra support to the spine due to her weakened bones.

Xiu Qin was sent home only one week after the second surgery.

She then began a comprehensive program of pain management, nutrition, and physical therapy—a regimen which continues today.

“At the start of post-operative therapy, Xiu Qin presented with a great deal of weakness and decreased endurance. She lacked flexibility and looked down while walking,” recalls Lisa Cannegieter, PT, DPT, a rehabilitation specialist at HSS. “Now she is moving with greater ease, better control, and is standing proud.” Xiu Qin’s twice weekly rehabilitation includes a consistent routine of balance and strength training as well as lowimpact cardiovascular activity and a daily home exercise program.

Alongside rehabilitation, Xiu Qin also receives treatment for an underlying rheumatologic condition discovered during her initial evaluation. The need for further surgery remains to be seen, but thus far Xiu Qin’s prognosis is promising. “The progress Xiu Qin has made since her first visit has been remarkable,” says Dr. Blanco. “Her body and will to succeed are strong and getting stronger everyday.” Today, at 18 years, Xiu Qin is a successful high school student in Brooklyn, where her family has established their new home. “I owe my second life to Dr. Blanco and everyone who helped me at the Hospital,” says Xiu Qin. “As the Chinese saying goes, ‘sunshine always follows the storm.’”

Due to the complex nature of the surgical procedure, Dr. Blanco requested the assistance of Dr. Michael LaQuaglia from Memorial Sloan-Kettering’s Pediatric Surgical Service.

Dr. LaQuaglia is a leading specialist in anterior spinal surgical approaches. His expertise ensured that the vital organs surrounding Xiu Qin’s spine were carefully manipulated during surgery and blood loss was tightly controlled. Following the

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Pediatric Connection

A PUBLICATION OF THE PEDIATRIC MUSCULOSKELETAL DEPARTMENT OF HOSPITAL FOR SPECIAL SURGERY

Question of the Quarter Can a patient’s saliva be used to predict curve progression in adolescent idiopathic scoliosis?

By Shevaun M. Doyle, MD

Q& A

When initially diagnosed with idiopathic scoliosis, patients between the ages of 9 and 13 years can undergo a simple genetic test to help determine the likelihood that their curve will progress.

The genetic test is called the ScoliScoreTM test, which extracts DNA from a patient’s saliva. The DNA contains specific genetic markers that are analyzed and scored. A high score would indicate a high number of genetic markers, hence a higher likelihood that the scoliotic curve will progress with skeletal growth. In addition to a thorough history, physical examination, and radiographs, the ScoliScoreTM test can provide the physician with additional information to help individualize treatment recommendations based on risk of progression.

www.hss.edu/peds Editor Shevaun M. Doyle, MD For inquiries, please call (877) HSS-1KID or e-mail: Peds@hss.edu ©2010 Hospital for Special Surgery.

All rights reserved.

The HSS Pediatric Musculoskeletal Department: First Row (from left): David M. Scher, MD; Cathleen L. Raggio, MD; Shevaun M. Doyle, MD; Roger F. Widmann, MD; Leon Root, MD. Second Row: H. Susan Cha, MD; Victor M. Zayas, MD; Lisa S. Ipp, MD; Stephanie L. Perlman, MD; Thomas J.A. Lehman, MD; Daniel W. Green, MD; John S. Blanco, MD. Third Row: Emma Jane MacDermott, MD; Andrew C. Lee, MD; Kathryn (Kate) DelPizzo, MD; Chris R. Edmonds, MD; Alexa B. Adams, MD.