Department of Neurosurgery

Volume 2

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Page 2 Pediatric neurosurgeons set the bar for technical excellence

MANY STRENGTHS. ONE MISSION. A Seventh-day Adventist Organization

“The truth is that TO DAY ’ S C H I L DR E N are some of the strongest people I know. It’s my pediatric patients who remind me that R E SI L I E N C E I S T H E B E S T M E DIC I N E .”

Y E S , I ’ M R E A DY! Looking back, I think it was a lot easier for children to be scared of lions, tigers and bears — oh my — than today’s unending sphere of violence and hate.

One of the hardest things any child can go through is feeling unaccepted or viewed as different based on sex, religion or even a rare health condition. But the truth is that today’s children are some of the strongest people I know. It’s my pediatric patients who remind me that resilience is the best medicine.

It was about six months ago, that I met a 7-year-old girl who was bright, outgoing and all around vivacious.

For many looking on the outside in, it would come as a surprise to learn she was born with a rare genetic disorder called Sturge-Weber syndrome. Though she attended school like every other child, my patient was aware of the debilitating seizures she endured on a daily basis.

Prior to her surgery, her parents asked her one simple question: Are you ready for this? Her response was priceless. She smiled and replied “Yes, I’m ready!”

She didn’t fear the surgery itself, but rather she was inspired by the life that was to come after.

It is children like her and many others who remind me and our team at Loma Linda University Health that when we focus on the positive, the possibilities for a cure are endless.

Our team of esteemed surgeons are more than ready to dispel the health differences in children and give them the tools they need to live healthy, happy lives — oh my!

Warren Boling, MD Chairman of the Department of Neurosurgery Loma Linda University Health

PH YSIC I A N S F I R S T. E XC E L L E N C E A LWAYS .

Pediatric neurosurgeons set the bar for technical excellence.

At Loma Linda University Health, caring for the patient goes hand-in-hand with using the most innovative technologies to assure surgical procedures, genetic testing and neuroimaging provide the highest quality of diagnosis and success for long-term care.

Every patient is cared for by a multidisciplinary team of specialists who review, discuss and find solutions that will deliver positive outcomes. It is never a solo enterprise when it comes to treating patients with epilepsy, dystonia, brain or spinal tumors, Robison says.

“It’s important that we streamline each clinic visit with the various disciplines to make it easier for our patients and families who are facing extreme difficulties,” says Tanya Minasian, DO, FACOS, a pediatric neurosurgeon at Loma Linda University Children’s Hospital and Loma Linda University Medical Center.

“Our goal is to focus on a holistic approach to help our patients heal, coupled with innovative technology.”

Loma Linda University Children’s Hospital sees approximately 40-50 pediatric patients a year who suffer from a brain (or spine) tumor. Treatments change for patients every two years, says Chenue Abongwa, MD, pediatric hematology-oncology at Loma Linda University Children’s Hospital. “Our job has many dimensions, it makes a difference when physicians can focus on a single specialty.”

The Department of Neurosurgery provides pediatric patients with access to a variety of seasoned physicians and staff dedicated to early prevention and advanced techniques, including deep brain stimulation (DBS), selective dorsal rhizotomy, laser ablation and all types of brain, spine and peripheral nerve surgery.

In addition, Loma Linda University Health offers a dedicated neuro-oncologist who specializes in the care and treatment of pediatric patients living with brain and spinal tumors.

The continued goal is to provide patients with additional support and treatment options built around a strong, collaborative team who can improve their care. Individualized clinics focused on neuro-oncology, craniofacial, spina bifida and hypertonicity have been established to treat patients with unique needs.

According to Minasian, the department provides a great benefit to the children of this community and can give them a chance to overcome obstacles they face with the latest technology and surgical advances only available at Loma Linda University Health.

“Our goal is to serve as physicians first and as outstanding technicians second,” says Aaron Robison, MD, a pediatric neurosurgeon at Loma Linda University Children’s Hospital and Loma Linda University Medical Center. “We have the tools to propel neurological care forward in the Inland Empire.”

“The continued goal is to PROV I DE PAT I E N TS W I T H A DDI T IO NA L S U PP O RT A N D T R E AT M E N T OP T ION S built around a strong, collaborative team who can improve their care.”

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Tanya Minasian, DO, FACOS Pediatric Neurosurgeon at Loma Linda University Health

Miguel A. Lopez-Gonzalez, MD, FACS Neurosurgeon at Loma Linda University Health

E A R LY PR E V E N T ION M A K E S A DI F F E R E N C E ThinkFirst and ThinkFirst Baby offer local families and expectant parents everyday safety tips.

Inland Empire families can learn health and safety tips to prevent life-threatening injuries through free educational seminars offered at Loma Linda University Health.

many aspects of infant safety, including how to properly secure a car seat, safe sleeping, home safety and how to calm an infant who is crying.

In addition, parents and caregivers were introduced to shaken baby syndrome, a type of abusive head trauma that results from a parent or individual violently shaking a baby. As many as 3,000 babies suffer from shaken baby syndrome in the U.S. each year, according to ThinkFirst. According to Minasian, 25 percent of babies die from their injuries and the rest can suffer permanent brain damage.

Miguel Lopez-Gonzalez, MD, FACS, a neurosurgeon at Loma Linda University Health introduced ThinkFirst to a group of local students in September 2017. The program educates young students — kindergarten through high school — on how to safely protect themselves against trauma injuries. Many injuries to the head, spine or body are preventable, according to Lopez-Gonzalez. The key is to be aware of how and when these injuries occur.

“We want to provide a safe area for parents to express any doubts, questions or concerns,” says Minasian.

“Our goal is to provide information and ways to alleviate their stress, reduce potential frustration and assure them that Loma Linda University Health is here for them.”

“Our goal is for children and their parents to not be afraid of an injury, but rather be aware,” says Lopez-Gonzalez.

ThinkFirst is a National Injury Prevention Foundation effort rooted in educating students, educators and parents on the best safety precautions.

Topics include learning safety measures to prevent serious injuries, such as wearing a seat belt, driving free from distractions or wearing a helmet while riding a bike.

Loma Linda University Health is the only chapter in Southern California to offer ThinkFirst Baby, and Dr. Minasian is the only physician in the United States credentialed to teach ThinkFirst Baby seminars, according to ThinkFirst. Sessions are held monthly at Loma Linda University Health for ThinkFirst Baby, while ThinkFirst is offered throughout the community at participating schools. Both physicians value this platform as an innovative way to reach the community with resources and knowledge to prevent future traumas in both children and adults.

This past summer, Tanya Minasian, DO, FACOS, a pediatric neurosurgeon at Loma Linda University Health, coordinated the first ThinkFirst Baby seminar for expectant parents and caregivers. The seminar offered families a unique opportunity to learn about brain and spine health in infants and how to properly care for their tiny bodies. The seminar demonstrates

For more information on upcoming ThinkFirst seminars, call Janine Davis at 909-651-4721.

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A I M I N G H IG H FOR E V E RY C H I L D ’ S F U T U R E Neurological experts set sights on comprehensive hypertonicity center for pediatric patients. physical medicine and rehabilitation at Loma Linda University School of Medicine.

The multidisciplinary hypertonicity center at Loma Linda University Health treats pediatric patients who suffer from movement disorders, including genetic dystonia and cerebral palsy, with an exceptional team of healthcare professionals experienced in advanced treatments.

The Department of Neurosurgery offers a comprehensive program in surgical treatments for pediatric patients living with motor disorders, including DBS, selective dorsal rhizotomy (SDR) and intrathecal baclofen (ITB). Two pediatric neurosurgeons recently joined the Department of Neurosurgery at Loma Linda University Health — Aaron Robison, MD, and Tanya Minasian, DO, FACOS. Both have vast experience in pediatric surgeries, including cranial, endoscopic, laser ablation and selective dorsal rhizotomy, Kim says. Robison has extensive and unique experience in pediatric DBS surgery that will be implemented at Loma Linda University Health.

The hypertonicity team at Loma Linda University Health specializes in multidisciplinary evaluations encompassing the experience and knowledge of neurosurgeons, neurologists, physical medicine and rehabilitation specialists, physical therapists and occupational therapists.

“Our goal is to provide a complete medical home for these children where there is a ‘village’ that knows, understands and PROV I DE S T H E B E S T P O S SI BL E C A R E F OR E AC H C H I L D.”

“Every child has a unique story and a developmental trajectory, and any small difference we make now can mean big differences for their future,” Kim says.

To learn more about the program and available services, contact Pediatric Neurology at 909-835-1810.

“These children have very complex motor disorders that are often misdiagnosed,” says Young-Min Kim, MD, assistant professor of pediatrics and neurology at Loma Linda University School of Medicine.

“Our goal is to provide a complete medical home for these children where there is a ‘village’ that knows, understands and provides the best possible care for each child.”

Dystonia is a movement disorder characterized by involuntary muscle contractions leading to abnormal postures or repetitive movements. It is commonly misdiagnosed as spasticity, Kim says. While activitybased treatments are essential to promote motor learning, treatments such as botulinum toxin injections, oral medications and deep brain stimulation (DBS) can improve the quality of life for children affected by dystonia. “We provide an amazing service that is very difficult to find anywhere else,” says Thaddeus Wilson, MD, MPH, assistant professor of 4

A DE DIC AT E D T E A M FOR E V E RY PAT I E N T Pediatric epilepsy patients receive comprehensive care from a multidisciplinary team.

As of October 2017, the CETC had over 100 patients who received medical care focused on electrical stimulation (vagal nerve stimulator), ketogenic diet therapy, medication management and epilepsy surgery.

The Complex Epilepsy Team Center (CETC) at Loma Linda University Health comprises a dedicated team of epileptologists, nurse practitioners, social workers and nutritionists who work collaboratively with neurosurgeons and neurologists on a weekly basis to secure optimal treatment for pediatric patients living with epilepsy.

“We love to see our pediatric patients reach certain milestones in their lives — such as attending school for the first time — following treatment and support at the CETC,” says Pilar D. Pichon, MD, a pediatric epileptologist at Loma Linda University Children’s Hospital. The ultimate goal is to improve their quality of life. Even though not all patients find 100 percent relief from seizures, their pain and discomfort can be significantly improved. Many of their patients experience fewer side effects and are more alert or interactive — as children should be, Pichon says.

Epilepsy currently affects as many as 325,000 children in the U.S. each year, says Joshua D. Loeb, MD, a pediatric epileptologist at Loma Linda University Children Hospital. According to Loeb, epilepsy and status epilepticus is a leading cause of admission to the pediatric intensive care unit.

“It’s devastating to see children living with epilepsy,” says Richard Tang-Wai, a pediatric epileptologist at Loma Linda University’s Children Hospital. “Their brains tend to seize more and escalate faster than adults.”

A team of multidisciplinary experts, including neurologists, neurosurgeons, neuroradiologists and neuropsychologists meets once a week to discuss in greater length a particular patient’s case. Each member of the team provides their insight, experience or previous successes to help determine next steps.

According to Tang-Wai, it’s not just one thing or person that is impacted by a child’s epilepsy diagnosis.

It encompasses their ability to walk, eat, speak, and, of course, their family carries the weight of the disease.

This is why the team at Loma Linda University Health works closely with one another to accurately pinpoint the best solution for each patient.

“It’s our job to know the concerns of the family before any surgery takes place,” Loeb says.

There are currently four epileptologists at the CETC, and a four-bed epilepsy monitoring unit is utilized in the hospital for inpatient EEG evaluation.

“Even children who aren’t surgical candidates deserve the discussion among our experts and resources to help preserve their developmental process,” Tang-Wai says.

For more information on the Complex Epilepsy Team Center, contact 909-558-7043.

“It’s our job to know the concerns of the family before any surgery takes place.”

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FO O D FOR T HOUG H T: K E TO G E N IC DI E T T R E ATS E PI L E P SY Pediatric epilepsy patients use diet therapy as a means to help control their seizures.

Ketogenic diet therapy offers pediatric epilepsy patients a specialized diet program using a high-fat diet to help control seizures. Patients with intractable epilepsy — epilepsy that has not been controlled by at least two seizure medications — may be determined to be ketogenic diet therapy candidates by their epileptologist. Loma Linda University Children’s Hospital is one of the few institutions in California offering this diet therapy.

After the pediatric epilepsy patient is determined to be a candidate, parents will have to attend classes and learn how to prepare food and follow a strict monitoring schedule. This will involve how to prepare food; learning about the conditions that may present with the diet, such as constipation or low blood sugar levels; and knowing when to call the ketogenic diet team for help.

Once on diet therapy, patients are followed in the Complex Epilepsy Team Center and complete lab work every three months to evaluate efficacy. Patients are generally asked to maintain daily seizure logs and home monitoring logs tracking urine ketones and blood sugar levels. Families are asked to commit to the diet program for at least three months. If the quantity or quality of their child’s seizures have improved, they may remain on the diet for up to two to three years and then be weaned off.

“The team at Loma Linda University Children’s Hospital and Complex Epilepsy Team Center has built a foundation to PROV I DE E AC H PAT I E N T W I T H A C O M PR E H E N S I V E A N D M U LT I DI S C I PL I NA RY T E A M TA I L OR E D TO THEIR NEEDS AND T R E AT M E N T.”

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While on this diet therapy, “keto patients” are monitored by the keto team, which includes a team of pediatric specialists: an epileptologist, dietitian, nurse practitioner and social worker.

The team at Loma Linda University Children’s Hospital and Complex Epilepsy Team Center has built a foundation to provide each patient with a comprehensive and multidisciplinary team tailored to their needs and treatment.

For more information regarding the Complex Epilepsy Team Center and Ketogenic Diet Therapy, contact Teresa Serna, MS, RN, CPNP at 909-835-1820.

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Warren Boling, MD Program Chair, Neurosurgery Genesis Gonzalez Writer and Editor Shaina Burns Marketing

DEPARTMENT OF NEUROSURGERY Warren Boling, MD, FAANS, FRCSC, FRACS Chairman of Neurosurgery Specialty expertise in Epilepsy, Neuro-Oncology

Clifford Douglas, MD, PhD, FACS, FAANS Specialty expertise in General Neurosurgery and Orthopedic Spine Surgery

Kenneth De Los Reyes, MD, MSc Specialty expertise in Skull Base and Cerebrovascular Surgery

Tanya Minasian, DO, FACOS Specialty expertise in Pediatric Neurosurgery

Namath Hussain, MD Specialty expertise in Minimally Invasive Spine Esther J. Kim, MD Specialty expertise in General Neurosurgery and Spine Surgery

Daniel J. DiLorenzo, MD, PhD, MBA Specialty expertise in Functional, Epilepsy and Spinal Neurosurgery Ramachandran Pillai Promod Kumar, MBBS Specialty expertise in Endovascular and Cerebrovascular Neurosurgery

Anish Sen, MD Specialty expertise in Adult Neurosurgery Nikhil Sahasrabudhe, MD Specialty expertise in Neurosurgery U.S. News & World Report ranked Loma Linda University Medical Center number one in the Riverside and San Bernardino metro areas for 2018-2019. The Department of Neurosurgery was one of seven areas to be recognized as “high performing� this year. More than 4,500 medical centers across the country were evaluated in 25 specialties, procedures, and conditions.

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Miguel A. Lopez-Gonzalez, MD, FACS, FAANS Specialty expertise in Movement Disorders, Cerebrovascular Skull Base and Spine Surgery

R. Aaron Robinson, MD Specialty expertise in Pediatric Neurosurgery