A Unique Dual-Specialty Approach: Pediatric Orthopedic Spine and Neurological Spine
Reducing OR Time and Blood Loss in Pediatric Spine Cases
As featured in NYP's Advances
When it comes to pediatric spinal surgery, both neurological spine and orthopedic spine surgeons play critical roles. The specialties often collaborate on adult spine surgeries; however, only a few programs around the country have implemented a similar model in pediatrics. At Och Spine at NewYork-Presbyterian, pediatric orthopedic spine and neurological spine surgeons have spearheaded an integrated model of care that brings in both specialties as equal partners in the planning and delivery of pediatric spinal surgery.
Michael G. Vitale, M.D., chief of pediatric spine surgery at NewYork-Presbyterian Morgan Stanley Children’s Hospital and Och Spine at NewYork-Presbyterian, and Taemin Oh, M.D., a pediatric neurosurgeon and director of pediatric neurosurgical scoliosis surgery at Och Spine at NewYork-Presbyterian and Columbia, are setting an example on the critical ways the two specialties can collaborate on complex pediatric spine surgeries.
“Neurological spine surgeons are better at handling nerves, working around the spinal cord, and managing cerebral spinal fluid,” says Dr. Vitale. “Conversely, orthopedic spine surgeons have a deep understanding of the bones and biomechanics of the spine.”
The goal is to be “proactive as opposed to reactive,” Dr. Oh explains, so he and Dr. Vitale work together on a surgical plan, mapping out the workflow for the procedure, perform the surgery in tandem, and see patients together after surgery.
“For us to be at our best, we need to get out of the thinking about surgery as cut to close,” Dr. Vitale says. “The surgical episode starts way before that in terms of understanding the problem, the family, the social situation, the needs and priorities of the patient, and then planning accordingly.”
Tackling Complex Cases
Dr. Vitale and Dr. Oh recently completed a complex case together, successfully performing a hemivertebrectomy and posterior spinal fusion in an 11-year-old with progressive congenital scoliosis with a L5 hemivertebra. The hemivertebra, which caused 70 degrees of scoliosis, needed to be excised and the spine fused, so Dr. Vitale and Dr. Oh devised a surgical plan that involved Dr. Oh performing the hemivertebrectomy and Dr. Vitale performing the spinal fusion.
“This was a high-risk surgery because we had to remove that whole vertebrae from the spinal cord and the nerve roots,” says Dr. Vitale. “The nerve roots, especially at the bottom of the spine, are very sensitive to mobilization and there’s potential for postoperative weakness and bowel and bladder dysfunction. Working with a neurosurgeon like Dr. Oh allows me to utilize the expertise from both specialties to ensure that the patient has the best outcomes possible. The surgeons used intraoperative surgical navigation to visualize the bone and the nerve roots. Dr. Vitale placed screws above and below the hemivertebrae and Dr. Oh assisted him. A laminectomy was performed to remove the caudal aspect of L5a. Dr. Oh removed the hemivertebrae with Dr. Vitale assisting. They used drills and other tools while carefully retracting the nerve roots and protecting the spinal cord. Once the vertebrae was removed, rods were then measured, cut, and contoured and bent into coronal and sagittal alignment to correct the spinal deformity. The rods were inserted, and the screws were appropriately torqued down.
Dr. Vitale and Dr. Oh collaborated on a surgery to correct progressive congenital scoliosis with a L5 hemivertebra. Together, they performed a hemivertebrectomy and posterior spinal fusion to remove the vertebra and correct the patient’s spinal alignment.
“Dr. Vitale and I have different but complimentary skill sets which allow us to work on achieving the outcome in a much more coordinated fashion,” says Dr. Oh. “With the two specialties working together, we’re able to provide the absolute best for the patient – the surgery time is shorter, blood loss is lower, and it’s safer for the patient overall.”
The procedure was successful; the patient has experienced dramatic improvement in her spinal alignment and deformity and has resumed her normal activities, including gymnastics.
Best of Both Worlds
Neurosurgeons bring different training and different expertise than orthopedic surgeons and the combination is a win for patients. For instance, neurosurgeons receive more time in spine surgery training in residency while orthopedic surgeons often come out of training with a more holistic view of the syndromes and conditions affecting the spine.
“It’s really complementary and it’s fun to get to learn from each of the neurosurgeons that I work with because they have different tricks in terms of nerve handling,” Dr. Vitale says.
The combination of these different skill sets and having two experienced surgeons leading the spine surgery leads to fewer complications and other quantitative benefits in the operating room, Dr. Oh says.
“In our mind, patient safety is always number one and we are constantly looking for ways – big and small – to be leaders on that front and better advocate for our patients. If it were my child and there was a way to make the surgery a little safer, go a little bit smoother, I would take that option,” Dr. Oh says. “We’re forward thinking at Och Spine at NewYork-Presbyterian and we’re demonstrating the benefits and the beauty of this model.”
Scaling the Program
NewYork-Presbyterian and Columbia began moving forward with the collaborative approach to pediatric spine surgery in 2004, shortly after Dr. Vitale joined NewYork-Presbyterian. Over the years Vitale has lectured and published widely on the advantages of this approach. In fact, Vitale has developed a unique Advanced Pediatric Spine Deformity Fellowship which attracts applicants from both the neurosurgical and orthopedic fields committed to being the best pediatric spine surgeon they can be. This model attracts positive attention from other surgeons nationally and internationally who are impressed by the teamwork culture.
As part of this effort, NewYork-Presbyterian and Columbia’s pediatric comprehensive spine fellowship and the advanced pediatric spinal deformity fellowship include fellows from both orthopedic surgery and neurosurgery — the only spine fellowships in the country to include both specialties.
Not everyone favors this approach, but Dr. Vitale, who is the co-director of the fellowship program, rejects this type of turf battle over spine surgery. “If I can help train people who have different skills than me, they’ll go on to do better things in different places, take care of more people. And that’s part of my overall goal, to scale what we do,” he says
