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I Wanted to Be a Neurosurgeon, So I Did It · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehmint, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit, depending on our topic or podcast.
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Today, we have a neurosurgery update, and I'm thrilled because our new pediatric
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neurosurgeon, Joanna Gernsback, is here with me in the podcast studio.
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Joanna, thank you so much for being here.
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Thank you for having me. So I hear you recently climbed Mount Kilimanjaro. How did that go?
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Slowly, slowly. The first Swahili they teach you is poli poli,
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which means slowly, slowly.
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Yes, it's a very slow uphill slog, both the angle and also the altitude.
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It goes up to 19,000 and some feet, which is much higher altitude than most
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of us are used to being at.
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And your lungs don't really like that very much.
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And it was a challenging climb. Yeah. But you don't plan to do it again?
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I think once was enough. Are you glad you did it? Oh, yeah.
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Did you do anything else while you were in that area of the world?
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We went on safari and saw all the all the cool wild animals.
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Oh, how was that? Oh, it's a lot of fun.
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And did you take your teenage kids with you?
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We did not take the kids. I actually didn't go with my husband.
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I went with my best friend who's also a neurosurgeon. Oh, she's in India. In Indiana.
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Did you all train together? We did, yeah. So we went to medical school together,
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and then we ended up at the same residency.
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And then became close friends from there. Yeah.
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So I was talking to our infectious disease doctor and our ER doctor.
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They were both talking about how there have been a lot of ATV accidents,
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and a lot of those patients come to you needing brain surgery.
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But what do you want to say to the pediatric practitioner about ATV accidents?
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So ATV accidents are super common, particularly in Texas.
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Texas, depending on which source you read, might be the most common place to
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find ATV accidents because there's so much rural area.
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And ATVs, you might think they're super safe, but they're not necessarily all that safe.
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In fact, it can be misleading because there's no training that goes into or
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license required as far as we know. Correct.
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There is training that's available, but it is not required.
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It is certainly recommended. If you know that it exists, you should take it.
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But the laws are not very stringent, and there's not a lot of oversight,
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and there's a lot of people doing whatever they want, which is not necessarily
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the smartest thing to do. Mm-hmm.
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And is it that...
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Parents desire to, well, but look, he's having so much fun and this is what
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she wanted for her birthday.
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We definitely see it both from the parents' side and from the kids' side,
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where the kids are like, this is what I want to do.
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Or they're out with friends and their parents have no idea.
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But yeah, we see it from both sides. Is there any specific case you wanted to
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bring up just in general, just as a cautionary tale?
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Yes. There was fairly early on after I got here this summer.
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There was a teenager, so old enough to be on an ATV, unsupervised.
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The AAP recommends that if you're under 16, you should have adult supervision.
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And this child, this teenager was older than that, so good.
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But strike number one, he was not wearing a helmet. You should always wear a helmet on an ATV.
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And we don't actually know all the circumstances of his accident because he
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was never able to tell us.
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But we do know that it was a rollover and he came to us very,
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very sick. He had injured his lungs.
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He had injured his brain, his skull.
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He never needed formal brain surgery, but his brain was very sick for a long
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time and his lungs were very sick for a long time.
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And nobody thought he was going to survive. At one point, I don't know if you
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remember during COVID, there were people talking about being proned because
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their lungs were so bad, we had to prone this child for several weeks.
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That means when you're, instead of being laying on your back,
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which is how most people think of being in a hospital, you're actually flipped
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over onto your belly. So lying prone. Exactly.
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So that changes where the pressure on your lungs lies and that alleviates some
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of it and can help re-erate different parts of your lungs and it can help with respiratory problems.
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So he was so sick for the longest time and he He actually walked into my clinic
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last month. Wow, that's amazing.
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So, and as far as we know, was he in the wilderness or in nature somewhere?
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Yes, yes. He was out in a rural area. So, yeah, one of the big things for ATV
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safety is do not ride on paved roads. They are not designed for that.
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Yes, you can cross a road after, you know, you look both ways and at an appropriate
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speed, but you should not be riding on the roads.
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And he was not. So that's good, at least.
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And there's a big issue that you see a lot. And I wanted to mention University
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Hospital is the only level one trauma center in this area other than BAMC,
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and a lot of people don't know that.
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But when adolescents are coming in, it's often they've been using a substance
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and driving some sort of vehicle or an ATV.
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That's a big problem. That is very common.
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We see lots of older teenagers come in under the influence of substances and
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involved in some sort of trauma, you know, a car accident, a motorcycle accident.
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It's not always their fault. Sometimes they're just walking home and they get
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hit by a car, but the substance doesn't help anything, right?
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It doesn't help their reaction time, something they might have been able to
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avoid if they hadn't been on substances.
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So if you're, you know, don't do substances, but if you're going to do substances,
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do them in a supervised environment where you're not going to get hurt.
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Absolutely. That's great advice. And then we also, there's the smaller cars
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that kids eight and under tend to gravitate to. Can you tell me about those? Sure.
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So there are youth ATV, which are like ATV, not really a great design,
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but that's a whole nother issue.
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There's also the little sort of like Barbie cars that,
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toddlers and young children play with. These are sort of medium in the safety profile.
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They tend to have a much lower center of gravity, so they're much less likely
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to flip over than, say, an ATV.
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But some of them actually go fairly fast, and if you're not watching your child,
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you know, they're very low to the ground, so an actual car or truck can't see them.
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So anytime your child is using one of these out of doors, you need to be watching them.
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I worked in television news as a reporter for about a decade.
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And so we would see a lot of the accidents right after they happened.
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And so I could not relax in the cul-de-sac when my kids were,
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you know, borrowing a neighbor's one like that. Like I would be nervous the
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whole time and standing.
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It probably took away from They're fun somewhat, but a lot of times you see
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kids just going down the road on their own without a helmet in one of these vehicles.
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Yeah, I would always recommend anytime you're on a wheeled conveyance,
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whether it's roller skates or scooters or bicycles or ATVs or anything,
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you should wear a helmet.
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And I don't think I've ever seen a kid on the street on a skateboard with a helmet on. Very rare.
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Yeah. Why is that so rare? I mean, why isn't it just part of the deal?
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Have you seen any kids with skateboard injuries?
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Yeah. We had one in training that had a very bad epidural hematoma,
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which is a blood clot sitting outside the brain but under the bone.
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He came in very, very sick.
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We took out the blood clot because
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it was very large, and he woke up a few days later and did very well.
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That's amazing. But, yeah, we definitely see those. And something a lot of people
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don't think about, there's always a risk for infection or lifelong problems.
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Correct. An accident that could have been prevented.
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Correct. So anytime we have to do an intervention, that intervention,
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whether it's putting a tube in your head or doing a whole brain surgery,
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or if you break your leg and you need surgery on your leg,
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anytime there's opening in the skin, you can get an infection.
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Anytime you're in the hospital for a prolonged period of time,
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you can get an infection even without a procedure.
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You can get pneumonia just from being in the hospital.
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And if this is something that could have been prevented by simply wearing protective
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gear or having adult supervision, that would save so much effort,
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so much money, so much time, so much heartache.
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And Dr. Grunzbeck, as a neurosurgeon and also a parent, what would your advice
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be regarding your own children?
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Fortunately for me, my children have never asked to ride ATVs or anything like that.
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I would probably make them take a safety course and have all of the appropriate
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gear. You're supposed to have a helmet and goggles and gloves and boots and
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long sleeves and long pants, and they would have to do all of those things.
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They would need to know what they were doing. They would need to know the area they're going to.
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They could not ride with anybody else on their ATV unless it were a specific
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like two-person model, because that's a big way that people get into accidents
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is going off ATVs that aren't meant to have multiple people on them.
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So I don't think it would be a hard and fast no, but there would be a lot of
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stipulations to get to that.
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I know with my son, he was really getting into skateboarding when he was about 12, 13.
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And I asked him why he loved it and he
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said that it's that thrill because he was trying to go like fly off of things
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I guess oh yeah and it was the thrill of wondering will I make it and I asked
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him like well what if when you don't or if you don't I mean that could stop
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you from playing sports for the rest of your life it could kill you too and
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then I did tell him like he would.
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And the American Academy of Pediatrics recommends skateboarding not where cars
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go at all. Not just that there aren't cars there.
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Don't skateboard where cars ever go. Right. But a skate park is okay with all the proper gear.
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So anyway, he kind of slowly trickled down from there, and he lost interest
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in it. I did take him to a skate park.
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Yeah, that would be my recommendation if my kids wanted to skateboard.
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Wear your gear and go to the park. Yeah, exactly.
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So let's talk about the brain injury guidelines.
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It's important to know about those. So the brain injury guidelines are,
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I think, about 20 years old.
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They were originally designed for adults, and they've been adapted with the
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data that we have for children.
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So there are a different pediatric set. They're updated every few years.
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And I think they're important. You know, they're designed for the in-hospital
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care of pediatric traumatic brain injury. So as an outpatient pediatrician,
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they're probably not relevant for you other than to know that they exist.
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But they are very important for in-hospital practitioners to be aware of and
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to keep up with because the data does change from time to time.
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You know, things that we didn't know five, 10 years ago, we know now.
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You know, there's so many things that have changed just since I graduated from
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medical school, which was not that long ago.
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Mm-hmm. And so know that they're out there. And if need be, look them up if you have a question.
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They're easily findable. Yeah. Yeah.
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On the internet, you know, they're on tons of different websites,
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most of which are not behind a paywall.
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So you should have ready access to them if you want them.
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So a lot of what you focus on, you do everything in neurosurgery,
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but the spine is a focus. I have always had an interest in the spine.
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I actually thought about being a spine neurosurgeon rather than a pediatric neurosurgeon.
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So I do like all things in the spine, starting from little tiny babies with
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spina bifida or myelomeningocele or sacral dimples.
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So your congenital spine issues, kids with back pain, kids with herniated discs,
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kids with scoliosis, kids with spine tumors, pretty much anything in the spine
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I will take care of for you.
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And, Joanna, you see patients at University Hospital? I do. You take the Rio Tower?
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Is that right? It's the Rio Tower, second floor, the D elevators.
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In the neurosurgery clinic there.
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And eventually you'll be seeing patients at a UT clinic? At some point I will
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probably see spine patients at the MARC.
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Okay. The Medical Arts and Research Center. Okay.
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We're going to go through a few things that pediatricians, where they'll see
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this patient, what to look out for, some red flags.
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But when you were eight, you said you wanted to be a brain surgeon,
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like a lot of kids. I probably said that at some point, I think. I don't know.
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No, but you really stuck to it. You knew this is what you wanted to do.
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Yeah. So I was a smart aleck little kid, and I was just being obnoxious when
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somebody asked me what I wanted to be when I grew up. But for some reason,
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it just kind of always stuck in the back of my mind and nothing else really
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sounded cooler. So we went with it.
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And so you're the first person in your family to have a college degree?
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Or your parents went to some college? My parents went to some college.
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One of my older sisters had a degree before I did, but I'm the first person
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to have any advanced, like a professional degree.
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And so your parents that were very supportive of education and putting you in
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advanced programs at an early age and that you say that really helped you. Yes, absolutely.
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My parents were big proponents of, you know, having me go into higher levels of math.
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At one point, we actually switched schools because the school district we lived
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in did not offer enough advanced classes for me. I was just bored out of my mind.
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So they actually bought a house and we switched schools. Wow.
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They sent me to all the academically talented pullout programs.
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You name it, I did it. But yeah, I mean, it's gotten me to where I am.
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And you're self-described as being a stubborn person, and that also helped?
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Yes, yes. I don't think I would have gotten this far in neurosurgery without being stubborn.
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I think there were too many roadblocks for neurosurgery in general.
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Being a woman in medicine, not coming from an academic medical family,
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there were just too many points where it would have been easy to say,
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no, I'm going to do something else.
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And yeah, I mean, it's so it's that stubbornness that just really kept you going. Yeah.
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Did doubt ever creep into your mind? A few times. Yeah.
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A few times, but never let it take over. And then you kind of had to figure it out as you went along?
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Right. I didn't have, you know, my parents and my siblings weren't in medicine,
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so none of them could advise me, this is what you need to take in college,
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this is what you need to do next.
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And I didn't know even who to look for in college to help me with those sorts
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of things. So I was very much making it up as I went along.
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And how's it going now that you're practicing and seeing patients?
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I made it into the world of academia. I'm a board-certified pediatric neurosurgeon,
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so I think I did something right along the way.
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And just, is there one thing that's your favorite thing right now, being a neurosurgeon?
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Ooh, favorite thing about being a neurosurgeon. So I'm a pediatric neurosurgeon
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primarily, And I really love the babies because you get to operate on them and
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fix whatever is wrong with them,
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whether it's trauma or too much fluid in their head or a back problem or whatever.
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And then you get to watch them grow up and they become a normal human being
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that goes off to college and has a great life. Amazing.
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That is really cool. And we talk a lot in the podcast about customer service
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and compassion and kindness in medicine, but I love how today we're talking about stubbornness.
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I bet that helps you also when you're doing surgery.
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Do you have to follow your gut a lot, too? Sometimes, yeah.
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So particularly in surgery, you always need to have plans A through Z, right?
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So most of the time, plan A works.
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Cool. But when it doesn't, you need to have a backup. And if that backup doesn't
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work, you need a backup to the backup. And so on and so forth.
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And stubbornness is very helpful when you're like on plan Q and you're like, nothing is working.
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But you can't give up because you're not done yet. And then plan Q might work.
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And then plan Q might work or plan Z might work or.
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Yeah. So 1A. Yes, exactly.
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So, Joanna, we were talking about differentiating what, when do you know to
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send to a neurologist versus a neurosurgeon?
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Any advice there for our listeners?
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That is a tricky question. The easiest answer, which is probably not a very
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helpful one, is if it's something that we can fix with surgery, it goes to a surgeon.
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If it's something we fix with medicine, it goes to a neurologist.
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Now, there is some overlap. For example, if you have a child with epilepsy or
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even just one seizure, they always start in neurology because we start with medicine.
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Sometimes they end up in the neurosurgery office, but you don't start with neurosurgery for that.
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Other things that come to mind, I've seen a lot of referrals over my years for
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microcephaly, which is a tiny head.
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And there's nothing I can, okay, yes, there is a surgery I can do to make the
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head bigger, but if the head needed to be bigger, the head would have been bigger, right?
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So just because you have a small head doesn't mean I need to make it bigger.
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So those sorts of things go to neurology. So if you can, if you don't know,
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it's fine to call your friendly neighborhood neurosurgeon or neurologist or
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consult your friendly Google and be like, is this appropriate it for a neurosurgeon or a neurologist.
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And there are plenty of things that end up going to both of us.
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You know, I had a kid the other week who had a Chiari malformation,
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which is a problem in the back part of the head, and also had dizziness.
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And I was like, well, you have the strongest family history of migraines I've ever seen.
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And your dizziness is getting worse. And I don't think it's your Chiari.
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So yes, I can fix your Chiari, but you also need to see neurology to see if this is a migraine.
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And you also need to see ENT to see if this is just vertigo.
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So sometimes there's not always a clear answer. And unfortunately,
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it tends to be easier to get somebody in to see a neurosurgeon than to see a neurologist.
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So we end up seeing a lot of things and then shunting them where they need to.
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There is an episode in this podcast called The Headache Diet, and it's where Dr.
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Sheldon Gross talks about foods to avoid and vitamins to take that can help
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with migraine headaches.
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I should listen to that one. Yeah, it's in this Pediatrics Now newsfeed and
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I used to have migraine headaches and and I followed what he said and I mean
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it's been amazing I haven't had a migraine headache in about a year so amazing incredible.
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And so migraine headaches right now, there's not a surgical intervention right
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now, but there's a study being done.
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So in the future, there may be. Correct.
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So a common problem in older adults is something called a chronic subdural hematoma.
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And I mean like older, older adults, retired age.
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And I don't remember the specific history of it, but somehow we found out that
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embolizing the middle meningeal artery, which is a blood vessel that supplies
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the covering of the brain, would ultimately fix those chronic subdural hematomas.
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And while they were doing a study looking at that, they discovered,
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sort of as a happy accident, that a number of those patients had had chronic
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migraines and didn't anymore.
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So that was sort of an unexpected finding in this study for something completely
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unrelated. So now there are actually people enrolling in a study to look specifically
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at this blood vessel embolization for migraines.
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Wow, that sounds really interesting. Maybe in the future even for pediatric patients? Maybe.
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That could be available. Shall we talk about butt dimples?
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Yes. So what's important there? So the first most important thing is to check
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the baby for the dimple, because I've definitely had teenagers show up in my
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clinic and had their parents tell me, oh, we were told it was nothing,
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which may or may not be the case. So first look for the dimples.
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If there are no dimples, cool, you've done your job. Check.
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If there is a dimple, the most important thing about that dimple is where is
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it and what does it look like?
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If the dimple is down inside the butt crack, can I say butt crack?
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Sure. Okay. If it is inside the butt crack and very close to the anus, it is not concerning.
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You do not need to get any imaging on that child. You do not need to call me.
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That child can have a normal life.
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Unless, of course, you have a different concern. If that dimple is above the
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butt crack or off to the side, that's a different story. Those children need imaging.
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Also, if anything is coming out of the dimple or if you cannot see the bottom
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of the dimple wherever it is, we need to see those children and those children need imaging.
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When it's in those other places, what could it be?
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Then it's more likely to be associated with some flavor of tethered spinal cord,
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which is where the spinal cord is held down too low in the spinal column.
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And that can come from a number of different things. It can come from a fatty
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phylum, which is a nice easy one to fix.
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It can come from a spinal lipoma or a lipomyelomeningocele.
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Those are more complicated to fix, but all of those need to be evaluated for
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and addressed by a neurosurgeon if they exist. If you find one,
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you can get a spinal ultrasound in a little baby up until they're about three months old.
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So no radiation and no anesthesia.
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And you can quickly rule in the possibility of something or rule out the possibility
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of something. Because if it's negative, they don't need any additional imaging.
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They don't need a referral. They can go have a nice life.
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Wow. And is ultrasound not used for older than three months? No.
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So the reason why you can do it in little tiny babies is because the back parts
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of their spinal column, the bone, has not ossified enough so that you can actually
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get the ultrasound through the bones.
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Once they get older, the bone is too bony and you can't see through it.
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And then you have to get an MRI, which requires sedation and several months
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of waiting and it's a whole thing. And it's better the sooner you know in a baby what's going on.
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So you can, or is there a treatment that can start then? There are.
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So we do typically offer surgery for all the various flavors of tethered spinal cords.
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With the exception of a dermal sinus tract, most of them are not done until
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the baby is a little bit older in the 6 to 12 month neighborhood.
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But just knowing that there might be something there, you can start the process
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of getting a full workup.
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Getting an MRI scan, which will require sedation and take several months to
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orchestrate, having them seen by urology to make sure their bladder is working,
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getting them on the schedule, talking to parents, making sure they're understanding
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what's going on and that they want to proceed with surgery.
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All of those things take time. And if we find the tethered cord,
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if we find it older, then we're behind the eight ball.
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And do we know what causes tethered cord?
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So it depends on the flavor of tethered cord, but it's all a problem during
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embryologic development.
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And for the most part, we don't know what causes it, just that we know where
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the errors are, but we don't know what made the error happen.
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So as near as we can tell, it's not related to anything mom or dad did or didn't do.
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Most of it is bad luck. Hmm.
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Moving on to back pain, a lot of kids who come to you, they've had imaging,
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but they didn't really need it because it's mostly musculoskeletal.
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So most commonly, back pain in kids is musculoskeletal.
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So they did something in gym class or something playing football,
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and they pulled a muscle or strained something, and it will get better on its own.
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That being said, lots of people get worried when they hear back pain,
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and they automatically jump to imaging.
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And the thing that shows up in my office the most is x-rays.
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Those x-rays are almost always normal, because most things that cause back pain
25:19
in a kid cannot be seen on an x-ray.
25:22
The two major exceptions to that are scoliosis, which can be seen on an x-ray
25:26
but doesn't usually cause back pain, and something called pars defects or spondylolisis,
25:32
which can sometimes be seen on x-rays, but not always.
25:36
So is your advice in general with back pain, don't get the imaging?
25:41
Unless there's a red flag. So if there's a red flag, absolutely get imaging,
25:44
but probably not x-rays.
25:46
But if there's no red flags, I would always start with simple stuff, right?
25:50
Unless parents are really like, we must have an x-ray, an x-ray is not going
25:54
to give you an answer, right?
25:56
So start with non-steroidals, start with ice, start with heat,
26:00
start with a rest from football or whatever sport the child is playing,
26:04
start with some physical therapy, start with some stretching,
26:07
some yoga, some swimming.
26:09
All of these things are very likely to help the back pain of whatever cause.
26:14
So even if there is a surgical problem there, we don't necessarily need to do
26:18
surgery on it unless it That stays a problem.
26:23
So I have kids that have large herniated discs. You'd think,
26:27
oh, we should do surgery on that.
26:28
They do a course of physical therapy. They take some Motrin.
26:31
They're better. I don't need to do surgery.
26:35
Wow. So a lot of things will go away on their own. Correct. Sometimes kids will grow out of stuff.
26:42
What about red flags for back pain if it wakes you up at night?
26:46
If it wakes you up at night is a big one.
26:49
We don't entirely understand that pathophysiology, but it's particularly associated with tumors.
26:55
It's thought to have something to do with the hypercarbia related to your slower
27:02
respiratory rate overnight.
27:04
I'm probably not explaining that very well, but it's a big red flag.
27:08
If you have pain that wakes you up at night, back pain that wakes you up at
27:10
night, that is very concerning for a tumor.
27:14
Another big red flag, which is a tricky one in kids, is pain out of proportion to exam.
27:19
So everything looks normal. They're walking.
27:23
They have full strength. They don't have any numbness. They don't have any bowel
27:27
or bladder issues, but they are just in your office absolutely screaming in pain.
27:31
Now, if you know this child and know that they are not particularly prone to
27:36
screaming at inappropriate times,
27:39
100% that child needs imaging and an urgent referral because that's super suspicious
27:44
for osteomyelitis, which is an infection in the bones in the spine.
27:47
And what do you do for that?
27:49
Antibiotics, usually. So sometimes we have to do a biopsy to prove what it is.
27:55
Sometimes we can get that just from taking a blood test.
27:58
Most of the time it gets better with antibiotics and the bones that are affected
28:02
will actually go on to autofuse, so they'll grow together on their own.
28:05
In some cases, if it's very severe, we do have to do surgery.
28:09
And if the child does not receive treatment in a timely manner?
28:16
The infection will get out of control. It could spread to their blood.
28:20
It could spread to other levels in their spine.
28:22
It could put them into a septic shock.
28:25
Terrible. So that's great, great advice.
28:29
What What other red flags, if the pain gets worse when you're lying down?
28:35
Pain that's worse with lying down.
28:37
Again, we don't have a great physiologic explanation for that,
28:40
but most mechanical pain or musculoskeletal pain is worse with activity.
28:44
It's worse with standing. It's worse with sitting. It's worse with walking.
28:47
So if you tell me your pain is worse with lying down, I'm going to be more interested
28:51
in getting imaging sooner rather than later.
28:54
Another big one is any sort of neurologic symptoms. So if you see that the child
28:59
is not walking right or can't run, if they have any weakness,
29:02
if they're complaining they can't feel something, if they're having any changes
29:05
in their bowel and bladder habits, all of those are red flags.
29:09
So refer quickly to neurosurgery. Correct.
29:13
And then when is it time to go to the ER?
29:17
So...
29:19
We talked about with headaches. So you also, you know, in that case,
29:23
if it's the worst headache of your life.
29:24
Worst headache of your life, you should absolutely go to the ER because that's
29:27
concerning for what's called a subarachnoid hemorrhage, which is typically from
29:31
a ruptured aneurysm or in a child, typically from a ruptured arteriovenous malformation.
29:37
Other things that should send
29:38
you to the emergency room are rapidly progressive neurologic findings.
29:43
So if your child is not able to walk or or for a small child unwilling to walk,
29:50
that should be seen urgently. So either urgent care or the ER.
29:55
And Joanna, you were talking about a test you could do, have the child run.
29:59
Yes. So a great way to check for motor dysfunction, at least in the lower extremities,
30:04
is to have a kid run in a in an ambulatory child, because if they have a motor
30:10
deficit, they won't be able to run.
30:12
So if they're able to run and it looks normal, probably don't have a motor deficit.
30:17
And then if the child is having trouble running?
30:20
Then that would be concerning, and you should refer them. What other advice do you have?
30:25
I would say one thing I see a lot of is overzealous radiology doctors,
30:32
sorry, radiology, calling an insignificant
30:35
amount of scoliosis or another insignificant finding on imaging,
30:40
that then puts everybody into a panic, both the parents and the pediatrician,
30:45
and they need an urgent referral to me for something that's not even a finding.
30:50
Scoliosis is not even scoliosis until it hits 10 degrees. So I love when I get
30:54
a referral for seven degrees of scoliosis because I'm like, go have a nice life.
30:58
Because that's, yeah, so it's not significant.
31:00
It's not significant. Yeah. I have seven degrees of scoliosis.
31:03
So if it's 10 degrees, yes, refer?
31:07
So 10 degrees is the cutoff. And if you're truly not comfortable with it at
31:11
all, yes, by all means, refer to your friendly scoliosis doctor.
31:14
However, 10 degrees of scoliosis is not likely to progress super quickly, possibly not at all.
31:21
And you can just get an x-ray in six months or a year. And then if it's progressing
31:26
at that time, send him over.
31:27
If it's not, because that's all I'm going to do is get an x-ray in six months
31:31
or a year and say, nope, still 10 degrees. see you next year.
31:35
So they don't necessarily need to come to a specialist for that.
31:38
And there's fetal surgery being done for spina bifida?
31:42
Yes. We are able, not us personally, but neurosurgeons are able to do surgery
31:48
in utero for myelomonegocele, which is one of the most severe types of spina bifida.
31:53
It's been done since around the late 90s, and it is very helpful in terms of
32:02
preventing or actually reversing what's called hindbrain herniation,
32:08
which is where the back part of your brain is squished down where your spinal cord goes.
32:11
It reduces the rates of hydrocephalus, which is too much fluid in your brain.
32:16
So those kids are less, the fetal surgery children are less likely to need treatment
32:21
for their fluid, less likely to need a shunt.
32:24
They have a little bit better motor outcomes when they have the fetal surgery.
32:28
That being said, if your spina bifida is very, very low all the way down in
32:32
your sacrum, or if you don't have hindbrain herniation on your initial,
32:38
prenatal imaging, you are probably not likely to benefit from fetal surgery.
32:43
And so then you're just giving risk to the mom and risk to the baby for no particular plus.
32:50
And how early do you do surgery for spina bifida?
32:55
Surgery for spina bifida is typically done at about 24 to 26 weeks of gestation.
33:02
And is it important to get it done right around that time frame? We think so.
33:08
You know, all the studies that have been done have done it at that time.
33:13
And our best guess, because we also do surgery after you're born,
33:17
right? But our best guess is that something is happening in between when fetal
33:22
surgery happens and when birth happens that is irreversible.
33:26
And so the later you do it, the less benefit you are likely to get from that surgery.
33:32
And then after the child's born, when should they have the surgery?
33:36
So if it's not corrected in utero, we typically do surgery within three days
33:40
of birth, unless there's an overwhelming medical reason not to.
33:44
And that can make a significant difference, getting it that soon.
33:48
So, in places that are not well-developed, they don't do it that soon.
33:54
And if you support the child nutritionally, that defect will ultimately cover over with skin.
34:00
Those children don't have great neurologic outcomes, but they survive.
34:05
We recommend doing it sooner so that you don't essentially have to wait until
34:10
skin grows over it, but also it reduces your risk of infection.
34:13
So the sooner you close it, the sooner you close it, the lower the rates of
34:17
infection are. That's why we do it within 72 hours.
34:19
If it's delayed past 72 hours, the rates of infection are higher.
34:24
Do you have any advice for pediatricians who have patients who have spina bifida?
34:30
So spina bifida comes in, like everything in neurosurgery, comes in a lot of flavors.
34:34
The classic spina bifida that we think of is the open myeloma endocele.
34:38
So the baby that needs surgery either before they're born or right after they're
34:41
born. And those kids are very complex.
34:43
They tend to have a lot of different chronic issues. They have neurogenic bowel and bladder.
34:50
A lot of them have hydrocephalus. They may have brainstem dysfunction.
34:53
They may need a tracheostomy. They may need a feeding tube.
34:56
They have a lot of things going on. So I would say if you are not comfortable
35:01
managing all of those different things, know when you are out of your league.
35:05
There are pediatricians who are very comfortable managing these things,
35:09
and there are pediatricians who never manage these things.
35:11
And that's okay. You don't need to.
35:14
Just know when something's out of your league and when to refer it.
35:18
And do you follow patients throughout their childhood? We follow them forever.
35:23
So you really get to know the patients. That's part of the joy of your job,
35:28
and then also getting to do these cool surgeries.
35:32
Do you have a particular favorite type of surgery? The open spina bifida,
35:37
the myelomeningocele surgery is actually one of my favorites.
35:40
Because you can see that, or tell me why. So what you're looking at is normally
35:45
your spinal cord is a cylinder.
35:49
So it's sort of like a burrito. And in spina bifida, it doesn't form properly.
35:54
So instead of rolling up like a burrito, it stays flayed open like a flatbread.
35:58
I know I'm mixing my cuisines. Sorry.
36:00
So what you have to do is you have to take that flatbread and make it into a
36:04
burrito to sort of recreate what the normal spinal cord is supposed to be.
36:10
And the surgery itself is not that gratifying, but I find the patients to be
36:14
very gratifying because they are so complicated.
36:18
They have so many things going on, but at the same time, just because they have
36:23
so many things going on doesn't mean that they can't live a full and happy life.
36:28
And I love being able to help them achieve that.
36:32
That's wonderful. That's really inspiring. Joanna, is there anything else that
36:37
you would like pediatric practitioners or parents to know?
36:40
I wish this child had come in sooner or didn't need to come in at all or anything of that.
36:48
And probably the biggest thing that comes to my mind is kids that have had progressive
36:55
issues and either they have been blown off by whomever,
37:02
the parents, the pediatricians,
37:05
the ER, I've seen it from pretty much everybody, but they're having progressive
37:09
issues and they're being blown off.
37:11
And it's something that I could have fixed had I gotten to it sooner.
37:16
And as a result of when it came in, I was able to fix it, but not as well as I could have.
37:23
So if there's something that's giving you, if your spidey sense is tingling,
37:29
either refer the child or call your friendly consultant and be like,
37:33
is this something you need to see?
37:35
Again, we don't mind those calls. We are happy to take them because they help
37:40
us weed out things that do or don't need to come to us.
37:44
Because I can be like, oh, I need to see that child tomorrow or,
37:47
oh, that child needs to see rheumatology.
37:50
Right. And so then the parents aren't wasting a visit to see me when they really
37:54
need to get in to see somebody else.
37:56
And even for parents, too, the spidey parent. Oh, yeah. Spidey sense goes for parents, too.
38:01
And it's it's not going to hurt to at least get it checked out. Correct.
38:06
And for parents, if you feel like the first person you're seeing is blowing
38:11
you off, see a second person.
38:14
That's great advice. Is there a particular case that comes to mind where you
38:18
wish, where that happened that you want to talk about? Or if not, we can skip that.
38:23
There is a child that I had in my first practice who came to me.
38:29
Referred, I think, by their physical therapist. They had been referred to physical
38:34
therapy for sort of stopping walking, right?
38:39
So it was a school-aged child, about six.
38:43
So old enough that obviously they know how to walk, but was uninterested in
38:46
walking and didn't want to walk and was slowly and slowly getting weaker.
38:50
And all that had been done was the child was sent to physical therapy.
38:53
And I believe it was physical therapy that ultimately sent the child to me.
38:56
By the time the child got to me, she could barely move her legs.
39:00
Like, physical therapy is not going to help this.
39:03
She was hyperreflexic, so she was very jumpy in her reflexes.
39:08
All of these things were highly suspicious to me. She was having some back pain.
39:11
It was waking her up at night.
39:14
And she actually had a mid-back spinal cord tumor that I had to take out.
39:18
She did get better, but she's never going to be a track star. Mm-hmm.
39:24
So that's a great example. And thanks for sharing that. Is there anything else
39:29
you want to say, Joanna, that we didn't cover?
39:32
This has all been so interesting, and I thank you so much for being here today.
39:36
Wear your helmets. Make your children wear their helmets. Wear your own helmet
39:40
and be a good example for your child.
39:42
I know most of us that are parents are of the age where nobody wore a helmet for anything.
39:48
Right, or seatbelts even when I was a kid. Exactly, exactly.
39:50
Like, oh, yeah, we ride in the back of the truck, no big deal. Yeah.
39:54
Back when I was a kid, we didn't know how dangerous that all was. Now we do.
39:59
And so now we need to take advantage of that knowledge and use that knowledge.
40:05
Yes. So you recommend wearing a helmet while skiing, too? Yes. 100 percent.
40:09
Skiing and snowboarding. 100 percent. With all of your knowledge and experience
40:12
as a neurosurgeon in living life, do you have any advice for us all? Ooh.
40:19
Besides wearing your helmet? I mean, yours sounds like you're pretty adventurous.
40:23
You just climbed Mount Kilimanjaro. Yeah. You run. I run. Yeah,
40:28
I run and hike. Those are your main unplugging activities?
40:32
Running, hiking, reading, and building Lego.
40:35
So a little bit of everything. Building Lego like with kids?
40:40
No. No, not with kids. So do you have at your house, are you building something?
40:46
I just finished a large, so there's this whole series of Lego movies,
40:52
and they made a Lego Batman movie several years back. I remember.
40:56
I have not seen this movie, but they made it. And apparently there's like a roller coaster in it.
41:01
And so it was a Lego model of the roller coaster from the Lego Batman movie.
41:08
Wow. So what do you like about this?
41:12
Building with Legos? It's very soothing. It's like Ikea furniture,
41:17
but better because the directions actually make sense and don't look like they're
41:22
intended for a drunken monkey.
41:24
And also you start with this pile of plastic, essentially. You're like,
41:28
what am I going to make out of this? And then at the end, you have this whole big, cool thing.
41:33
Have you ever made those Lego flowers? I have a bunch of the flowers,
41:37
yeah. There's even some in my office. What about Legoland? Have you been there?
41:43
Shortly after we moved to Texas, because there's one downtown,
41:47
we tried to go to Legoland, but we did not have a child with us,
41:51
and they would not let us in. Really?
41:54
Correct. You have to have a child to go to Legoland. Oh, that must have been crushing. Yeah.
41:59
Then did you eventually go back with? We have not because our kids are too old
42:03
to care, but my sister has younger kids, So the next time she comes and visits, we will go with them.
42:09
And like, little do they know, here you are building Legos as an outlet in between
42:15
doing all this for children.
42:18
I think something needs to change. They need to let you in. I think so, too.
42:22
But I love that. Tess Barton, our infectious disease doctor,
42:26
she goes to Barbie conventions.
42:28
And that Barbie thing, that's like her outlet. I think it's so important,
42:33
especially in medicine, where there can be a lot of stress.
42:38
So, yeah, I would say find what makes you happy outside of your work and do
42:43
that, regardless of what other people think about it, whether it's Barbie or
42:47
Lego or running marathons or whatever.
42:52
I love it. Is there anything you're reading that you would recommend?
42:56
Ooh, I'm always reading something that I would recommend. I just have to think of it.
43:01
So this is not a book for children. It's a book called The Death of Bunny Monroe,
43:06
which is actually quite graphic and a little bit disturbing in many places.
43:10
But it's written by one of my favorite musicians, Nick Cave.
43:13
And apparently they're making it into a Netflix series.
43:17
So maybe read the book before you see the show. I'm not sure when the show is coming out.
43:22
What about in the future for neurosurgery? Is there anything before we wrap
43:26
up you want to mention about that?
43:28
Anything cool with AI? All the really interesting stuff in AI hasn't really
43:33
hit neurosurgery yet, to my knowledge.
43:34
A lot of people are doing things with, like, natural language processing,
43:38
which just seems, like, boring to me.
43:43
So I don't think it's really gotten mainstream to neurosurgery yet,
43:48
but I'm sure that will happen at some point in my career.
43:51
I don't think it's the next generation. I think it's going to be my generation,
43:55
but I don't know exactly what that's going to look like. Dr.
43:58
Joanna Gernsbeck with University Hospital and the University of Texas at San
44:03
Antonio. Thank you so much for joining us.
44:05
Music.