[Music] thank you [Music] thank you for taking time from your busy day to watch this special presentation from the El Paso County Medical Society I'm Dr Joel Hendricks president of the El Paso County Medical Society and it is my hope that you will find our program of great interest educational and informative about the medical care provided by some of our best physicians in our country right here in the Borderland from all of us at the El Paso County Medical Society please enjoy tonight's program foreign [Music] there are many different types of Neurosurgical conditions we're going to talk about diagnosis and treatment of issues affecting the nervous system including the brain the spine peripheral nerves and especially cranial facial surgery this evening if you have any questions regarding this show or any other show that PBS puts out please email them to the El Paso County Medical Society and that email address is EP Med SOC aol.com we can have them answered by one of our doctors and we'll also address them on the next program that we have this evening's program is underwritten by the El Paso children's hospital and a big thank you to the El Paso County Medical Society for bringing this program to you I'm Catherine Berg and you're tuned into the El Paso physician [Music] thank you hello thank you for joining us for Pediatric neurosurgery and also cranial facial surgery this evening's program we've got two doctors that are with us today and we're also um having this program in memory of a certain doctor Dr David Jimenez who was the medical director of pediatric neurosurgery at the El Paso children's hospital and we're honoring him this evening with us this evening we have Dr David Yates who is the medical director of the cleft cranial and facial clinic at the El Paso children's hospital and we have Dr Zaid makushi who is a pediatric neurosurgeon of the El Paso children's hospital and also the vice chair of the Department of neurosurgery so we were joking although none of this stuff is a joke it's like oh yeah you're a neurosurgeon what do you do there's all kinds of stuff that you guys do um on that note though I would love to just kind of start with Dr Yates if you can explain to the audience um not jokingly but you two have have the same discipline but very different disciplines at the same time what do you focus on during your day so I focus on deformities that are usually that people are usually born with of the face and the cranial so these include cleft lip and Palette they include ear deformities eyelid deformities nasal deformities jaw deformities the mandible or the maxilla and then also where we have a lot of overlap is when it comes to the skull so in skull cases the craniofacial surgeon and the pediatric neurosurgeon work very closely together to really help deliver the best and highest level care for these patients and I think all of you all can see from uh from your angle but we have I call like playing marbles up here but we have different models of different schools and these are real people these are real children the formations of the real skulls of real children um which is fascinating to me as you were just pointing things out prior to the program of different sometimes vein issues that are involved pallets that don't quite close I mean this is going to be a great show and I like this guy here in the helmet he's going to be some fun too and Dr makushi so you are hand-picked and recruited by Dr Jimenez and so nice to have you here thank you and to cover what it is that you do all day every day and you're really kind of the the person that that's taking over a lot of what what he was doing how would you explain that to our audience um he had recruited me to add to as well the neurosurgery program one of the two things that we're still we're missing at the time was epilepsy surgery and spasticity which are two big areas where we still had a lot of patients that had to leave town and the closest centers are at least five to six hours away in order to get specialized treatment so in his vision which we're continuing to to try and accomplish and build on uh is to have all those specialty services for neurosurgery and El Paso children's is expanding with all the other Specialties so that patients for example that I still see it time and time again that are following up from four years ago traveling to Denver Colorado or out to Houston because no one was here at the time to help them to get specialized treatment trying to transition to say no we can take care of it here you don't have to have that worrying on a year-to-year basis of where are we going to get the money where are we going to stay because we need to see those Specialists so the hope is that we continue to build on what we have here with the Specialties and grow on it so that things like as far as brain tumors don't need to be flown out epilepsy surgeries which are a multitude of different surgeries to help cure in some patients or even at least decrease the burden of seizures that occur in children spasticity where we have a large population of cerebral palsy for example and affects our day-to-day lives so those are specialized treatments called rhizotomies where we actually deal with some of the nerves that help them walk better and mobilize getting around in school dealing with all types of brain and spine tumors deformities he doesn't stop there's no quite a few I was going to say so I I liked I like the idea too when we're talking about not just brain but we're talking about all the neurosciences and all the neurosurgeries and and I I apologize for I was just like going through this it's like man that's a lot more than I have here I'd like to also Focus later on too how the micro surgeries goes when you're looking at nerves they're so to my eyes microscopic and when you're looking at micro surgeries and we're going to talk about that too because you're looking at face and nerves and in the face and the tongue and the teeth and everything else um when is it that you talk about birth defects so you you almost have a pre-knowledge that something is going to be happening and stuff that you're going to be working on Dr makushi are some of the things that you're talking about when does somebody know to go see a doctor because maybe there's something wrong and I don't know what it is I mean these are things that you can't really put your finger on immediately how many of them start in childhood Etc and maybe kind of take that tangent a large number and it even starts as early as prematurity where we have children that are born too early and a lot of them have a high risk of developing intracranial bleeds bleeds inside the brain and then developing problems with we're normally producing fluid but we can't reabsorb it so as early as that it can cause pressure inside the brain and we're not even fully born yet wow so those require treatment interventions sometimes to stabilize to let the brain continue to grow and occasionally require interventions to help continue to drain the excess fluid so that that shoulder can develop as normally as possible but then even throughout childhood where things as far as even dimples on the back may be an indication that there's something going on deeper inside the spine problems with the head growing too fast is there something going on that's affecting that fluid balance so all these very early on in life will say that might be serious Neurosurgical conditions you have to take care of so let me let me go back to a pregnant woman then and being able to see sonograms I don't know how many are done these days I know with my first child there was one and that was it bing and my second child at like three or four um so developmentally as a woman is pregnant how how can they see how is the sonogram able to to picture all of this and that's been one of the fields that have been expanding over the last decade or so ultrasounds for screening for example where something is caught they're being now referred earlier on to Specialists um one of the things for example are the myeloma meningoceles which is a spinal defect in the back where it's open like a book and it's not closed to protect the nurse now some of these have caught early can be treated well in utero so the baby is still inside the belly you close it up and apparently have a better outcome others are as far as counseling you can't do anything early on but at least preparing and having discussion with the mother and the father to say as far as this is what it looks like is going on getting more specialized Imaging such as MRI scans which we can do right getting a better picture of the head in order to have that discussion well this is what it might expect immediately after delivery these are the things that we're going to watch out for help deal with that anxiety and have a plan in place for them so is there ever a time when you do surgery on the mother on the baby when the mother is still pregnant with the baby now currently we don't have that here but they're okay okay big trials um that had come out that showed that there was a major benefit to treating the open spinal cord defects in utero right before they were even born has now continued on to different areas and we're hoping to bring that here we still need to build that program but it makes a huge difference in the outcome including as far as Mobility ability to walk they're dependent on instrumentation to as far as shunt fluid from their brain so the entire outcome seems to be much better where we can fix these things very early on that's fascinates me I saw some kind of a program or a segment on that and not not too long ago maybe in the last year or two and it was just fascinating that you can even do that that you can even do that Dr Yates I know we were together I don't know several months ago maybe not quite a year ago and some of the things that you talked about so again mother's pregnant you're able to see that some of these issues are are going to be an issue once the baby's born I don't know if sometimes you have to take the baby early or not in those cases I'd love to maybe talk about a case study or two that you remember that really sticks out in your mind of of these skulls that we have on the table or one that's not here but just one that really sticks out that that kind of explains like some of the interesting things that you're able to do and fix yeah okay I think there's there's a couple real quick that I can bring up so prenatally when people are seeing for their ultrasounds they different things are able to be seen and as Dr makushi was just saying more and more so one of the things I was recently referred was a skull like this and so you can see the skull looks triangular and this is called trigonocephaly but basically even as early as on the ultrasound now they're able to visualize whether or not these sutures of the skull which you can see this one's open this one's open this one's open but this one is fused this allows the brain to grow normally so when we see one of these prenatally it enables the parents or the pregnant what you know mother to be able to come to the office and we sit down we have a conversation we show an entire PowerPoint talking about the importance of earlier intervention we like to operate on these kids when they're one to two months old if possible oh so it's not immediately no and you know talk about why I remember you talking a little bit about this last time but why not immediately there's a there's a good reason for that yeah you know babies now there are some babies we have to operate on immediately I'll talk about one of those in a minute but like something like this it sometimes helps for them to just be a little bit older yeah right because anesthesia and a very small child is already you know a very high risk game so if you can wait just a little while it really provides a lot better safety profile so we do like to wait on some of these this is one where we didn't wait and you can see this child is born with a very small jaw oh my goodness right yeah and the problem with a small jaw like this is that pushes the tongue back and then the child comes out unable to effectively breathe wow yeah choking choking on their tongue so in this situation this child needed an operation you know within the first week or two of life and until then we have to actually provide an airway for the child but we'll come in and we'll cut the mandible and we put actually these distractors on and you can grow bone in a child at a rate of one to two millimeters a day Kate tell me how so I mean is this a it's something you're implanting in there okay so this is called a distractor a distraction and we do it for the skull we do it for the mid face but this device right here you can see is kind of the same thing we cut the maxilla off and then we put one plate here one plate here literally a screwdriver basically attaches here and this is something that the parents do or the you know and they basically just turn it every day and I've had older patients say it feels like their braces are getting tightened so it's not painful right but it is incredible because this Baby's jaw is probably only 15 to 20 millimeters and we turn it a millimeter a day in 20 days the child's jaw has doubled in size and now we actually just excavated one at El Paso children's hospital um they were not unable to breathe they were unable to feed and we do this we do the surgery we just move that every day seven days later the child the tube comes out they have no difficulty breathing they're starting to feed well and it's really a life-changing situation so explain to me a typically developing child with bones is this because it it as you're talking about it seems awfully fast so when you're looking at the strength of the bones is there a certain point where there's a pause to then you know let the stretching stop for a little while get a little stronger or is that even necessary I know babies are getting dark Dr makushi's like he's literally if you could see them you just said sitting back so on that note come on into the conversation this is a parade I know that growth tissue is super super fast especially when they're brand new right and then it starts it slows down through life but explain how that how that happens even when it comes to the brain so one of the things that we always talk about with uh with neonates and even premature neonates is that the grain is growing expected about a centimeter of head size a week and that's just telling you the rapid expansion of the brain tissue a centimeter a week which is a normal growth so you're expecting in premature babies that they're trying to catch up because they're trying to get that normal growth and then as they reach their full term even though they're outside the womb then it starts to slow down slightly but it's still rapid but it's very very fast early on because we really are as far as generating new tissue because that's what the body's supposed to do what it's telling it to do and that's the amazing part that we try and take advantage of when we can and also to prevent injury to Growing tissues such as the brain and this is nothing that you're doing aside from don't get me wrong this is something that the body is doing using the baby's body regenerative as far as ability that's amazing it's incredible I mean you can like if you take you can literally take off the entire skull of a newborn and it'll grow back but you make a hole the size of my thumb right here and getting up here and so when does this stop so I know there's growth plates I don't know where when that works in the brain Etc but uh technically if I I'm thinking about Orthopedic shows that we've done right growth plates kind of close up and finish like 16 17 depending on the person when you're looking at the skull when does that stop and I know it's a little bit different for everybody but in general what would that be and I'm throwing it to whoever wants to answer it Dr makushi Dr Yates okay sounds good so basically babies similar to their brains the brain is what pushes the skull to grow so the growth of the brain If a baby's brain is not functional the skull will not grow and they end up with very small heads however if the brain is normal it will try to grow and grow and grow in the first few months of Life the skull circumference grows two centimeters I mean uh yeah two centimeters a month but it slows down significantly and by 18 to 36 months of life that entire 18 months skull growth during that whole time is only two centimeters okay so the skull is actually one of the first things to complete growth and especially when you're looking at facial development so the skull is pretty much completely grown by five six years of age that's why they're so cute yeah that's right it's age eight okay and then the maxilla you know the upper jaw around 12 to 15 and then the lower jaw you know 18 to 20. so growth of the face grows like this okay so on your point too because we were there's a there's a slide that we're going to show and specifically unique corneal synonymostosis yeah and you were talking about uh we've got different images at three months six months 12 months 24 months yes so um just visually if you could talk through what that is yeah you can see that so unicoronial synastosis this is one of the conditions that Dr makushi and I get to treat together um and basically it's a fusion of this suture which is called the coronal suture okay so there's a coronal suture on this side that's normal um and there's the sagittal sooner suture and lambdoids but what ends up happening is since this is fused the brain is unable to grow in this direction and the skull is unable to grow in this direction I see right so it causes actually a twisting of the skull base it causes abnormal it's like this but this is the metopic suture okay this is a unicoronal so the kid that you're looking at in the slide right now um we used the pioneering technique that Dr David Jimenez invented 27 years ago and really radically changed the world and the way this surgery is approached around the world by his technique so we used that on the child that you're viewing right now and you can see this child and what I want you to notice is the eye is initially up that's the first thing that comes down around three to six months and then the nose drains and then the jaw straightens out and then the last thing is this forehead and by two years of age or two years post-op that forehead that kid looks 100 normal and that is one thing that is really unique to operating early on these kids and being able to do this minimally invasive technique which literally just requires a an incision this big right here and as you were talking about you know it's the body doing these things right it's that's what I love about this technique we're literally just recreating the suture That was supposed to be there and then as David Jimenez would always say he's like brain is king and the Brain just would just pushes that bone where it's supposed to be right and how it develops in all of us so it's sometimes it's the simplest answers exactly that are the most elegant and that's that's really true oh I like that wording the simplest answers are the most elegant I like that we were talking a little bit prior to the show so this is happening in El Paso right now UMC thank goodness it chilled El Paso children's um when I know that there are children that come to you from not only outside the United States but in areas of the world too and I'm thinking to myself three months is nothing six months is nothing when someone is diagnosed or thinking somebody in El Paso can help you how I don't even know exactly what I'm asking but how does that come about like where do the parents know how to talk how do they know who who's in charge of putting this together the navigation of it all um I'm throwing that out to either one of you as well I'd like to talk a little bit about it as far as even just identifying these yeah which are hard because some of them are subtle enough that it can take a while even for parents which is normal because your kid's doing well right and but something may be a little bit off and sometimes there can be a delay until even recognition by pediatricians which is hard because again these are subtle things that we're trained to look for but sometimes you'll see them and you're not sure is it simply a child that's been laying on the back for too long and it's just a positioning from Gravity rather than a true early Fusion of the suture but that's also where it's important educating uh community and educating pediatricians where if there is any doubt with these we're more than happy to receive the referrals are even to look at whether pictures or images in order to give our expert opinion to say no this does look like something that would benefit from early instead of having that delay and having a more extreme surgery necessary and helpful but still a more extreme surgery that could have been avoided right and I will tell you when it comes to the the national side of things and the way patients find us believe it or not it's generally Facebook yeah um social media that's that's and it's not doctors it's these fam like I had I talked to two patients today who one is from the West Coast one is from the central United States and they both were talking to other parents on Facebook who had received similar treatments and conditioned as their child these are rare as Dr makushi said so I mean even though they're actually very common when it comes to facial deformities it's only it's one in every two thousand births however still if you think maybe a pediatrician has 5 000 patients in their whole practice well that might be only two patients exactly exactly so parents actually I'd say identify this 50 of the time probably more or less but you know and with this day and age too and you and I were talking about before the show there was somebody who's coming to El Paso one to look at your program and they literally looked up the El Paso physician and neurology and you said that they watched the show so even in that that note for anybody who's watching if you you Google the specific words like if you're looking at craniofacial surgery neurological surgeries that they would get to this so I just think that that's such a beautiful way to sometimes you get a bunch of stuff that's not necessary to be out there but um Dr Yates I want to talk a little bit about um when mainly you focus on birth defects and you fix them but then there's also times when somebody's in a crucial car accident or when there's you know something brain injuries now with football season happening with you know just in general damages that can happen to the skull and to the brain and issues there talk to us a little bit about some of those cases yeah so I really you know for me I really focus on the face and the skull and then if there's a brain issue Dr makushi is quickly roped in but you know I think it's really uh an interesting thing that I've heard my neurosurgery colleagues say but it's very true the brain is the the face is the airbag of the brain okay so all of this as sad as it is yeah and how beautiful we like to think of our faces the great thing is all of this can collapse as long as this is okay we can fix this yeah and we do I mean you know we just had a 17-hour surgery where we were reconstructing an entire face you know and it was a motor vehicle crash uh but we get horses that kick people in the face I've had two and a half year olds two of them actually fall into dishwashers and they're implanted you know so there are a lot of facial injuries that occur Burns you know grease burns from bacon and you know so um there is a lot of that and I am really proud to say that El Paso children's is part uh you know basically the level one Trauma Center that treats all of the patients with these conditions in about a 400 mile diameter so it really is the place where people are flown we have patience flown from Arizona um we have patients flown from you know Central Texas um all over New Mexico Mexico yeah and really it's great to be kind of that Beacon of Hope and light where we can help these people yeah and Dr makushi when you're when the airbag doesn't protect the brain let's talk a little bit about that now that the airbag deployed but somebody really has now a brain injury and where and how do you come in and your team and and again just give us different examples that's always what what captivates people and and helps explain and I think it's it can't even be emphasized enough because it could be as simple as the concussions that happened just with football soccer Seasons coming into play um regardless of the motor vehicle accidents or ATVs but the concussion education which luckily has gone better with coaches to recognize concussions and keep people out of play but there's still a reasonable number of kids or parents that aren't aware where they've had one concussions two concussions and if you have more than one there's a serious risk of having severe injury and rare circumstances death from repetitive trauma to the head so that is part of that education where you need to watch out for those which we're trying to again increase that awareness to society we've developed those protocols and as far as instructions for patients when they see us and we'll follow them for the complications of the concussion so there can be chronic headaches where they can't concentrate at school I need some time off others are more severe where you need an intense team including as far as the Intensive Care Unit the neurosurgeon sometimes the neurologist will be involved if there are seizures the trauma team where it's controlling the pressure inside the brain as the brain swells in order to keep it as normal as possible so that that child survives and is able to get back into society and when that's the case of the brain is swelling do you at that point make a physical relief in the skull to then relieve that pressure and that's where we do have an escalation of Tears going from medical treatment for Less severe where we can give medications or similar to just giving salt into the the body where it shrinks the cells a little bit sometimes that's enough otherwise there's been a major bleed or a major trauma for example where there's multiple fractures or blood inside the brain we'll have to make a large incision sometimes remove the bone for a period of several weeks to several months in order that pressure to come down and at a later date reconstruct that scum wow reconstruct the skull and again that do it's an age thing too like after a certain age it's a lot more difficult because there's not a lot of growth at that point is that is that correct that is correct and depending on the trauma some bones can be as far as preserved to keep and actually use their own bone later some of them are so severely damaged that we actually have to use implants that are 3D designed in order to fit to reestablish that contour for the head so and you do have a 3D the implant that goes in there would that be something that's flexible to grow with the brain or maybe I'm maybe in my head I'm thinking Pediatrics but it's not necessarily the case and it depends on the age okay that's where we do have the benefit of younger kiddos where they can form bone around it versus older where they've already reached their maximal growth and you can put that in they should be justified okay huh okay Dr Yates I want to talk about nerves um let's talk about nerves because they're itsy bitsy tiny itsy bitsy things that are so important right so when you are reconstructing reconstructing facial issues just just all around and it's something is very important to swallowing and breathing and is something as as non you know like smiling which is pretty important you know what I mean but but how do you deal with the nerves when you're reconstructing the space you're just talking about the 17-hour surgery yes how much of that is nerve portion you know actually interestingly very little of it and the the thing about nerves is um usually when a face is crushed it's it doesn't the the the soft tissue around the face right which is what the nerves are in generally the airbag yeah the airbag is pretty flexible okay so only if you really have a laceration like a bad knife cut through here or and you have to realize it also has to go in the direction opposite to the nerve so the facial nerves go like this so very elasticy kind of okay but I'm thinking of a case Dr makushi and I did this morning we were talking about the nerves and um we were reconstructing the front of a forehand on a child and so in this case you know it's if you are not careful with your dissection and we were talking to the trainees about this if you're not careful with your dissection it's very you can clip this nerve and the child can never move their eyebrow again right so it's critical that we and we have all these kind of rules surgical rules things we don't violate so when you do a certain type of surgery with a certain type of dissection you always do it in a manner to protect the nerves right now if you do end up let's say you do up and end up cutting nerves unfortunately especially when it comes to facial nerves um they're so small that it is pretty much if your anterior to it at this line you're not going to be able to put those nerves back together and that's what I've read about I've read that they're so crucial that you can't reconstruct a nerve or you can't take a nerve from one play at least facially and that's kind of where I was going with on that especially with the facial nerve now with our nerves that Supply sensation like to our tongue or our teeth um we can reconstruct those nerves because they're a little bit bigger okay okay okay but interestingly when you reconstruct an earth you can even take a dead cadaver nerve if you're missing a piece if you can put it in there and the nerve will grow regenerative that dead cadaver nerve really but the problem with that is that you know maybe you can feel your tongue but you're not really gonna taste again okay right you're able to move it I think your brain is able to talk to that nerve and still yeah do the movements yeah at least you have something okay right so you have something right but nerves that is one of the problems with nerves you know yeah Dr vacushi is he works on the biggest nerve of all right so he might be a great person to talk to about well I want to talk about epilepsy that's a topic that that you work a lot in and I feel like all of us knew the kid in school that had had epilepsy and there was a seizure get everything out of his way make sure he's gonna not gonna swallow his tongue but but many of us only know that um talk about your work in epilepsy and I'm 56 years old so from when I was 10.

I there's a girlfriend of minehood epilepsy when we were in school and I watched her have a see a seizure and it scared me to death and so maybe that's just the image I have in my mind but I know that there's so many new things that have developed since that day medications um feel free to just go on that note no and I think you're exactly right is that our view of epilepsy is very centered on our own experience or honestly what we see in the movies for the shows good point yeah and that reflects even on the patients that have epilepsy or the individuals because they're afraid to engage in society sometimes if they have uncontrolled epilepsy and they're sitting they want to go into parties they don't do anything because they figure it might trigger a seizure so it can change a lot in someone's lives and what they can do including as far as driving assertion career choices um education because you're on medications to keep the seizures under control but then those medications can have side effects so anywhere from a one in five to one and seven can have as far as seizures that still happen despite the medications even after multiple trials and some of them if not all of them at least should deserve a chance to go through a fuller workup because there are opportunities sometimes for cure where we can identify a certain area of the brain that's causing the seizures and then or sick then if we safely can so is the word cure new in this world in the epileptic world it's improved it used to be localized as far as things like temporal lobe actually when we're talking to adults which is a specific area in the brain and one of the more common things where it's it's localized enough that there was a big enough trial that showed well look this is our outcome where we're reaching a cure no more seizures and up to 70 percent of patients compared to medications which was sitting down to as far as 25 30 percent so that was a huge shift of saying surgery does play a major role in helping these people out but then other advances that are not cures like vagus nerve stimulators that can decrease the burden of severity of frequency of medications by about 50 percent and that can make a huge difference where else the patient in the family so when you're talking about Vegas the vagus nerve is something that I feel like this year I've heard so much about and I'm fascinated with it because it controls everything um explain to the audience what the vagus nerve is you brought it up and and in all the highways and byways at this nerve deals with so the vagus nerve this is the most interesting part about it is about 10 of the nerve tends to control movement structures which is just causing something to do something okay but as far as the feedback back to the brain that's 90 of the fibers and it connects to multiple different areas in the brain so all of our other cranial nerves or nerves inside the brain stop somewhere around the clavicle and then the vagus nerve supply stuff as far as all the way from the head the neck and then down for the rest of the body including as far as heart gastric organs so it goes from everywhere and comes back to multiple places in the brain so it's so spread out which why it was such a good Target to consider for things like vagus nerve stimulators or because of those relays one of the theories was it might interrupt a seizure and that could improve over time and it's one of the few things that we have that if you have a good response from it you actually continue to get better responses as years go by just because of that change in the brain that plasticity so it is an amazing thing that vagus nerve taking advantage of so many Connections in different areas and making use of it by just stimulating it and how do stimulate it so it's a little electric that we wrap our little pacemakery type it is exactly like it we can give the magnet just like the patients with pacemakers just in case and it's similar just to a battery that's inserted along the chest so it's a very similar thing but it stimulates that nerve and there's different frequencies to find the right one that will help control the seizures now it does take a while to take effect can take up to three to six months but if we do see a response the good thing about it as I said is that you continue to see improvement over time I'm going down the rabbit hole on this because it's very curious to me so with the stimulator is there external stimulation or does the stimulate later read what the nerve is doing what it needs to do is that something that you're able to control from the outside it's very sci-fi to me it's getting better and better some of them are things where even I had heard of um at the beginning of my training that were coming out that I didn't believe were true because it was we can do that now and that's just technology so there is RNs which is as far as a little battery that's inserted into the brain that similar to a defibrillator can be put into different areas and then uploaded into a laptop to read it's almost like it can just continuous monitor of as far as the activity that's happening from the area okay and you can see how many seizures happened the characteristics of the seizures and then program it in order to disrupt those seizures to stop them from happening so we're coming a long way and we still have longer ways to go in order and that's the idea is that there are surgical operas it's not just medications for epilepsy that is really taking off to help these patients because medications have side effects and going to two three four medications can be very very difficult and detrimental for people so it's important to know there are other options I love this we're nowhere near to closing up but I want to make sure because there are so many different side things going on here Dr Yates coming here tonight we wanted to get several things across to the audience and I again we have this this beautiful colorful table and I would love to know those stories of each and every one of these beautiful brains that were in these um but what is it that that we haven't talked yet about that you would really like to talk about this evening and you're going to get the same question as well you know I think one thing I would like to talk about is the most common facial deformity of all cleft which is cleft okay yes absolutely and you know a cleft lip is one in every 700 live births that's a lot it's a lot and that is actually even more intensified in Latino populations and also Native American populations both of which we have in abundance here in El Paso so it is something that really affects a lot of our families here and it can be transmitted from one member of the family you know down to the Next Generation and um and then a lot of times it's not actually genetically linked so but it is one thing that I think many mothers also find on a prenatal ultrasound and it can be devastating and scary um and so it is really a treat I do think this has been a change in our City a lot of these patients are getting referred before they even have the babies nice which allows us to plug them into our nationally so on a sonogram you can see the severity of the deformation yeah it's one of the great things about the advances in sonograms right I mean you know we have these 4D sonograms now and you can see the whole face and so our Maternal Fetal Medicine colleagues or OB gen colleagues are sending these patients very early and it allows us to so there's there's nothing I think that could be worse than expecting your baby and then all of a sudden your baby's born and then you're like yeah and that should still be a wonderful joyous moment because cleft can be taken care of I mean these kids do great I mean I love the stories of our clef kids um I had one who brought us they they were graduating from high school and they brought us their National debate speech award oh and speaking and speaking right so that was a huge deal for this kid right you know but these kids do great and they have to overcome a little adversity through their life and I think this makes them so much more beautiful yeah you know and they really are beautiful people beautiful kids and describe the different severities I mean there are some that are that are minor and almost just cosmetic but it's rarely just cosmetic because it goes into the palette yeah but visually you see it from the lips but if you can explain what what is happening on the roof of the mouth and the palate of them that's a great great question so a cleft lip in and of itself is actually one of the least common okay and that is really just where the lip is only affected usually it's truly a facial cleft which involves not only the lip it involves the nose it involves the bone of the face this is a cleft kit actually so the cleft went straight through the bone of his maxilla okay and so these kids and then and then basically you look into their mouths there's no pallets and you can see straight up basically to the skull base so the palette that we all have it was just missing it's just not there it's just not there didn't form it did not form okay and so you're looking up at the base of their skull okay but you can see I mean one of the when we drink water we have a pallet and we can close that off right and swallow well these kids they just have an opening into their nose so you know milk and food can just pour out of their nose and then also similarly with speech so if you think of it when you blow a balloon you're the back part of your palate is touching the back part of your or the anterior part of your spine more or less right and that's closing off your nose so you can puff out your machine or do it as we're sitting here you can puff out your cheeks these kids can't puff out their cheeks huh because they can't create a pressure gradient so they also can't say words that require that like pizza the Peppa Peppa Pig sounds like you need to have pressure it all comes out of their nose you know so these are severe functional defects and issues that these children need to overcome but the great thing is we have great surgeries that are not big surgeries that really can make a huge difference in these kids lives that's amazing to me truly Dr makushi um what are my gosh there's a laundry list of things I mean I can actually show the audience like there there are these all these Neurosurgical things and and literally I got to you guys are like oh let's not focus on all those so instead I'm gonna oh sorry I'll just show this again but let's focus on I know epilepsy is is a topic that that you're super interested in um but cerebral palsy there's a clinic that you all are looking at putting together in the process of putting together and just some things that you see that are up and coming at El Paso children's so cerebral palsy is the most common motor dysfunction um that can happen in children so it's one of those things that everyone either knows someone has someone that's been affected by cerebral palsy and it's a wide spectrum it's a big umbrella term where there's different severity it's very severe where you're going to have to be transported in a wheelchair to walking independently about requiring orthosis on your ankles to needing reverse wheelchairs or crutches spasticity is one of the big Parts where it's an increased tone in the movement of the hands or in the legs and that happens in up to 80 90 percent of kids with cerebral palsy and you can imagine a kid that's trying to play soccer as far as run around with the other kids and then getting caught because that leg keeps stripping them or even more severe where he's trying to catch up with the other kids and using the crutches so one of the things that has taken off over the last two decades by being spread more and more centers is a selective dorsal rhizotomy so the rhizotomy is where the nerves because every time you touch the leg or you move it those sensory nerves don't have that information coming down from the brain because it's been injured to say no it's okay someone's just as far as you're touching your leg or you feel something it bypasses stimulates the area that says crunch down and you get that increased tension so selective dorsal rhizotomy selective because we pick very abnormal nerves in the back and it's in the spine and then rhizotomy is cutting those nerves not all of them because we want to keep sensation in the legs but enough of them so that that tone is now very loose and that makes it really a huge difference for kids so it's like ablation of certain nerves to help the other nerves you are exactly right in fact the older procedure used to be ablation of the spinal cord oh my gosh that has a lot more consequences to it some kids had very good benefits and more severe cases but in the minor cases that benefit risk tend to seem to equal so the selective dose of rhizotomy has been spreading more and more because it's been taught more and more although it's been available since the early 1920s and that's really held change things for these kiddos where now they can walk around with looser Limbs and faster speeds and it's made a huge difference in their lives so when you're looking at different uh kids that are already diagnosed and and obviously everyone's at a different stage how is it that you find out which nerves to ablate and again when we're talking just the vagus nerve it has like a billion different highways and byways I I don't know why I'm obsessed with nerves because they they fascinate me because there's just one little cut in an herb and all of a sudden your smile's gone through the rest your knife or or what have you how how is it that you find out which nerves are the ones you need to ablate do you do it while they're moving is it while the children are awake almost similar to the nervous system being awake with the child being asleep so it's a general anesthetic where they're put out they're sleeping on their tummies we take only one of the bones in the back where it's called the cada Aquinas or the spinal cord ends and then all those other nerves that go down to the leg that are just swimming in there are now exposed and we take the back part of those nerves with sensory nerves and we actually stimulate them so if you have one nerve that's supplying one area of the thigh if you stimulate it you should only get a response in the thigh now if you're stimulating that nerve you're getting the thigh you're getting lowered down to as far as the ankle to the foot you're not only getting the left side you're getting the right side this is a very abnormal nerve because it's spreading to places it shouldn't so there's a scoring system for that the more severe so we aim to take two-thirds of those most severely affected by stimulating those nerves during surgery those are the ones that we cut because they're causing the most problems and leave the more normal ones that you still have sensation in your legs and you still get that benefit of a looser limb movement to help you move around so going through life now and let's say we're doing this before the age of 10 15 or so maybe earlier you can continue to do it until adulterate you yeah okay and so now once you hit 20 and 30 years old it's still it just stays effects like I think I feel that nerves sometimes not regenerate but they find different Pathways to go do what they need to do and so that's something that can be continuously ongoing it's one of those things where from a functional perspective there seems to be a plateau around the age of five and six for development there's still an ongoing debate of whether it's better to do it early versus not definitely if we catch it early we'll operate around that age ideally between five and seven years old and then earlier three years old but when it comes to those nerves what we've learned over time is that if you cut closer to 30 percent you do have a risk of the rest of the nerves becoming hyperactive in the spasticity that makes sense so that's that threshold of at least 50 to two-thirds to maintain that benefit and there's studies going on 28 to 30 years follow up in these patients that have maintained that loose tone of legs well how guys do a lot of cool stuff Dr Yates you had a great word makushi uh let's talk about following up so when and again I'm just looking at some of the photographs that you've shown on some of these uh in past 24 months now you're looking at four years and then six years and then 10 years and you're just beautifully talking about this young man woman not sure um who did debate but in general following up on severe cleft palate cases and or other severe cases that you've been involved with how long is your follow-up in a good it's depending on each person I get that um but how long does that follow-up stay with you and and I'd love some of the stories that you said last time you've got kids that come back to you and you know sing your Praises like hey Doc what's up and you're looking at them like what happened to you yeah you know there's there's one kid I don't know if y'all can see him or not but um but I included him because his skull is also right here he's the young man we talked about last time yes I enjoy him yeah so he had I don't know if we talked about maybe maybe we did this guy had complete Fusion of every suture and um He Is We we it's important to see these patients and I think that's one thing that sets our program apart like we we we think that seeing our craniosynostosis patients yearly is important seeing our cleft lip and palate patients yearly is important because really it's the growth that determines whether or not you feel like the actual surgery you did all that long time ago was really as successful and that's one thing that David Jimenez was incredible at I'm still getting follow-ups from his patients 27 years later oh wow I just got a picture of another one she's 23 years out she just got married completely normal she had this um so you can see um this the skull is fused here so the the skull can't grow this way and it only grows long this kid too who you might see he had significant pressure on his brain and the brain was actually you know almost trying to like herniate out of the skull and so when we took this bone flap off you can see the imprint and it should be on that slide of the brain into there this kid he had two major cranial surgeries I just saw him for a six year follow-up and he said he wants to become a craniofacial surgeon I love that that's what you're talking about how old is he so six year follow-ups yeah yeah so he's like seven now so but really doing great I tell you I think for for anyone who goes into Pediatrics you know right like seeing these kids grow and develop it is like the best part of our job yeah and um I love it when parents send us pictures from Christmas and Halloween or whatever it is but also it's critical in keeping track exactly what you're doing and are you helping these kids or are there better ways you can help these kids and so I think that's we we have two nationally approved teams in town um one that is focused on cleft one that is focused on craniofacial which is out of El Paso children's and um it's the only acpa approved craniofacial team within about 430 miles oh wow so it really is a unique thing it really is a center of excellence and it's it's great that we're able to do it I love that and there's so many people that are coming here too and it's again the biggest thing we do not want people leaving our community to get treated um I want to cover quite quickly because I know we did a program on it but I found it fascinating too brachial plexus um uh and maybe we can explain what that is to the audience when I'll let you do existence I just always think of my you know the inverted backpack Etc the brachial plexus um there's two major nerves that kind of come to supply the limbs the hands and legs the brachial plexus and the lumbosacral plexus brachial plexus is as the big term that we use for the clinic but we'll deal with any other peripheral nerves that are further out or involved lower down the main thing about brachial plexus uh is that a lot of birth related injuries so pregnant women that have gestational diabetes that may have children that are born born with as far as a larger size bigger weight can have fractures in the clavicle have as far as difficult labors where the hand is pulled in One Direction or the other or the neck and cause an injury to the nerves now luckily in the majority of cases they tend to recover but in some they don't so we follow them early because that's a big functional thing for the child where a lot of them may become preferentially left-handed or right-handed because they just can't use the other arm so it's catching them early to find out if they're not recovering in a timely fashion is there a role for doing some type of nerve regeneration to try and improve their function to make use of that hand and that's at least part of what we do at the brachial plexus clinic for any birth related injuries but also any other nerve related whether tumors as well whether uh treatment talks about tumors at all yet really that is a long topic too you know what let's talk let's touch base on that because that that was a lot of Neurology stuff that happens there too so tumors and talk about areas and which which type of cancers are most involved here so what I've seen is a variety of different cases um which has actually been rather impressive in El Paso there's other centers that I've worked at that you tend to see some spectrum of it but in El Paso especially because of the catchment area we'll get as far as more difficult cases for example that might be deemed inoperable because of location that are referred here that will take care of a good example is the thalamus the thalamus sits right in the middle of the brain and right as far as that Highway controlling your awareness because it connects everything from the top down to the bottom and a patient that was referred to us that had a little tumor just sitting at the edge of the thalamus that had blocked off the fluid flow down to the rest of her brain so she developed the swelling now the treatment that she had was just placement of a shunt that shouldn't cause problems it over drains it came with the bleed so what we did is we took out the bleed we then took out the shunt by also taking out the tumor taking out the bleed meaning drying just we made a little hole in the skull we evacuated that blood and because she's so young that brain just expanded gotcha and because that shunt was causing problems that didn't need to be there we actually went between the two hemispheres okay we split a little opening in the highway between the brain the corpus callosum found that tumor removed it opening that pathway of fluid and then removed the shot from the patient so they didn't need any instrumentation she did just fine I saw her now for her six-month follow-up lovely lovely girl yeah wow nice goodness gracious okay I I'm we're running out of time but I know there's something else you want to talk about what is it you know I think the only one big area is jaw deformities because a lot of people have them yeah so you see patients that like this or and again this is not cosmetic this is eating no I mean you can't you don't have a good time eating swallowing Etc yeah I had a 63 year old in my office yesterday and she's had this persistent jaw deformity her whole life and she's like I can't take it anymore you know she's got a lisp she it also causes breathing issues at night so exacerbates sleep apnea that she's had chewing issues and so you know it's a really important functional thing that is not a long surgery takes two to three hours and it can change their life forever and that's very common those are people that's everyone walking around it can be a lot of different people so when you look at it at jaw surgery especially this type of a jaw surgery or changing different things um good there you go so do you make a model for every person that you're going to do a surgery for we don't okay this one was a little bit more complex and they needed these because of the cleft the history of cleft but basically if you saw a jaw like this we have different ways of cutting the jaw and preserving the nerves you can see a nerve runs right through the jaw so we actually cut the jaw lengthwise so that we miss that nerve and then we can slide it okay and you can slide it back or slide it Forward similarly we cut we'll cut straight across the mid face here and just pull this top part of the jaw forward and then that not only expands their Airway but it also gives them a much more cosmetic smile it also lets their teeth come together as they're chewing and lets them speak appropriately do you ever have to rob Peter from Paul whatever it is as far as bones you know all the time okay I mean yeah and you'll have people whose Jaws are out here here right yeah well I can't just if I push that jaw back they won't be able to breathe at all so I gotta pull I gotta pull out right and push Peter back a little bit gosh right right exactly and then they have a nice balanced face and it works right so yeah you do so when you're when you're looking at this because I can imagine too and and I'm watching TV shows right you've got this 3D model on a computer screen and you're trying to move things out and I'm assuming that's how these are are exactly you know 3G printing out how do you uh it's almost like you're an artist sculpting yeah is that how what is your training when it comes to that well I think a lot of it is we pay attention to how the soft tissues drape over the face okay how much tooth to lip show can you see how does the nose and the labial angle meet how should your nose look here or here right what should the the jaw bones and the cheekbones look like as they come out through the soft tissue of the face so those are the cosmetically what we look at and then um but also you're thinking functionally because you have to get the bones in the right place even if that may cause an abnormal right so I think an example of that would be sleep apnea okay the sleep apnea patients they come in they're real retrusive you have to bring them very far forward right but then they don't need CPAP or any breathing AIDS tonight okay got incredibly interesting show I mean really I can go on and on and on uh Dr Yates thank you very much Dr makushi thank you and again this show is in memory of Dr David Jimenez uh with El Paso children's who is the medical director of pediatric neurosurgery and again the the inventor of all kinds of things that I I think are going to be built upon for years and years to come um again if you want to watch the show back you can do it several different ways you can go to kcost TV actually now it's PBS all pass so you can still do it through kcos but pbselpasso.org you can also go to the El Paso County Medical Society site and that's epcms.com and you can always look us up on YouTube which a lot of people have been doing so just insert the word the El Paso position if there's a certain topic you're interested in write that in and YouTube Just magically shows all these things up and if there's a question about the show either this evening or shows that we've had in the past feel free to email the El Paso County Medical Society and that email address is EP Med SOC aol.com and you can email your questions there and we will address them here on your show thank you so much for watching this is the El Paso physician I'm Catherine Berg good night [Music] thank you