(From the July 2013 Issue of PediatricsOnline)
Collaboration between orthopedic surgeons and anesthesia providers isn’t just good patient care, it’s essential to the proper management of complex pediatric cases, such as posterior spinal fusion for scoliosis. That’s what Allan Beebe, MD, orthopedic surgeon in the Department of Orthopaedics at Nationwide Children’s Hospital, and his colleagues have come to appreciate about their own teamwork. In a case study featured in the May issue of the International Journal of Clinical and Experimental Medicine, Dr. Beebe and fellow authors discuss the details of perioperative pain management during posterior spinal fusion for a pediatric patient with Rett syndrome.
Rett syndrome is a neurodevelopmental disorder that causes delays and regression in physical and cognitive development, often leading to scoliosis, seizures, breathing difficulties and significant functional limitations. “Often the patients are unable to communicate the extent, duration, and severity of their pain in normal ways,” says Dr. Beebe.
“Pain management in children with such conditions is complex, so patients benefit from thorough preoperative consultations among specialists,” says Hiromi Kako, MD, an international research fellow in the Department of Anesthesiology and Pain Medicine at Nationwide Children’s and first author on the case report.
“Thanks to advanced case discussion, the patient in our report did very well and had an uncomplicated postoperative course,” Dr. Kako says. “The primary challenges were the various comorbid conditions, including alterations in cardiac and respiratory function.”
The physical complications associated with Rett syndrome make the need for consultation obvious, but collaboration among specialists is essential to achieving optimal outcomes with other patient populations as well.
“Most of our muscular dystrophy patients, many of our developmentally delayed or cerebral palsy patients, myelomeningocele patients, congenital heart patients with associated scoliosis and essentially all of our non-idiopathic patients have a level of greater complexity that involves collaboration to some degree or other,” says Dr. Beebe.
“Communication is crucial,” adds Joseph Tobias, MD, chief of the Department of Anesthesiology and Pain Medicine and co-author of the case study. “We are always alerted to challenging cases by the orthopedic team. This allows appropriate preoperative evaluation and planning. As needed, consultations can also be obtained from subspecialists in pediatrics including pulmonary, cardiology and intensive care.”
This close partnership between orthopedic surgeons and anesthesia providers at Nationwide Children’s has also facilitated a recent prospective, randomized study investigating neuropsychological monitoring with different anesthesia methods (total intravenous versus inhalational anesthesia) in the management of idiopathic scoliosis surgery. The study further explores the importance of attentive management of pediatric pain and wellbeing during complex operations.
“Anesthesia controlling blood pressure helps us with blood loss, optimizing neurophysiologic monitoring and allowing us to perform our procedures in a safer manner. Communicating during these cases allows for a better post-operative course and enables us to facilitate care at the highest level,” says Dr. Beebe.
The abstract detailing this randomized trial will be featured at the International Meeting of Advanced Spinal Techniques on July 11-13 in Vancouver, Canada. The associated paper, pending publication, has been nominated for the Scoliosis Research Society’s Thomas Whitecloud Clinical Award.
Dr. Beebe plans to continue working closely with experts in the Department of Anesthesiology and Pain Medicine to improve the standard of care for complex pediatric orthopedics cases. “I enjoy the professionalism of the staff with which we work and the genuine respect we have for each other’s expertise and opinion. It is a relationship that has really grown over the past three or four years and has definitely benefitted our patient population.”