Knowing if and when to refer a child with CP for surgery can prevent serious problems, such as hip dislocation and pain, as well as improve the whole family’s quality of life. Orthopedic surgeon Ravinder K. Brar, MD, MPH, explains the potential consequences of cerebral palsy on growing bodies and gives a quick lesson in the motor function classification system. Her talk offers PCPs a simple plan for hip surveillance and guidance on maximizing health before surgery.
Mm. So thank you again. Um, like Maria said, I'm Ravinder Bar and one of the pediatric orthopedic surgeons here, um, at UCSF, mainly in the Oakland and Walnut Creek campuses. And I specialize in cerebral palsy. And, um, it's a big topic to discuss in a short amount of time. Um, so there's always more to talk about, but, um, I'm happy to answer questions at the end, Um, for disclosures, I have nothing to disclose. Uh, in terms of relevant financial relationships, Um, I am a part of the cerebral quality Research Network, which is a wonderful organization that also has, like, my CP, um, for any of your patients with CP, where they may be able to join, find other people, like support groups to talk to and participate in patient reported outcomes research as well. I'm also a member of the American Academy of CP and Developmental Medicine. Um, so we'll just start with the definition of cerebral policy. It's a static encephalopathy with progressive effects on the musculoskeletal system. Um, it's caused by injury to the immature brain in the perinatal period. Um, and the clinical manifestations vary widely based on the location and degree of injury to the motor cortex. There are other areas of the brain that may be affected as well. UM, which could lead to cognitive speech and sensory difficulties. Although it's considered a non progressive disorder, that's what they're referring to, just the static encephalopathy part. It does have progressive effects on the growing skeleton. Um, and Children need to be routinely surveilled because of this, so CP does affect muscle growth. And there's a discrepancy between the muscle growth and the bone growth, which can lead to bone deformities, loss of function, pain and difficulty caring for the patients. Those with spasticity um, they have muscles with fewer fibers that are short and they have longer tendons, and so the muscle is weaker has diminished excursion. Um, and with that last excursion that only that leads to decrease joint range of motion muscles need a stretch stimulus to grow and develop, and developmental delay, plus this fastest of your hyper Tonia may limit the physical activities that provide that stretch stimulus for proper development. And then these issues are accentuated with increasing age and continued growth, so patients that are ambulatory may fatigued more easily or decline in their ambulatory status as they age, especially as they reach that adolescent growth spurt. Um, so it's something to be aware of when these kids are are reaching adolescence. So what can orthopedic surgery help with? We can help with an atomic issues such as contractors, orginal abnormalities, mall alignment, lever arm dysfunction in dysplasia, some of the common contractors we see our elbow flexion, um, wrist flexion, hip flexion, deflection and a quickness at the ankles. The way we communicate and discuss different patients involves the gross motor function classification, um, Otherwise known as the GMFCS and their levels one through 5 with increasing severity. GM FCS one Kids can run, jump and climb stairs without issue. They often have, like a mild CP, but they have difficulties with speed, balance and coordination. Um, compared to kids who do not have cerebral policy. GM FCS to how I can decipher that. As I usually ask, Does the kid need to hold on to a railing when climbing the stairs? Um, do does the child have limitations when walking outdoors on uneven surfaces such as on a hike or on incline drawn grass? Uh, a key change this GM FCS level three. So that's when um, a patient, uh, needs an assistive device. Um, for mobility, they can have a wheelchair that they propel themselves. Um, with manually, um, and then GM FCS four patients. They can walk short distances with a walker. Um, but they're more reliant on a wheelchair when it comes to mobility. At home school and in the community Are most affected patients of the G. MSCS five patients. And they like head and trunk control. They have no independent mobility, and they're fully dependent on their caregivers. So one of the biggest things when it comes to taking care of these patients is goal setting. Um, and this is something that we do in our orthopedic clinic, where we asked the family and the patient what their goals are. And the idea is to focus on what intervention, um can make the most impact on their quality of life. And it's important to discuss these goals and develop shared realistic goals and objectives, um, for the treatment of each patient, and then to discuss a plan to achieve those goals. So if surgery is involved, like orthopedic surgery, then there's going to need to be a commitment to physical therapy, Um, embracing after surgery, Um, even if, like, the intervention is just wearing braces like a commitment to wearing those braces, um, and to stretching successful Ortho surgery at its minimum is reliant on Inter displaying team, which includes us, Our rehab physicians, physical therapists, orthodontists, et cetera. And which goals can be achieved does depend on that gross motor function classification. Our priorities are to improve or maintain the function that the child has, um, to treat or prevent pain and and appearance. We want to focus on the quality of life. So some of the goals for our patients that are GM FCS levels one through three are to optimize gait, efficiency and energy conservation to preserve or improve physical function to help them be more independent. Um, sometimes the appearance of gate, um such as if they, Our two internally rotated um in their lower extremities to reduce the reliance on walking aids, if possible, to give them a more symmetric gait. Um, if only one side, um, is affected, and then sometimes we rely upon three D gate studies for more objective info prior to surgery to ensure that we're making the right decision for what surgical interventions were doing for most effective, sorry, affected patients. RGM FCS levels, fours and fives. Um, I do list these goals during my clinic visits, and our primary focus is to preserve or improve health, improve the quality of life of the patient and facilitate transfers and mobility's, um, I want them to have reasoning positioning in their reasonable position in their wheelchairs so they don't develop any kind of pressure sores. Um, I want to help with any contractors that make it difficult to take care of the patient. Um, such as perennial care like diapering want them to be able to open their hips, Um, and to build to put on clothes. I want them to have breakable feet, even if they don't walk on him. Um, and you know, you worry as the kids get bigger, especially for the caregivers, um, to make sure that they have the right support for the caregivers to take care of the other patients, too. And sometimes they need something like a Hoyer lift to help get the patient, um, in and out of the wheelchair, in and out of other positioning. You may have heard of symbols that stands for single event multilevel surgery. We try to correct as many deformities as possible during one anesthetic episode. We involve other specialists of other procedures or need to be done sometimes that I don't know e N t. Or I work a lot with plastic surgery because they do the upper extremity contracture releases. And they can do that while I work on the lower extremities. Or if say, I'm doing a surgery, um, on the hips or the feet and the rehab positions would like to give Botox, um to a different location. Then we try and do everything together, and it's important to try and do as much as safely possible, um, in one anesthetic episode so that we reduce the number of hospitalizations for our Children, um, and reduce the periods of rehabilitation. It's more cost effective, and there's less disruption to the school and less episodes of parental leave from work as well. And then it always comes up like what can Ortho surgery not do? And this is a part of the goal setting and expectations that are discussed with the family. But we cannot change someone's insufficient strength. That is something that they can work on with physical therapy. But I can't give someone strength. Often, orthopedic surgery makes you weaker for a portion of time, especially if we do any osteo Tommy's um, they cut, uh, any instances where we cut the bone, and then we ask you to be non weight bearing for a period of time. You can have a little period of regression. Um, and because we we essentially make you weaker with, we can't address issues with balance. So there's a tactic. Cerebral palsy. Because of that coordination and the communication of the brain to the muscles, we can't change that. We also can't address selective motor control. Um, there can be transfers can be done. It's sort of muscles fire and others don't, um, but then again, that's like more working with physical therapy to see if there's improvement that can be made as well. And as mentioned earlier, I can't change, unfortunately, the communication between the brain and the muscle itself. So one of the things I'm super passionate about is hip surveillance. Um, so what is it? Why is it important? So Children with cerebral palsy have an increased risk of hip subluxation and dislocation and monitoring the hips regularly. Um, it's very important to identify early indicators of hip displacement. Uh, this involves regularly scheduled physical exams, um, and radiographs. And so subluxation and dislocation can cause pain and fair impair function, uh, and range of motion and reduced quality of life. It also can make it difficult for a patient who is sitting to have good sitting balance. And it can lead to more pressure sores if one hip is dislocated and the other is not. And if we have early detection, then we're able to do early intervention. Um, and early Ortho intervention can improve outcomes. It can reduce the number of reconstructive surgeries and reduce the need for future salvage surgery. Anything that we call that the salvage surgeries like, kind of like our last ditch effort. That isn't the best, um, surgery we have for a patient. But it's all we have to offer. Um, and so we're trying to avoid that, Um, and our goal is to treat or prevent pain by early intervention, uh, to any progressive hip subluxation. So the path of physiology of acquired hip dysplasia when you have asbestos, your dystonia or that lack of muscular control. It causes abnormal, imbalanced forces across the hip joint and across other joints, the hip for this discussion when it comes to our spastic patients. And that's like the most common. The adductor is in the hip. Flexors and hamstrings become tighter, and this happens with growth as the bones grow longer, Um, and it eventually causes the federal head to sub blocks out of the acid pabulum. And those imbalanced forces also changed the anatomy of the developing vote. You have increased anti version, um, of your femoral neck, more Valdas or an increased next shaft angle. Um, proximal femoral head deformity, uh, and so that can lead to early arthritis. Um, in Aceh tabular dysplasia where the socket itself does not develop. Deep enough, um, or wide enough for the femoral head and what is, you know, like some kids have no pain and dislocated hips. So why would you operate on that? Especially, you know, it's a different story when both are dislocated in their firstborn. But if it's a hip, that's come out, um, like and it's not painful, like, why would we operate on it. And the point is that reduced well shaped, well covered hips are less likely to cause pain in the future. Um, and if they're in the right position and have the right shape, you have a stable platform for both standing and walking. It facilitates level sitting, which is important, especially in our most effective kids. Because then, um, if you're sitting is not level, then that can contribute to neuromuscular scoliosis later on. If your hips are in the right position, then you have greater range of motion thinking about diapering again. Um, and again, it decreases, Uh, early rate of osteoarthritis when you have, um, the right shape of femoral head, um, in the right shape of Assad tabular, um, like socket, um, don't have a monsieur mismatch. Um, and it decreases the risk of pain in that. This is, um, just a graphic, uh, to show the anatomical path pathology of the spastic hit on the left. You have a normal hip on the right. Um, you see that the femoral head is forced posterior early and laterally, um, and superior early, and then that bends right up on the Assad tabular rim and the labrum and it just makes it more vertical. It should be more horizontal because this isn't in the socket. This part a doesn't get as deep as it needs to be. So that medial wall gets wider and the tri radiant cartilage that's there grows laterally. Um, and that decreases the depth of your socket. It makes it too shallow to really fit, um, the shape of the femoral head. So there are three components to hip surveillance physical exam X rays. And the third part is regularly seeing, uh, regularly performing the X rays and the physical exam, Um, at scheduled intervals. And how often you do that is based on the age and the GM FCS level of the patient you're seeing on physical exam? Um, I I look, if they have any head control, it helps me decide. Like how affected they are if they're able to sit on their own, what their balance is like when they sit on their own. Can they get from supine to sitting on their own? Or do they have to be propped up in a certain position by their parents to hold themselves up? Are they able to stand? And when they do. What's their balance like, Um, do the parents have difficulty changing the diapers? And I asked the parents to show me because they'll say no and then you'll see them like put their whole torso in between the kid's legs to keep the legs open while they change the diapers. And they figured out really interesting, um, and resourceful ways to change the diapers. And though they get by every day with it, it's just it's not sustainable. And so, you know, they're used to doing that. Um, but there are ways we can make that better. And I look for any asymmetry on rotation, any limited range of motion skin breakdown or a symmetry of the joint range of motion as well. And you can see on the bottom right. That is an example of the chart I put in my clinic notes to like, put some of these measurements down when it comes to physical exam. Please, please, please refer to Ortho. If you see any of the following present. If the hip abduction with the hips and extension And then he's an extension is less than 30°. So um, that's looking at this image at the top right here. Um, so if that's less than 30°, please send us um, if hip abduction is a symmetric because that means there's probably something wrong with one of the hips. Um, if hip abduction is getting worse, So it's compared to the last time you saw the patient that's decreasing. And if hip extension is decreasing because of maybe a flexion contracture of the service when it comes to X rays for hip surveillance technique does matter. Um, because that affects our ability to, uh, take measurements. And so, um, it's just one X ray for routine surveillance. It's the supine ap view. The legs are nearly peril. And then you want the patella, um, facing upwards. And the spine needs to be supported, um, to reduce lumbar lord doses, which can happen with hip flexion contractors. I'm very sorry, have a bit of reflux, so I cough, Um, so this is accomplished when you put support underneath the knees. What we're looking to measure is the migration percentage. Um, and, uh, that helps us quantify the hip subluxation or the amount of the femoral head that is not covered by the Assad pabulum. Take one more simple water. Sorry. Yeah, Yeah, You can see the measurements and the schematic on the top, right? And it looks a little complicated, but I'll show you guys soon. An easy way to measure it. That's much faster in clinic that I personally use myself. It's a great app. And then So just to show you the natural history of, um, of hip subluxation, uh, in kids with CP, uh, This is a patient where the first image, um, at 18 months old has 10% subluxation. Um, and then at one year, ah, one year later, 2.5 years. There's a noticeable increase where 25% of that femoral head is not covered by that assad tabular roof. Then you can see it just progress and continue. Um, so age five years old, you C 40% is out. Um, and then you're also seeing the changes that come along with that. So between the 40% and 50%,, you can see how that asset tabular roof is now more inclined because of the pressure from the femoral head pressing on it, um, e centric Lee, causing it to, um develop like dis plastic lee rather than, um, properly shaped. And then, as you can see, um, the shape of the femoral head just gets worse and there's no socket to put it back into. And then even if, um, that socket were perfect, you wouldn't put such a mis shaped femoral head in the socket because the miss shape would just be arthritic and cause pain in itself without proper loading. Um, from contact pressures the federal head in the socket in that last picture, you see, um, that the lateral column of the femoral head is just osteo Penick and not present because it hasn't had the contact pressures to continue its developed. So the key is to refer to orthopedics. If your X. Ray shows a migration percentage of 30% or greater, and the risk of hip subluxation and eventual dislocation is correlated directly, um, with the GM FCS level of each patient. Um, this article is a landmark article that showed this, um, linear and direct proportionality between the GM SCS levels and hip displacement. And this is the reason why any child with cerebral palsy gets a baseline pelvis, X ray. And so throughout childhood, the total risk of displacement or, um, subluxation. And that's defined as a migration. Percentage of 30% or greater is 90% for a patient with G M f. C. S. Five, it's 79%. If you're GM. FCS level is 4 40% of your GM FCS level is 3 15% in the GM FCS level twos and then negligible and level one Unless, um, it's a patient with him. Ecclesia and hip involvement. Um, there's a special definition for that. But for you know, what this says to me is that any child with cerebral policy gets a baseline, have X ray, Um, and then based on their G m X C s levels, a monitoring schedule needs to be, uh, in place and established. And so this is the app I was talking about. It's called hip screen. Um, you can download it on your iPhone or your android. It's available for free. Um, it's designed by, um, the group at the Shriners Hospital in Northern California in Sacramento. It's a wonderful app. It's won a lot of awards. Um, and it makes it really easy to measure the migration percentage, and it's changed my practice because it was really hard to sit there like draw the lines, um, do the division or whatever, and this just makes it really easy, so I'll just go through it really quickly. So this is what the APP looks like, and there's a lot of really good information in it. Um, with hip surveillance guidelines frequently asked questions. And I think this is great. Where has a radiology protocol to make sure that these X rays are being taken appropriately. And then these are just posters that you can print out, um, and put in or to send to people or to put up an X ray room as well. And then so in clinic, I'll get a supine ap pelvis. It's hopefully taken the right way. Uh, and so then you take a picture of it on your phone, you take a picture in the app. Um, you can't access your library to use the picture that you already have. Um, and I'm sorry that the pictures didn't come out as well. Some of them look a little whitewashed on this. Um, but so the first thing you do after you take the picture as you fix the rotation so you can move it clockwise or counterclockwise, and I try and line it up with the, um, the horizontal line across the tri rated cartilage. Um, or I line it up with, um uh, like, you know, like the back of the S I joint or something, Trying to get the rotation correct. So after you've done that, the next thing you do is you, um you use the ruler, you just press this function right here. And that brings up these lines with the red box. Um, and so each line is 10%. So what you do is you zoom in on the right side or the left side, and you put, um, for instance, on this side you have the black line touching the side of the femoral head. Then I know it's hard to see because the osteopenia on on the lateral aspect of the federal head, but the white line lines up with that. And so then you count. So this is 10 20 30. So the red box tells you 30, so if you hit the red box and the the source seal or the established roof isn't there yet? River to orthopedics. So it's just easy to just be like you're either, um, within the box or outside the box. You know, if you're outside the box, no need for for all the orthopedics. But if you're in the red box, like, please send orthopedics and then so 40 50 60 70% for this kid, the severely so lock step. Okay, um, organized hip surveillance needs. There's, you know, unfortunately, in our country, um, it it's not done in a formal way. There's no national hip surveillance. There's not even like, um, National agreed upon guidelines. Um, but everyone has recognized its importance. And individual states, including California, um, doesn't have organized hip surveillance as well. Other countries have been able to do it, Um, and it's led by primary care physicians, therapists, rehab positions. Or so, um, and other part sorry and other members. And that has really created, like an awesome safety network for these patients. Um, for early like intervention, um, with their hips surveillance in some countries have been able to eliminate the need of salvage surgery, and they've eradicated dislocated hips with early preventative surgery. Um, each country does have, like, differences between their protocol But the point is like having a protocol alone and sticking to it has made like, Um, has made a huge impact on the care for the patients with three real policy, and it requires universal access to the surveillance access to the orthopedic surgeons. Once, Um, the migration percentage is 30% or more, and then by and from the caregivers, providers and policymakers to make sure that this happens. What surgical options do we have for hips? We have soft tissue releases and lengthening, especially useful in kids that are like very young, like under the age of four. Various d rotational Osti autumn ease with shortening. So that's where we change the angle of the femoral neck to better position the femoral head into, um, the Assad pabulum. A pelvic cost ya to me. If the Assad tabula more socket is not developing, Well, then the salvage procedure, the hip resection that I mentioned, that's not the greatest, um, option. But I'll show you what that looks like. So this is an example of soft tissue lengthening. So, um, this is your adductor Tina to me where we just released this often. Kids undergo Botox before um before we get to just cutting the tendon. But we just transected, which weakens it often. The abductors are much tighter, um, and stronger than the abductors. And so the idea is to weaken it so that you can strengthen the the abductors and as, um, depending on how much range of motion we get in the O. R, we do a graduated release like we continue to release more as needed. Based on the measurements we take inter operatively. Um, this is a patient on of mine on the left. Um, they presented two years old of limited abduction that interfered with mom's ability to diaper. Um, and they had just started sitting up and on the right side of the migration percentage was 50%. And on the left, it was 30. So I did a because of because of the age bilateral addict, autonomy, bilateral Priscilla's lengthening because it wasn't enough to do the adductor tsunamis, and then bilateral earlier so is lengthening. And that's for that superior migration of that right hip on the side to kind of prevent those contractions. And then so at four years old, you can see that the child has, Uh, wide symmetric abduction. Um, the migration percentage actually looks improved like it's better underneath. It's not perfect. Um, it's still at 35%, but that right side is improved. Um, and if the kid is actually walking now and doesn't have sizzling, which if they had addiction directors, they'd be more likely to scissor the bilateral video roo option or sorry, video rose, I'm more likely to do if you're four on up the bony work. Um, and that's because our hardware doesn't really fit in kids that are younger. But if we have to get creative, we have to get creative sometimes. And you can see that this child had essentially a dislocated hip on the right. Um and, um, you can see that we did. Bilateral video arose on both sides. That involves shortening the legs as well. Just about a centimeter. And then that right, um, as a tabula, um, was dis plastic because the femoral head was dislocated. So we did. A pelvic cost ya to me where we took the part of the member from here. We put it in here to keep it wedged open, and we really brought that roof horizontal to help prevent, um, future subluxation as well. And this is a hippo section. This is our salvage osteo to me where the femoral head here is just completely dislocated. Um, and it has the wrong shape. There's, like, no range of motion to it. I did not do this. One of my partners did it. Um, but you can see that now. The femoral head is just gone. Um, and so the idea of this is now you have a floppy hips that you can, uh you can do diapering a little better, and you can move it. The pain is improved because you no longer have the femoral head of butting against the pelvis where it shouldn't be hitting it. Um, but the truth is, it doesn't guarantee the pain is gone. Um, because this little spike of femur can still migrate with continued contractions of the muscles approximately, and that can eventually hit the pelvis as well. So it's just not the greatest surgery. Um, but it's definitely a way to really help some kids who are having difficulty with diapering or having way too much pain in that hip. I just wish it had better outcomes than it really does. So the key point is that hip surveillance is extremely important. Um, and we recommend getting supine pelvis X rays at the initial visit for hip surveillance. And then as you get to know the child and are able to establish a G M S D s score tailoring, um, or sorry classification. Tailoring your schedule like your regular monitoring scheduled. Um, you know, in the beginning, I see kids every six months to take X rays. Um, and as I know, they are getting older. If I know the GM FCS level isn't high, it's a it's a low one. Then I might go to yearly X rays like, Um, after a certain age, like five or 6. Um, but if they're, um, Like high levels four or 5 and I'll continue seeing them every six months, you follow them until their skeleton mature. Um, and the risk of hip dislocation is directly correlated with that GM FCS level. The other key point is that, um please send for an evaluation to orthopedic surgery. Um, if the migration percentages Greater than 30%,, Um, and hip abduction is less than 30°. Where has decreased or is a symmetric. Um, we're happy, um, to see these kids. I do my own hip surveillance. I'm happy. Like, if it's too much, I'm happy to do it. Um, and I like love seeing the kids really early. Ah, and then taking care of them as they continue to grow and develop in forming that relationship. So happy to have any referrals for that. And then where we really look to our pediatric colleagues for help is in our preoperative optimization. Um, in the longer version of this talk, I talk about neuromuscular scoliosis. Um, but that and hip surgery, like, um, I take preoperative optimization very seriously. Um, just because the outcomes improved if we're really able to, uh, to maximize their health before surgery and their nutrition before surgery set the healing, um, go smoothly. And so at Oakland, we've been, um, doing kind of the shared decision making guide to help parents. These are big surgeries on their kids, and often their kids have had a lot of other surgeries, but really having them understand the goals that we're trying to have, um, the risks of not doing the surgery. Um, what to expect in the recovery process A lot of times if we don't if we cut bone, we're not letting them use a standard gait trainer walk For 4-6 weeks. So what they can do in terms of physical therapy during that period and what they will need to do with physical therapy afterwards? Um, and I think nutrition is extremely important. Um, so g I will see all our patients. They usually have a relationship with them beforehand. Um, and if G. I says this kid's nutrition is not up to par, I won't do the surgery until they are, um, if they're, like underweight, Um, and then in terms of bone health, uh, it's it's sort of surprising, Um, just in our regular population, how many kids have low vitamin D and especially in our Children that do not walk? Um, their bones are more osteo Penick. And so I find it very helpful to start, um, supplementing calcium and vitamin D to ensure better bone, bone health and biology. When it comes to healing any Osti autumn ease or any bony procedures, we've also done this roadmap to orthopedic surgery to really like, engage the parents on the stuff we do beforehand, and you can see a lot of things go into the decision to do surgery on a child, even if the first time I see them. Um, I think or I know they need surgery. Like I don't sign them up for or that day. We, like, reach out to the primary care doctor to their sub specialists to really see where everyone feels if this kid can tolerate a surgery, Um, just for an example, like, you know, it'll take us like less than two hours to do soft tissue lengthening. But if we're doing bilateral, we've been doing a lot of like bilateral proximal femurs plus bilateral pelvic cost economies. And each of those is like two hours. So then we're in the O. R for like, 6 to 7 hours for each patient. So we want to make sure that they tolerate, um, these long procedures. Well, you worry about their pulmonary status afterwards. And so, um, you know, we ask if there's any any recommendations for the peri operative period from any of their specialists in their primary care doctors. We have them have a special bathing solution beforehand to minimize the risk of infection, especially our kids with diapering, um, and just really guide them. What to expect. And what I'm referring to here is that it's a big team approach, like even though I'm doing the surgery. Um, we do not take the decision lightly, and we really, really rely on our core team members. Um, that's partnering with pediatricians, the psychiatrist, nurses, case managers, therapists, nutritionists, social work's important, um, orthotics and our anesthesiologist and, um, the other consulting specially services. A lot of are more affected Kids have a lot of other comorbidities that we have to worry about. Um, whether it's airway considerations, um, the need for aggressive pulmonary toilet afterwards, Um, if they have a trick, Um uh, the kids with a lot of spasticity, uh, most of them do have some chronic restrictive lung disease. They can have some chronic inflammation from their reflux or if they have difficulty swallowing or a lot have excessive salivation. If you do see a lot of kids with drilling to, that is something that they can Botox to minimize. That, um, you do worry about obstructive sleep apnea. Do they have, um, an oxygen requirement at night? You know, this matter is the same as it does for adult surgery. When you give them narcotics afterwards, Um, like, how is that affecting them? And so a lot of kids will get a sleep study first. Um, sometimes we'll pre admit kids before surgery to get respiratory therapy beforehand. Um, we care about pain Control would do multimodal. Um, anxiety. Some of these kids have spent so much time in the hospital seeing so many, um, so many physicians that they get pretty anxious when they see us. Um, poor nutrition is correlated with poor wound healing and compromised immune function, so we like to tee them up as much as possible. A lot of a lot of our kids have constipation, urinary retention. We get labs further, um, vitamin D level. Need to know about their seizures and everything and what we're doing. The more affected kids. Um, I know as an orthopedic surgeon, I'm not as talented as my medicine colleagues. Um, when it comes to balancing all these, um, difficult medical problems and so we co manage the patients after the surgeries, if they're G. M. F. C s four or five will co manage them together, um, on the floor. And so this is just a quick study. Um, that's about last minute, um, pre anesthetic clearance in kids with neuromuscular scoliosis undergoing a spine fusion. Um, and it's a retrospective chart review. Um, and what they looked at is whether the pediatrician did an evaluation prior to the anesthesia evaluation. Um, and the General Pedes evaluation involves screening, review and care of the child's coexisting conditions, Um, and paying attention to things like under nutrition G i dis motility, energetic bladder that might compromise the preoperative safety and health health recovery of the patients. Um And then they evaluated the rate of last minute activities like new peri operative care plans, communications referrals, etcetera, performed when anesthesia saw their patients right before spinal fusion. So they compared the patients who saw General Pedes and had a comprehensive health assessment with those who did it. And what they saw was the rate of last minute activities for anesthetic clearance was lower by about half for the kids. Um, who saw their general pediatrician versus those who didn't, um And so that's big because, uh, like that means that no one's like running two. Um, get some last minute studies in or anything and that, um, the last minute changes in plans were mostly, um, or were most commonly, respiratory and neurologic changes. And so, um, I think it's really important for us to have to partner with, uh, the kids primary care providers to make sure that if you guys have any concerns that we're addressing that before we even get to the stage of anesthesia scene their patient, Um and you know, at the end of the day with this talk, this is just the tip of the iceberg. There's a lot more that goes into caring for our Children affected by cerebral policy. Um, and we can spend days talking about it. Um, but I really think a focus is hip surveillance, because that's where everyone can just get a baseline X ray, Um, and see where the hip health is. Um, and we can take we can be one step closer to more like national Or I mean, I'll be done with just regional surveillance so that kids don't We don't discover the dysplasia too late. Um, this is, uh these are the wonderful members of the Peas Ortho team here at UCSF um, really happy to work with every single person on this page. They're all wonderful. Um, we all have our specialties. Um, and please don't hesitate to ask or to reach out to any of us. And, um, for any questions, like, this is how to refer your patients to UCSF. And we're happy to see any of your kids with, um, cerebral policy. So thank you again for your attention.