Voiceover:This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.
Dr. Allison Williams: Hi, I'm Alli Williams, a pediatric hospitalist here at UPMC Children's Hospital of Pittsburgh.
Dr. Sameer Agnihotri: I'm Sameer Agnihotri, an assistant professor in the Department of Neurological Surgery.
Dr. Williams: And today we are so thrilled to join us on That's Pediatrics Podcast, Dr. Stephanie Greene. She is one of our wonderful pediatric neurosurgeons here at UPMC Children's Hospital of Pittsburgh. And honestly, she wears quite a few different hats that we're looking forward to talking with her about today. Thanks so much for being here.
My favorite thing to do, when we always start a podcast, is to ask, "What's your favorite thing about the Pittsburgh area?"
Dr. Stephanie Greene: I think my favorite thing about the Pittsburgh area is how accessible it is for families. There's great schools. There are parks all over the place. There's all sorts of free things to do with your kids, the Science Center. At the symphony, they have a program called Fiddle Sticks where little kids can go and try out the instruments and then when they make noise during the performance, nobody cares because everybody else brought their little kids. I like all that kind of stuff about Pittsburgh.
Dr. Williams: I think we're all a little biased. I also love the Science Center with my kids. It's a great place that I can try to instill medicine into them nice and early.
Dr. Greene: Exactly.
Dr. Williams: Not only being busy at home with kids, you also have a lot of different hats that you wear here at UPMC Children's Hospital of Pittsburgh. Can you talk a little bit about your career journey to getting to where you are today?
Dr. Greene: Oh, sure. I guess, you want to start in childhood. I wanted to be a doctor since my pediatrician told me that I didn't want to be a nurse. I got really into the books about the pioneer nurses, Clara Barton and Florence Nightingale, and I wanted to be on the battlefield saving soldiers lives. And my pediatrician told me that was really more of a doctor job nowadays.
Dr. Williams: Oh yeah, true.
Dr. Agnihotri: Yeah. Wow. The history.
Dr. Greene: That's pretty good. In the mid seventies, my male pediatrician told the little girl to become a doctor, so that's pretty good. But I got interested in neuroscience after a head injury in high school. I was in a car accident and in a coma for a period of time, and then I lost some skills. I was the point guard on my basketball team, and six months later I couldn't dribble a ball.
Dr. Williams: Oh my gosh.
Dr. Greene: It took me about a year to get back to normal and I just wanted to figure out how that happened and why, so that was my neuroscience interest. I was a neuroscience major. I went to Dartmouth College and then I thought I'd become a neurologist because how else would you figure that out?
Dr. Williams: Sure.
Dr. Greene: And then I discovered that the neurologists were really more diagnosticians and they weren't fixers. And somehow it never really crossed my mind that I played the piano and I knitted. And when my family bought a gas grill, I put it together and I really was a fixer. I was won over by a neurosurgeon during my neurology rotation. I suppose pediatric neurosurgery came later. Our training is seven years of adult neurosurgery and then we sub-specialize in pediatric neurosurgery. And I loved every rotation. I wanted to do everything. I didn't want to eliminate anything, but I wanted to be in academics.
And the only way to stay in academics and do everything is to do it on little people, so that's the pediatric piece, so that came at the end of residency. I did my residency in Boston at Boston Children's and Brigham and Women's. And I did my fellowship in Seattle at Seattle Children's. And then I started elsewhere in my career and it wasn't the perfect job for me. And then I wound up in Pittsburgh, which has been the perfect job for me.
Dr. Williams: That's amazing. You're also in the process of creating a neurovascular center, correct?
Dr. Greene: Correct.
Dr. Williams: Can you tell us a little bit about that and what that's going to look like?
Dr. Greene: Sure. Within neurosurgery, vascular neurosurgery has always been my passion. I love the Moyamoya and the arterial venous malformations. I love cavernous malformations, so we've got a fairly good sized practice of vascular cases here, but I noticed some of these patients need endovascular treatment. And not every place has pediatric endovascular capability. We do and there are a few others around the country, but there's no real established pediatric neurovascular center of excellence. They have the pieces in a couple of programs around the country, but nobody markets themselves as a sort of a one stop shop where you can get your diagnostic angiogram, you could get gamma knife treatment if you needed it. You can have open surgery, you can have endovascular treatment. We're working together with hospital administration to establish this center. We're working on formulating the website right now. We're publishing papers on vascular neurosurgery in children, trying to up our profile so that we'll be attracting patients on a national level.
Dr. Agnihotri: That's amazing. Can you also highlight, because you have so many hats, talk a little bit about the fetal neurosurgery program as well.
Dr. Greene: Sure. We established a fetal program for spina bifida, it's probably about eight years ago now. We've done a few surgeries. We do them over at Magee because at that stage of pregnancy, the mother is really the patient. They've got a NICU at Magee, but we don't have the ability to take care of adult women at Children's, so the surgeries are done over there together with the maternal fetal medicine specialists.
And sort of sprouting out of that endeavor was a research project looking at infants with aqueductal stenosis. That's a condition that develops pretty early in gestation, and they develop hydrocephalus, the build up of fluid above the blockage, so their heads just get bigger and their brain damage becomes cumulative until that's treated, which is conventionally after birth, usually the babies are delivered by C-section because their heads are so large by the time that they're at term, so it's tougher on the mother as well. We started thinking about ways to treat that in utero, and we've come up with ventriculoamniotic shunt. It shunts cerebrospinal fluid from the ventricles in the brain out into the amniotic cavity to normalize the pressure. There's little valves so they don't drain too much. It's one way, so the fluid in the amniotic cavity doesn't get into the ventricle. That would be bad.
Dr. Williams: It seems important.
Dr. Greene: It's low profile because babies will reach up and pull things off of themselves, so there are a lot of pieces to this. So Dr. Emery from Maternal Fetal Medicine, Dr. Chun from the School of Engineering and I, came up with this fetal shunt. We've got a couple of patents for it now as we've gone through revisions and we are getting close to applying to be able to use it on a humanitarian use basis through the FDA.
Dr. Williams: Wow. And is this a device that's envisioned to be used in utero while the child develops to not only to... Well, I guess to prevent, of course, the sequelae that occurs from the brain damage, but it's not, I assume a permanent device, you would still potentially need the shunt afterwards, but it would lead to better outcomes for the patient and for the mom potentially. Is that kind of the idea?
Dr. Greene: Correct. It's pretty well established that the ventricular enlargement produces tearing of the axons around the ventricles, which leads to cerebral palsy, seizures, developmental delay, so if we can prevent that, it's a better neurologic outcome for the baby. But this, we obviously don't want to be draining cerebrospinal fluid out into the air postnatally, so they'll have to be treated with either an endoscopic third ventriculostomy or a ventricular peritoneal shunt shortly after birth.
Dr. Williams: I'm at a loss for words as to how amazing that is because we are seeing here at UPMC Children's Hospital of Pittsburgh, we have such a wide variety of patients that we see, but we do see plenty of patients that have had these in utero experiences that lead to complications throughout the entirety of their lives, not only through pediatrics, but as they get older as well. Like you mentioned, they have developmental delay, they have other issues as well, sometimes epilepsy, things like that. Thinking about preventing that is not to do a bad pun, but it is mind blowing.
Dr. Greene: Well, thank you.
Dr. Agnihotri: Switching gears a little bit and just to embarrass you a little bit, you are a thought leader, a role model, and I have had the privilege of having three amazing female medical students, one that's gone on to do neurosurgery, two that look up to you. Can you speak to the responsibility and being a role model as a woman in neurosurgery?
Dr. Greene: Well, thank you for the kind words, now I'm uncomfortable. I think there are not a lot of women in neurosurgery. Right now, I'm the only woman in the department, although I know we have just recently recruited another woman who's going to be based at Passavent. She hasn't started yet, but I'm excited about that. I think the most important thing that I can do for people that are thinking about it is just be. I think they need to see that there are women doing this and it makes it seem possible. But I'm grateful to hear that there are some medical students looking up to me, that's nice to hear. I'm pretty involved with the medical students in my role as Vice Chair of Education. I'm trying to meet with them all regularly to help them be as competitive as they can through the neurosurgery match, so I'm aware of more female medical students than I have encountered in the past, which is great.
Dr. Williams: You had even mentioned through your childhood, you had a good experience of your male pediatrician saying, "Well, you should be a doctor if that's what you want to do," and not everyone has those experiences, and we know there's plenty of research to show that there is still gender disequity when it comes to specializations that medical students choose. What do you think are some of the barriers to women being more involved in neurosurgery?
Dr. Greene: For sure, I've had some great male role models. It doesn't require just female role models. My father says there's no feminist like a father of daughters.
Dr. Williams: That is true.
Dr. Greene: I think he's right. Yeah. My Chairman of Neurosurgery at the Brigham had daughters in medicine and he was a gigantic feminist. I think the men are important too.
Dr. Williams: Yeah, absolutely.
Dr. Greene: Barriers, I think it helps people to see people like them in the field. I think that's certainly true. I think that a seven year residency sounds intimidating to an awful lot of people, maybe more so if they're not sure they'd be welcomed. I think people should be considering if they go into pediatrics or medicine and then they do a fellowship, that's going to wind up being the same length of time as their neurosurgery residency. But we don't want everybody to go into neurosurgery. We want the people to go into neurosurgery that love it, that don't want to do anything else, because it's hard. If you were deciding between neurosurgery and dermatology at three in the morning in the emergency room, you might decide to switch fields.
Dr. Williams: Sure. Yeah. No, I think every field has their challenges. I know neurosurgery, at least for me as a medical student, was very intimidating to think about.
Dr. Greene: It's not for people that like a low stress existence. That's definitely true.
Dr. Agnihotri: But one of the cool things about neurosurgery has been told is you guys love your toys, so putting on your future thinking hat, how do you envision the field changing in the next five, maybe 10 years?
Dr. Greene: One of my favorite things about neurosurgery is that I knew I was always going to keep learning. You never know everything because the field is advancing so fast, not just understanding, but also technology. Here, we got an intraoperative MRI a few years ago, which helps us with tumors where the borders are indistinct, so we can get an MRI while the patient is still under anesthesia and say, "I think we could take a little bit more in this area and improve their outcomes," that's really helped us.
We have an inoperative CT scanner, which helps us accurately position screws when we're doing spinal fusions. That's probably the main thing that we use it for. We've got a laser that we use to ablate lesions that are in surgically inaccessible areas, so we have some pretty great toys already. I think the possibilities are endless in terms of technology. The advances are coming like crazy. We all would love to see advances in the development of ventriculoperitoneal shunts for hydrocephalus, because they have so many problems and it's real cumbersome on the families to have malfunctions. There's lots of research going on all the time with self-clearing valves and that sort of stuff, but there's nothing earth shattering that has happened on that front yet. But the technology is changing all the time and that's one of the really great things about neurosurgery.
Dr. Williams: There's just so many things that we've talked about that have been so exciting so far. You've talked about your neurovascular center that's coming up. Is there a timeline on when that might develop at all? You said it's in the future, but I don't know if we should expect that soon, or is that still in early stages for that?
Dr. Greene: We're very close. The website will probably be up and running within a month, and it will have contact information for people all over the country to call into a specific number, so I think about a month away. We've already got clinic time where the vascular neurologists are there at the same time as me and the endovascular surgeons, so we'll be able to see patients together as they come. And I'm just going to move my patients that I see in my regular clinic into the vascular center, as there becomes room for them.
Dr. Agnihotri: Right. Speaking of the other hats that you wear, you do a lot of amazing research and you're a scientist. Can you share with us some things that are coming down in the pipeline or some things that you published or are working on that you're really passionate about?
Dr. Greene: Thank you. Lots of compliments today. I've got papers coming out having to do with the outcomes of cavernous malformations in children. That's a vascular malformation that's reasonably common in adults and kids, but there's not great data on outcomes in a large series, so I think we'll have the largest series to date when it comes out, just to help patients and families have a little better understanding of what the future holds.
We just had a manuscript come out on our ventriculoamniotic shunt. We've got proof of concept with that, so that's very exciting. Other things coming down the pipeline, we've got some research on spina bifida, looking at how nerve monitoring has changed the outcomes of surgery for tethered cord syndrome, which is something these children develop later in life. The data that we use to tell families what their outcomes are likely to be after a tethered cord release, is based on numbers from before the advent of neurophysiology monitoring in the operating room. The historical numbers are that a third of patients improve with surgery, a third of patients stay the same with surgery, and a third of patients are worse with surgery. And I think in reality, it's not close to that anymore. With the use of nerve monitoring, the outcomes are much more favorable than having a 33% chance of worsening. We should have that paper submitted within two months, so we've got lots of stuff moving through.
Dr. Williams: Wow, that is so exciting. With all of your different hats and just to inflate your ego some more and make you blush a little bit more on this podcast, we have a lot of trainees that listen to this. We have residents, we have medical students that are listening to this. Do you have any words of wisdom for those that are thinking about either pursuing neurosurgery specifically or even just maybe a field of medicine that is not predominantly with women in it, kind of an underrepresented gender? Do you have any words of wisdom for those folks that might be looking for it?
Dr. Greene: Yeah. I think we devote so much time to our education that we really should pursue our passion. You shouldn't settle for something because it's almost as good as what you want to do. You need to do the thing that you love, which makes work not feel like work. And I think everybody responds to passion. If you're passionate about this field and you're the only woman that's in your group, everybody wants you there. If you're the one that's the most passionate or one of the most passionate, you're welcomed, if this is important to you, everybody recognizes themselves in that.
Dr. Williams: And I don't think we could look for any other stronger advice than that. Those are words to live by. And so we are so thankful that you were able to come today and take some time out of your busy schedule to put your hats on the hat rack just for a minute, so you could talk all about them as opposed to wearing them. Thank you again for coming and talking with us today, and thank you for listening to That's Pediatrics.
Dr. Greene: Oh, it's my pleasure. Thank you for having me.
Dr. Agnihotri: Thank you so much, that was great.
Dr. Williams: Thank you.
Voiceover: You can find other episodes of That's Pediatrics on Apple Podcasts, Google Podcasts, Spotify and YouTube. For more information about this podcast or our guests, please visit chp.edu/thatspediatrics. If you've enjoyed this episode, please be sure to rate, review, and subscribe, to keep up with our new content. You can also email us at podcast.upmc@gmail.com with any feedback or ideas for topics you'd like our experts to cover on future episodes. Thank you again for listening to That's Pediatrics. Tune in next time.
Stephanie Greene, MD
