Jane and John Justin Neurosciences Center

At Cook Children's, we know it's about more than medical expertise and advanced technology. It's about working together to tackle even the most complex condition.

That is why the Cook Children's Comprehensive Cerebral Palsy and Movement Disorders program offers a full range of diagnostic and therapeutic interventions based on a patient-centered, interdisciplinary team approach. Our movement disorders and neuromuscular clinics have dedicated teams of professionals, including physicians, nurse practitioners, physician assistants, physical therapists, occupational therapists, speech therapists, orthotics and prosthetics technicians, a clinical nurse specialist, a patient liaison, a social worker, bio-behavioral therapists, Child Life specialists and therapy dogs. The team works to meet the specific needs of each individual child and family, by developing comprehensive treatment plans that will enhance movement and empower lives.

Cook Children's Comprehensive Cerebral Palsy and Movement Disorders program serves approximately 2,900 children each year and offers:

• One of the largest motion analysis laboratory dedicated to children in the United States.
• One of the most experienced with pediatric deep brain stimulation in the United States.
• One of the most experienced in using the intraoperative-MRI image-guided lead placement system, that helps reduce the need for secondary epilepsy surgeries.
• Two decades of experience in spasticity management using botulinum toxin and intrathecal baclofen pumps.
• Selective dorsal rhizotomy (SDR) surgery as an option for some patients with spasticity.
• A full range of electrophysiologic testing.
• A comprehensive Tourette syndrome treatment program.
• Both inpatient and outpatient rehabilitation programs.

Cook Children's is a Muscular Dystrophy Association-sponsored neuromuscular clinic and is active in clinical research to enhance the lives of people affected by movement disorders.

What is DBS?

Cook Children's is the first independent pediatric hospital in the United States, and the only children's hospital in North Texas, to offer a comprehensive movement disorder program that includes deep brain stimulation (DBS).

DBS is a surgical procedure involving the placement of electrodes into the brain that are connected to an implanted medical device, sometimes referred to as a brain pacemaker. The electrodes deliver continuous low-voltage electrical impulses to the targeted part of the brain. These pulses block the abnormal firing of neurons in the targeted area providing relief for patients whose symptoms are not properly controlled by medication. Goals of DBS surgery are to reduce muscle tone, improve function and prevent the progression of movement disorders from spreading throughout other areas of the body.

Successful DBS surgery can make significant improvements to a patient's quality of life, although those changes may occur three to six months after activation of the system.

At Cook Children's, DBS surgery has been performed on patients with Parkinsonian syndromes and dystonia, and, in the future, may be performed to help with other neurological disorders.

In December 2015, Cook Children's celebrated its 100th DBS surgery, further cementing its global leadership role as an international center of excellence for pediatric DBS surgery. The deep brain stimulation program was launched in 2007 and is performed on children struggling with dystonia, a group of severe movement disorders. Its goals are to reduce muscle tone, improve function and prevent the progression of movement disorders to other areas of the body. To date, Cook Children's Jane and John Justin Neurosciences Center has completed more than 100 DBS surgeries.

How does DBS work?

• DBS involves surgically implanting electrodes deep into the thalamus, the part of the brain that handles movement-related communication.
• The electrodes deliver constant small electrical impulses to a small region of the brain providing remarkable therapeutic benefits for otherwise treatment-resistant movement disorders. It is used to restore normal movements in patients with Parkinson's disease, tremors and dystonia.
• The DBS system consists of three components: the implanted pulse generator (IPG), the lead and the extension. The IPG is a battery-powered neurostimulator which sends small electrical impulses to the brain to interfere with abnormal neural activity at the target location.
• The lead is an insulated coiled wire with four electrodes and is placed in a specifically targeted area of the brain. It is connected to the IPG by another insulated wire (the extension) that runs from the head, down the inside of the neck, behind the ear to the implanted IPG.
• All three components are surgically implanted inside the body. Under local anesthesia, a hole about 14 mm in diameter is drilled into the skull and the electrode is inserted for optimal placement. The installation of the IPG and lead is performed under general anesthesia.
• After implantation, the IPG is programmed by a specially trained neurologist and nurse to optimize symptom suppression and control side effects.

What is SDR?

SDR is a surgery performed on the spinal cord in the lower back of children with cerebral palsy or spasticity in the legs. There are two kinds of nerve rootlets in the spine – dorsal rootlets and ventral rootlets. The dorsal roots are ones that carry signals from the child's legs to the spinal cord and then to the brain. These are the roots that usually have abnormal communication between the muscle and the brain, therefore allowing spasticity in the muscle. In the surgery, very specific dorsal rootlets are cut to reduce spasticity, while preserving the child's ability to move.

Most candidates for SDR are able to walk, with or without the use of an assistive device, and have relatively good leg strength and muscle control. However, there are some cases in which surgery is performed on non-ambulatory children in order to improve their care. Ultimate candidacy is determined by our team of doctors and clinicians, but it's usually performed on children between the ages of 2-10 years who have a diagnosis of cerebral palsy causing increased spasticity, or stiffness, in their legs. Children will be evaluated by a team of specialists at Cook Children's Cerebral Palsy and Movement Disorders Center and in our motion analysis lab. During these visits, we will review your child's diagnosis, medical history and imaging and assess his/her tone, strength, range of motion, walking pattern and cognition. These pieces will help determine their appropriateness for the surgery.

For patients who have failed two appropriate and adequately dosed medications for epilepsy, the chances of becoming seizure-free on a third medication or combinations of medications are less than three percent. More than a quarter of patients become "medically intractable" to treatment and should be evaluated for other treatment options to control seizures.

Cook Children's Comprehensive Epilepsy Program provides the highest level of care recognized by the National Association of Epilepsy Centers. We also provide the most advanced and accurate imaging with the magnetoencephalography (MEG) and the iMRI. It takes less than two weeks to evaluate patients in the program and results are presented at our weekly case conferences. Our neurosurgeons also consult neurologists in the operating room for the best possible patient outcomes.

Our epileptologists provide thorough testing and evaluation to help answer why a patient has epilepsy, what the patient can expect for the future and what treatments will provide the best seizure control and the best quality of life.

Diagnosis and treatment can involve many avenues, including:

• In-depth historical reviews to insure prior medication trials were appropriately matched to epilepsy type and dosed appropriately for maximum efficacy.
• Comprehensive analysis of imaging to localize previously unrecognized epileptogenic foci.
• Review of prior laboratory testing to insure genetic causes of epilepsy have been completely evaluated.
• Advanced treatment options including: investigational new drugs, ketogenic diet, epilepsy surgery and neuromodulation (i.e., vagal nerve stimulator).

Determining candidates for surgery:

For appropriate surgery candidates, multimodal imaging allows for localization of the seizure focus, as well as precise mapping of nearby language, motor, sensory or visual functions to avoid post-operative deficits. Imaging includes:

• 3-Tesla MRI
• Magnetoencephalography (MEG)
• Positron emission tomography (PET)
• Single photon emission computer tomography (SPECT)
• 3-D multimodal imaging
• Functional MRI imaging
• iMRI
• Diffusion tensor imaging-tractography

We offer:

• A Level 4 epilepsy center, the highest recognized by the National Association of Epilepsy Centers (NAEC), with expertise in all facets of epilepsy care.
• A technologically advanced EMU equipped with 10 beds featuring 24-hour EEG observation by ABRET accredited technologists.
• Wireless monitoring capabilities to allow children more freedom while being evaluated.

Cook Children's craniofacial and cleft surgical team specializes in plastic and reconstructive surgery for children with face, head and neck conditions that they are born with, or may acquire later due to traumatic injury, disease or developmental disorders. Cook Children's Craniofacial and Cleft Surgery Program embraces a multidisciplinary team approach to craniofacial and cleft care, enlisting the talents of neurosciences, primary care physicians, pediatric and neonatal intensive care, anesthesiology, genetics, oral surgery, orthodontics, speech pathology, otolaryngology, ophthalmology, gastroenterology, pulmonology and radiology. The program works together with other specialties to care for the unique issues of each patient.

Cook Children's is a member of the International Society of Craniofacial Surgery and the American Society of Craniofacial Surgery.

Our team participates in national and international lectures on craniofacial and cleft surgery.

The Craniofacial and Cleft Surgery program received a physician-named Vitals Compassionate Doctor Award from the Vitals Awards & Recognition Program, 2014.

Conditions treated:

• Cleft lip and palate, primary/secondary
• Speech anomalies, velopharyngeal incompetence (VPI)
• Facial clefting
• Hemifacial microsomia

Abnormalities of the skull:

• Craniosynostosis
• Positional plagiocephaly
• Traumatic and post-surgical cranial deformities

Abnormalities of the orbits and midface:

• Orbital hypertelorism
• Vertical or horizontal orbital asymmetry

Abnormalities of the jaws:

• Dental dysharmony
• Malocclusion and jaw growth anomalies

Ear deformities:

• Prominent ears

Tumors:

• Dermoids
• Fibrous dysplasia

Vascular lesions:

• Hemangioma
• Vascular malformations

Named syndromes:

• Apert's
• Beckwith-Wiedemann
• Amniotic band syndrome
• Crouzon's
• Pfeiffer's
• Treacher Collins
• Saethre-Chotzen
• Goldenhar's
• Nager's
• Proteus syndrome
• Pierre Robin
• Romberg's hemifacial atrophy
• Stickler's

Following surgery for SDR, patients will be transferred to Cook Children's Rehabilitation Care Unit (RCU). Cook Children's RCU also serves children and teens with head injuries and neurological illnesses. In the RCU, patients receive treatment from medical staff members from a variety of specialties and departments. Our inpatient pediatric rehab program combines medical and nursing care with individualized therapies, including education, support and discharge planning. This enables our team to focus on providing the best care for each child based on their particular diagnosis, while working alongside each family to create a plan of care that fits their unique needs. The overall goal of the RCU is to help patients reach their highest level of function following an injury or illness and return them to their homes as soon as possible.

Neurological rehabilitation

The RCU helps children recover from neurological problems caused by:

• Brain injuries
• Movement disorders
• Brain tumors
• Encephalitis
• Spinal cord injuries
• Neuromuscular diseases
• Other neurological diagnoses

Cook Children's RCU features the latest rehabilitation technology, including:

• Overhead lift track system for activities of daily living and therapies
• Motor-driven, software-controlled movement therapy system for legs and upper body to help reduce spasticity and improve flexibility
• Visual motor and neuro-cognitive rehabilitation and sports training device with programs to improve cognitive processing ability, balance and functional mobility
• 16 private rooms with parent bed space in each room
• State-of-the-art gym for therapies
• FWISD classroom
• Family-centered play area

	John Honeycutt, M.D. – Medical Director, Neurosurgery Medical Director, Neuro-Trauma Co-Director of the Jane and John Justin Neurosciences Center at Cook Children's Specialties: Neurosurgery Education: University of Arkansas Medical Center, Little Rock, Ark. Residency: University of Oklahoma, Oklahoma City, Okla. Fellowship: University of Tennessee, Knoxville, Tenn. Dr. Honeycutt is one of the lead physicians of the neurosurgery program at Cook Children's. Aside from his work as a neurosurgeon, he is frequently consulted and asked his expert opinion on difficult cases.
	Daniel Hansen, M.D. – Neurosurgeon Specialties: Neurosurgery Education: University of Kansas School of Medicine, Kansas City, Kan. and Wichita, Kan. Residency: University of Iowa Hospitals and Clinics, Iowa City, Iowa Fellowship: Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
	Richard Roberts, M.D. – Neurosurgeon Specialties: Neurosurgery Education: Louisiana State University Medical School, New Orleans, La. Residency: Children's Hospital, New Orleans, La. (Pedi Neurosurgery) Fellowship: Children's Hospital of Philadelphia, Philadelphia, Pa.
	David Donahue, M.D. – Medical Director, Emeritus. Surgical Director, Pediatric Epilepsy Program of the John and Jane Justin Neuroscience Center Specialties: Neurosurgery Education: University of Tennessee College of Medicine, Memphis, Tenn. Residency: Baptist Memorial Hospital, Memphis, Tenn.; University of Tennessee, Memphis, Tenn.; Children's Memorial Hospital, Chicago, Ill. Fellowship: University of Tennessee, Semmes-Murphey Clinic, St. Jude Children's; Le Bonheur Children's Hospital, Memphis, Tenn. Awards/Recognition: Living Magazine: Best Doctors in America List 2015-2016, Super Doctors® Texas 2015

	Scott Perry, M.D. – Medical Director, Neurology Co-Director of the Jane and John Justin Neurosciences Center Medical Director, Tuberous Sclerosis Complex Clinic Specialties: Neurology Education: University of Mississippi School of Medicine, Jackson, Miss. Residency: Emory University School of Medicine, Atlanta, Ga. Fellowship: Miami Children's Hospital, Miami, Fla. Dr. Perry's clinical and research interests focus on the treatment of childhood onset epilepsy, specifically those patients with uncontrolled epilepsy or those for which the cause has not been determined.
	Warren Marks, M.D. – Medical Director, Movement Disorder and Neurorehabilitation Program Specialties: Neurology, Rehabilitation Education: Texas Tech University School of Medicine, Lubbock, Texas Awards/Recognition: Super Doctors® Texas 2015 Residency: University of Oklahoma College of Medicine, Oklahoma City, Okla. Fellowship: University of Oklahoma College of Medicine, Oklahoma City, Okla.
	Cynthia Keator, M.D. – Medical Director, Epilepsy Monitoring Unit Specialties: Neurology Education: University of Texas Health Science Center, Houston, Texas Residency: University of Colorado at Denver, Denver, Colo. Fellowship: University of Colorado at Denver, Denver, Colo. Dr. Keator has dedicated her career to the field of pediatric epilepsy, in part because there is always something new to learn, and especially because great strides are constantly being made in the medical treatments available to kids who are diagnosed with this condition.
	Jeffery McGlothlin, M.D. – Neurologist Specialties: Neurology, Neuro-Oncology Education: University of Texas Southwestern Medical Center, Dallas, Texas Residency: Baylor College of Medicine, Houston, Texas Fellowship: Baylor College of Medicine, Houston, Texas Awards/Recognition: Super Doctors® Texas 2015

Eric Hubli, M.D., FACS, FAAP, FICS – Medical Director of Craniofacial, Cleft and Plastic Surgery Specialties: Craniofacial Reconstruction Education: Tufts School of Medicine, Boston, Mass. Residency: Baystate Medical Center, Springfield, Mass.; Lahey Clinic Medical Center, Burlington, Mass. Fellowship: Lahey Clinic Medical Center, Burlington, Mass.; International Craniofacial Institute, Dallas, Texas Dr. Hubli brings 25 years of Craniofacial, Cleft and Pediatric Plastic Surgery experience to Fort Worth, Texas and the Cook Children's Healthcare System.

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