The team of doctors, technicians and nurses who perform scoliosis surgery at Johns Hopkins All Children’s Hospital have sometimes been compared to an orchestra. And during a complex, four-hour operation to straighten the spine of a teenage girl, it’s easy to see why. All 10 members of the team are playing a part in the operation. Together, the team will transform the girl’s spine. And quite possibly, her life.

But if this operation is a symphony, it’s a quiet one. A technician hands Jeffrey Neustadt, M.D., the exact surgical instrument he needs - and he didn’t even ask for it. Gregory Hahn, M.D., begins a crucial stage of the operation called derotation, moving the spine into its new shape - and fewer than a dozen words pass between the two surgeons.

This kind of teamwork takes years to develop. Hahn joined Neustadt in 1999 at Children’s Orthopaedic and Scoliosis Surgery Associates (COSSA), a collaboration with Johns Hopkins All Children’s that U.S. News & World Report ranked among the top 50 Pediatric Orthopedics programs three of the past four years. Hahn and Neustadt have performed these procedures at Johns Hopkins All Children’s together ever since they became a team. They treat only the most severe, painful and crippling cases of scoliosis, in children whose spines are sometimes shaped practically like an “S.”

As board-certified, fellowship-trained orthopaedic surgeons, Neustadt and Hahn are each fully capable of performing these surgeries on their own. Instead, they choose to operate together. The reason? By working together, surgeries go faster, with less blood loss, less time under anesthesia and a smaller chance of complications.

“You have two minds thinking together, instead of one,” Hahn says.

This system was rare when Neustadt and Hahn joined forces. Now the two-surgeon approach is more common, and you can find it at other hospitals as well. What you probably will not find is two scoliosis surgeons like Neustadt and Hahn who have worked side-by-side for two decades and performed more than 1,500 surgical cases together.

Neustadt and Hahn say the whole surgical team plays a key role in each successful surgery, and they’re lucky so many other team members have been with them for years.

This team includes a neurophysiologist who watches wavy lines on a computer monitor throughout the operation, checking electrical impulses moving through the patient’s spinal cord. If any concerns crop up, she will catch them in real time and alert the surgeons. Equipment specialists make sure the right surgical screws and rods are ready for use. Along with a fellowship-trained pediatric anesthesiologist, a nurse-anesthetist monitors the patient for safety throughout the operation.

“For us it’s like a dance, everybody has a role,” says Doug DeRosa, R.N., clinical team leader. Having such a large team with so many years working together is what he would want for his own child. “And if I want it for my child, I want to do it for everyone’s child. As long as we live by that, the cases should go well.”

The Power of Technology

Neustadt and Hahn believe in using the best technology available in the operating room, and this is why they have helped pioneer a system known as surgical navigation. In the surgeries, Neustadt and Hahn place several screws in the vertebrae of the patient, and the screws are attached to metal rods that will hold the spine in its new shape. Each screw will be drilled into a small bony knob on the vertebra called a pedicle. These pedicles can be less than a quarter-inch wide, and often have an unusual shape or angle in deformed spines.
Anyone who has ever done a home repair that involves inserting a screw at an angle - and who has wondered if it will go where it’s supposed to - can understand the need for precision in this operation where stakes are so high.

So Neustadt and Hahn start with a 3-dimensional CT image of the patient’s spine, which is entered into a computer before the operation. This image is marked with the point where each screw should go. Then during surgery, “we can find those points and we use a special tool that then tells the computer where those points are and matches it up with the scan,” Hahn says.

Of course, Neustadt and Hahn already know where each screw should go, and they could place them without this computerized guidance, as many other surgeons do. But the navigation system fine-tunes their work to pinpoint accuracy. “As we use that tool to put the screw in, it’s telling us exactly what the trajectory is,” Hahn says.

Improving Life Outcomes

Many children and adults have mild scoliosis, and sometimes it barely affects them. Surgery is not needed or recommended. But Neustadt and Hahn focus on the most severe cases, maybe only 2 or 3 percent of the total. Research has shown that if these cases aren’t treated, they can cause lifelong problems for patients, including pain, inability to work and depression. Correcting the scoliosis can have a huge impact on improving their quality of life.

“The goal of the surgery is to correct the deformity, but also to lead to an improvement with all these outcomes, which will put them on a par with people who never had scoliosis in the first place,” Neustadt said.

Ricki had hoped to avoid the surgery. When she was just 10, her mother, Terri, noticed a curve in Ricki’s ribs, and a pediatrician referred her to Neustadt.

The curvature of Ricki’s spine was 42 degrees, just below the level at which surgery is recommended. So all during the rest of elementary school and through middle school, Ricki wore a stiff brace to stabilize the curvature. She was allowed to take the brace off for her favorite activities - gymnastics and cheerleading. And then she would put the brace back on for the rest of the day and night.

But as sometimes happens, the curving of her spine progressed. At the end of her eighth grade school year, Neustadt recommended surgery.

“My first question when he told me that was, can I still tumble?” Ricki recalled. Her surgery would require 26 screws to be placed in her vertebrae, with two long metal rods fixed to the screws. Could she do a handspring with all that metal in her back?

Neustadt told her she could still tumble after recovering from the surgery, but she would have to take it slow and learn everything anew.

Now it has been 18 months since her surgery and Ricki is a junior in high school who also is enrolled in college classes. Not only that, but she’s on the cheerleading squad and the softball team. She actually has done handsprings since her surgery.

’’It amazed me at first that I could get back to all of my tumbling,” Ricki said. “Now it’s just kind of part of me. I don’t think it's really amazing anymore it’s just something that I do.”

She appreciates what the surgery has done for her body, but also what the whole experience has taught her. “It gave me a better understanding of life at a young age. It showed me that I shouldn’t stress over small problems and that I can overcome huge obstacles with faith and perseverance.” It also motivated her to mentor other youths who are about to have similar surgeries, so she can help them understand it from a fellow patient’s perspective.

Her mother, Terri, says “The outcome that Ricki has gotten from the surgery is life-changing. Her future would have been bleak, with a lot of pain.”

Not every patient can be as athletic as Ricki. But these surgeries do have the potential to change lives. Neustadt, who has been performing them in St. Petersburg since 1991, said he feels humbled and gratified to be able to help his patients in this way. When families thank him afterward, he tells them, “It was my honor. Thank you for placing your trust in me. And I wish you the best.”

Learn more about orthopaedic and scoliosis treatment at Johns Hopkins All Children’s Hospital.