yes neither the el paso medical society its members nor pbs el paso shall be responsible for the views opinions or facts expressed good evening we are going to talk about neurosurgery today it is a specialty dedicated to the diagnosis and treatment of issues affecting the nervous system and that includes the brain the cervical spine peripheral nerves and structures specifically because we're looking at surgeries and how to fix stuff that shouldn't be there or how to fix things that are not correct at this point we're specifically focusing on pediatrics tonight and we have a veteran with us this evening and i'm going to introduce you to those two people in a moment but i want you to be aware that this is a live program so please call us with your questions at 881-013 this evening's program is unwritten by the el paso children's hospital and again we want to say thank you to the texas tech paulo foster school of medicine for providing medical students to manor phones today we have with us josh gardner and he is great about asking what exactly is it that we need so he's going to be taking down the questions and sending them my way so please uh let him know what you'd like to ask and again this is about pediatric neural surgery this evening we also want to say a huge thank you to the el paso county medical society for doing the show for almost 25 years now it's been a long time and they keep going every single month several times a month i'm catherine berg and you're watching the el paso physician [Music] good evening once again i am catherine berg and we have with us dr david jimenez who is a neurosurgeon who specializes now here in el paso he came to us via san antonio and we're very very lucky to have him here he is the medical director of the pediatric neural surgery at el paso children's hospital and also with us is his right-hand man so to speak right-hand woman right i should i don't want don't give me calls the right-hand woman this is sandra flores and she is a pediatric nurse practitioner and together they make a great team of what is happening here in el paso as i said dr jimenez uh quickly what your title is i would love for you to give an idea to the audience at home of who you are what you do and you said that you are a neurosurgeon but you practice in all kinds of other areas as well and that way there's some kind of a background when people have questions asked specifically of you yeah great thank you for having me it is a great opportunity to celebrate neurosurgery awareness month which is august so i'm the director of pediatric neurosurgery at el paso children's hospital i am a doubly board certified neurosurgeon i have taken care of both adults and children but kids are my first love and this was the great opportunity to come and service a community that really needed this kind of service and to work at a great hospital with a great team of people and it's all about the teams and that's where sandra you come in so when we're looking at who it is that we work side by side with every single day that's where everything happens it's where the magic happens and sandra as a pediatric nurse practitioner when you are side by side every day with dr jimenez give some of the the day-to-day duties that you have well thank you for having me too um well our day usually starts when we have clinic okay um we come in get ready for the day go in see patients get histophysicals um do their assessments and you know i present the patients to dr jimenez dr jimenez then goes in and makes the plan with the patient and then we coordinate whether it be surgery or any other kind of treatment that they may need so oftentimes i'd imagine that you and your staff your team they're front line people that get to interface with the parents and the children at the same time and that's something too that i think that you stressed last time we were here that parents are such a huge part of this equation we were talking about pediatrics yes but nothing can happen without the parents seeing and understanding and noticing things that are going on um on that note i know that i kind of talked about what neurological conditions were earlier but when we're looking at neural surgery it encompasses so much i mean just doing the research on this program it just goes into so many depths if we're looking at keeping this in an hour which we have to because that's what we have to do how would you describe the encompassing issues with neurosurgery that you do so neurosurgery is a uh i'm biased but i think is a wonderful discipline of medicine it deals with the most complex organ in the body obviously we all know how complex the brain is made up of trillions and trillions of tiny super powerful computers all connected that allows us to communicate and interact the way we do one of the things that attracted me to neurosurgery was you know we know a lot about the rest of the body the heart and the kidneys and all that but the brain is still this black box in it in a way and so the challenge of really getting to know it and so there are two main groups right you have neurology that deals with chronic illnesses and the like of the brain or the spinal cord or i chose neurosurgery because that's an area where you can literally make a difference immediately right so the child presents with headache nausea vomiting and all of a sudden we find that tumor is the size of a grapefruit in the baby's head well we take it out of the size of a grapefruit in a baby's head i feel like it even fits in there yeah i mean really we've taken out tumors half the the head is filled with so i'm going to do a this is a follow-up question that's probably being asked a little bit too soon in the show but it just goes along to what you're talking about when you are looking at nausea when you're looking at and let's say a brand new baby let's say the baby's not even a month old yet but there's there's something off um and can tumors be can can babies be born with the tumor and have it grow that quickly and the reason i'm asking that is when you're looking at different symptoms parents immediately especially if you're a first-time parent to a first-time baby and you're looking at it and the doctor's like oh they're going to be fine or the next-door neighbor was like ah my baby threw up a lot too what specifically is a parent looking for and i'm going to ask you that same question too because i think that sometimes you get to do all the science in the background but you're listening to you know mom and dad freaking out like literally freaking out so what is it that they're looking for and i'm going to ask you kind of the same question as a follow-up well yeah so it's it babies can be born with tumors but most commonly they tend to show at around age three four five six so typically you have an absolutely beautiful normal gorgeous baby running around being a baby and one day they mommy i have a headache mommy have a headache and you know parents blow it off it's just nothing then they throw up then they get throw up and they have a headache oh it's probably a gi bug or something right and that's what we all hope it is right yeah and then typically eventually it's like wait a minute something's wrong here so then we get a scan and sure enough there's a tumor it increases the pressure in the brain so one of the things that parents should look for is the soft spot becomes full and tense and the head begins to grow faster than it's supposed to so when you said that because we were talking and actually sandra i'm going to take this on to you real quick i do want to talk about the head begins to grow i don't know if this is the water on the brain that we were talking about earlier uh so keep that fox i want to get right back to that um and you sandra when parents come to you and again you're doing the intake you're trying to ask the questions and figure out where am i going to put you now do we go to talk uh talk to dr jimenez do we you know kind of carry us through what some of the questions are that you have encountered from different parents before well most importantly like he said the growing of the head a lot of times the parents start noticing when they're babies when they're little they go to their primary care physician which is their you know pediatrician and they do measurements at two four and six you know when you get your immunizations you know they have the well baby checks and that's when they start noticing if they are going off the curve the the growth curve right um like dr ximena said you know that's one of the biggest things that they see you know the head growing the the bulging of the fontanelle babies are sometimes not uh explain what the fontanelle is to people who don't know like literally take your hand and show the fontanelle is right here it's the uh this is an interior one okay this is um the soft spot is what they call it and when they're born they're born with the front one and then the the one in the posterior but which usually closes early on um but when like he said you know the the growing of the head um the bulging of the soft spot and a lot of times what they also see is that the kids are not reaching their developmental milestones you know there's certain things that they should be doing at certain ages so that kind of cues them in as to you know something's not right so when you're talking about that the head growing and bigger than it should be what ages are we looking at here are we looking at like you were talking about zero to three years old or is this something that happens earlier earlier okay uh when they're babies because your head grows about two centimeters per month for the first five months okay and then it slows down but that's where the the growth curve comes in you know if you start seeing that there's a deviation like you know one month it was here and then the next month it you know jumped two curves two two lines and that's when you start saying you know something's not right here right right so so back to that because we are talking about uh again it was it was hydro syphilis is that right what you were talking about so let's let's go specific now as to what is physiologically happening so we've got um the soft spot to keep it in layman's terms and is there just fluid that's accumulating there that should be absorbed else you know a different way or what is the body doing in that so this is a great point here so we our brain floats inside of our skull as if it was inside of a fish tank okay and where does the water come from and the water is literally clear as water we drink oh wow okay there are specialized cells deep in the brain that take that water out from the blood and make it into what we call ventricles these are chambers or caves inside the brain so think about us having a faucet turned on inside at all times and we make about a half of a liter of this a day constantly half a liter a day our bodies makes it happen yeah constantly it's okay it's a faucet that's turned on and fluid is constantly going 24 hours a day from the minute where we're born or before so the water goes through a set of pathways deep in the brain and then it comes out at the base of the brain and surrounds the brain and the spine and so it helps to protect it it does a whole bunch of things right then there are specialized cells that take that fluid out of the brain out of the head send it back to the heart through the jugular the heart recycles it sends it back up the car is this all within the venous system i mean arterial the arteries go sends it to the brain okay the arteries then the the brain sucks it out of the blood vessel okay makes it into spinal fluid goes through a whole set of pathways filtrations yeah exactly and then and then it returns to the heart via veins right right so imagine your sink your sink is always gone full blast but the drains down at the bottom are open but what happens if you block the drain either partially or fully well the water spills on the floor right but water doesn't come out of our ears or nose right it stays inside and begins to compress the brain against the skull putting pressure and damaging the cells that's the headaches that you're talking about correct but again you're talking about babies too and sometimes they can't with this condition it's not something they can tell you it's something you're physically looking at right so hydro water cephalus in greek means brain and so in babies the head just keeps growing and growing and growing and i took care of a baby whose head was a hundred literally it was this big oh my goodness he was nine months old his head was this big so we we treat it and there are a number of ways in which we that would be my last question so how does the drainage happen and does it start affecting the rest of your body because if you're talking about a liter a day um and let's first start let's end with the the one that's you know we're talking that's over like an 18 16 inches type thing but look at let's look at someone who's head you're noticing parents are noticing the head is growing and i don't know if it is their is it soft i mean is the the water outside of the skull is the skull actually expanding within i mean how how i'm embarrassed i don't know this but i'm trying to figure is it something you can feel because you know water feels like a water balloon but the skull's there you've got the water on the brain but then where is that barrier no need to be embarrassed it took me 16 years of training to learn this stuff really no so the the fluid is between the brain and the skull and the skull and so how does that depend so there's two ways either the fluid accumulates between the brain and the skull and pushes the skull out okay or the fluid accumulates inside the brain pushing the brain out which then pushes the skull out that's that's pretty bad also yeah so depending on there there are multiple categories and we continue to talk about this for a while right right but they're multiple categories some of it can be treated with endoscopes and lasers and doing internal openings which works great i do a lot of that and i've written a textbook on that area another option which is the most common one is where we put actually a little tube a terrain inside the brain we run it under the skin and it runs all the way into the abdomen we put it into the peritoneal cavity not in the stomach but in that area right that extra fluid gets absorbed by the blood vessels of the gut sends it back to the heart the heart sends it back to the brain and that's called ventricular peritoneal shunting or vp something and that way you're not shocking the system by just eliminating that fluid immediately would that be part of that right right and and and and the the shunts that we have now have uh they're programmable and we can control them with magnets and it's really really fancy so when we are at and sandra i'm going to go back to a second because i'm just fascinated about the ability of our bodies you're talking about this nine-month-old baby whose head and i'm thinking you know should be here and how is the skull number one able to handle that how the dot i'm gonna sound horrible right now but i feel like that would be something that would just blow up right how did that not happen number one number two once you get to that point is there any kind of neurological damage that is irreversible at that point well unfortunately for this baby the the waiting nine months with so much pressure he was severely affected he was blind and he's still he's still alive today and will care about his parents but um the goal yeah there is a membrane that covers the the brain between the skull and the brain and that's called the dura mater and latin means the heart mother because it looks it's heart like leather when we're born this is a fascinating point uh the brain like sandra said doubles in size within the first year of life right so say you're six feet tall and you come back a year from now you're 12 feet you go whoa yeah what happened to you but right in this in the skull because it's a round circle sphere going from here to here you really can't tell that as much right first year of life it doubles in size well as it brain grows what happens to the skull well the skull passively enlarges and grows in response to the brain below it so in the baby that i was telling you about as as the brain expanded the dura made new bone that is amazing that it can do your that your body can do it that quickly so i can take a baby that comes out of mom's wound take them to surgery right take the entire skull including the orbital rims everything down throw it in the bucket close the scalp and in nine months the baby has a brand new skull really yeah this regenerates a branch we're bone factories we're babies now now it's gone if we put it all in your head you'll have a lot of that little dent in my hair for the rest of my life i get it my goodness so um sandra i don't even know what to ask you at that point so what i'm going to do though because i've got some questions that are specific to some of the other things that we're going to be talking about so this is water on the brain so old old school that's what people know as water on the brain and then the drainage that we've talked about i want to talk about brain tumors as well because that when we're talking about neurological issues and neural surgery and tumor on the brain you said that it's possible but not likely that a baby can be born with the tumor and i would like to talk to you too about pre-op post-op etc so let's talk about the most common areas of the brain if that's even the thing if there is a most common area of the brain where a tumor does grow where is that and what is being affected by that tumor and and also throw in age groups let's say you know two to five years you were talking about the three-year-old age a little while ago right yeah great question so in the pediatric population we so if you if you think of our think of our skull as having multiple layers multiple levels right where there's two primary levels one we call supratentorial which is everything above about this level which is where the brain lives the cerebrum and then below that this is the the first floor not the second floor the first four second point is is where the cerebellum right and the brain stem live high real state right brain stem keeps us alive and cerebellum balance and all of that right and then that becomes the spinal cord and then goes into the spine the pediatric population is most affected in brain tumors in the posterior fossa or in the first floor interesting i would not have thought that yes okay so we're looking near the brain stem yes okay so that's where the spinal fluid it's on its way to get out of the brain so guess what happens the tumor grows what happens to the spinal fluid it can't get out right so the br the pressure goes up ventricles blow up kid gets headaches and starts throwing up right right and so i always think of tumors and there's benign there's a malignant i get it but either way it's fast growing and if you are in a confined space like the brain benign or malignant at this point yes it matters but if it's growing even if it's benign and there's pressure now in certain areas of the brain and we're talking about the brain stem a lot of the functioning is on the second floor if that's correct if i'm saying that right so you now are the person that goes in there and let's talk about actually i'm gonna take this to sandra real quick and feel free to to cross uh speak with one another but diagnosing this right when you're looking at is it a cat scan is it an mri is it all of the above is it you know asking questions how long have you had headaches for how much is the nausea how is your staff the nursing staff and you know prepping the questions and asking the parents how does that all go down especially the diagnosis and again feel free to kind of cross talk with one another as well on that well i think sometimes when um we see a lot of the patients that come in through the emergency room that come in with those symptoms you know headaches throwing up being off balance and that's a big one too because headaches thrown up you think that could be associated with something else but being off balance that is not normal for for a child you know so that that's one that i would think that okay that's something i'd look out for so when they come into the emergency room you know if they're suspecting something's going on in the head they usually do ct scans because they're a little faster and um than the mri and a lot of times you know little ones won't stay still for the mri mris take a little longer when they come in from a referral from their pediatrician with that with those symptoms you know headaches um that just won't go away they are not relieving any medication um we ask those questions you know what other symptoms are you having are you throwing up are you having any dizziness are you off balance are you having any numbness tingling sensation to your extremities any visual disturbances you know any visual changes if the patient has not had any imaging you know we don't require for them to get it then we have them come in we assess them and then that's where you know dr jimenez suspects that something's going on we usually do order mris because of the radiation exposure with the ct scans okay that makes sense and now that we have an mri what specifically are you looking for when you have that test in front of you well scan through the through all the images and look for asymmetry that both halves of the brain are should be identical so any asymmetry any fluid buildup in the brain any swelling of the brain any shift of the brain flattening of the tissues and then of course we have what's called a blood brain barrier exactly doesn't allow anything in there right so we give contrast put an iv and the contrast if it's typically a malignant tumor will light up like a christmas tree so that kind of leaves the next question when do you know when it's time to go in you know when it's time to you know it's time to scrub up go in and i know that often you don't exactly know what to do until you get in there but now with all the imaging you can kind of see what you're going to be doing so that decision right there and i know that's a tough question to answer because it's different with every single patient but you're looking at and you said if it is a malignant tumor things light up you know it's time to go in is that usually done say it was a person that came in through the er is that something you do that day is it something that you you know study for a while and again everyone's different i get it but maybe throw out a case study that you might remember well so you can have a patient who has mild symptoms and then we get the scan and mild hydrocephalus otherwise the patient is doing well we have time to sort of water them up a little bit we have patients that come in almost comatose very very sick and then we have to do something right away so typically the first thing that i do uh is to drill a hole in the skull and pass the catheter into the ventricle relieve the pressure get control of the pressure inside of the brain then typically within next day or within 48 hours we plan to take the patient to the or now these surgeries we're not taking any grown toenails here right right exactly it's brain surgery yeah like literally yes very complex you know so you require literally the 18 right and you know yes i do the surgery but it isn't just me it's the whole team so i need my the surgical techs the nurses the anesthesiologists so we it's it's it's a group effort to do this correctly that's what i'm saying it's not something you just do right away turn on the dime right now so for me to try to do a case like this on on a saturday night with the b team or with a group of people who not used to doing it is not the right thing to do so we delay until we get our a-team everything's in order we get all the necessary preparations all the equipment there's a ton of very high-end equipment we use navigation which is basically gps in the operating room right i've heard about this which is so you can see exactly where you're going just microscopically because if you are outside in the morning right and somebody says hey where is east well you see oh there's the sun right or where's west but if i put you in the cave and spin you around and say where's east or west what do you say oh i have no idea right but we're inside the brain we're inside the cave right and it's easy to get lost so we have a mechanism where we take scans before surgery right we put them in this very complicated high-end servers stations computer stations we register the patient and we have the ability through trackers to know exactly where we are once we're inside the brain and just and again i think to myself our hands are so and you've got beautiful perfect hands but i'm thinking they're so big when you're looking at a brain especially if we're looking at pediatric brain and just the different tools that you're using and i know that we don't have anything here tonight and i know that you you know probably do some of this prepping but what are some of the tools that you use you were talking about the catheter you're talking about literally drilling a hole into the skull um describe what some of those are just because it's just curious to me because we're not just talking soft tissue we're talking like you said we're all bone factories especially at that age drilling a hole into the brain into the brain pardon me into the skull and then that within a couple of years if not sooner than that in a small child will be completely fixed and grown over correct correct so some of the tools that you're using in this small hole that you had to do brain surgery explain to the audience how you do that that's fascinating to me yeah it is incredible the kind of the work we do so especially in the brain right so because every part of the brain is so critical i i just get can just open up the skull and go let me go ahead and find it no no you have to fan pathways areas where we minimize damage to the patient and there's special specific areas that we can sort of sneak through very specialized micro surgical instruments very fine equipment to do that ultra there is a special lasers that i use a gold laser which is incredible which pulverizes the tissue controls bleeding i mean all kinds of um ultrasound very high power ultrasound that gets into the tissues of pulverizes yeah so again all this is through this little hole well it depends some surgeries are done through the hole the size of a of a diameter okay right that's the endoscopy and that's what i'm picturing okay that's fuel endoscopy okay and that's one of my areas of expertise i do a lot of that kind of surgery and then there are other surgeries where which we're required to make big openings so back in here i do have to make an incision back there and i do have to make a large opening to get in there and and to to have access to the whole area okay the challenge is that we're working in we neurosurgeons work in in an area that is very narrow very small right next to the brain stem blood vessels literally the size of your hair and if i pull one out by mistake i leave the patient blind mute paralyzed right so it's pretty tasty no it is pretty tense i can imagine yeah being in there again that that i can go on all day and then you know one time i would i would love to get some graphics so we can kind of see this you know that to me is where some of that that happened so sandra as i would like for you to talk a little bit more about your team um when we're looking about you know again parents and there's a question we just got here from the audience uh linda who's 40 we're not telling your last name but she has a question here if a child is experiencing loss of balance so it's nice that it's nice when they pay attention right so uh but she said at this point that that right now seems to be the only thing and it doesn't have an age of the child here so we don't know so let's just assume the child is three and so it's someone who is able to walk well enough to where if you're off balance you can tell not someone who's so young that you know being off balance because they're just starting to work is um is normal but is that a symptom in and of itself that they should be concerned about i know that we talked a little bit about headaches nausea etc but balance in and of itself could that be neurological could that be just equal you know it could be a ear issue that we're looking at too but just in general if that's one of the complaints from the parents what what might that be if it's something new if it's a loss of balance i mean your kid was already walking with you know fairly steady gait and all of a sudden you notice that your kids start like you know going to the side bumping into the walls having frequent falls um you know that's definitely it's definitely to get checked out yes okay and when they do want to do that how like right now if there's parents listening or if there's grandparents listening how do they do that like who do they call do they need a referral do they go to their pediatrician how is it that they could do that well there's um initially a lot of parents do go to their pediatrician and they bring up the concerns say you know i've noticed that my child has been a little bit off balance or i've noticed you know a lot of frequent falls um usually uh referrals come through with a pediatrician okay um they go through them and then we get the referral and you know we're able to get them in like right away okay um when then we've also had the parents that call directly you know it's like i have a concern and we can see them too but most of them do come with a referral you know seen by the pediatrician and that's how they get sent to us so when they call directly they're calling the neurological unit at el paso children's hospital or how is it who is it that they're calling directly physicians um specialists at uh el paso children's gotcha that's always good to know here um i know this is crazy but we're already half an hour into the show and i feel like we haven't touched base on a lot of things yet but i want to talk about um some congenial uh issues that just that children are born with just different uh deformities if that's still the word that we're that we're using but we talk specifically about water on the brain we talk specifically about brain tumors but there are a lot of other issues that little tiny ones are born with that you need to deal with as a neurosurgeon what are some of the most common issues when it comes to that so we depends on what part of the nervous system yeah so we have the brain we have the spine cervical spine thoracic spine lumbar spine so fortunately we don't deal with it as much as we used to was what was called a spina bifida oh yes of course yeah so that's a condition in which the bottom part of the spine never closes and when the baby's born the spinal cord is literally wide open like a book and when in birth we went in birth when in vitro is that supposed to start closing i remember us talking about this a long time ago there's a certain month in vitro when the spine naturally starts or should start closing right so by day 21 why did and i remember that being crazy early on so mom does not know that she's pregnant yet and already the bulk of the nervous system it's already the brain and the spinal cord is already formed isn't that crazy yes right so as she's getting her first sonogram say it month three is this something that shows up it can't yeah sorry okay so the the but yeah the nervous system is set up by then so typically day 18 16 18 of the pregnancy of conception of conception so again they have no idea that they're pregnant for the most part right have no idea that they're even pregnant at that point something happens that doesn't allow the spinal cord to close right think of it as like a zipper right so we we are now we've been in detail but we were born you know out of two cells become one right that one becomes two two becomes four four become eight eight sixteen so on and so forth at one point one of those cells is going to become all of the nervous system one of the cells is going to be can't become all of the the muscles another cell is going to become all of the bones another cell is going to become of the skin and so on and so forth but the first thing that happens is the brain and the spine the nervous system closes itself and forms itself interesting following that then think about it right the dura the membrane that covers it comes and seals it like a zipper then the bones come over right and bones zip up up then the muscles literally is layer by layer then the muscles come and they close okay and then the last thing is the skin comes and closes but if a part of the nervous system part of it doesn't close right because what happens there's nothing else nothing else and when the baby's born right their back is wide open oh my gosh and this can happen anywhere along the spine you can have it back here it can happen in the brain i took care of a ton of kids when i was in the philippines doing medical missions in the 90s where literally the entire brain is coming comes through here eyes are right here what do you do at that point as as a neurosurgeon as the doctor what is it that you can do at that point and and maybe we can look at a hundred years ago there was nothing that could be done and then maybe 50 years ago a b and c could have been done and we can even look at now because just doing this program it is amazing to me what a difference a year can make or two years can make so when you're taking care of babies in the philippines what were the axis of tools and medicine that you had that can help what was that and then what is the difference between having that somebody born tomorrow with these issues and what you're able to do now well yeah let me regress back to this this pineapple right one of the new things that we're doing which i think is incredible and fascinating is that we are doing fetal surgery yes so now we we i don't do that specialized centers three or four across the country where somewhere in in the third trimester they would go in open up the uterus go inside do the surgery close things back up so when the baby's born they don't have that problem right the incidence of hydrocephalus seems to go down so that that's something that wasn't available many years ago right now for any deformity that the patient is born with we just have to wait and see what happens and fix it on the fly oh my god they think that's fascinating and i love about pediatric surgery and my colleagues in general surgery in cardiothoracic surgery and myself sharing this is that if you herniated disc right and i do your surgery and fix your herniated disc in your neck which by the way i do need but yes okay i'll give you my card i'll take my card uh if sandra hernia is a disc yeah if a hundred people in this in this in this building herniated disc it's the same operation exactly the same operation right if you have carpal tunnel same same operation right whatever it is right but with congenital anomalies everyone everyone is different you can't open up a book and say how am i going to do this right so you just wait until the baby's born you look at it and you go in and you just fix it you know you make it sound so easy you just go in and you fix it um okay my mind is in three four different places right now so we're looking at going in and fix it so when you're talking about this baby who literally nothing has closed up yet yet they're born full term are we talking eight nine months so we're trying to get them to as we try to get them as full-time as possible how many babies are you able to save as one word but also get to where functioning at a relatively normal pattern how how often is that like i don't even know how i'm asking it i'm not i know what i'm trying to say but i can't you know what i'm asking the answer is we can get about 85 percent of the kids ambulator become ambulators okay about 85 that to me is fascinating if you're describing i've seen you know we've done these programs before and we've actually seen the graphics before in the past and it is fascinating to me because it doesn't look like things would the organs wouldn't work right that you know and how many surgeries on average would this take i mean it can't just be a one and done thing well typically for the nervous system is one with my the primary closure right then if the babies are born with again there's a spectrum right you can have a very mild case of spina bifida and you will close it and the baby other than the scar in the back they're perfect and then you have other babies who are born with very bad deformities because the nervous system didn't develop correctly it wasn't it wasn't just that the clothes is just malformed it affects muscles limbs and legs right you know the hips are all twisted the knees are all bent and ankles you know they're born with club feet and all that then they need a lot of orthopedic surgery for corrections they you know we work with the team of and like you said the bone factories if there are uh different types of neurological surgeries uh neurosurgeries that need to go along and then when you're looking at ortho and you're looking at muscular um it just fascinates me how that works and the follow-up so i guess this is a question for sandra when when and how is the follow-up once dr jimenez and doctors and everybody on your entire team does the magic then you're looking at you know days first and then getting through the weeks and then the months following and then the years following how is the follow-up done when it comes to and i know again there's so many different cases but what is the follow-up that you all do with your unit well we have different clinics i mean i don't think we mentioned it but we do have a clinic specifically for spina bifida the spina bifida clinic that does incorporate ortho urology after dr jimenez does the surgery we follow them up uh two two and a half weeks after surgery in our office okay and make sure everything looks good um and then after that we do pass them on to the spina bifida clinic too so that the patient can get the everybody seen by everybody in the team in one visit instead of having to send them to ortho and then two euro you know everybody gets to see the patient in one visit you know including dr jimenez and you know that's where they get physical therapy appointments um that goes on usually they see them after a month and then i'm thinking it's three months and then six months and then so on depending on the needs of the patient okay and the needs of the patient too i mean some of you're looking at following up for years and years they that they're ours for for the rest of the life you throw through me because i remember last time we talked and i know it's been a while but i i feel like there's always a story and there's always that that's a success story that story that you remember um you're talking about this baby that that had water on the brain i'll just use again the the easy way of talking about it and he he she is still living and parents are taking care of her him today again i'd rather not know her or him but what has been a story of yours that has been a great success story like i remember this and this is how it went down and i know how this child is doing today oh gosh of all the many many that are out there i'd imagine you do i'd imagine you do doing this for 30 years yeah you know god blessed me with uh doing this work for him yeah and uh so i've had so many wonderful opportunities but it depends you know there are some with tumors which um there's so many of them right sandra that we've seen here others are traumatic that's another area we take we haven't even talked about trauma that that in and of itself trauma and neural surgery when it comes to trauma and then pediatric so we you know what since we haven't touched space on that let's do talk a little bit about that because that we could talk a little bit about prevention when it comes to trauma but throw a case study out there that uh that you really saw a great turnaround on how you treated a trauma patient well we just had one not too long ago okay and tell us what it was was it a car accident was it a fall car accident okay it was a car accident so this this young gentleman 16 years old 350 pounds six something football players up in new mexico drives his bronco don't know exactly what happened rhymes it into a tree right right when you see if i show you the pictures you said there's absolutely no way that this patient this person could have lived the steering wheel which is here ended up about here oh jesus the car completely mangled because there's no way that this individual could have survived right they come in they take them out he's kind of still talking and gets out goes to a hospital he's still talking gets out okay he goes to another hospital in new mexico and then they're moving them around eventually he gets transferred to our medical center here we'll come in to find out because well we need to we need let's scan them it's fine his spine in the back was literally the spine was like this and like this when you look when you look at the scan you said this patient has got to be paralyzed well no he was in bed okay you know intubated and all that maybe he broke his legs and all that okay but yet this kid still he knew how to sign so he was signing to his mom and dad and us won't we come find out oh my god this kid we're moving him around his spine completely broken i mean this kid should have been dead on the spot and if he didn't die he should have been paralyzed right we come over we take him we fix him we take him to surgery he literally walks out of the hospital two weeks later comes to our clinic he looked perfect i mean i know you guys can't see sandra over here but sandra's got this big smile on her face and just nodding like she absolutely remembers this happening so two weeks later the kid's walking i mean this is this is tells you fate yeah this was not his time to either die or be paralyzed right and yet somebody may triple the banana peel and die on the spot you know i've had a doctor on in the past and sometimes he says sometimes we don't have the answers sometimes only god has the answer as to why this happened or that happened and i guess this is one of those times and so he was 16 and this was in new mexico so you've been here this was the last two years and your time frame here like like a month ago oh my goodness gracious like two weeks ago has he baked you a cake bought you dinner anything like that no my gosh to see him walk and smile is all that i need well i i love that um we have a couple of questions here from the audience before we start going so what i'm going to do is stop our program as far as question goes from the audience in a couple of seconds seconds couple of minutes um and just see if there's anything that we haven't covered yet that you want to talk about and same thing with you but in the meantime there's a question here um about what is the progression i'm reading this cold sorry what is the progression of a cavernous hemogee hemogenoma in a child and is there a treatment for this am i saying this yes so that is the question from the audience that's a very good question yeah so the camera is the cavernous hemangioma is a vascular malformation so we have arteries that turn into very small little arteries to turn into capillaries which then exchange the oxygen with the red cells and then then become little tiny veins bigger veins and then go back right okay a specific pattern if in utero there is a male development sometimes you go straight from an artery to a vein and there's no capillaries those blood vessels tend to be very friable and they tend to bleed okay if you look at them they look like little mulberries mm-hmm look that's right yes i'm actually familiar with that i had a nephew that had this issue yeah so so they can bleed now they're not like aneurysms where they can blow and kill you on the spot right but they can bleed they can cause large hemorrhages they typically if they're located in on the cortex they can cause seizures so everyone is a little different oftentimes we just follow them if they don't cause problems we leave them alone particularly if they're in very critical areas but if they tend to bleed or re-bleed or if the patient has seizures then surgically i go in and remove them so here's the question how do you know in the first place this person has this condition do they present with a headache do they present with imbalancing do they present like you said if they're not causing an issue you kind of watch right how do you know this is happening in the first place it's location location location ah right okay if i have one here right i may go to my grave and never know it uh-huh but if i have one over my speech area right and it bleeds a little bit [Music] then i can't talk if i have one in my brain stem and there's an area that controls my hand then i go paralyzed it depends on where it is you know i have a story to tell you after the show because we don't have enough time but i'll quickly say i have a nephew that just won a bronze in the olympics for germany and he had this condition two years ago they thought he was gonna die and the the surgeons they he was in palm at the time in spain they did what you're doing but whatever they did they saved his life and he's better than ever so that's just gave me goosebumps when you're talking about this another question here from the audience um and this i'm going to direct to sandra but both of you i'd like to chime in on this a couple in their late 30s are trying to get pregnant you know i have my first baby at 30. good job good job hang in there um is there anything that they can do to decrease the possibilities of neurological issues in the fetus again as parents start getting older there are these questions um that's a question i'm throwing your way if you'd like to throw it to doc you can do that too but i'm just throwing it out there because i want to respect the questions from the audience well making sure that the mom has doesn't have folic acid deficiency i mean that's um it decreases the chances of spina bifida um basically that's the prenatal vitamins make sure that they go to many people folic acid folate i love that folic acid you have to take folic acid i know there's orange juice that is fortified vitamins but little pills with folic acid any female who could possibly get pregnant regardless of their age they should be on folic acid okay because when i was a resident many many moons ago we used to have literally dozens of these kids with spina bifida born almost almost every other day we had a kid i mean it was just massive numbers then we realized we uh medicine realized that it was linked to a folic acid deficiency interesting we began giving women folic acid and the incident would literally almost drop now i see one a month maybe once every few months which is great so if you're to answer that question take folic acid another one is avoid toxins i eat alcohol right smoking all that stuff right we're assuming that you know they're not doing that right but avoiding avoiding that are the main two things and a good diet of course i remember being pregnant at 29 and folic acid was the answer that was kept throwing because i was an old i was an old first mom um i'm 54 now so i don't think that can happen but we are at that point in the show where i'd like to stop questions from the audience and dr jimenez is there anything i know there's a lot that we could still cover don't get me wrong but is there anything that you'd like to talk about before this show finishes because i know it goes so so fast um and we've got a good ten ish minutes that we can we can play with actually we have five minutes we can play with thank you very much we have about five minutes we can play with which is actually a long time yeah i don't think so right so um no i i think simply for people to to know that uh we have this service available to our community which we didn't have before um i think it was great of el paso children's administration and everyone to think about bringing someone like me here and my original goal was not just to come here to do cases because if i leave and whatever years then you'll be back to square one is to build programs and my goal to work with the hospital and the community in general is to build a neuroscience program where we can take complete care of the patient and not just one person but a group of us and that this can go on an infinite as i mentioned earlier we're hiring a second pediatric neurosurgeon we're also in the process of bringing in a high level pediatric neurologist and epilepsy is an area of that's a lot of interest right so what we're planning on doing is setting up an epilepsy program that's that's something and there isn't one here that i don't know well you know we have a neurologist who treats epilepsy with with medicine right he does a great job right so in epilepsy let's finish with that so epilepsy is where the certain part of the brain gets activated and causes the problem there are two main categories one category is what we call medical which you can only treat it with medicines and then there's another category in which a maybe a mass a cyst a tumor or some kind of deformity causes the brain to get irritated mm-hmm well surgery would go away the surgery right we take out the causative effect and cure the epilepsy okay so we're in the process and we will within a year have a full-blown epilepsy program doing with equipment doing the latest and greatest and i'm very excited about that well that i know that it's a very neat thing in epilepsy it's just one of those i all of us remember the kid in school that had seizures and you know that's for me at least was my first education of what do you do with someone who has a seizure do you leave them be do you in fact sandra i'm going to ask you that right now for people who are listening if you know someone who's having a seizure if you see somebody having a seizure what do you do as a bystander well make sure it's safety that they don't have to get all the chairs and tables and everything out of the way and make sure that they don't aspirate that they don't choke on their own uh secretions you know um and how do you do that do you turn them to the truth you can okay yeah if you can um but basically it's just safety okay you know make sure that they don't hurt themselves right um i want to ask you this question before we wrap up and just about the programs you guys have going on cause i know that's something that you're very involved in and we've got a little bit of time but can you describe what's happening over at your place right now well we have a lot happening i know dr jimenez has so many so many things that he wants to you know get done um like i mentioned earlier we have the spina bifida clinic that is available uh they also started a scoliosis clinic which you know a lot of kids younger kids have scoliosis you know we have a great doctor dr haidem and that is doing that clinic we also have brachial plexus clinic which is when babies are born you know injuries can happen to to their nerves dr diamond and dr jimenez are doing that clinic we also have a craniofacial clinic that where they see kids with plagiocephaly and you know dr gates sees patients with cleft palates and all that and um we are planning on a plagiocephaly clinic you know to see patients just for our you know a lot of deformities for the positional that we see a lot of patients like that at our clinic that if we could just see those in the separate clinic i think we would be able to see more bottom line you're trying to look at these these specific issues that are in the grander populace and trying to be you know epilepsy here and we've got different different uh programs going on and so again how long has the el paso children's been open 10 years 10 years so there's a lot that's been going on in these 10 years really congratulations to everybody when i say doctors to nurses but again it's the entire team especially in this time of kobe 2 and again we're a medical show and we're not telling you to go get your copic vaccine but we're encouraging it for sure um to make sure that there are fewer hospitalizations and the disease doesn't get too far in that situation so i want to say thank you very much to el paso children's hospital and again found my paper josh thank you so much for your questions they have been wonderful coming this way and again to dr jimenez and to sandra flores and el paso children's like i said in the el paso county medical society who's been around for gosh you've been around forever but doing the show for more than 25 years if you are looking at getting the covid vaccine you can go to the civic center at any time between eight and three and get that done thank you so much i'm katherine berg and you've been watching the el paso physician [Music] [Music] you