the - Hospital for Special Surgery

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
2
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
3
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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: [email protected]
©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.