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John Dormans, MD: If the chest wall is more or less normal, we'll go with the growing rods. If the chest wall, however, is abnormal with missing or fused ribs, then the VEPTR device comes into play and is a better device for treating those situations.
Oscar Henry Mayer, MD: Growing rods and the VEPTR treat different aspects of thoracospinal disease.
John Flynn, MD: The traditional growing rod is fixed only to the spinal elements, sometimes to the pelvis, but generally, fixed only to the spinal elements.
John Dormans, MD: There are anchors placed at either end of the spine. So, if there's a curvature, there are anchors placed above the apex of the curve and anchors placed below the apex of the curve. And then from those anchors there are two rods, and they're connected in the middle with an expander, or expansion device. And so when we do the correction, we're distracting through those connecters to try and straighten the spine.
John Flynn, MD: You're pushing those fusions apart and driving spinal growth.
John Dormans, MD: Essentially, by pulling or stretching the crooked spine into a straighter spine. And then, generally, we'll go back every six months and distract a little more just to drive the spine, if you will, and promote longitudinal growth of the spine and, as a result, preserve pulmonary and chest function.
Robert Campbell, MD: And treatment of thoracic insufficiency syndrome with the VEPTR device it's the same routine, a major surgery -- with the implantation of the devices and the reconstruction of the rib cage to make it larger for lung growth. But then once again as the child grows we have to lengthen the implanted devices to keep up with this growth. VEPTR stands for Vertical Expandable Prosthetic Titanium Rib. It's a curtain rod of strong titanium that is able to expand when it's unlocked and then locked in an expanded position.
John Flynn, MD: The VEPTR can hook to the ribs. It can hook to the pelvis. It can hook to the spine. And what VEPTR will allow us to do is literally expand the chest itself. It will correct the chest wall deformity and, secondarily, through the way the ribs are connected to the spine, it will actually correct the scoliosis itself.
Robert Campbell, MD: It's placed in the child collapsed down in its minimum position, attached, and then, as the child grows, we access the bottom of it, expand it as much as we can, and then relock it in that position.
John Dormans, MD: When the child goes back to the operating room, generally, there's a lot of preparation that's involved with that.
John Flynn, MD: We have the good fortune of working with really world-class anesthesiologists who can, are used to taking care of the most difficult problems in even the very youngest children.
John Dormans, MD: They'll generally go to sleep with an inhalation anesthetic or with a gas. So they're asleep before any procedures are done, before any lines are placed, before any needles are used.
We have special positioning devices that we use to hold or position a patient during surgery, such that they're safe and protected. Such that bony prominences are not irritated or the skin isn't damaged. We protect the eyes. There's a bite block that's used to prevent injury to the teeth or the tongue.
Michael Nance, MD: There's several layers of safety monitoring that occur in the operating room during the case.
John Dormans, MD: Safety is king. We focus a great deal on safety, avoiding mistakes, avoiding obstacles, complications, problems.
Michael Nance, MD: It's obviously vital, when a patient is asleep and can't communicate and let you know if there's problems, then we have to be able to figure those out for them.
John Dormans, MD: One of the most difficult or problematic complications of spinal deformity surgery would be a spinal cord injury. It's a complication that we go to great lengths to avoid.
John Flynn, MD: We really have, I think, the best spinal cord monitoring group around, and they are true pioneers in spinal cord monitoring. And they are pioneers in monitoring even the very youngest children.
John Dormans, MD: They've developed some of the key techniques for monitoring the function of the spinal cord during these difficult surgeries.
John Flynn, MD: So they can tell us if the spinal cord is not behaving or if we need to back off a little bit in our correction. Having that information in real time in the operating room in an environment where we're communicating with them just really enhances the safety of these complex procedures.
Daniel Schwartz, D.ABNM: So we apply sensors from the head down all the way to the feet.
Michael Nance, MD: There are small needles which are placed in the tissues to monitor their nerve conduction--
Daniel Schwartz, D.ABNM: --that allow us to monitor signals that go down from the brain, through the motor pathway of the spinal cord, out to muscles of the upper and lower extremities, or the arms and the legs. And in addition, we monitor signals coming from the feet and the arms up the spinal cord to the brain, which allows us to monitor the integrity or strength of the sensory pathways of the spinal cord. We're actually looking at a computer screen, and on that computer screen we can see different types of signals that occur from stimulating the spinal cord. And we will see responses either coming from the brain or the muscles that the spinal cord feeds. And so, if we, for example, see that the strength of the motor signal during a specific surgical maneuver is going down, we can alert the surgeon that, "Whatever you're doing right now is potentially setting the child up for an injurious state." And, therefore, we need to do something to reverse that.
John Dormans, MD: So it's very complex, very technical, but very important to what we do. With these new techniques and new approaches, it's radically changed how these kids are treated.