Founded in 1950 by Variety Clubs International, Nicklaus Children’s Hospital is South Florida’s only licensed specialty hospital exclusively for children, with approximately 800 attending physicians, including more than 500 pediatric subspecialists. The 307-bed hospital, known as Miami Children’s Hospital from 1983 through 2014, is renowned for excellence in all aspects of pediatric medicine with many specialty programs routinely ranked among the best in the nation by U.S. News & World Report since 2008. The hospital is also home to the largest pediatric teaching program in the southeastern United States and since 2003 has been designated an American Nurses Credentialing Center (ANCC) Magnet facility, the nursing profession’s most prestigious institutional honor.

The Nicklaus Children's Hospital network includes more than a dozen outpatient centers extending from Martin County to southern Miami-Dade County, offering a range of pediatric healthcare services, including urgent care, rehabilitation services and subspecialty physician appointments for children of all ages, including up to age 21.

We are committed to being a resource for children from throughout South Florida and around the world.

About Nicklaus Children's Health System

Nicklaus Children’s Health System is the parent organization of Nicklaus Children’s Hospital, South Florida’s only licensed specialty hospital exclusively for children. The 307-bed nonprofit hospital, known as Miami Children’s Hospital from 1983 through 2014, was founded in 1950 by Variety Clubs International and is renowned for excellence in all aspects of pediatric medicine, with many programs routinely ranked among the nation’s best by U.S. News & World Report. The health system also includes Nicklaus Children’s Hospital Foundation, the organization's 501c3 fundraising arm; a network of nonprofit outpatient and urgent care centers situated in Miami-Dade, Broward, Palm Beach and Martin counties; a nonprofit physician practice subsidiary; and an ambulatory surgery center. Nicklaus Children's Health System is the region’s only healthcare system exclusively for children.

Our vision is to create a healthy future for every child. Ultimately, this means being there through all stages of health and life, both physically and emotionally. To be a trusted partner to children and their families, not only in times of illness but throughout their life journey.

Our Mission

To inspire hope and promote lifelong health by providing the best care to every child.

Our Vision

To CREATE a healthy future for every child. 

Values and Guiding Behaviors

• C ollaboration
• R esponsibility
• E mpowerment
• A dvocacy
• Transformation
• E mpathy

Forward for the Children, 2023-2025 Strategic Plan

Nicklaus Children’s Health System is pleased to share our 2023-2025 Strategic Plan. As stewards of the region’s only freestanding children’s hospital – one that has served this community with distinction for more than 70 years – we recognize the critical importance of strategic planning and alignment. Our three-year plan guides our collaboration internally and within the broader community to advance our mission of providing the best care to every child.

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Become a Volunteer 

Volunteers are an important part of the patient-care process at Nicklaus Children's Hospital. Each makes a significant contribution to our mission of providing the highest quality healthcare to our patients.

Sponsor a Special Event

Special Events refer to visits that allow our patients the opportunity for hands-on participation and involvement via unique experiences and activities. Since many of our programs already provide ample craft and play opportunities daily, we value your creativity in proposing a visit which will provide our patients with a “one-of-a-kind” activity.

Make a Donation

Each year, our hospital provides thousands of children with the pediatric care they need. You can help us be there for the children by making an investment in their future through a contribution to Nicklaus Children's Hospital Foundation.

Join our Advocacy Team

Nicklaus Children's Hospital Department of Public Policy and Government Relations needs the support and involvement of parents, families, physicians and other interested individuals, as well as healthcare and community organizations, to ensure a better quality of life for all children. You can take an active role in ensuring that our young people enjoy a healthier and safer future by joining the Children’s Advocacy Network.

ENRICH Literacy Program

The ENRICH Literacy Program was created in collaboration with clinicians to educate and empower all parents to engage, nurture, and read to infants and children. The program provides resources for parents and educators in our community to increase literacy rates from birth and beyond.

Nicklaus Children's Hospital offers a wide array of resources for pediatric physicians, other pediatric healthcare providers and medical researchers. Whether you are a new pediatric physician looking for residency opportunities, a pediatric nurse looking into the Nicklaus Children's Hospital Nursing program or a member of our medical staff wanting to refer a patient or conducting research, this section will help you find the answers to your questions.

Pediatric Medical Education

The Nicklaus Children's Hospital Medical Education Department is committed to the oversight and provision of high-quality, evidence-based, and innovative education.

• Continuing Medical Education (CME)
• Graduate Medical Education (GME)
• Undergraduate Medical Education (UME)
• Maintenance of Certification (MOC)

For Pediatric Nurses

Nicklaus Children's Hospital is proud to have received multiple Magnet designations - a testament to our nurses and our commitment to pediatric health. Learn more about our nationally recognized nursing leadership.

• Art of Nursing
• Science of Nursing
• Horizon Nurse Residency Program
• Nursing Scholarships

For Students and Interns

Nicklaus Children's Hospital is committed to its role as a teaching hospital providing medical school rotations throughout most of the departments. 

• Clinical Programs
• Nursing Programs
• Administrative Health Programs
• General Healthcare Experience Programs

Latest News

In order to help families make an informed decision when considering where to seek healthcare for their child, Nicklaus Children's Hospital is making available a link to the consumer health website www.FloridaHealthFinder.gov

The State of Florida's FloridaHealthFinder website includes information regarding all ages of patients in all Florida hospitals and healthcare facilities. It is important to note that Nicklaus Children's Hospital is a specialty hospital licensed to serve children from premature newborns to 21 years of age.

The FloridaHealthFinder website displays information regarding:

• Number of patients admitted to the hospital or seen for specific procedures
• Average length of stay (days) in the hospital
• Average hospital charges
• Average readmission rates to the hospital
• Mortality rates
• Complication rates for various medical conditions and procedures
• Quality care indicators such as these are monitored very closely at our hospital, and our staff strives to perform at levels that are often times the standard for other hospitals nationwide.

Hospital Services

While reviewing the data pertaining to Nicklaus Children's Hospital you may find the following information helpful in clarifying our unique services:

Neonatal Intensive Care Unit (NICU)

Nicklaus Children's Hospital has a Level 3 NICU. Level 3 represents the highest level of services that any hospital can provide a newborn. Because we do not have a maternity department nor do we birth infants at Nicklaus Children's Hospital other hospitals throughout Florida, U.S. Territories, and Atlantic/Caribbean countries regularly send their seriously ill newborns to our NICU for specialized, comprehensive medical and surgical care. Learn more.

Burn Centers

The State of Florida has designated 4 trauma centers throughout the state as 'burn centers'. These burn centers offer comprehensive, specialized care for the most serious burns (3rd degree burns or 2nd degree burns affecting a significant percent of the patient's body surface area) as outlined by the American Burn Association. Any pediatric patient who comes to Nicklaus Children's Hospital with a burn receives initial treatment at the Nicklaus Children's Hospital Emergency Department. All pediatric burn patients with a mild to moderate burn (1st degree burn to a 2nd degree burn affecting a less expansive of the body surface area) will remain at Nicklaus Children's Hospital for treatment. All severe burn patients are transferred to the designated burn unit in the region.

Trauma Center

Nicklaus Children's Hospital is a state approved pediatric trauma center. Nicklaus Children's is proud to be one of only two freestanding pediatric trauma centers in the State of Florida; and the only freestanding pediatric trauma center in South Florida. Learn more.

Pediatric Open Heart

Nicklaus Children's Hospital, a Children's Medical Services (CMS) Pediatric Cardiovascular Center, performs more cardiac procedures with better outcomes than any other facility in the region. Learn more.

Adult Open Heart

Since Nicklaus Children's Hospital is a pediatric facility that provides care for children 21 years of age and younger, The Heart Institute treats only a limited number of cases where the patient is between the ages of 18-21 years.

Organ Transplantation

Nicklaus Children's Hospital is a certified Bone Marrow Transplantation center. The Nicklaus Children's Hospital Bone Marrow Transplantation Program has been accredited by The Foundation for Accreditation of Hematopoietic Cell Therapy (FAHCT).

Nicklaus Children's Hospital works with patients and families to select the optimal transplant center for the specific organ and medical condition of the patient. Learn more.

Statutory Teaching Hospital

Nicklaus Children's Hospital is not listed as a statutory teaching hospital on the FloridaCompareCare website.

A statutory teaching hospital is defined as "any Florida hospital officially affiliated with an accredited Florida medical school". Nicklaus Children's Hospital is affiliated with the State University of New York (SUNY), an accredited medical school which is located in New York, not Florida. Nicklaus Children's is a world leader in pediatric medical education and is the largest freestanding pediatric teaching hospital in the Southeastern United States. Learn more.

Psychiatric Acute Care

Nicklaus Children's Hospital provides psychiatric acute care services for the pediatric population only. Learn more.

Rehabilitation Care

Nicklaus Children's Hospital works with patients and families to select the optimal rehabilitation program based on the child's specific needs. Learn more.

Rural Hospital

Nicklaus Children's Hospital is located in Miami, FL, a metropolitan area in the southeastern part of the state.

Critical Care Access Hospital

Nicklaus Children's Hospital does not meet the criteria of a Critical Care Access Hospital based on the fact that the hospital is not located in a rural area.

By definition, a Critical Care Access Hospital is a hospital located in a rural area that must maintain key services for patients needing critical care, as designated by the Social Security Act and certified by the Secretary of Health and Human Services.

Primary Stroke Center

Nicklaus Children's Hospital is not a Primary Stroke Center due to the fact that this category is applicable solely to adult acute care facilities.

Comprehensive Cancer Center

Nicklaus Children's Hospital is not a National Cancer Institute-designated Comprehensive Cancer Center.

The Nicklaus Children's Hospital Cancer Center has received national recognition and full member status in the Children Oncology Group (COG), a national cooperative oncology research group, and was awarded a grant by the National Cancer Institute for pediatric cancer research. Nicklaus Children's Hospital provides care for more pediatric cancer patients than any other hospital in South Florida. Learn more.

Risk Adjusted Average Charge Data

The risk adjusted average charge data contains charge information from hospitals and healthcare facilities throughout the State of Florida. While Nicklaus Children's Hospital average charge data is higher than the statewide average, please note that the cost of living in Miami-Dade County is 17.9% higher than the average cost of living statewide*.

Please note that the data compares risk adjusted average charges for hospitals caring for adults, children, and newborns; thus, as a specialty hospital caring solely for acutely ill children and newborns, this overall state average is not optimal for purposes of comparison.

It may be more appropriate for parents/guardians to contact Nicklaus Children's Hospital directly in order to obtain a more accurate estimation of charges and/or receive counseling on the availability of known financial resources for their own child's potential healthcare needs.

Risk Adjusted Readmission Data

It is important to note that the risk adjusted pediatric data comparisons (i.e. readmission rate) provided on the FloridaCompareCare website are based on entire state populations (all age groups), not just the pediatric population (ages 0-17 years).

Nicklaus Children's Hospital clinical programs are highly acclaimed by peer children's hospitals across the country. We're here for the children and to help you make the right choice for your child's healthcare needs.

*Average cost of living calculated by Sperling's Best Place (www.bestplaces.net). Visit FloridaHealthFinder.gov, for more information.

Nicklaus Children's Hospital, part of Nicklaus Children's Health System, is Florida's pediatric care leader. The 307-bed pediatric specialty hospital and its network of pediatric outpatient centers offers comprehensive care for children of the region and beyond.

Our Campus

• The 40-bed Level III and Level II Neonatal Intensive Care Unit receives referrals of the most critically ill neonates from hospitals throughout South Florida, the Caribbean and Latin America.
• The 40-bed Pediatric Intensive Care Unit (PICU)Pediatric Intensive Care Unit receives referrals of complex cases from throughout the region and beyond.
• The 34-bed Cardiac Intensive Care Unit was the first in the Southeast, and provides care for newborns and children receiving treatment for congenital heart defects.
• Nicklaus Children’s Hospital is home to South Florida’s only freestanding pediatric trauma center and one of the most visited emergency rooms in the nation.

Our Community Outreach

Nicklaus Children’s Hospital contributes greatly to the well-being of Florida’s children and their families. Here’s how we make a difference in ways both BIG and small:

• The health system contributes millions of dollars in uncompensated care.
• The hospital is proud to be the largest provider of pediatric medical education in the southeastern United States.
• ​The hospital provides primary care and a medical home to the Medicaid population through its 10 Pediatric Care Centers.
• Dental services for underserved children and adolescents are offered at the Nicklaus Children’s Doral Outpatient Center. In addition, a Nicklaus mobile dental unit extends services to communities with little access to affordable dental care.
• Nicklaus Children’s Hospital’s School Health Program aims to improve access to quality healthcare through the delivery of health services and community resources to children in schools. The School Health Program is supported by two partnerships, one with The Children’s Trust serving 13 schools, and the other with the Department of Health and Miami-Dade County Public Schools, serving 62 schools. These programs bring RNs, APRNs, licensed social workers, care assistants and mental health therapists to more than 30,000 students in schools throughout Miami-Dade county.
• ​Nicklaus Children’s Hospital has served children from every single county in Florida, providing care that only a world-class children’s hospital makes possible.
• Nicklaus Children’s Virtual Care offers convenient access to pediatric care through the hospital’s Telehealth Center, bringing expert care and peace of mind to families in the comfort of their homes.
• Through the Nicklaus Children’s Research Institute, the hospital contributes significantly to pediatric medical research, with approximately 300 research protocols underway with potential to advance future clinical offerings for children around the globe.

• Nicklaus Children’s is the exclusive member hospital for Children’s Miracle Network in the region, serving eight counties in South Florida and the Treasure Coast. Visit give.nicklauschildrens.org

Awards, Highlights and Achievements

Mission

To inspire hope and promote lifelong health by providing the best care to every child.

Vision

To create a healthy future for every child.
 

Values and Guiding Behaviors

• Collaboration
• Responsibility
• Empowerment
• Advocacy
• Transformation
• Empathy

Search our phone number listings and department phone number directory.

To search for a physicians' office please search using the physician directory.

Ethics & Compliance

Nicklaus Children's Hospital is proud of its tradition of conducting its business in an ethical manner. To this end, Nicklaus Children's Hospital has established a compliance department and program to advance the prevention, detection and correction of violations of federal, state or local law or regulations governing health care and human services programs by employees, contractors of agents.  Our compliance staff is available as valuable resources in your decision making processes or to answer questions regarding the ethical conduct of business practices at Nicklaus Children's Hospital.
 

Denise Longman

Chief Compliance Officer
 (786) 624-3838
 Send email

Cory Hall

Information Security Officer
 (786) 624-6939
 Send email

Lisa Arenas

Privacy Officer
 (786) 624-3500
 Send email

Internal Audit

Internal Auditing is an independent, objective, assurance and consulting activity that adds value to and improves an organization's operations. It helps an organization accomplish its objectives by bringing a systematic, disciplined approach to evaluate and improve the effectiveness of risk management, control, and governance processes.

Remote User Citrix Access

If you are connecting from home or a computer other than a Nicklaus Children's Hospital computer please click here to login to the NCHS Portal.

We are dedicated to supporting an army of
curious problem solvers in their pursuit of:

Amazing Patient Care

Operational Excellence

Building the Future

The purpose of our Process Improvement Office is to:

• Facilitate operational and clinical continuous improvement across the organization.
• Connect the purpose and people of the organization from the top down and from the bottom up and across via formalized channels.
• Enable the mechanism for problems to be solved scientifically and locally, where they happen, when they happen, with top-level support to help build infrastructure to sustain improvement

The Process Improvement Team

The Process Improvement team is an exceptionally talented group who provide project facilitation, quality science training, and technical support, and analysis for accelerating clinical, and operational quality improvement across the organization.

Elise Hermes

Executive Director of Quality
 Email Elise

Fahd Lahrech

Manager, Quality and Data Sciences
CPIM, CQE, CMfgE, ML, MS, LSSBB
(305) 793-9579
Email Fahd

Mary Szabo

Project Management Coordinator
(786) 564-0225
Email Mary

Lazaro Alfonso

​Lead Quality Analytics Analyst
BSEE, BSMATH, MSEE, LSSBB
(​786) 624-5080
Email Lazaro

William Smit

Data/Quality Program Analyst
BME, MSCE
(786) 624-2392
Email William

Effective date: March 26, 2013
(Revised: July 17, 2020)

You may also download this notice in PDF form:

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CAREFULLY.

As a parent/legal guardian of a minor patient at Nicklaus Children’s Health System “NCHS”, you are the patient’s “personal representative.” When reading this Notice please understand that when we use the term “you” we mean the pediatric patient.

Applicability of Notice - This Notice describes the privacy practices of Nicklaus Children’s Health System and affiliated entities, including Nicklaus Children’s Hospital and outpatient facilities listed on the signature page. Each of these affiliated entities are legally separate covered entities, but for purposes of the HIPAA privacy rule designate themselves as a single covered entity and will each follow the terms of this Notice. For purposes of this Notice, the terms “NCHS,” “we” and “our” are used in this Notice to refer to Nicklaus Children’s Health System and its facilities and affiliated entities, including Nicklaus Children’s Hospital and outpatient facilities. Each of these entities may share information with each other for purposes of treatment, payment or health care operations as described in this Notice.

Privacy Obligations - NCHS is required by law to maintain the privacy of health information about you that can identify you (“Protected Health Information” or “PHI”), to provide you with this Notice of our legal duties and privacy practices with respect to your PHI, to notify you following a breach of protected health information and to abide by the terms of this Notice currently in effect. We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in each of the locations identified below. The Notice will contain the effective date. A copy of the current Notice will be made available to you when you initially register with Nicklaus Children’s Health System for treatment or services, upon your request, and on subsequent visits if the Notice has been revised.

Our Pledge - We understand that all information about you and your health is personal. We are committed to protecting this information. When you receive services at NCHS, a medical record is created. This record describes the services provided to you and is needed to provide you with quality care and to comply with certain legal requirements.
This Notice applies to care generated by NCHS, whether made by a NCHS employee or a doctor involved in your care at NCHS. This Notice tells you about the ways in which we may use and disclose your medical information. It also describes your rights and certain obligations we have regarding the use and disclosure of your medical information.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

The following categories describe different ways in which we use your health information within NCHS and may release your information to persons and entities outside of NCHS. We have not listed every use or disclosure within the categories, but all permitted uses and disclosures will fall within one of the following categories:

Uses and Disclosures for Treatment, Payment and Health Care Operations: : Your PHI may be used to treat you, to obtain payment services provided to you and to conduct “health care operations” as described below:

Treatment: Your health information may be used and disclosed to provide treatment and other services to you – for example, to diagnose and treat your injury or illness. We may disclose your PHI to doctors, nurses, technicians, medical students, interns, or other personnel who are involved in taking care of you during your visit with us or to individuals outside of NCHS who are also part of your healthcare team.
Payment: Your PHI may be used and disclosed to your insurance company or other third party to collect payment for services. For example, we may need to give your health plan information about surgery you received while here so that they will pay us or reimburse you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Exception: If you pay out of pocket in full for a health care item or service, you have the right to restrict certain disclosures of your PHI to your health plan (see section on ‘Right to Request Restrictions’).

Health Care Operations: Your PHI may be used and disclosed in connection with our health care operations. For example, your PHI may be used to conduct quality assurance activities, such as for evaluating the quality and competence of physicians, nurses and other health care workers; to perform customer service activities, or for investigating complaints. We may also disclose this information to our business associates who assist us with administrative and other functions. We require our business associates to appropriately safeguard the health information of our patients.

Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services - We may use and disclose your PHI to contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fundraising Activities - NCHS may use or disclose health information about you to contact you in an effort to raise money for our organization and its operations. We may disclose this information to the Nicklaus Children’s Health Foundation to assist us in our fundraising activities. Only contact information such as your name, address and telephone number, and the dates you received treatment or services at NCHS would be released. You have the right to opt out of fundraising communications at any time and your request must be honored. If you would like to opt-out of receiving fundraising communications, please notify our Privacy Officer in writing or make your opt-out request using the method provided to you with every fundraising communication.

SITUATIONS WHERE YOU HAVE AN OPPORTUNITY TO AGREE OR OBJECT TO USES AND DISCLOSURES OF YOUR PHI

Hospital Directory - Nicklaus Children’s Hospital may include your name, location in the hospital, general health condition (e.g. fair, stable, etc.), and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory. This information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing.

Individuals Involved in Your Care or Payment for Your Care - Your PHI may be disclosed to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care. Before we disclose your medical information to a person involved in your health care or payment for your health care, we will provide you with an opportunity to object to such uses or disclosures. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest.

SPECIAL SITUATIONS THAT DO NOT REQUIRE YOUR AUTHORIZATION

In certain circumstances, federal or state laws may require or allow us to provide your PHI to the following agencies without any oral or written permission from you:

Public Health Authorities/Health Oversight Agencies - We may disclose your medical information for public health activities, including for the reporting of disease, injury, vital events such as birth or death, and for the conducting of public health surveillance, investigation and/or intervention. We may disclose your medical information to a health oversight agency for oversight activities authorized by law, including for audits, investigations, inspections, licensure or disciplinary actions, administrative and/or legal proceedings or actions.

Abuse or Neglect - In accordance with federal and state law, we may disclose your PHI when it concerns abuse, neglect, or domestic violence to you. We are required to report suspected child or vulnerable adult abuse or neglect to the Florida Department of Children and Families Central Abuse Hotline.

Department of Health and Human Services/Florida Agency for Health Care Administration (the “Agency”) - We may disclose your PHI when required by the United States Department of Health and Human Services as part of an investigation or a determination of our compliance with relevant laws. We may disclose your PHI to the agency for purposes of health care cost containment or in response to a subpoena.

In Connection with Judicial and Administrative Proceedings - We may disclose your PHI in any civil or criminal action, unless otherwise prohibited by law, in response to a court or administrative order or if compelled by subpoena at a deposition, evidentiary hearing, or trial, but only if efforts have been made to tell you about the request.

Law Enforcement - We may disclose your PHI to a law enforcement official or the medical examiner to alert them about a death we believe may be the result of criminal conduct. We may notify a law enforcement official if you were injured in a motor vehicle crash and your blood alcohol level is above the legal limit. We are required to report to local law enforcement officials any gunshot wound or life-threatening injuring indicating an act of violence.

National Security and Intelligence Organizations - We may disclose your PHI for specialized governmental functions, such as national security and intelligence activities, and for the provision of protective services to the President.

Coroners, Medical Examiners, and Funeral Directors - We may disclose your PHI to coroners, medical examiners or funeral directors consistent with applicable law to carry out their duties.

Organ and Tissue Donation Organizations - If you are an organ donor, we may disclose your medical information to an organ donation and procurement organization.

Workers’ Compensation Agents - We may release your PHI for workers’ compensation or similar programs.

Military Command Authorities - If you are a member of the armed forces, we may disclose your PHI as required by military command authorities.

Correctional Institutions - We may disclose your medical information to a correctional institution having lawful custody of you if doing so would be necessary for your health and the health and safety of other individuals.

Emergency Circumstances and Disaster Relief - Your PHI may be used or disclosed to a public or private entity authorized by law or by its charter to assist in disaster relief efforts (such as the Red Cross).

To Avert a Serious Threat to Health or Safety - We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to a government agency or authority that is able to help prevent the threat.

Research - Under certain circumstances and provided that your identity is protected, we may use and disclose medical information about you for statistical and research purposes, including research planning and the creation of research proposals as long as Protected Health Information is not removed, copied, or compromised.

As Required by Law - We will disclose your PHI when required to do so by federal, state or local law.

If a use or disclosure of health information described above in this Notice is prohibited or materially limited by state law, it is our intent to meet the requirements of the more stringent law.

SITUATIONS THAT REQUIRE YOUR AUTHORIZATION

Special Protections for HIV, Alcohol and Substance Abuse, Mental Health, and Genetic Information - State and/or federal laws may place restrictions on the manner in which specific types of PHI may be used and/or to whom such medical information may be disclosed, such as HIV status, alcohol and substance abuse treatment, psychiatric treatment, and genetic information. In those instances where the use and/or disclosure of this PHI is specifically restricted, we will seek appropriate authorization from you, your legal representative or a court of law/administrative tribunal before using or disclosing this information.

Marketing - We will not use your PHI for marketing purposes without your authorization. If you have consented to receive marketing information but no longer wish to receive further information, please notify our Privacy Officer in writing to make your opt-out request.

Sale of PHI - We will not disclose your PHI in return for any financial compensation without your authorization.

Research - We may share your health information with researchers after you have signed a specific written authorization for a specific research study. In very limited circumstances, we may share your health information with researchers when the Institutional Review Board (IRB) issues a waiver after having ensured that safeguards are in place to protect your privacy. An IRB is a committee responsible for protecting individual research subjects and ensuring that research is conducted ethically. All research projects are subject to special approval by the IRB. Your health information will not be used and you will not be asked to participate in a research project that is not reviewed and approved by an IRB.

Other Uses and Disclosure of Your PHI - Other uses and disclosures of your PHI not covered by this Notice or the laws that apply to NCHS will be made only with your written permission (authorization), which authorization may be revoked as described below.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

Right to Request Restrictions - You have the right to request limits on the use of your medical information for either treatment, payment or health care operations. You also have the right to request a limit on medical information we disclose to someone who is involved in your care or the payment of your care, such as a family member or friend. For example, you could ask that we not disclose information about a surgery you had. To request restrictions, the request must be made in writing to the Nicklaus Children’s Health System Health Information Management Department. If your health care provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If Nicklaus Children’s Health System does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.

Out-of-Pocket Payments - If you make a payment in full at the time of, or prior to, receiving an item or service from Nicklaus Children’s Health System, you have the right to request that your Protected Health Information with respect to that item or service not be disclosed to your Health Plan. We will honor your request as long as financial obligations are met.

Right to Request Confidential Communications - You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests. To request restrictions, the request must be made in writing to the Health Information Management Department.

Right to Inspect and Copy - You have the right to inspect and/or receive a copy of any medical information maintained about you that may be used to make decisions about your care or payment for your care. Typically, this will include your medical and billing records, but not psychotherapy notes. If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy be given to you or transmitted to another individual or entity.

To inspect and/or get a copy of your medical or billing records you must submit your request in writing to:

Nicklaus Children’s Health System
Health Information Management Department
Attention: Director
3100 S.W. 62 Avenue
Miami, Florida 33155-3009

We may charge a reasonable fee for copying and mailing the records. We may deny your request in certain limited circumstances. If your request is denied, you may request that your denial be reviewed. Such reviews will be performed by an independent licensed healthcare professional chosen by our Privacy Officer. We will comply with the outcome of the review.

Right to Amend - If you feel that information about you is incorrect, you may ask us to amend the record. To request an amendment, the request must be made in writing to the Health Information Management Department at the address noted above. In addition, you must provide a reason that supports your request. We are not obligated to comply with your request to amend your record.

Right to Revoke your Authorization - If you provide us with authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we provided to you. A form of written revocation is available upon request from our Health Information Management Department.

Breach Notification - In certain instances, you have the right to be notified in the event that we, or one of our Business Associates, discover an inappropriate use or disclosure of your health information. Notice of any such use or disclosure will be made in accordance with state and federal requirements.

Accounting of Disclosures - You have the right to request an «accounting of disclosures.» This is a list of disclosures that we have made of your PHI. We are not required to list certain disclosures, including (1) disclosures made for treatment, payment, and health care operations purposes, (2) disclosures made with your authorization, (3) disclosures made to create a limited data set, and (4) disclosures made directly to you. You must submit your request in writing to our Health Information Management Department. Your request must state a time period which may not be longer than 6 years before your request. Your request should indicate in what form you would like the accounting (for example, on paper or by e-mail). The first accounting you request within any 12-month period will be free. For additional requests, we may charge you for the reasonable costs of providing the accounting. We will notify you of the costs involved and you may choose to withdraw or modify your request before any costs are incurred.

Right to a Paper Copy of this Notice - You have a right to a paper copy of this Notice, even if you agreed to receive it electronically. Please contact us as directed below to obtain this Notice in written form.

Foreign Language Version - If you have difficulty reading or understanding English, you may request a copy of this Notice in Spanish or Creole. Additional languages or formats will be made available upon request.

QUESTIONS OR CONCERNS

If you would like more information about our privacy practices or have questions or concerns about this Notice, please contact our Privacy Officer at the number listed below.
If you believe your privacy rights have been violated, you may file a complaint, in writing, to the NCHS Privacy Officer located at:

Nicklaus Children’s Health System Privacy Officer
3100 S.W. 62 Avenue
Miami,  Florida  33155-3009
Telephone:  (786)  624-3838

or you may contact the Secretary of the U.S. Department of Health and Human Services (HHS).

To file a complaint with the U.S. Department of Health and Human Services, you may call toll free 1-877-696-6775 or visit the website of the Office of Civil Rights at www.hhs.gov/ocr/privacy. You can also mail a written request to:

Office for Civil Rights
U.S. Department of Health and Human Services
Sam Nunn Atlanta Federal Center
Suite 16T70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909

NICKLAUS CHILDREN’S HEALTH SYSTEM FACILITIES AND AFFILIATED ENTITIES

• Nicklaus Children’s Hospital
• Nicklaus Children’s Urgent Care Centers
• Nicklaus Children’s Outpatient Centers
• Nicklaus Children’s Pediatric Specialists
• Nicklaus Children’s Health System Foundation

Every three years not-for-profit hospitals are required to conduct a Community Health Needs Assessment (CHNA) of the local populations they serve.

Our goal in conducting the assessment was to better understand the health status, behaviors, and needs of children and adolescents in South Florida so that we as a community – patients, families, Nicklaus Children’s, and partner organizations – can optimally support their health and wellbeing. Information on both the CHNA and Implementation Plan can be found below.

 

Report

Download 2022 Community Health Needs Assessment Report (PDF)

 

Implementation Plan

Download 2022-25 Implementation Plan (PDF) 

Implementation Plan Goals

Access to Community and Health Services

• Enhance access to timely, equitable and comprehensive medical, social, behavioral health and wellness services for children and their families in traditional and non-traditional settings.
  • Increase care coordination and collaboration within the intersecting systems of health, social and community services (collaborators) through the development of collaborations.
  • Continue to enhance hospital care coordination through new strategies that address culture, language, etc.
  • Increase utilization of primary care and social service systems.

Health Education

• Empower parents and children to lead healthy lifestyles by providing culturally, linguistically, and developmentally tailored education and resources.
  • Increase awareness of preventative primary care, and knowledge and utilization of appropriate levels of care, through educational campaigns and messages.
  • Increase points of distribution for nutrition education materials and resources in each of The Children's Trust defined priority zip codes.
  • Promote community understanding of comprehensive health and safety through the implementation of community initiatives.

Children’s Mental Health

• Promote overall mental wellness of children and adolescents by engaging an ecosystem of support and services for them and their families.
  • Implement mental wellness initiatives for children and youth.
  • Expand intervention services across the ecosystem for children and their families through collaborative initiatives.
  • Increase skills and capacity throughout the ecosystem to respond to mental health crisis among children and youth through training opportunities.

Previous Reports

• Community Health Needs Assessment 2020
  • 2021 Implementation Plan
• Community Health Needs Assessment 2018
  • 2018 implementation Plan
• Community Health Needs Assessment 2015
  • 2015 Implementation Plan
• Community Health Needs Assessment 2012

We are now on NAFCAS!

There are two ways to apply to the Nicklaus Children's Administrative Fellowship Program:

1. Apply via the National Administrative Fellowship Centralized Application Service (NAFCAS)website and then submit a copy of your NAFCAS application materials to our Career Portal by September 27, 2024 at 11:59PM EST.
2. Apply directly through our Career Portal by September 27, 2024 at 11:59PM EST.

Applicants who apply via the Career Portal will be asked to upload:

1. Resume
2. Personal Statement (one page, single spaced, 11-point Times New Roman Font) answering the following questions:
   1. Why are you interested in Nicklaus Children's Health System?
   2. What are your future career objectives within healthcare administration?
   3. How will this fellowship help you to obtain your goals?
3. Official graduate school transcripts (from all universities attended)
4. Three letters of recommendation (1 professional, 1 academic, & 1 academic or professional)

Fellowship Application Timeline

Application Receipt Deadline: September 27, 2024 at 11:59PM EST
Selection Announcement: November, 2024
Start Date: June 2025 (Date Negotiable)

Qualifications

• Recent graduates with an MHA, MSHA, MHSA, MPH, MBA with an emphasis in healthcare management, or degree equivalent to the aforementioned studies.
• Applicants from CAHME accredited programs are strongly preferred.
• Applicants completing the fellowship as a requirement for graduation are welcome to apply.

Salary and Benefits

Nicklaus Children’s Health System will provide a salary that is competitive with the industry and a comprehensive benefits package that includes medical, dental, vision, life and disability insurance. In addition, reimbursement and travel expenses to one health care conference of the fellow’s choosing will be provided.

Selection Process

The fellowship selection process is highly competitive. Each application will be given careful review, upon which qualified applicants will be contacted for first-round phone-interviews. After the round of phone-interviews, selected candidates will be invited to further rounds of interviewing via video conference. Later, interviews with the executive leadership team will occur on-site, COVID-permitting.

Please note that completion of the one-year fellowship does not guarantee prolonged employment within Nicklaus Children’s Health System. Nicklaus Children’s Health System is an equal opportunity employer. Selection of applications will be conducted without regard to race, religion, creed, sex, national origin or disability.

Incomplete applications will not be considered. Again, please submit all materials as a consolidated PDF to the aforementioned contact person. Nicklaus Children’s maintains the right to modify the application timeline (selection dates) as time and schedules permit.

The following list contains examples of past projects that fellows have worked on at Nicklaus Children's Hospital:

Past Projects

• Advanced Pediatric Care Pavilion Inpatient Demand Analysis
• Ambulatory Care Center Construction/Expansion
• Ambulatory Surgery Center Project Management
• Budget (Operational and Capital) Planning
• Developing Bioethics Committee
• Evaluating Value Based Care Programs
• Management Services Organization (MSO) Development and Coordination
• Master Facility Planning
• Observation Case Task Force
• Pediatric Health Optimization Program Development
• Population Health and Health System Integration Framework Development
• Primary Care Strategic Planning
• Process Improvement
• Service Provision Analyses for Joint Ventures
• Telehealth Strategic Planning, Development, and Operations

Upon review of the following FAQs, if you are unable to find the information and answers you were looking for, please feel free to contact the current fellows.

Can I apply for the Nicklaus Children's Health System Administrative fellowship on NAFCAS? 

Yes, applicants can now apply for our fellowship on the National Administrative fellowship Centralized Application Service (NAFCAS) website. Individual applications can still be submitted through the process outlined under the Application Requirements tab, if applicants choose not to utilize NAFCAS.

When are the application materials due?

September 27, 2024, at 11:59 p.m. EST. Applications received after this date will not be considered.

What documents should I submit for consideration of the 2025-2026 fellowship program?

Updated resume, official graduate school transcripts (from all institutions attended), completed Nicklaus Children’s Health System fellowship Application (including Personal Statement), and and 3 letters of recommendation (1 professional, 1 academic, & 1 academic or professional). All materials should be submitted as a consolidated PDF, letters of recommendation should be sent separately from recommendation writers.

When will the 2025-2026 fellows be selected?

Early November 2024 is when the selected fellows and all other applicants will be notified of a decision.

How long is the administrative fellowship and when is the start date?

One year (12 months) beginning in June or July (negotiable).

How many fellows are selected each year?

Two.

Can the current fellows be contacted with further questions about the application/fellowship experience to date?

Absolutely. Comments and questions are most welcome. You can reach the current fellows via email at Adminfellows@NicklausHealth.org

How long has the Nicklaus Children’s fellowship Program existed?

The fellowship program has existed for over 12 years.

Can the administrative fellowship program substitute as the administrative residency requirement for my university’s degree program?

Yes, it can serve as a substitute for university required administrative residencies.

Does the administrative fellowship choose students from any university?

Nicklaus Children’s has a strong preference for choosing qualifying applicants from a CAHME-accredited graduate program, but applicants from non-CAHME-accredited programs will also be considered.

Will applicants to the program be notified of the status of their final application?

Yes, all applicants who are no longer considered for the fellowship program will be notified in writing on a timely basis.

Will the fellows have the opportunity to attend senior leadership meetings?

Yes. The fellows will have many opportunities to attend a diverse range of meetings throughout the organization, including but not limited to Executive Leadership Team (ELT) meetings, Board of Directors meetings, finance and investment committees, technology committees, physician advisory councils, chiefs and heads (medical executive meetings), and health system strategic planning meetings.

Are rotations preselected or based on the interest of the fellows?

The fellows must rotate through core departments, which include Finance, Clinical Service Lines, Information Technology, and Hospital Operations areas. In addition to these rotations, the fellows will have full opportunity to select specific areas of interest for rotation.

What facilities are owned/operated by Nicklaus Children's Health System?

Please visit our Locations page for a full list of facilities.

Where will the fellows be based?

The fellows will be based at the Main Campus (Miami, FL) but there will be sufficient opportunity to assist at each of the health system’s entities.

Is there a requirement that the fellows accept a position after completing the fellowship?

No.

Is there any obligation for Nicklaus Children’s to hire the fellows upon completion of the fellowship program?

No.

Is there a requirement that the fellows be bilingual in English and Spanish?

No. However, fluent or at least conversational Spanish will be helpful in your interaction with the culture of Miami. 

Culture

Attractions

• History Miami
• Vizcaya Museum
• Fairchild Gardens
• The Everglades
• Zoo Miami
• Miami Seaquarium
• Arsht Center

Recreation and Sports

• Greater Miami Chamber of Commerce
• Greater Miami and the Beaches
• Key Biscayne, FL
• American Airlines Arena
• The Miami Dolphins
• The Miami Marlins
• The Miami Heat
• University of Miami Athletics
• Florida International University Athletics

Professional Associations

• Florida Agency for Healthcare Administration: www.ahca.myflorida.com
• American College of Healthcare Executives (ACHE): www.ache.org
• Healthcare Financial Management Association (HFMA): www.floridahfma.org
• National Association of Health Service Executives (NAHSE): www.nahse.org
• Medical Group Management Association of Florida (FMGMA): www.flmgma.com

Links available in this page are not necessarily endorsed, reviewed, or sponsored by Nicklaus Children's Hospital, by clicking on any of the links, you will be leaving Nicklaus Children's Website.

Current Administrative Fellows

Previous Administrative Fellows

2023 - 2024 Fellow

Meredith Steinfeldt, MPH
Tufts University School of Medicine
Manager, Administrative Services
Nicklaus Children’s Health System
Email: meredith.steinfeldt@NicklausHealth.org

2022 – 2023 Fellow

Madeline Cremin, MHA
University of Missouri School of Medicine
Business Analyst
Mayo Clinic

2021 - 2022 Fellow

Leigh Bouskila, MHA
Columbia University Mailman School of Public Health
Director, Practice Development & Support Services
Nicklaus Children’s Health System
Email: leigh.bouskila@nicklaushealth.org

2020 - 2021 Fellow

Alex Wolfred, MHSA
Xavier University
Implementation Manager, Population Health & Wellness
Kroger Health

2019 - 2020 Fellow

Megan Murphy, MBA, MHA
University of Missouri
Manager, Telemedicine
University of Missouri Health Care

2018 - 2019 Fellow

Jasmine Oesch, MHSA
University of Michigan
Senior Project Manager, Division of General Medicine
Michigan Medicine

2017 - 2018 Fellow

Mayra Caswell, MHA
Tulane University
Grant Coordinator
CMC Community Health Foundation

2016 - 2017 Fellow

Umar Ahmad, MHA
Texas State University
Program Manager
UNC Health Care

2015 - 2016 Fellow

Sofia Debs, MHA
Saint Louis University
Manager, Healthcare Strategy
Baptist Health South Florida

2014 - 2015 Fellow

Brian Gurucharri, MHA
University of Florida
Associate Administrator
Manatee Memorial Hospital 

​2013 - 2014 Fellow

Peter Carr, MHSA, MSHI
The University of Alabama at Birmingham
Director, Digital Health & Innovation
Moffitt Cancer Center

​2012 - 2013 Fellow

Briana (Rader) Sikir, MSHA
The University of Alabama at Birmingham
Program Manager, Strategy and Business Development
Northwestern Medicine

The Division of Neurosurgery offers state of the art surgical management of disorders of the nervous system including:

Among the special procedures performed by the ENT physicians at Nicklaus Children's are:

• Head and neck cancer and tumor surgery
• Diagnostic and therapeutic surgery for pediatric airway disorders
• Speech fluoroscopy
• Removal of foreign bodies from the ears, nose and throat
• Treatment for complex head and neck tumors
• Treatment of symptoms resulting from cystic fibrosis
• Tonsillectomy and adenoidectomy for children with bleeding disorders
• Routine procedures performed on children with high-risk medical problems
• Evaluation and treatment for facial trauma
• Routine and complex surgery for pediatric sinus disease
• Treatment for craniofacial disorders
• Treatment for complex airway diseases
• Treatment for various pediatric otology and neurotology diseases, including mastoid disorders and tumors of the cerebellopontine angle
• Additionally, physicians perform reconstruction of the eardrum or associated ossicles and repair of congenital aural atresia

Health and Safety Resources

Financial Support

Child Care

Child Development

Other Important Resources

The following information guides are provided to educate patients in the most common dental concerns in children and children with specific conditions or diseases that require extra care to maintain healty teeth.

Nicklaus Children's Hospital's Telehealth Center is a high-tech program designed to advance pediatric care for children around the world through enhanced access to pediatric subspecialty physicians and remote reading of diagnostic tests by highly trained experts.

For more information, please call Global Health at 305-662-8281 or email globalhealth@nicklaushealth.org

Physician-to-Physician Videoconferencing

The center makes possible sophisticated videoconferencing, bringing together referring physicians from countries all over the world to consult with renowned subspecialty physicians based at Nicklaus Children's Hospital. Physician-to-physician consultative offerings include:

• Pediatric subspecialist consults
• Emergency care consults
• Complex multi-specialty team consultations
• Second opinions

Remote Reading of Diagnostic Tests

Nicklaus Children's Hospital also offers remote reading of diagnostic tests. The imaging teams at Nicklaus Children's Hospital, are among the region’s most experienced at reviewing and interpreting diagnostic tests.

Consultative Services with a Pediatric Leader

Nicklaus Children's Hospital, is one of the leading pediatric hospitals in the United States, with a 650-member medical staff that includes experts in virtually every pediatric subspecialty.

Consultations can be scheduled with individual subspecialists or a team of subspecialists as needed. Medical translation services are also provided when needed to support communications.

Offering Benefits for Overseas Patients and Partners

The Telehealth Center offers benefits to our overseas patients, physician colleagues and insurers.

• Participation in plan of care
• Educational opportunities
• Quality service offerings
• Efficient response time

Benefits to Overseas Patients

Physician-to-physician consultative services benefit patients in many ways. Families avoid the stress and expense of traveling, saving on airfare, local transportation and accommodations. They also avoid missing school and work days.
 

For More Information

The Nicklaus Children's Hospital Telehealth Center is a service of Global Health Services, which offers coordinated care and ease of access for international children and their families. For more information, please call Global Health at 305-662-8281 or email globalhealth@nicklaushealth.org

Nicklaus Children's Hospital's Telehealth Center is a high-tech program designed to advance pediatric care for children around the world through enhanced access to pediatric subspecialty physicians and remote reading of diagnostic tests by highly trained experts.

For more information, please call Global Health at 305-662-8281 or email globalhealth@nicklaushealth.org

Physician-to-Physician Videoconferencing

The center makes possible sophisticated videoconferencing, bringing together referring physicians from countries all over the world to consult with renowned subspecialty physicians based at Nicklaus Children's Hospital. Physician-to-physician consultative offerings include:

• Pediatric subspecialist consults
• Emergency care consults
• Complex multi-specialty team consultations
• Second opinions

Remote Reading of Diagnostic Tests

Nicklaus Children's Hospital also offers remote reading of diagnostic tests. The imaging teams at Nicklaus Children's Hospital, are among the region’s most experienced at reviewing and interpreting diagnostic tests.

Consultative Services with a Pediatric Leader

Nicklaus Children's Hospital, is one of the leading pediatric hospitals in the United States, with a 650-member medical staff that includes experts in virtually every pediatric subspecialty.

Consultations can be scheduled with individual subspecialists or a team of subspecialists as needed. Medical translation services are also provided when needed to support communications.

Offering Benefits for Overseas Patients and Partners

The Telehealth Center offers benefits to our overseas patients, physician colleagues and insurers.

• Participation in plan of care
• Educational opportunities
• Quality service offerings
• Efficient response time

Benefits to Overseas Patients

Physician-to-physician consultative services benefit patients in many ways. Families avoid the stress and expense of traveling, saving on airfare, local transportation and accommodations. They also avoid missing school and work days.
 

For More Information

The Nicklaus Children's Hospital Telehealth Center is a service of Global Health Services, which offers coordinated care and ease of access for international children and their families. For more information, please call Global Health at 305-662-8281 or email globalhealth@nicklaushealth.org

What is fMRI?

Functional magnetic resonance imaging (fMRI) is a development of MRI techniques that allows visualization of brain functions related to specific tasks. The study does not require any substance to be administered since it is based on the indigenous brain vascular response, requiring only cooperation for periods ranging from 15 to 60 minutes.

To date, several tasks have been utilized for mapping the brain cortex. Simple tasks include stimuli based on presentation of light, colors, tones, chords, music, syllables, movement of fingers and basic sensory perceptions. More complex and refined experiments have been implemented to map subtle cognitive functions. Currently, there is a vast armamentarium for mapping memory, attention, inhibition, face recognition, sensory discrimination, fear, etc.

However, most fMRI work has been directed in mapping language. Language mapping has been performed in children and adults. Reading, listening to meaningful text, generating words, making semantic decisions, are the most frequent paradigms described in the abundant current literature on fMRI. The technique has received ample acceptance among neuroscientists interested in epilepsy for the potential it has to become a tool to replace the Wada test.

T1 weighted MRI

Transverse image at the level of the planum temporale. The left hemisphere is seen in the right side (radiological convention). The subject's task was listening to a story.
The red bubble seen on the left side corresponds to areas related to complex semantic processing.

Functional MRI is based on small signal changes that result from the following cascade of events. A task elicits activation in one or several brain areas. These areas increase their metabolic demands, suffer vasodilatation, and alter their levels of deoxyhemoglobin and oxyhemoglobin. Since deoxyhemoglobin is a paramagnetic molecule, it influences the phase of local proton-spins, altering the source signal that is converted into images. Therefore, the image is a representation of local changes of levels of deoxyhemoglobin, related to the brain region performing a task.

Although fMRI is almost risk-free, it cannot be performed in patients with claustrophobia, metal implants, wires and pace-makers. Patients with vagal nerve stimulators, or dental braces, may be included. However, some degradation of the images is expected.

Research and studies conducted by:

Dr. Nolan Altman and Dr. Byron Bernal of the Radiology Department

Go to a Section

Clinical Cases Language Mapping Auditory Mapping 3D fMRI

fMRI in Sedated Children

What is fMRI?

Functional magnetic resonance imaging (fMRI) is a development of MRI techniques that allows visualization of brain functions related to specific tasks. The study does not require any substance to be administered since it is based on the indigenous brain vascular response, requiring only cooperation for periods ranging from 15 to 60 minutes.

To date, several tasks have been utilized for mapping the brain cortex. Simple tasks include stimuli based on presentation of light, colors, tones, chords, music, syllables, movement of fingers and basic sensory perceptions. More complex and refined experiments have been implemented to map subtle cognitive functions. Currently, there is a vast armamentarium for mapping memory, attention, inhibition, face recognition, sensory discrimination, fear, etc.

However, most fMRI work has been directed in mapping language. Language mapping has been performed in children and adults. Reading, listening to meaningful text, generating words, making semantic decisions, are the most frequent paradigms described in the abundant current literature on fMRI. The technique has received ample acceptance among neuroscientists interested in epilepsy for the potential it has to become a tool to replace the Wada test.

T1 weighted MRI

Transverse image at the level of the planum temporale. The left hemisphere is seen in the right side (radiological convention). The subject's task was listening to a story.
The red bubble seen on the left side corresponds to areas related to complex semantic processing.

Functional MRI is based on small signal changes that result from the following cascade of events. A task elicits activation in one or several brain areas. These areas increase their metabolic demands, suffer vasodilatation, and alter their levels of deoxyhemoglobin and oxyhemoglobin. Since deoxyhemoglobin is a paramagnetic molecule, it influences the phase of local proton-spins, altering the source signal that is converted into images. Therefore, the image is a representation of local changes of levels of deoxyhemoglobin, related to the brain region performing a task.

Although fMRI is almost risk-free, it cannot be performed in patients with claustrophobia, metal implants, wires and pace-makers. Patients with vagal nerve stimulators, or dental braces, may be included. However, some degradation of the images is expected.

Research and studies conducted by:

Dr. Nolan Altman and Dr. Byron Bernal of the Radiology Department

Go to a Section

Clinical Cases Language Mapping Auditory Mapping 3D fMRI

fMRI in Sedated Children

What is fMRI?

Functional magnetic resonance imaging (fMRI) is a development of MRI techniques that allows visualization of brain functions related to specific tasks. The study does not require any substance to be administered since it is based on the indigenous brain vascular response, requiring only cooperation for periods ranging from 15 to 60 minutes.

To date, several tasks have been utilized for mapping the brain cortex. Simple tasks include stimuli based on presentation of light, colors, tones, chords, music, syllables, movement of fingers and basic sensory perceptions. More complex and refined experiments have been implemented to map subtle cognitive functions. Currently, there is a vast armamentarium for mapping memory, attention, inhibition, face recognition, sensory discrimination, fear, etc.

However, most fMRI work has been directed in mapping language. Language mapping has been performed in children and adults. Reading, listening to meaningful text, generating words, making semantic decisions, are the most frequent paradigms described in the abundant current literature on fMRI. The technique has received ample acceptance among neuroscientists interested in epilepsy for the potential it has to become a tool to replace the Wada test.

T1 weighted MRI

Transverse image at the level of the planum temporale. The left hemisphere is seen in the right side (radiological convention). The subject's task was listening to a story.
The red bubble seen on the left side corresponds to areas related to complex semantic processing.

Functional MRI is based on small signal changes that result from the following cascade of events. A task elicits activation in one or several brain areas. These areas increase their metabolic demands, suffer vasodilatation, and alter their levels of deoxyhemoglobin and oxyhemoglobin. Since deoxyhemoglobin is a paramagnetic molecule, it influences the phase of local proton-spins, altering the source signal that is converted into images. Therefore, the image is a representation of local changes of levels of deoxyhemoglobin, related to the brain region performing a task.

Although fMRI is almost risk-free, it cannot be performed in patients with claustrophobia, metal implants, wires and pace-makers. Patients with vagal nerve stimulators, or dental braces, may be included. However, some degradation of the images is expected.

Research and studies conducted by:

Dr. Nolan Altman and Dr. Byron Bernal of the Radiology Department

Go to a Section

Clinical Cases Language Mapping Auditory Mapping 3D fMRI

fMRI in Sedated Children

What is fMRI?

Functional magnetic resonance imaging (fMRI) is a development of MRI techniques that allows visualization of brain functions related to specific tasks. The study does not require any substance to be administered since it is based on the indigenous brain vascular response, requiring only cooperation for periods ranging from 15 to 60 minutes.

To date, several tasks have been utilized for mapping the brain cortex. Simple tasks include stimuli based on presentation of light, colors, tones, chords, music, syllables, movement of fingers and basic sensory perceptions. More complex and refined experiments have been implemented to map subtle cognitive functions. Currently, there is a vast armamentarium for mapping memory, attention, inhibition, face recognition, sensory discrimination, fear, etc.

However, most fMRI work has been directed in mapping language. Language mapping has been performed in children and adults. Reading, listening to meaningful text, generating words, making semantic decisions, are the most frequent paradigms described in the abundant current literature on fMRI. The technique has received ample acceptance among neuroscientists interested in epilepsy for the potential it has to become a tool to replace the Wada test.

T1 weighted MRI

Transverse image at the level of the planum temporale. The left hemisphere is seen in the right side (radiological convention). The subject's task was listening to a story.
The red bubble seen on the left side corresponds to areas related to complex semantic processing.

Functional MRI is based on small signal changes that result from the following cascade of events. A task elicits activation in one or several brain areas. These areas increase their metabolic demands, suffer vasodilatation, and alter their levels of deoxyhemoglobin and oxyhemoglobin. Since deoxyhemoglobin is a paramagnetic molecule, it influences the phase of local proton-spins, altering the source signal that is converted into images. Therefore, the image is a representation of local changes of levels of deoxyhemoglobin, related to the brain region performing a task.

Although fMRI is almost risk-free, it cannot be performed in patients with claustrophobia, metal implants, wires and pace-makers. Patients with vagal nerve stimulators, or dental braces, may be included. However, some degradation of the images is expected.

Research and studies conducted by:

Dr. Nolan Altman and Dr. Byron Bernal of the Radiology Department

Go to a Section

Clinical Cases Language Mapping Auditory Mapping 3D fMRI

fMRI in Sedated Children

What is fMRI?

Functional magnetic resonance imaging (fMRI) is a development of MRI techniques that allows visualization of brain functions related to specific tasks. The study does not require any substance to be administered since it is based on the indigenous brain vascular response, requiring only cooperation for periods ranging from 15 to 60 minutes.

To date, several tasks have been utilized for mapping the brain cortex. Simple tasks include stimuli based on presentation of light, colors, tones, chords, music, syllables, movement of fingers and basic sensory perceptions. More complex and refined experiments have been implemented to map subtle cognitive functions. Currently, there is a vast armamentarium for mapping memory, attention, inhibition, face recognition, sensory discrimination, fear, etc.

However, most fMRI work has been directed in mapping language. Language mapping has been performed in children and adults. Reading, listening to meaningful text, generating words, making semantic decisions, are the most frequent paradigms described in the abundant current literature on fMRI. The technique has received ample acceptance among neuroscientists interested in epilepsy for the potential it has to become a tool to replace the Wada test.

T1 weighted MRI

Transverse image at the level of the planum temporale. The left hemisphere is seen in the right side (radiological convention). The subject's task was listening to a story.
The red bubble seen on the left side corresponds to areas related to complex semantic processing.

Functional MRI is based on small signal changes that result from the following cascade of events. A task elicits activation in one or several brain areas. These areas increase their metabolic demands, suffer vasodilatation, and alter their levels of deoxyhemoglobin and oxyhemoglobin. Since deoxyhemoglobin is a paramagnetic molecule, it influences the phase of local proton-spins, altering the source signal that is converted into images. Therefore, the image is a representation of local changes of levels of deoxyhemoglobin, related to the brain region performing a task.

Although fMRI is almost risk-free, it cannot be performed in patients with claustrophobia, metal implants, wires and pace-makers. Patients with vagal nerve stimulators, or dental braces, may be included. However, some degradation of the images is expected.

Research and studies conducted by:

Dr. Nolan Altman and Dr. Byron Bernal of the Radiology Department

Go to a Section

Clinical Cases Language Mapping Auditory Mapping 3D fMRI

fMRI in Sedated Children

At Nicklaus Children's, not only do we offer pediatric imaging excellence, we also offer convenience.

Main Hospital Campus Service Hours

Nicklaus Children's Hospital (Main Campus) in Coral Gables

Monday – Friday: 5:45 A.M. to 8:00 P.M.

Saturday: 5:45 A.M. to 8:00 P.M.

Sunday: 7:00 A.M. to 12:00 P.M.

Self-scheduling Hospital X-ray Services

As part of Nicklaus Children’s Hospital’s ongoing focus on enhancing service access for patient families, we now offer self-scheduling of X-rays (for the main hospital campus). To self-schedule an X-ray, fill out the Central Scheduling request form, when selecting a procedure, choose Radiology/Digital X-ray. You will then be presented with a series of available dates/times to choose from. Complete the form, and submit your request.

*Scoliosis series and full length bone service not available in outpatient centers.

The EOS x-ray is the first technology that creates full-body 3D images of patients in a natural, standing position. While it provides orthopedic imaging for patients with spine, hip, and leg disorders, the EOS scanner also produces much less radiation than traditional scanners do. In fact, this technology forms high-quality images with radiation levels up to nine times less than a computed radiography x-ray, and 20 times less than a CT scan.  

What is an EOS scan like?

When your child comes in for EOS medical imaging, they will stand inside the machine for about 30 seconds. Unlike traditional x-rays, the EOS scanners produce such small amounts of radiation that protective lead aprons are not necessary.

What are the benefits of EOS imaging?

An EOS scan creates a comprehensive 3D image, making it much more accurate than other scanners (all other x-rays require piecing multiple pictures together to approximate). And because the chamber allows the patient to stand up straight, the images reflect the most realistic depiction of posture. For patients with ongoing concerns such as scoliosis, the EOS Imaging System offers shorter scanning times than a traditional x-ray while producing a fraction of the radiation. This makes it both safer and more convenient for routine visitors.

Key Aspects of the EOS Imaging System

Patients with scoliosis typically undergo imaging every three to six months over a period of several years, which can amount to more than 20 total scans over the course of treatment. This technology makes possible high-quality images with a radiation dose up to nine times less than a computed radiography X-ray and up to 20 times less than a CT scan, enabling clinicians to make a more informed diagnosis and create individualized treatment plans for children with musculoskeletal disorders. The device also reduces the amount of time it takes to conduct a radiological scan.

Leaders in EOS radiology

The Radiology Department at Nicklaus Children’s Hospital housed the first EOS medical Imaging System in the Miami-Dade area and the second in the state of Florida. A leader in pediatric radiology, we produced 120,000 radiological images in 2012 and have served thousands since. At Nicklaus Children’s Hospital, we offer the most advanced technology to ensure your child receives the highest quality care possible.

EOSEdge: The Newest Spine Imaging Technology Reduces Radiation Exposure

At Nicklaus Children's Hospital, we are committed to providing our patients and their families with the best care and technology available. This focus has led to our recent acquisition of the EOSedge™, an imaging system that delivers high-quality, three-dimensional full-body images of patients in a standing position using low-dose radiation. 

EOSedge has a unique setting called Flex DoseTM that adjusts the amount of radiation patients receive. This setting minimizes exposure of areas of the body when possible, while still delivering the high- resolution images needed for our doctors to make treatment decisions. EOSedge is now available at Nicklaus Children’s Hospital’s main campus. 

The Center for Spinal Disorders at Nicklaus Children's has been using EOS imaging systems for its pediatric spine patients since 2013.

The EOS x-ray is the first technology that creates full-body 3D images of patients in a natural, standing position. While it provides orthopedic imaging for patients with spine, hip, and leg disorders, the EOS scanner also produces much less radiation than traditional scanners do. In fact, this technology forms high-quality images with radiation levels up to nine times less than a computed radiography x-ray, and 20 times less than a CT scan.  

What is an EOS scan like?

When your child comes in for EOS medical imaging, they will stand inside the machine for about 30 seconds. Unlike traditional x-rays, the EOS scanners produce such small amounts of radiation that protective lead aprons are not necessary.

What are the benefits of EOS imaging?

An EOS scan creates a comprehensive 3D image, making it much more accurate than other scanners (all other x-rays require piecing multiple pictures together to approximate). And because the chamber allows the patient to stand up straight, the images reflect the most realistic depiction of posture. For patients with ongoing concerns such as scoliosis, the EOS Imaging System offers shorter scanning times than a traditional x-ray while producing a fraction of the radiation. This makes it both safer and more convenient for routine visitors.

Key Aspects of the EOS Imaging System

Patients with scoliosis typically undergo imaging every three to six months over a period of several years, which can amount to more than 20 total scans over the course of treatment. This technology makes possible high-quality images with a radiation dose up to nine times less than a computed radiography X-ray and up to 20 times less than a CT scan, enabling clinicians to make a more informed diagnosis and create individualized treatment plans for children with musculoskeletal disorders. The device also reduces the amount of time it takes to conduct a radiological scan.

Leaders in EOS radiology

The Radiology Department at Nicklaus Children’s Hospital housed the first EOS medical Imaging System in the Miami-Dade area and the second in the state of Florida. A leader in pediatric radiology, we produced 120,000 radiological images in 2012 and have served thousands since. At Nicklaus Children’s Hospital, we offer the most advanced technology to ensure your child receives the highest quality care possible.

EOSEdge: The Newest Spine Imaging Technology Reduces Radiation Exposure

At Nicklaus Children's Hospital, we are committed to providing our patients and their families with the best care and technology available. This focus has led to our recent acquisition of the EOSedge™, an imaging system that delivers high-quality, three-dimensional full-body images of patients in a standing position using low-dose radiation. 

EOSedge has a unique setting called Flex DoseTM that adjusts the amount of radiation patients receive. This setting minimizes exposure of areas of the body when possible, while still delivering the high- resolution images needed for our doctors to make treatment decisions. EOSedge is now available at Nicklaus Children’s Hospital’s main campus. 

The Center for Spinal Disorders at Nicklaus Children's has been using EOS imaging systems for its pediatric spine patients since 2013.

The EOS x-ray is the first technology that creates full-body 3D images of patients in a natural, standing position. While it provides orthopedic imaging for patients with spine, hip, and leg disorders, the EOS scanner also produces much less radiation than traditional scanners do. In fact, this technology forms high-quality images with radiation levels up to nine times less than a computed radiography x-ray, and 20 times less than a CT scan.  

What is an EOS scan like?

When your child comes in for EOS medical imaging, they will stand inside the machine for about 30 seconds. Unlike traditional x-rays, the EOS scanners produce such small amounts of radiation that protective lead aprons are not necessary.

What are the benefits of EOS imaging?

An EOS scan creates a comprehensive 3D image, making it much more accurate than other scanners (all other x-rays require piecing multiple pictures together to approximate). And because the chamber allows the patient to stand up straight, the images reflect the most realistic depiction of posture. For patients with ongoing concerns such as scoliosis, the EOS Imaging System offers shorter scanning times than a traditional x-ray while producing a fraction of the radiation. This makes it both safer and more convenient for routine visitors.

Key Aspects of the EOS Imaging System

Patients with scoliosis typically undergo imaging every three to six months over a period of several years, which can amount to more than 20 total scans over the course of treatment. This technology makes possible high-quality images with a radiation dose up to nine times less than a computed radiography X-ray and up to 20 times less than a CT scan, enabling clinicians to make a more informed diagnosis and create individualized treatment plans for children with musculoskeletal disorders. The device also reduces the amount of time it takes to conduct a radiological scan.

Leaders in EOS radiology

The Radiology Department at Nicklaus Children’s Hospital housed the first EOS medical Imaging System in the Miami-Dade area and the second in the state of Florida. A leader in pediatric radiology, we produced 120,000 radiological images in 2012 and have served thousands since. At Nicklaus Children’s Hospital, we offer the most advanced technology to ensure your child receives the highest quality care possible.

EOSEdge: The Newest Spine Imaging Technology Reduces Radiation Exposure

At Nicklaus Children's Hospital, we are committed to providing our patients and their families with the best care and technology available. This focus has led to our recent acquisition of the EOSedge™, an imaging system that delivers high-quality, three-dimensional full-body images of patients in a standing position using low-dose radiation. 

EOSedge has a unique setting called Flex DoseTM that adjusts the amount of radiation patients receive. This setting minimizes exposure of areas of the body when possible, while still delivering the high- resolution images needed for our doctors to make treatment decisions. EOSedge is now available at Nicklaus Children’s Hospital’s main campus. 

The Center for Spinal Disorders at Nicklaus Children's has been using EOS imaging systems for its pediatric spine patients since 2013.

What is the PACU?

PACU (which stands for Post- Anesthesia Care Unit) is also called the recovery room. It is a specialized care unit near the operating room where patients who have had surgery are cared for as they wake up from anesthesia. In the pediatric recovery room, a nurse will be at your child's bedside for the entire recovery period to ensure his/ her safety and comfort.

You may be invited into pediatric post-anesthesia care unit to be with your child as they wake up from their surgical procedure. Please understand that your ability to visit your child in the PACU depends on the activity and patient load of the unit at the time.

If you are asked to enter the PACU, you will be escorted in and out of the recovery room area either by a hospital employee or volunteer.

When you enter the PACU, you may see that there are several patients in the PACU in different stages of recovery post-anesthesia. We ask you to respect the privacy and confidentiality of all our patients and families by staying at your child's bedside. We also ask that you avoid the use of cell phones and cameras.

Before you enter the PACU, staff will first be sure that:

• No child's safety or privacy will be affected
• Your child is breathing well and has regained the ability to cough

Before you enter the PACU, you must first be sure that:

• You feel comfortable in a medical setting – you do not have to go into the post-anesthesia care unit if you are not comfortable in a medical setting
• You can provide a calm, supportive presence for your child
• You are willing to follow all directions from staff. If we cannot answer your questions or explain a situation fully at the moment you inquire, we will be sure to attend to your concerns as soon as we can.

For a patient's safety, yours or someone else's, you may be asked to leave PACU and return to the family waiting area.

What you'll see in pediatric post-anesthesia care unit

• Most children receive oxygen for a period of time after anesthesia. Sometimes children look pale, puffy or swollen after surgery. This is normal.
• Children differ in their reactions to anesthesia. Some have an upset stomach and may vomit. Often children are given medications to help decrease the possibility of nausea and vomiting. Some may have dizziness and/or blurred vision for a period of time.
• If a breathing tube is used during surgery your child may have a sore throat. This is normal.
• Children wake up differently from anesthesia. Some children wake up quickly and may be awake before their families arrive at their bedside. Other children may still be sleeping from the effects of anesthesia.
• Please do not wake your child. In our experience, children often have a gentler and more comfortable wake-up process when they do so on their own.
• Some children wake up shivering even if they are not cold. Your child will receive warmed blankets by the post-anesthesia care unit staff if needed.
• Some children who have had intravenous (IV) pain medication may have an extremely itchy nose. This itch will go away.
• Some children wake up restless or irritable. Some appear awake but are not aware of what is going on around them.
• Emergence Delirium: Some cry, thrash, arch their back, reach out and seem inconsolable, even when they are in their parents' arms. This behavior is not usually related to pain, and children do not usually remember it. This restless or irritable behavior is known as "emergence delirium". About one third of young children who have brief procedures experience emergence delirium. It may occur in children of any age, even after procedures that require a longer time under anesthesia. Emergence delirium may be upsetting for parents to see, but be assured that it will go away. Sometimes it lasts about 10 minutes; other times it may last up to an hour or longer.
• By staying calm and speaking softly, you can be a comfort to your child.
• Pain medicine is given as needed. After receiving pain medicine, children need to be observed due to the sleepiness and possible changes in breathing caused by most pain medications.
• If your child takes a comfort item along to surgery – such as a toy or special blanket – it will be with him or her in the PACU. If he is comforted by a pacifier, and it is sent with him to surgery, he will be given the pacifier in PACU (unless contraindicated by the type of surgery he or she has had).

How long will my child be in the PACU?

Because each child and each surgery are different, the length of time spent in the post-anesthesia care unit varies from a few minutes to more than 2 hours. Do not be alarmed if your child is in PACU longer than you expected. A staff member or volunteer will keep you informed.

Children leave PACU when:

• They respond to their surroundings.
• They are medically stable.
• Our staff has treated any pain they may have to the best of our ability.

Where will my child go next?

Once your child is fully recovered, and his/her vital signs are stable, he/she will be moved from the PACU. If your child requires hospital admission, he/she will be moved to a regular patient room. If he/she will be coming home with you, he'll/she'll be moved to PACU II for a minimum of a one hour stay prior to going home.

What is the PACU?

PACU (which stands for Post- Anesthesia Care Unit) is also called the recovery room. It is a specialized care unit near the operating room where patients who have had surgery are cared for as they wake up from anesthesia. In the pediatric recovery room, a nurse will be at your child's bedside for the entire recovery period to ensure his/ her safety and comfort.

You may be invited into pediatric post-anesthesia care unit to be with your child as they wake up from their surgical procedure. Please understand that your ability to visit your child in the PACU depends on the activity and patient load of the unit at the time.

If you are asked to enter the PACU, you will be escorted in and out of the recovery room area either by a hospital employee or volunteer.

When you enter the PACU, you may see that there are several patients in the PACU in different stages of recovery post-anesthesia. We ask you to respect the privacy and confidentiality of all our patients and families by staying at your child's bedside. We also ask that you avoid the use of cell phones and cameras.

Before you enter the PACU, staff will first be sure that:

• No child's safety or privacy will be affected
• Your child is breathing well and has regained the ability to cough

Before you enter the PACU, you must first be sure that:

• You feel comfortable in a medical setting – you do not have to go into the post-anesthesia care unit if you are not comfortable in a medical setting
• You can provide a calm, supportive presence for your child
• You are willing to follow all directions from staff. If we cannot answer your questions or explain a situation fully at the moment you inquire, we will be sure to attend to your concerns as soon as we can.

For a patient's safety, yours or someone else's, you may be asked to leave PACU and return to the family waiting area.

What you'll see in pediatric post-anesthesia care unit

• Most children receive oxygen for a period of time after anesthesia. Sometimes children look pale, puffy or swollen after surgery. This is normal.
• Children differ in their reactions to anesthesia. Some have an upset stomach and may vomit. Often children are given medications to help decrease the possibility of nausea and vomiting. Some may have dizziness and/or blurred vision for a period of time.
• If a breathing tube is used during surgery your child may have a sore throat. This is normal.
• Children wake up differently from anesthesia. Some children wake up quickly and may be awake before their families arrive at their bedside. Other children may still be sleeping from the effects of anesthesia.
• Please do not wake your child. In our experience, children often have a gentler and more comfortable wake-up process when they do so on their own.
• Some children wake up shivering even if they are not cold. Your child will receive warmed blankets by the post-anesthesia care unit staff if needed.
• Some children who have had intravenous (IV) pain medication may have an extremely itchy nose. This itch will go away.
• Some children wake up restless or irritable. Some appear awake but are not aware of what is going on around them.
• Emergence Delirium: Some cry, thrash, arch their back, reach out and seem inconsolable, even when they are in their parents' arms. This behavior is not usually related to pain, and children do not usually remember it. This restless or irritable behavior is known as "emergence delirium". About one third of young children who have brief procedures experience emergence delirium. It may occur in children of any age, even after procedures that require a longer time under anesthesia. Emergence delirium may be upsetting for parents to see, but be assured that it will go away. Sometimes it lasts about 10 minutes; other times it may last up to an hour or longer.
• By staying calm and speaking softly, you can be a comfort to your child.
• Pain medicine is given as needed. After receiving pain medicine, children need to be observed due to the sleepiness and possible changes in breathing caused by most pain medications.
• If your child takes a comfort item along to surgery – such as a toy or special blanket – it will be with him or her in the PACU. If he is comforted by a pacifier, and it is sent with him to surgery, he will be given the pacifier in PACU (unless contraindicated by the type of surgery he or she has had).

How long will my child be in the PACU?

Because each child and each surgery are different, the length of time spent in the post-anesthesia care unit varies from a few minutes to more than 2 hours. Do not be alarmed if your child is in PACU longer than you expected. A staff member or volunteer will keep you informed.

Children leave PACU when:

• They respond to their surroundings.
• They are medically stable.
• Our staff has treated any pain they may have to the best of our ability.

Where will my child go next?

Once your child is fully recovered, and his/her vital signs are stable, he/she will be moved from the PACU. If your child requires hospital admission, he/she will be moved to a regular patient room. If he/she will be coming home with you, he'll/she'll be moved to PACU II for a minimum of a one hour stay prior to going home.

The Cystic Fibrosis Center at Nicklaus Children’s Hospital offers comprehensive family-centered care for children and adults with cystic fibrosis. Since 1993, the program has been awarded affiliate program accreditation status from the Cystic Fibrosis Foundation, ensuring access to the most current treatments and research findings.

The program serves as a referral center for cystic fibrosis patients identified by the state of Florida’s Newborn Screening Program. The center is equipped to provide prompt interventions with specialized therapies to provide newly diagnosed patients with immediate treatment, in order to prevent complications and promote health.

Conditions we Treat

• Genetic testing
• Routine blood work

A Comprehensive Approach to Care

The program includes a comprehensive care team including:

• Pulmonologist
• Gastroenterologist
• Endocrinologist
• Cystic fibrosis coordinator
• Nurse practitioner
• Dietitian
• Respiratory therapist
• Social worker
• Psychologist

Programs and Services

• Outpatient care clinics
• Family education to support care
• Inpatient care

Education to Support Care

The Cystic Fibrosis Foundation assists patients and their families with education, disease management and supportive care. 

Medical Research

The program participates in research protocols to advance care and understanding of cystic fibrosis. 

When your patients require cardiopulmonary function tests, Nicklaus Children's Hospital, the region’s pediatric care leader – offers a comprehensive array of tests geared for children ages 5 and up. The tests are administered in the hospital’s new state-of-the art Pediatric Pulmonary Function Lab.

You’ll be confident knowing that pulmonary function tests are performed and interpreted by experts specially trained and highly experienced in testing and evaluating children. 

Hard-to-Diagnose Asthma Patients

The Nicklaus Children's Hospital Cardiopulmonary Function Lab offers three specialized Bronchial Challenge Tests to confirm the presence or absence of bronchial hyperactivity in children. Bronchial Challenge Testing is indicated for the diagnosis of bronchial airway hyperactivity in subjects who do not have clinically apparent asthma. Bronchial challenge testing is an objective means to help you establish a diagnosis of asthma. A negative Bronchial Challenge Test result can rule out asthma as a potential etiology with a high degree of accuracy. By ruling out asthma as a causative factor in patient presentation, practitioners can work up an alternative diagnosis and avoid unnecessary medications or costs for patients.

Bronchial Challenge Tests

• Exercise Challenge Test: Utilizes a treadmill or ergometer. For those pediatric patients who are incapable or unwilling to sustain exercise long enough for reliable test results the Nicklaus Children's Hospital Cardiopulmonary Function Lab offers two additional widely supported reliable methods.
• Cold Air Challenge
• Methacholine Challenge Test

Cardiopulmonary Exercise Testing

• Cardiopulmonary performance in preoperative or postoperative congenital heart defects
• Functional capacity for vocational, recreational, armed forces, and athletic recommendations
• Specific symptoms or signs induced by exercise including palpitations, syncope, or possible arrhythmias
• Cardiomyopathies and overall fitness levels
• Suspected pulmonary disorders such as exercise-induced bronchospasm

Additional Pulmonary Function Tests

• Spirometry and pre- and postbronchodilator testing to quantify the severity of known lung disease and/or assess the change in lung function over time or following a change in therapy. The test is also used to assess the potential effects of environmental or occupational exposure.
• Lung Volume Studies (Body Plethysmography or Helium Dilution) to assist doctors in differentiating between obstructive and restrictive disease patterns and assess response to therapeutic interventions (transplantation, radiation, chemotherapy, lobectomy). The study also supports physicians in making preoperative assessments in patients with impaired lung function and in quantifying the amount of non-ventilated lung.
• Carbon Monoxide Diffusing Capacity (DLCO) testing to differentiate among chronic bronchitis, emphysema, and asthma in patients with obstructive patterns. The test also supports physicians in predicting arterial desaturation during exercise in obstructive pulmonary disease and in evaluation and follow-up of interstitial lung disease and parenchymal lung diseases associated with dust (eg, asbestos) or drug reactions.

Related informational web links:

• lupus.org - The Lupus Foundation of America
• arthritis.org - The Arthritis Foundation
• spondylitis.org - The Spondylitis Association of America
   

*Links available in this page are not necessarily endorsed, reviewed, or sponsored by Nicklaus Children's Hospital.

Parents have varied reactions to the experience of having a child hospitalized for depression or other behavioral health illnesses. Some parents become anxious upon learning that their child will be hospitalized, while others find it a relief that their child is getting help for his/her symptoms. We hope this guide will help in managing the experience. Our goal is to help you and your child through this transition to treatment and beyond.

Our interdisciplinary team provides evaluation and interventions for a broad spectrum of child and adolescent mental health conditions. The care of all patients admitted to the psychiatric unit is guided by a comprehensive, interdisciplinary treatment approach based on the bio/psycho/social model, which offers a holistic approach to evaluation and treatment.

The Hagerty Family Behavioral Health Unit embraces a family-centered approach to care. This means that you are an essential part of the team and will be involved in care decision making.

For the safety of patients, psychiatry is a secured unit with restricted access. The department features an acute stabilization program and the average inpatient stay is three to five days, although some patients may require a longer hospitalization to address individual needs. During your child’s stay the focus of treatment will include individual, group and family therapy, crisis intervention, on-going psychiatric/psychological evaluation, stabilization, and discharge planning.

Protecting your child’s safety and confidentiality is a priority for us. Due to the therapeutic structure of psychiatry, we do not offer open visiting hours/telephone calls, or parents staying on the unit.

Admission and Visiting Hours

On admission you will meet the assigned nurse and behavioral health technician who will provide you with in-patient information, including guidelines and policies for the unit. You will be asked to provide information regarding your child and sign consent forms. A family therapy session will also be scheduled on admission.

Within 24 hours of admission the attending psychiatrist, psychiatric fellow/resident, nurse practitioner, and a therapist will evaluate your child and contact you.

If you have special needs due to your work schedule, please inform your case coordinator or charge nurse so we may best accommodate your request. Visitors are limited to two at a time. Visiting minors need to be escorted by an adult while in the Hagerty Family Behavioral Health Unit. All visits are supervised by staff members.

The Treatment Plan

Your child will be seen by the treatment team every day to review his/her progress. The team can be available to answer any questions you may have. The team meets on an on-going basis throughout the week to discuss your child’s progress, including group participation, medication, and discharge planning.

Security and Personal Safety

For unit safety and the protection of patient confidentiality, a Personal Patient Identification Code (PPIC) will be given to you at the time of admission. Please remember that this number is necessary when asking for information or contact with the patient. This number is intended for guardians and immediate family.

All patients are under the close observation by a staff member 24 hours a day. Special precautions exist to provide a higher level of care for certain patients.

 Hagerty Family Behavioral Health Unit Guidelines:

1. Before entering the unit, family and visitors are required to obtain an identification tag from security. We ask all family members/visitors to leave personal belongings including cell phones in the lockers assigned by staff before entering the unit.
2. For the safety of your child and the unit environment, all personal baggage is examined before entering the unit. Any belongings that are inappropriate will be given to the guardian to take home or will be kept in a locker. No sharp items are allowed on the unit.
3. To help keep your child and the unit safe, acts of violence, and verbal or physical abuse are not allowed. All psychiatric staff is trained in crisis prevention interventions.
4. Please leave any valuable items at home.
5. Telephone calls can be made between the hours of noon to 1 pm, 5 p.m. – 7 p.m. and 8 p.m. – 9 p.m. as per unit protocol. Patients can only call individuals approved by the legal guardian. Parents are always welcome to call the unit to speak to the nurses or staff members if they have questions.

Because children and teens are still growing and developing, they experience different types of sports-related injuries than adults. The Nicklaus Children's Hospital, Pediatric Sports Medicine Program is dedicated to preventing and treating sports injuries in the growing athlete, or young sports enthusiast.

Our interdisciplinary orthopedic sports medicine specialists at three Nicklaus Children's locations work together to provide the most advanced care in orthopedic sports medicine for their patient by incorporating an array of diagnostic and therapeutic services such as X-ray, MRI, occupational and physical therapy to the treatment plan as needed.

The Orthopedic, Sports Health and Spine Institute at Nicklaus Children’s Hospital provides evaluation and treatment of a full spectrum of hip disorders in children, adolescents and young adults. These disorders include a variety of congenital, developmental and post-traumatic conditions. Treatment methods include open and arthroscopic surgical techniques such as hip surgery. Our evaluation process combines a detailed clinical examination with state-of-the-art radiographic imaging.

Pediatric Hip Conditions we Treat

Pediatric Hip Disorder Treatment

• Surgical dislocation of the hip
• Closed and open reduction of developmental hip dislocations
• Other pelvic and femoral osteotomies

Hip imaging

• MRI arthrogram with radial sequences
• CT scans with 3D reconstruction
• Low-dose radiation EOS radiographs
• 3D printing for complex and unusual hip conditions

MRI

• Magnet Resonance Imaging (MRI) uses a large magnet and radio waves to produce a picture of a body structure. Your child will be able to watch a movie, listen to the radio or play a favorite CD wile the scan is being performed. Learn more.

PillCam

• Camera pill, a non-invasive capsule endoscopy.

The members of the Craniofacial team work together to develop and deliver a coordinated plan of care to meet each child’s individual needs. The multidisciplinary team is comprised of specialists in the following disciplines:

Enhancements in prenatal ultrasound imaging technology have resulted in increasing numbers of families learning that their baby has a craniofacial difference before his or her birth. That knowledge can bring anxiety and many questions. Expectant parents often ask:

• What is the anomaly?
• What caused it?
• What is the prognosis for the baby?
• Can it be repaired?
• How do I take care of my baby?

To address the questions and concerns of expectant parents in a comprehensive way, the Nicklaus Children's Hospital Craniofacial Center has created a Prenatal Clinic in which families are evaluated by a team of specialists including nurses, plastic and reconstructive surgeons, and geneticists.

Families are provided information on the causes of craniofacial differences and what to expect when the baby is born. They are shown photographs of children before and after repair of craniofacial differences, and are given necessary contact information and supplies when the baby is born.

With this information, families feel more prepared for the birth of their baby. Further, the families leave knowing where to find support, which helps decrease anxiety and promotes a more enjoyable pregnancy and birth experience.

Care for a Full Spectrum of Craniofacial Anomalies

The Craniofacial Center at Nicklaus Children's Hospital, serves children with various craniofacial differences such as:

• Cleft lip and palate
• Pierre Robin sequence
• Hemifacial microsomia
• Treacher Collins
• Craniosynostosis

The Craniofacial Center conducts a multidisciplinary evaluation for affected children, and develops and coordinates a plan of care.

Enhancements in prenatal ultrasound imaging technology have resulted in increasing numbers of families learning that their baby has a craniofacial difference before his or her birth. That knowledge can bring anxiety and many questions. Expectant parents often ask:

• What is the anomaly?
• What caused it?
• What is the prognosis for the baby?
• Can it be repaired?
• How do I take care of my baby?

To address the questions and concerns of expectant parents in a comprehensive way, the Nicklaus Children's Hospital Craniofacial Center has created a Prenatal Clinic in which families are evaluated by a team of specialists including nurses, plastic and reconstructive surgeons, and geneticists.

Families are provided information on the causes of craniofacial differences and what to expect when the baby is born. They are shown photographs of children before and after repair of craniofacial differences, and are given necessary contact information and supplies when the baby is born.

With this information, families feel more prepared for the birth of their baby. Further, the families leave knowing where to find support, which helps decrease anxiety and promotes a more enjoyable pregnancy and birth experience.

Care for a Full Spectrum of Craniofacial Anomalies

The Craniofacial Center at Nicklaus Children's Hospital, serves children with various craniofacial differences such as:

• Cleft lip and palate
• Pierre Robin sequence
• Hemifacial microsomia
• Treacher Collins
• Craniosynostosis

The Craniofacial Center conducts a multidisciplinary evaluation for affected children, and develops and coordinates a plan of care.

What is Spinal Fusion Surgery in Children?

Spinal fusion surgery helps to stop the progression of curving of the spine, known as scoliosis. The surgery helps to not only straighten the curve, but can improve children’s posture, fit of clothing, prevent back pain, and minimize other side effects of scoliosis.

The spinal fusion recovery process can be difficult, as children may experience pain and find it hard to sit up, stand, and walk while recovering. Nicklaus Children's Hospital, formerly Miami Children's Hospital, is here to help your child have a smooth recovery from spinal fusion surgery and answer any questions throughout the process. 

Pediatric Spinal Fusion Surgery Program at Nicklaus Children's 

Is spinal fusion surgery in your future? If so, you are probably feeling some uncertainty. The best thing you can do right now is to learn as much as possible about the procedure and share the information with friends and family. Knowledge will prepare you for what is ahead and help you feel more in control and less anxious. Here’s how to get started. First, ask your doctor every question that comes to mind and read all the materials you can find on the subject. We also urge you to attend the Spinal Fusion Program at Nicklaus Children's Hospital. The Spinal Fusion Program provides an opportunity for you and your family to learn about what to expect during spinal fusion recovery.

Read our guides for Spinal Fusion Surgery

What is Spinal Fusion Surgery in Children?

Spinal fusion surgery helps to stop the progression of curving of the spine, known as scoliosis. The surgery helps to not only straighten the curve, but can improve children’s posture, fit of clothing, prevent back pain, and minimize other side effects of scoliosis.

The spinal fusion recovery process can be difficult, as children may experience pain and find it hard to sit up, stand, and walk while recovering. Nicklaus Children's Hospital, formerly Miami Children's Hospital, is here to help your child have a smooth recovery from spinal fusion surgery and answer any questions throughout the process. 

Pediatric Spinal Fusion Surgery Program at Nicklaus Children's 

Is spinal fusion surgery in your future? If so, you are probably feeling some uncertainty. The best thing you can do right now is to learn as much as possible about the procedure and share the information with friends and family. Knowledge will prepare you for what is ahead and help you feel more in control and less anxious. Here’s how to get started. First, ask your doctor every question that comes to mind and read all the materials you can find on the subject. We also urge you to attend the Spinal Fusion Program at Nicklaus Children's Hospital. The Spinal Fusion Program provides an opportunity for you and your family to learn about what to expect during spinal fusion recovery.

Read our guides for Spinal Fusion Surgery

Taking advantage of the remarkable fact that bone heals itself by growing, or regenerating, the ILIZAROV technique can correct disfigured bones by separating two bone halves millimeter by millimeter. During this process, the body's natural ability to grow bone fills in the gap between the two bones, correcting deformities or increasing length.

Use of the ILIZAROV Method

Limb length inequality and limb deformity can be due to many causes. The treatment plan and use of the ILIZAROV method will depend on the degree of the discrepancy, the age of the patient, and the underlying reason for the deformity.
 
Limb correction and ILIZAROV treatment may be prescribed for a variety of conditions:

Trauma, including: 

• Growth plate fractures
• Malunion (healing of bones in an incorrect position)
• Nonunion (incomplete healing of fractured bones)
• Shortening and deformity due to bone loss

Congenital limb length discrepancies, including: 

• Congenital short Femur
• Fibular hemimelia 
• Pseudarthrosis of the Tibia
• Hemiatrophy/Hemihypertrophy
• and other birth defects and deformities

Pediatric hip disorders

• Developmental Coxa Cara
• Perthes Disease
• Slipped Capital Femoral Epiphyses (SCFE)

 Other conditions

• Joint stiffness secondary to neuromuscular disease or following injury
• Bow legs 
• Knock-knees 
• Short stature (achondroplasia and other skeletal dysplasias) 
• Infection involving the bone (osteomyelitis) and joint (septic arthritis)

Taking advantage of the remarkable fact that bone heals itself by growing, or regenerating, the ILIZAROV technique can correct disfigured bones by separating two bone halves millimeter by millimeter. During this process, the body's natural ability to grow bone fills in the gap between the two bones, correcting deformities or increasing length.

Use of the ILIZAROV Method

Limb length inequality and limb deformity can be due to many causes. The treatment plan and use of the ILIZAROV method will depend on the degree of the discrepancy, the age of the patient, and the underlying reason for the deformity.
 
Limb correction and ILIZAROV treatment may be prescribed for a variety of conditions:

Trauma, including: 

• Growth plate fractures
• Malunion (healing of bones in an incorrect position)
• Nonunion (incomplete healing of fractured bones)
• Shortening and deformity due to bone loss

Congenital limb length discrepancies, including: 

• Congenital short Femur
• Fibular hemimelia 
• Pseudarthrosis of the Tibia
• Hemiatrophy/Hemihypertrophy
• and other birth defects and deformities

Pediatric hip disorders

• Developmental Coxa Cara
• Perthes Disease
• Slipped Capital Femoral Epiphyses (SCFE)

 Other conditions

• Joint stiffness secondary to neuromuscular disease or following injury
• Bow legs 
• Knock-knees 
• Short stature (achondroplasia and other skeletal dysplasias) 
• Infection involving the bone (osteomyelitis) and joint (septic arthritis)

What should I do about pain?

After surgery, a prescription for pain medicine is given. Tylenol is usually sufficient to make your child comfortable during recovery from surgery. In case of excessive pain, please contact the surgeon's office.

What should I do with the wound?

In the absence of specific instructions for care after surgery, most surgical wounds in children take care of themselves. All you have to do is try to keep them clean and dry for the first week, after which you may resume bathing. Pediatric surgeons try as hard as possible to use only absorbable sutures so that there are usually no sutures to remove.

When should I call the surgeon?

Call the surgeon whenever you are in doubt or have a question about your child's recovery from surgery. But some things must bring you back for a visit. Call and return to visit your surgeon, if you see:  

• Worsening redness around the wound and/or
• Seepage of liquid from the wound and/or
• Increasing pain
• Fever
• Swelling

What can my child eat?

Unless specifically addressed, your child can return to a regular diet as soon as he/she wishes to after surgery.

Presurgical Planning

Sometimes it is very important to know which brain functions are in the neighborhood of a lesion, particularly if that lesion is going to be removed by surgery. In lesions formed before birth, such as blood vessel abnormalities and some tumors, the areas of language and other mental process can be misplaced. fMRI shows the actual location of the functions and their spatial relationship with those lesions.

In the left image there is a little cyst in the left hemisphere (seen at the right side of the brain as a round black shape). This lesion produced seizures. The surgeon needs to know the location of the cortex in charge of the movement of the hand. This fMRI shows in colors the area used for the movement of the right fingers in a tapping task. This enables the neurosurgeon to extract the lesion without removing the area needed to move the hand.

Language Mapping

Brain functions can be divided into basic and complex. Basic functions require few areas of the cortex, while complex functions could be spread over one hemisphere, or even in both. Basic brain functions are consistently represented in the same places across different people, while the complex functions tend to vary from person to person. Language is a typical complex function. In most people, language is represented in the left hemisphere, but it is completely normal to find representation in the right hemisphere or divided between them. Prior to brain surgery, it is quite important to know the side in which the language is represented.

In epilepsy surgery this has a crucial importance. Some times it is necessary to remove part of the temporal lobe involved in the generation of seizures. The extension of the surgery must be restricted if it is found that this lobe is involved in language processing.

Here at Nicklaus Children's Hospital we have started to perform Language Mapping with fMRI to assess the localization of language, in adults and children over 7 years old.

Non-Surgical Applications

fMRI has a great potential to provide insight into neurologic and psychiatric disorders. fMRI has been used to assess childhood stroke, migraine and epilepsy. This procedure has also been applied to children with developmental disorders, including autism, dyslexia, and other learning disabilities. Currently we are conducting research in sedated children and infants. Our goal is to obtain activation of the brain regardless of the sedation.

These images are from a 2 year-old child. They are named coronal cuts. The head is seen on top and the neck is on the bottom. Inside you see the two hemishpheres of the brain, and below them the cerebellum. The patient was sedated for a regular procedure. Flashing lights were presented during 3 minutes. The visual cortex, located in the occipital lobes, is depicted in red and yellow colors.

Images of activation in sedated kids have been obtained by presenting sounds (such as the mother's voice), or tactile stimulation to the skin (such as rubbing the hand).

On of the future purposes of fMRI is to predict developmental disorders at very young ages in order to provide effective early treatment interventions.

Presurgical Planning

Sometimes it is very important to know which brain functions are in the neighborhood of a lesion, particularly if that lesion is going to be removed by surgery. In lesions formed before birth, such as blood vessel abnormalities and some tumors, the areas of language and other mental process can be misplaced. fMRI shows the actual location of the functions and their spatial relationship with those lesions.

In the left image there is a little cyst in the left hemisphere (seen at the right side of the brain as a round black shape). This lesion produced seizures. The surgeon needs to know the location of the cortex in charge of the movement of the hand. This fMRI shows in colors the area used for the movement of the right fingers in a tapping task. This enables the neurosurgeon to extract the lesion without removing the area needed to move the hand.

Language Mapping

Brain functions can be divided into basic and complex. Basic functions require few areas of the cortex, while complex functions could be spread over one hemisphere, or even in both. Basic brain functions are consistently represented in the same places across different people, while the complex functions tend to vary from person to person. Language is a typical complex function. In most people, language is represented in the left hemisphere, but it is completely normal to find representation in the right hemisphere or divided between them. Prior to brain surgery, it is quite important to know the side in which the language is represented.

In epilepsy surgery this has a crucial importance. Some times it is necessary to remove part of the temporal lobe involved in the generation of seizures. The extension of the surgery must be restricted if it is found that this lobe is involved in language processing.

Here at Nicklaus Children's Hospital we have started to perform Language Mapping with fMRI to assess the localization of language, in adults and children over 7 years old.

Non-Surgical Applications

fMRI has a great potential to provide insight into neurologic and psychiatric disorders. fMRI has been used to assess childhood stroke, migraine and epilepsy. This procedure has also been applied to children with developmental disorders, including autism, dyslexia, and other learning disabilities. Currently we are conducting research in sedated children and infants. Our goal is to obtain activation of the brain regardless of the sedation.

These images are from a 2 year-old child. They are named coronal cuts. The head is seen on top and the neck is on the bottom. Inside you see the two hemishpheres of the brain, and below them the cerebellum. The patient was sedated for a regular procedure. Flashing lights were presented during 3 minutes. The visual cortex, located in the occipital lobes, is depicted in red and yellow colors.

Images of activation in sedated kids have been obtained by presenting sounds (such as the mother's voice), or tactile stimulation to the skin (such as rubbing the hand).

On of the future purposes of fMRI is to predict developmental disorders at very young ages in order to provide effective early treatment interventions.

Presurgical Planning

Sometimes it is very important to know which brain functions are in the neighborhood of a lesion, particularly if that lesion is going to be removed by surgery. In lesions formed before birth, such as blood vessel abnormalities and some tumors, the areas of language and other mental process can be misplaced. fMRI shows the actual location of the functions and their spatial relationship with those lesions.

In the left image there is a little cyst in the left hemisphere (seen at the right side of the brain as a round black shape). This lesion produced seizures. The surgeon needs to know the location of the cortex in charge of the movement of the hand. This fMRI shows in colors the area used for the movement of the right fingers in a tapping task. This enables the neurosurgeon to extract the lesion without removing the area needed to move the hand.

Language Mapping

Brain functions can be divided into basic and complex. Basic functions require few areas of the cortex, while complex functions could be spread over one hemisphere, or even in both. Basic brain functions are consistently represented in the same places across different people, while the complex functions tend to vary from person to person. Language is a typical complex function. In most people, language is represented in the left hemisphere, but it is completely normal to find representation in the right hemisphere or divided between them. Prior to brain surgery, it is quite important to know the side in which the language is represented.

In epilepsy surgery this has a crucial importance. Some times it is necessary to remove part of the temporal lobe involved in the generation of seizures. The extension of the surgery must be restricted if it is found that this lobe is involved in language processing.

Here at Nicklaus Children's Hospital we have started to perform Language Mapping with fMRI to assess the localization of language, in adults and children over 7 years old.

Non-Surgical Applications

fMRI has a great potential to provide insight into neurologic and psychiatric disorders. fMRI has been used to assess childhood stroke, migraine and epilepsy. This procedure has also been applied to children with developmental disorders, including autism, dyslexia, and other learning disabilities. Currently we are conducting research in sedated children and infants. Our goal is to obtain activation of the brain regardless of the sedation.

These images are from a 2 year-old child. They are named coronal cuts. The head is seen on top and the neck is on the bottom. Inside you see the two hemishpheres of the brain, and below them the cerebellum. The patient was sedated for a regular procedure. Flashing lights were presented during 3 minutes. The visual cortex, located in the occipital lobes, is depicted in red and yellow colors.

Images of activation in sedated kids have been obtained by presenting sounds (such as the mother's voice), or tactile stimulation to the skin (such as rubbing the hand).

On of the future purposes of fMRI is to predict developmental disorders at very young ages in order to provide effective early treatment interventions.

Presurgical Planning

Sometimes it is very important to know which brain functions are in the neighborhood of a lesion, particularly if that lesion is going to be removed by surgery. In lesions formed before birth, such as blood vessel abnormalities and some tumors, the areas of language and other mental process can be misplaced. fMRI shows the actual location of the functions and their spatial relationship with those lesions.

In the left image there is a little cyst in the left hemisphere (seen at the right side of the brain as a round black shape). This lesion produced seizures. The surgeon needs to know the location of the cortex in charge of the movement of the hand. This fMRI shows in colors the area used for the movement of the right fingers in a tapping task. This enables the neurosurgeon to extract the lesion without removing the area needed to move the hand.

Language Mapping

Brain functions can be divided into basic and complex. Basic functions require few areas of the cortex, while complex functions could be spread over one hemisphere, or even in both. Basic brain functions are consistently represented in the same places across different people, while the complex functions tend to vary from person to person. Language is a typical complex function. In most people, language is represented in the left hemisphere, but it is completely normal to find representation in the right hemisphere or divided between them. Prior to brain surgery, it is quite important to know the side in which the language is represented.

In epilepsy surgery this has a crucial importance. Some times it is necessary to remove part of the temporal lobe involved in the generation of seizures. The extension of the surgery must be restricted if it is found that this lobe is involved in language processing.

Here at Nicklaus Children's Hospital we have started to perform Language Mapping with fMRI to assess the localization of language, in adults and children over 7 years old.

Non-Surgical Applications

fMRI has a great potential to provide insight into neurologic and psychiatric disorders. fMRI has been used to assess childhood stroke, migraine and epilepsy. This procedure has also been applied to children with developmental disorders, including autism, dyslexia, and other learning disabilities. Currently we are conducting research in sedated children and infants. Our goal is to obtain activation of the brain regardless of the sedation.

These images are from a 2 year-old child. They are named coronal cuts. The head is seen on top and the neck is on the bottom. Inside you see the two hemishpheres of the brain, and below them the cerebellum. The patient was sedated for a regular procedure. Flashing lights were presented during 3 minutes. The visual cortex, located in the occipital lobes, is depicted in red and yellow colors.

Images of activation in sedated kids have been obtained by presenting sounds (such as the mother's voice), or tactile stimulation to the skin (such as rubbing the hand).

On of the future purposes of fMRI is to predict developmental disorders at very young ages in order to provide effective early treatment interventions.

Presurgical Planning

Sometimes it is very important to know which brain functions are in the neighborhood of a lesion, particularly if that lesion is going to be removed by surgery. In lesions formed before birth, such as blood vessel abnormalities and some tumors, the areas of language and other mental process can be misplaced. fMRI shows the actual location of the functions and their spatial relationship with those lesions.

In the left image there is a little cyst in the left hemisphere (seen at the right side of the brain as a round black shape). This lesion produced seizures. The surgeon needs to know the location of the cortex in charge of the movement of the hand. This fMRI shows in colors the area used for the movement of the right fingers in a tapping task. This enables the neurosurgeon to extract the lesion without removing the area needed to move the hand.

Language Mapping

Brain functions can be divided into basic and complex. Basic functions require few areas of the cortex, while complex functions could be spread over one hemisphere, or even in both. Basic brain functions are consistently represented in the same places across different people, while the complex functions tend to vary from person to person. Language is a typical complex function. In most people, language is represented in the left hemisphere, but it is completely normal to find representation in the right hemisphere or divided between them. Prior to brain surgery, it is quite important to know the side in which the language is represented.

In epilepsy surgery this has a crucial importance. Some times it is necessary to remove part of the temporal lobe involved in the generation of seizures. The extension of the surgery must be restricted if it is found that this lobe is involved in language processing.

Here at Nicklaus Children's Hospital we have started to perform Language Mapping with fMRI to assess the localization of language, in adults and children over 7 years old.

Non-Surgical Applications

fMRI has a great potential to provide insight into neurologic and psychiatric disorders. fMRI has been used to assess childhood stroke, migraine and epilepsy. This procedure has also been applied to children with developmental disorders, including autism, dyslexia, and other learning disabilities. Currently we are conducting research in sedated children and infants. Our goal is to obtain activation of the brain regardless of the sedation.

These images are from a 2 year-old child. They are named coronal cuts. The head is seen on top and the neck is on the bottom. Inside you see the two hemishpheres of the brain, and below them the cerebellum. The patient was sedated for a regular procedure. Flashing lights were presented during 3 minutes. The visual cortex, located in the occipital lobes, is depicted in red and yellow colors.

Images of activation in sedated kids have been obtained by presenting sounds (such as the mother's voice), or tactile stimulation to the skin (such as rubbing the hand).

On of the future purposes of fMRI is to predict developmental disorders at very young ages in order to provide effective early treatment interventions.

In order to understand how functional magnetic resonance (fMRI) works it is important to know some basic things about brain anatomy and function. Also, it is necessary to know some magnetic resonance imaging (MRI) basic facts. Let's begin with the first part:

A very short course on Neuroanatomy

The brain is divided in two hemispheres, the right and the left. Each hemisphere is divided into lobes. And each lobe has different areas as is depicted in the next figure taken with permission from http://www.umich.edu/~cogneuro/home.html

Each region in a different color is a lobe. In yellow the frontal lobe; in green, the parietal lobe; the occipital lobe appears blue, while the temporal lobe is red.

Areas 1,2,3, and 5 "feel" the sensations of touch, position and temperature. Areas 4, 6, and 8 move the muscles of the body. Areas like 44, 45 and 47 produce language. Areas 41 and 42 "hear", areas 17 to 19 "see".

Other areas like 37, 46, 10, 22, 38 are in charge of the complex process involving memory, internal language, comprehension and planning.

This is a regionalization of the function. Also, there is something called "lateralization" of the function. This means that a particular activity can be predominantly located in one hemisphere. That happens with language. In almost all right-handed people the left hemisphere is dominant for language.

Each thing we do, any thought, feeling or sensation is produced by the activity of cells localized in a specific area of the brain. For example, if you receive the credit card bill and you panic, that is because a group of cells in the inner part of the brain start to fire, increasing its electrical current, transmission, and metabolism. These cells need more blood since they need more fuel. And it happens that when an area of the brain becomes activated, that area receives more blood because in that region there is dilatation of the tiny blood vessels.

So, ultimately, any action of the brain occurs along with an increase of blood at the point of the cortex where that action is commanded.

Now, let's continue to the second part.

A very, very short course on MRI basics

MRI is a procedure to see the anatomy of the internal organs of the body. It is based on three things: magnetism, radiofrequency and computers.

Nevertheless, to understand how an MRI works and how these three things can show us the anatomy of the brain (and the whole body) it is important to know five other things:

1. Our body contains large amounts of water.
2. Water is formed by hydrogen and oxygen (The hydrogen is presented basically as protons).
3. Protons are positive charges that spin.
4. A charge that spins creates a magnetic field that can be oriented. In other words, these micro-magnets can be up or down, right or left.
5. The spin of these micro-magnets have a specific frequency (or velocity).

And that is it. Let's return to the three things needed to perform an MRI: magnetism, radiofrequency and computers.

Magnetism

The magnetic resonance machine is a big and strong magnet. When the body is inside, every proton of the body is oriented in the same way (for instance, with the positive pole up). This means that the body becomes a magnet, but a non-homogeneous magnet, because the amount of water in each part of the body varies with the specific characteristics of the organ: the layer, the location, and even the types of cells. Therefore, the human body can be pictured as a 3D-map of changes of magnetic field with a human body form. If we knew the density of those changes we could obtain the images of the internal anatomy. And how do we know the density? By means of radiofrequency.

Radiofrequency

Radiofrequency gives energy to the spin of the protons, increasing the amplitude of their turns without changing the frequency. Now the 3D-magnetic map becomes a 3D-map of energy. Each particular point in the body has a particular energy (or intensity, in terms of radiofrequency). If radiofrequency is no longer applied to the body, the proton-spins return to their original state and in that moment release radiofrequency waves. Now we have a 3D-map of radiofrequency. And radiofrequency can be registered with coils.

Computers

The rest of the procedure is done by the computers that convert the signal intensity, the signal phase, and the signal location into a matrix of dots with different values. Each value is represented with a tone of gray. The minimum value is black, and the maximum value is white, and in between is a scale of gray. At this point WE HAVE THE MR IMAGE!

How the FMRI Works

In functional imaging we have two components: a task and a result. The task is an action or activity that the subject does in order to produce a particular activation of the brain. For example, moving the right hand fingers continuously is a motor task that "activates" the brain cortex in the left frontal lobe. The result in fMRI is an image which depicts this activation.

The task can be of any type. Motor, feeling a sensation, having a perception, thinking in abstract words, attending to a changing stimulus, listening to music, comprehending a story, and many others. The task will produce this sequence of events:

1. Increases in metabolism of the brain area involved in the task
2. Increases in volume of blood in that particular region
3. Increases in oxygen level
4. Changes in the local magnetic field (Do you remember the 3D-magnetic field map discussed earlier?)
5. Changes in the intensity of the energy (radiofrequency) in the same area.

In brief, the task elicits activity of a region of the brain, and this activity changes the intensity of the radiofrequency coming from that part. This is a very small change. But, if we repeat the task several times we are able to sum the changes to get a significant result that can be registered.

We compare a person's brain activity during a particular task with their activity level during a resting state. However, the brain works continuously, even during the resting state. For that reason the resting state is a baseline of the background activity of the brain.

So we must know the value of the background signal activity and the value of the signal related to the task. To do this, hundreds of images of the region targeted are taken during a few minutes. Meanwhile, the subject is alternating between periods of activity (performing the task) and periods of rest. In this manner we have a group of images of a region taken during the task, and the same number of images of the same region during rest. Two averaged images are obtained corresponding to two conditions in which one is "activated".

As we have seen before, images are the result of the values of the signal intensity, encoded on a gray scale. These values can be added, subtracted, etc. Well, that is exactly the next step. Powerful computers subtract the baseline values from the activated ones. These values of activation are then transformed into a map of colors. Usually the scale of this map varies from blue to red in a increasing manner. Finally, the colors are overlaid upon anatomical images, in a similar way that the weather maps are overlaid upon geographical pictures.
 

How fMRI can be helpful in Medicine

fMRI has a particular terminology. The next images explain the must important terms used to describe one experiment.

One epoch is a period of time in which something is occurring.

• ON: The name of the epoch in which the task is performed
• OFF: The name of the epoch in which the subject is at rest

A scan is the image obtained in each unit of time

A level is the localization of the site to explore. Several levels can be explored at once.

In this graphic is shown: 5 epochs ON, in which the subject performs the task; 5 epochs OFF, in which the subject is at rest; each epoch lasts 30 seconds for a total length of the experiment of 5 minutes. Four levels of the brain are explored, with 120 images (or scans) divided in alternated groups of 12.

A Final Result

The areas in color depict the activation of the brain regions involved in hearing and comprehending the human voice. The left hemisphere shows greater activation.

In order to understand how functional magnetic resonance (fMRI) works it is important to know some basic things about brain anatomy and function. Also, it is necessary to know some magnetic resonance imaging (MRI) basic facts. Let's begin with the first part:

A very short course on Neuroanatomy

The brain is divided in two hemispheres, the right and the left. Each hemisphere is divided into lobes. And each lobe has different areas as is depicted in the next figure taken with permission from http://www.umich.edu/~cogneuro/home.html

Each region in a different color is a lobe. In yellow the frontal lobe; in green, the parietal lobe; the occipital lobe appears blue, while the temporal lobe is red.

Areas 1,2,3, and 5 "feel" the sensations of touch, position and temperature. Areas 4, 6, and 8 move the muscles of the body. Areas like 44, 45 and 47 produce language. Areas 41 and 42 "hear", areas 17 to 19 "see".

Other areas like 37, 46, 10, 22, 38 are in charge of the complex process involving memory, internal language, comprehension and planning.

This is a regionalization of the function. Also, there is something called "lateralization" of the function. This means that a particular activity can be predominantly located in one hemisphere. That happens with language. In almost all right-handed people the left hemisphere is dominant for language.

Each thing we do, any thought, feeling or sensation is produced by the activity of cells localized in a specific area of the brain. For example, if you receive the credit card bill and you panic, that is because a group of cells in the inner part of the brain start to fire, increasing its electrical current, transmission, and metabolism. These cells need more blood since they need more fuel. And it happens that when an area of the brain becomes activated, that area receives more blood because in that region there is dilatation of the tiny blood vessels.

So, ultimately, any action of the brain occurs along with an increase of blood at the point of the cortex where that action is commanded.

Now, let's continue to the second part.

A very, very short course on MRI basics

MRI is a procedure to see the anatomy of the internal organs of the body. It is based on three things: magnetism, radiofrequency and computers.

Nevertheless, to understand how an MRI works and how these three things can show us the anatomy of the brain (and the whole body) it is important to know five other things:

1. Our body contains large amounts of water.
2. Water is formed by hydrogen and oxygen (The hydrogen is presented basically as protons).
3. Protons are positive charges that spin.
4. A charge that spins creates a magnetic field that can be oriented. In other words, these micro-magnets can be up or down, right or left.
5. The spin of these micro-magnets have a specific frequency (or velocity).

And that is it. Let's return to the three things needed to perform an MRI: magnetism, radiofrequency and computers.

Magnetism

The magnetic resonance machine is a big and strong magnet. When the body is inside, every proton of the body is oriented in the same way (for instance, with the positive pole up). This means that the body becomes a magnet, but a non-homogeneous magnet, because the amount of water in each part of the body varies with the specific characteristics of the organ: the layer, the location, and even the types of cells. Therefore, the human body can be pictured as a 3D-map of changes of magnetic field with a human body form. If we knew the density of those changes we could obtain the images of the internal anatomy. And how do we know the density? By means of radiofrequency.

Radiofrequency

Radiofrequency gives energy to the spin of the protons, increasing the amplitude of their turns without changing the frequency. Now the 3D-magnetic map becomes a 3D-map of energy. Each particular point in the body has a particular energy (or intensity, in terms of radiofrequency). If radiofrequency is no longer applied to the body, the proton-spins return to their original state and in that moment release radiofrequency waves. Now we have a 3D-map of radiofrequency. And radiofrequency can be registered with coils.

Computers

The rest of the procedure is done by the computers that convert the signal intensity, the signal phase, and the signal location into a matrix of dots with different values. Each value is represented with a tone of gray. The minimum value is black, and the maximum value is white, and in between is a scale of gray. At this point WE HAVE THE MR IMAGE!

How the FMRI Works

In functional imaging we have two components: a task and a result. The task is an action or activity that the subject does in order to produce a particular activation of the brain. For example, moving the right hand fingers continuously is a motor task that "activates" the brain cortex in the left frontal lobe. The result in fMRI is an image which depicts this activation.

The task can be of any type. Motor, feeling a sensation, having a perception, thinking in abstract words, attending to a changing stimulus, listening to music, comprehending a story, and many others. The task will produce this sequence of events:

1. Increases in metabolism of the brain area involved in the task
2. Increases in volume of blood in that particular region
3. Increases in oxygen level
4. Changes in the local magnetic field (Do you remember the 3D-magnetic field map discussed earlier?)
5. Changes in the intensity of the energy (radiofrequency) in the same area.

In brief, the task elicits activity of a region of the brain, and this activity changes the intensity of the radiofrequency coming from that part. This is a very small change. But, if we repeat the task several times we are able to sum the changes to get a significant result that can be registered.

We compare a person's brain activity during a particular task with their activity level during a resting state. However, the brain works continuously, even during the resting state. For that reason the resting state is a baseline of the background activity of the brain.

So we must know the value of the background signal activity and the value of the signal related to the task. To do this, hundreds of images of the region targeted are taken during a few minutes. Meanwhile, the subject is alternating between periods of activity (performing the task) and periods of rest. In this manner we have a group of images of a region taken during the task, and the same number of images of the same region during rest. Two averaged images are obtained corresponding to two conditions in which one is "activated".

As we have seen before, images are the result of the values of the signal intensity, encoded on a gray scale. These values can be added, subtracted, etc. Well, that is exactly the next step. Powerful computers subtract the baseline values from the activated ones. These values of activation are then transformed into a map of colors. Usually the scale of this map varies from blue to red in a increasing manner. Finally, the colors are overlaid upon anatomical images, in a similar way that the weather maps are overlaid upon geographical pictures.
 

How fMRI can be helpful in Medicine

fMRI has a particular terminology. The next images explain the must important terms used to describe one experiment.

One epoch is a period of time in which something is occurring.

• ON: The name of the epoch in which the task is performed
• OFF: The name of the epoch in which the subject is at rest

A scan is the image obtained in each unit of time

A level is the localization of the site to explore. Several levels can be explored at once.

In this graphic is shown: 5 epochs ON, in which the subject performs the task; 5 epochs OFF, in which the subject is at rest; each epoch lasts 30 seconds for a total length of the experiment of 5 minutes. Four levels of the brain are explored, with 120 images (or scans) divided in alternated groups of 12.

A Final Result

The areas in color depict the activation of the brain regions involved in hearing and comprehending the human voice. The left hemisphere shows greater activation.

In order to understand how functional magnetic resonance (fMRI) works it is important to know some basic things about brain anatomy and function. Also, it is necessary to know some magnetic resonance imaging (MRI) basic facts. Let's begin with the first part:

A very short course on Neuroanatomy

The brain is divided in two hemispheres, the right and the left. Each hemisphere is divided into lobes. And each lobe has different areas as is depicted in the next figure taken with permission from http://www.umich.edu/~cogneuro/home.html

Each region in a different color is a lobe. In yellow the frontal lobe; in green, the parietal lobe; the occipital lobe appears blue, while the temporal lobe is red.

Areas 1,2,3, and 5 "feel" the sensations of touch, position and temperature. Areas 4, 6, and 8 move the muscles of the body. Areas like 44, 45 and 47 produce language. Areas 41 and 42 "hear", areas 17 to 19 "see".

Other areas like 37, 46, 10, 22, 38 are in charge of the complex process involving memory, internal language, comprehension and planning.

This is a regionalization of the function. Also, there is something called "lateralization" of the function. This means that a particular activity can be predominantly located in one hemisphere. That happens with language. In almost all right-handed people the left hemisphere is dominant for language.

Each thing we do, any thought, feeling or sensation is produced by the activity of cells localized in a specific area of the brain. For example, if you receive the credit card bill and you panic, that is because a group of cells in the inner part of the brain start to fire, increasing its electrical current, transmission, and metabolism. These cells need more blood since they need more fuel. And it happens that when an area of the brain becomes activated, that area receives more blood because in that region there is dilatation of the tiny blood vessels.

So, ultimately, any action of the brain occurs along with an increase of blood at the point of the cortex where that action is commanded.

Now, let's continue to the second part.

A very, very short course on MRI basics

MRI is a procedure to see the anatomy of the internal organs of the body. It is based on three things: magnetism, radiofrequency and computers.

Nevertheless, to understand how an MRI works and how these three things can show us the anatomy of the brain (and the whole body) it is important to know five other things:

1. Our body contains large amounts of water.
2. Water is formed by hydrogen and oxygen (The hydrogen is presented basically as protons).
3. Protons are positive charges that spin.
4. A charge that spins creates a magnetic field that can be oriented. In other words, these micro-magnets can be up or down, right or left.
5. The spin of these micro-magnets have a specific frequency (or velocity).

And that is it. Let's return to the three things needed to perform an MRI: magnetism, radiofrequency and computers.

Magnetism

The magnetic resonance machine is a big and strong magnet. When the body is inside, every proton of the body is oriented in the same way (for instance, with the positive pole up). This means that the body becomes a magnet, but a non-homogeneous magnet, because the amount of water in each part of the body varies with the specific characteristics of the organ: the layer, the location, and even the types of cells. Therefore, the human body can be pictured as a 3D-map of changes of magnetic field with a human body form. If we knew the density of those changes we could obtain the images of the internal anatomy. And how do we know the density? By means of radiofrequency.

Radiofrequency

Radiofrequency gives energy to the spin of the protons, increasing the amplitude of their turns without changing the frequency. Now the 3D-magnetic map becomes a 3D-map of energy. Each particular point in the body has a particular energy (or intensity, in terms of radiofrequency). If radiofrequency is no longer applied to the body, the proton-spins return to their original state and in that moment release radiofrequency waves. Now we have a 3D-map of radiofrequency. And radiofrequency can be registered with coils.

Computers

The rest of the procedure is done by the computers that convert the signal intensity, the signal phase, and the signal location into a matrix of dots with different values. Each value is represented with a tone of gray. The minimum value is black, and the maximum value is white, and in between is a scale of gray. At this point WE HAVE THE MR IMAGE!

How the FMRI Works

In functional imaging we have two components: a task and a result. The task is an action or activity that the subject does in order to produce a particular activation of the brain. For example, moving the right hand fingers continuously is a motor task that "activates" the brain cortex in the left frontal lobe. The result in fMRI is an image which depicts this activation.

The task can be of any type. Motor, feeling a sensation, having a perception, thinking in abstract words, attending to a changing stimulus, listening to music, comprehending a story, and many others. The task will produce this sequence of events:

1. Increases in metabolism of the brain area involved in the task
2. Increases in volume of blood in that particular region
3. Increases in oxygen level
4. Changes in the local magnetic field (Do you remember the 3D-magnetic field map discussed earlier?)
5. Changes in the intensity of the energy (radiofrequency) in the same area.

In brief, the task elicits activity of a region of the brain, and this activity changes the intensity of the radiofrequency coming from that part. This is a very small change. But, if we repeat the task several times we are able to sum the changes to get a significant result that can be registered.

We compare a person's brain activity during a particular task with their activity level during a resting state. However, the brain works continuously, even during the resting state. For that reason the resting state is a baseline of the background activity of the brain.

So we must know the value of the background signal activity and the value of the signal related to the task. To do this, hundreds of images of the region targeted are taken during a few minutes. Meanwhile, the subject is alternating between periods of activity (performing the task) and periods of rest. In this manner we have a group of images of a region taken during the task, and the same number of images of the same region during rest. Two averaged images are obtained corresponding to two conditions in which one is "activated".

As we have seen before, images are the result of the values of the signal intensity, encoded on a gray scale. These values can be added, subtracted, etc. Well, that is exactly the next step. Powerful computers subtract the baseline values from the activated ones. These values of activation are then transformed into a map of colors. Usually the scale of this map varies from blue to red in a increasing manner. Finally, the colors are overlaid upon anatomical images, in a similar way that the weather maps are overlaid upon geographical pictures.
 

How fMRI can be helpful in Medicine

fMRI has a particular terminology. The next images explain the must important terms used to describe one experiment.

One epoch is a period of time in which something is occurring.

• ON: The name of the epoch in which the task is performed
• OFF: The name of the epoch in which the subject is at rest

A scan is the image obtained in each unit of time

A level is the localization of the site to explore. Several levels can be explored at once.

In this graphic is shown: 5 epochs ON, in which the subject performs the task; 5 epochs OFF, in which the subject is at rest; each epoch lasts 30 seconds for a total length of the experiment of 5 minutes. Four levels of the brain are explored, with 120 images (or scans) divided in alternated groups of 12.

A Final Result

The areas in color depict the activation of the brain regions involved in hearing and comprehending the human voice. The left hemisphere shows greater activation.

In order to understand how functional magnetic resonance (fMRI) works it is important to know some basic things about brain anatomy and function. Also, it is necessary to know some magnetic resonance imaging (MRI) basic facts. Let's begin with the first part:

A very short course on Neuroanatomy

The brain is divided in two hemispheres, the right and the left. Each hemisphere is divided into lobes. And each lobe has different areas as is depicted in the next figure taken with permission from http://www.umich.edu/~cogneuro/home.html

Each region in a different color is a lobe. In yellow the frontal lobe; in green, the parietal lobe; the occipital lobe appears blue, while the temporal lobe is red.

Areas 1,2,3, and 5 "feel" the sensations of touch, position and temperature. Areas 4, 6, and 8 move the muscles of the body. Areas like 44, 45 and 47 produce language. Areas 41 and 42 "hear", areas 17 to 19 "see".

Other areas like 37, 46, 10, 22, 38 are in charge of the complex process involving memory, internal language, comprehension and planning.

This is a regionalization of the function. Also, there is something called "lateralization" of the function. This means that a particular activity can be predominantly located in one hemisphere. That happens with language. In almost all right-handed people the left hemisphere is dominant for language.

Each thing we do, any thought, feeling or sensation is produced by the activity of cells localized in a specific area of the brain. For example, if you receive the credit card bill and you panic, that is because a group of cells in the inner part of the brain start to fire, increasing its electrical current, transmission, and metabolism. These cells need more blood since they need more fuel. And it happens that when an area of the brain becomes activated, that area receives more blood because in that region there is dilatation of the tiny blood vessels.

So, ultimately, any action of the brain occurs along with an increase of blood at the point of the cortex where that action is commanded.

Now, let's continue to the second part.

A very, very short course on MRI basics

MRI is a procedure to see the anatomy of the internal organs of the body. It is based on three things: magnetism, radiofrequency and computers.

Nevertheless, to understand how an MRI works and how these three things can show us the anatomy of the brain (and the whole body) it is important to know five other things:

1. Our body contains large amounts of water.
2. Water is formed by hydrogen and oxygen (The hydrogen is presented basically as protons).
3. Protons are positive charges that spin.
4. A charge that spins creates a magnetic field that can be oriented. In other words, these micro-magnets can be up or down, right or left.
5. The spin of these micro-magnets have a specific frequency (or velocity).

And that is it. Let's return to the three things needed to perform an MRI: magnetism, radiofrequency and computers.

Magnetism

The magnetic resonance machine is a big and strong magnet. When the body is inside, every proton of the body is oriented in the same way (for instance, with the positive pole up). This means that the body becomes a magnet, but a non-homogeneous magnet, because the amount of water in each part of the body varies with the specific characteristics of the organ: the layer, the location, and even the types of cells. Therefore, the human body can be pictured as a 3D-map of changes of magnetic field with a human body form. If we knew the density of those changes we could obtain the images of the internal anatomy. And how do we know the density? By means of radiofrequency.

Radiofrequency

Radiofrequency gives energy to the spin of the protons, increasing the amplitude of their turns without changing the frequency. Now the 3D-magnetic map becomes a 3D-map of energy. Each particular point in the body has a particular energy (or intensity, in terms of radiofrequency). If radiofrequency is no longer applied to the body, the proton-spins return to their original state and in that moment release radiofrequency waves. Now we have a 3D-map of radiofrequency. And radiofrequency can be registered with coils.

Computers

The rest of the procedure is done by the computers that convert the signal intensity, the signal phase, and the signal location into a matrix of dots with different values. Each value is represented with a tone of gray. The minimum value is black, and the maximum value is white, and in between is a scale of gray. At this point WE HAVE THE MR IMAGE!

How the FMRI Works

In functional imaging we have two components: a task and a result. The task is an action or activity that the subject does in order to produce a particular activation of the brain. For example, moving the right hand fingers continuously is a motor task that "activates" the brain cortex in the left frontal lobe. The result in fMRI is an image which depicts this activation.

The task can be of any type. Motor, feeling a sensation, having a perception, thinking in abstract words, attending to a changing stimulus, listening to music, comprehending a story, and many others. The task will produce this sequence of events:

1. Increases in metabolism of the brain area involved in the task
2. Increases in volume of blood in that particular region
3. Increases in oxygen level
4. Changes in the local magnetic field (Do you remember the 3D-magnetic field map discussed earlier?)
5. Changes in the intensity of the energy (radiofrequency) in the same area.

In brief, the task elicits activity of a region of the brain, and this activity changes the intensity of the radiofrequency coming from that part. This is a very small change. But, if we repeat the task several times we are able to sum the changes to get a significant result that can be registered.

We compare a person's brain activity during a particular task with their activity level during a resting state. However, the brain works continuously, even during the resting state. For that reason the resting state is a baseline of the background activity of the brain.

So we must know the value of the background signal activity and the value of the signal related to the task. To do this, hundreds of images of the region targeted are taken during a few minutes. Meanwhile, the subject is alternating between periods of activity (performing the task) and periods of rest. In this manner we have a group of images of a region taken during the task, and the same number of images of the same region during rest. Two averaged images are obtained corresponding to two conditions in which one is "activated".

As we have seen before, images are the result of the values of the signal intensity, encoded on a gray scale. These values can be added, subtracted, etc. Well, that is exactly the next step. Powerful computers subtract the baseline values from the activated ones. These values of activation are then transformed into a map of colors. Usually the scale of this map varies from blue to red in a increasing manner. Finally, the colors are overlaid upon anatomical images, in a similar way that the weather maps are overlaid upon geographical pictures.
 

How fMRI can be helpful in Medicine

fMRI has a particular terminology. The next images explain the must important terms used to describe one experiment.

One epoch is a period of time in which something is occurring.

• ON: The name of the epoch in which the task is performed
• OFF: The name of the epoch in which the subject is at rest

A scan is the image obtained in each unit of time

A level is the localization of the site to explore. Several levels can be explored at once.

In this graphic is shown: 5 epochs ON, in which the subject performs the task; 5 epochs OFF, in which the subject is at rest; each epoch lasts 30 seconds for a total length of the experiment of 5 minutes. Four levels of the brain are explored, with 120 images (or scans) divided in alternated groups of 12.

A Final Result

The areas in color depict the activation of the brain regions involved in hearing and comprehending the human voice. The left hemisphere shows greater activation.

In order to understand how functional magnetic resonance (fMRI) works it is important to know some basic things about brain anatomy and function. Also, it is necessary to know some magnetic resonance imaging (MRI) basic facts. Let's begin with the first part:

A very short course on Neuroanatomy

The brain is divided in two hemispheres, the right and the left. Each hemisphere is divided into lobes. And each lobe has different areas as is depicted in the next figure taken with permission from http://www.umich.edu/~cogneuro/home.html

Each region in a different color is a lobe. In yellow the frontal lobe; in green, the parietal lobe; the occipital lobe appears blue, while the temporal lobe is red.

Areas 1,2,3, and 5 "feel" the sensations of touch, position and temperature. Areas 4, 6, and 8 move the muscles of the body. Areas like 44, 45 and 47 produce language. Areas 41 and 42 "hear", areas 17 to 19 "see".

Other areas like 37, 46, 10, 22, 38 are in charge of the complex process involving memory, internal language, comprehension and planning.

This is a regionalization of the function. Also, there is something called "lateralization" of the function. This means that a particular activity can be predominantly located in one hemisphere. That happens with language. In almost all right-handed people the left hemisphere is dominant for language.

Each thing we do, any thought, feeling or sensation is produced by the activity of cells localized in a specific area of the brain. For example, if you receive the credit card bill and you panic, that is because a group of cells in the inner part of the brain start to fire, increasing its electrical current, transmission, and metabolism. These cells need more blood since they need more fuel. And it happens that when an area of the brain becomes activated, that area receives more blood because in that region there is dilatation of the tiny blood vessels.

So, ultimately, any action of the brain occurs along with an increase of blood at the point of the cortex where that action is commanded.

Now, let's continue to the second part.

A very, very short course on MRI basics

MRI is a procedure to see the anatomy of the internal organs of the body. It is based on three things: magnetism, radiofrequency and computers.

Nevertheless, to understand how an MRI works and how these three things can show us the anatomy of the brain (and the whole body) it is important to know five other things:

1. Our body contains large amounts of water.
2. Water is formed by hydrogen and oxygen (The hydrogen is presented basically as protons).
3. Protons are positive charges that spin.
4. A charge that spins creates a magnetic field that can be oriented. In other words, these micro-magnets can be up or down, right or left.
5. The spin of these micro-magnets have a specific frequency (or velocity).

And that is it. Let's return to the three things needed to perform an MRI: magnetism, radiofrequency and computers.

Magnetism

The magnetic resonance machine is a big and strong magnet. When the body is inside, every proton of the body is oriented in the same way (for instance, with the positive pole up). This means that the body becomes a magnet, but a non-homogeneous magnet, because the amount of water in each part of the body varies with the specific characteristics of the organ: the layer, the location, and even the types of cells. Therefore, the human body can be pictured as a 3D-map of changes of magnetic field with a human body form. If we knew the density of those changes we could obtain the images of the internal anatomy. And how do we know the density? By means of radiofrequency.

Radiofrequency

Radiofrequency gives energy to the spin of the protons, increasing the amplitude of their turns without changing the frequency. Now the 3D-magnetic map becomes a 3D-map of energy. Each particular point in the body has a particular energy (or intensity, in terms of radiofrequency). If radiofrequency is no longer applied to the body, the proton-spins return to their original state and in that moment release radiofrequency waves. Now we have a 3D-map of radiofrequency. And radiofrequency can be registered with coils.

Computers

The rest of the procedure is done by the computers that convert the signal intensity, the signal phase, and the signal location into a matrix of dots with different values. Each value is represented with a tone of gray. The minimum value is black, and the maximum value is white, and in between is a scale of gray. At this point WE HAVE THE MR IMAGE!

How the FMRI Works

In functional imaging we have two components: a task and a result. The task is an action or activity that the subject does in order to produce a particular activation of the brain. For example, moving the right hand fingers continuously is a motor task that "activates" the brain cortex in the left frontal lobe. The result in fMRI is an image which depicts this activation.

The task can be of any type. Motor, feeling a sensation, having a perception, thinking in abstract words, attending to a changing stimulus, listening to music, comprehending a story, and many others. The task will produce this sequence of events:

1. Increases in metabolism of the brain area involved in the task
2. Increases in volume of blood in that particular region
3. Increases in oxygen level
4. Changes in the local magnetic field (Do you remember the 3D-magnetic field map discussed earlier?)
5. Changes in the intensity of the energy (radiofrequency) in the same area.

In brief, the task elicits activity of a region of the brain, and this activity changes the intensity of the radiofrequency coming from that part. This is a very small change. But, if we repeat the task several times we are able to sum the changes to get a significant result that can be registered.

We compare a person's brain activity during a particular task with their activity level during a resting state. However, the brain works continuously, even during the resting state. For that reason the resting state is a baseline of the background activity of the brain.

So we must know the value of the background signal activity and the value of the signal related to the task. To do this, hundreds of images of the region targeted are taken during a few minutes. Meanwhile, the subject is alternating between periods of activity (performing the task) and periods of rest. In this manner we have a group of images of a region taken during the task, and the same number of images of the same region during rest. Two averaged images are obtained corresponding to two conditions in which one is "activated".

As we have seen before, images are the result of the values of the signal intensity, encoded on a gray scale. These values can be added, subtracted, etc. Well, that is exactly the next step. Powerful computers subtract the baseline values from the activated ones. These values of activation are then transformed into a map of colors. Usually the scale of this map varies from blue to red in a increasing manner. Finally, the colors are overlaid upon anatomical images, in a similar way that the weather maps are overlaid upon geographical pictures.
 

How fMRI can be helpful in Medicine

fMRI has a particular terminology. The next images explain the must important terms used to describe one experiment.

One epoch is a period of time in which something is occurring.

• ON: The name of the epoch in which the task is performed
• OFF: The name of the epoch in which the subject is at rest

A scan is the image obtained in each unit of time

A level is the localization of the site to explore. Several levels can be explored at once.

In this graphic is shown: 5 epochs ON, in which the subject performs the task; 5 epochs OFF, in which the subject is at rest; each epoch lasts 30 seconds for a total length of the experiment of 5 minutes. Four levels of the brain are explored, with 120 images (or scans) divided in alternated groups of 12.

A Final Result

The areas in color depict the activation of the brain regions involved in hearing and comprehending the human voice. The left hemisphere shows greater activation.

Case 1

Patient	Female patient, age 19. Presurgical demonstration of eloquent areas
Paradigm	Phonetic fluency ON: Silent word generation starting with a given letter OFF: Think of nothing
Results	Activation of middle and inferior left frontal gyri, precentral left cortex, left angular gyri, and scattered areas in the parietal lobes.
Comments	The main activated area in this phonetic fluency task is the superior aspect of the left inferior frontal gyrus.   In contrast, the main area of activation on tasks requiring generation of verbs is the inferior aspect of Broca's area, along with the anterior insula.

Case 2

Patient	Male patient, age 13. Presurgical mapping of eloquent areas.
Paradigm	Phonetic fluency ON: Silent word generation starting with a given letter OFF: Think of nothing
Results	Strong activation in left middle and inferior frontal gyri, and left postcentral sulcus.   There is no significant activation in the right hemisphere

Case 3

Patient	Male patient, age 14, with seizures
Paradigm	Tapping task ON: Alternating Finger Tapping with the right hand OFF: Think of nothing
Results	Cortex of the left central sulcus was strongly activated. The relation to the tumor is clearly depicted by the images.
Comments	The tumor was resected without postoperatory motor deficit

Case 4

Patient	Male patient, 9 years old with a neoplastic lesion in the left sylvian fissure. No language deficit
Paradigm	Verbal fluency task ON: Think of actions related to given nouns OFF: Think of nothing
Results	Obvious left language dominance. Broca's area is well depicted along with left superior frontal gyrus. Activation in the right cerebellum has been described associated with expressive language tasks. A Case of Acalculia.

Case 1

Patient	Female patient, age 19. Presurgical demonstration of eloquent areas
Paradigm	Phonetic fluency ON: Silent word generation starting with a given letter OFF: Think of nothing
Results	Activation of middle and inferior left frontal gyri, precentral left cortex, left angular gyri, and scattered areas in the parietal lobes.
Comments	The main activated area in this phonetic fluency task is the superior aspect of the left inferior frontal gyrus.   In contrast, the main area of activation on tasks requiring generation of verbs is the inferior aspect of Broca's area, along with the anterior insula.

Case 2

Patient	Male patient, age 13. Presurgical mapping of eloquent areas.
Paradigm	Phonetic fluency ON: Silent word generation starting with a given letter OFF: Think of nothing
Results	Strong activation in left middle and inferior frontal gyri, and left postcentral sulcus.   There is no significant activation in the right hemisphere

Case 3

Patient	Male patient, age 14, with seizures
Paradigm	Tapping task ON: Alternating Finger Tapping with the right hand OFF: Think of nothing
Results	Cortex of the left central sulcus was strongly activated. The relation to the tumor is clearly depicted by the images.
Comments	The tumor was resected without postoperatory motor deficit

Case 4

Patient	Male patient, 9 years old with a neoplastic lesion in the left sylvian fissure. No language deficit
Paradigm	Verbal fluency task ON: Think of actions related to given nouns OFF: Think of nothing
Results	Obvious left language dominance. Broca's area is well depicted along with left superior frontal gyrus. Activation in the right cerebellum has been described associated with expressive language tasks. A Case of Acalculia.

Case 1

Patient	Female patient, age 19. Presurgical demonstration of eloquent areas
Paradigm	Phonetic fluency ON: Silent word generation starting with a given letter OFF: Think of nothing
Results	Activation of middle and inferior left frontal gyri, precentral left cortex, left angular gyri, and scattered areas in the parietal lobes.
Comments	The main activated area in this phonetic fluency task is the superior aspect of the left inferior frontal gyrus.   In contrast, the main area of activation on tasks requiring generation of verbs is the inferior aspect of Broca's area, along with the anterior insula.

Case 2

Patient	Male patient, age 13. Presurgical mapping of eloquent areas.
Paradigm	Phonetic fluency ON: Silent word generation starting with a given letter OFF: Think of nothing
Results	Strong activation in left middle and inferior frontal gyri, and left postcentral sulcus.   There is no significant activation in the right hemisphere

Case 3

Patient	Male patient, age 14, with seizures
Paradigm	Tapping task ON: Alternating Finger Tapping with the right hand OFF: Think of nothing
Results	Cortex of the left central sulcus was strongly activated. The relation to the tumor is clearly depicted by the images.
Comments	The tumor was resected without postoperatory motor deficit

Case 4

Patient	Male patient, 9 years old with a neoplastic lesion in the left sylvian fissure. No language deficit
Paradigm	Verbal fluency task ON: Think of actions related to given nouns OFF: Think of nothing
Results	Obvious left language dominance. Broca's area is well depicted along with left superior frontal gyrus. Activation in the right cerebellum has been described associated with expressive language tasks. A Case of Acalculia.

Case 1

Patient	Female patient, age 19. Presurgical demonstration of eloquent areas
Paradigm	Phonetic fluency ON: Silent word generation starting with a given letter OFF: Think of nothing
Results	Activation of middle and inferior left frontal gyri, precentral left cortex, left angular gyri, and scattered areas in the parietal lobes.
Comments	The main activated area in this phonetic fluency task is the superior aspect of the left inferior frontal gyrus.   In contrast, the main area of activation on tasks requiring generation of verbs is the inferior aspect of Broca's area, along with the anterior insula.

Case 2

Patient	Male patient, age 13. Presurgical mapping of eloquent areas.
Paradigm	Phonetic fluency ON: Silent word generation starting with a given letter OFF: Think of nothing
Results	Strong activation in left middle and inferior frontal gyri, and left postcentral sulcus.   There is no significant activation in the right hemisphere

Case 3

Patient	Male patient, age 14, with seizures
Paradigm	Tapping task ON: Alternating Finger Tapping with the right hand OFF: Think of nothing
Results	Cortex of the left central sulcus was strongly activated. The relation to the tumor is clearly depicted by the images.
Comments	The tumor was resected without postoperatory motor deficit

Case 4

Patient	Male patient, 9 years old with a neoplastic lesion in the left sylvian fissure. No language deficit
Paradigm	Verbal fluency task ON: Think of actions related to given nouns OFF: Think of nothing
Results	Obvious left language dominance. Broca's area is well depicted along with left superior frontal gyrus. Activation in the right cerebellum has been described associated with expressive language tasks. A Case of Acalculia.

Case 1

Patient	Female patient, age 19. Presurgical demonstration of eloquent areas
Paradigm	Phonetic fluency ON: Silent word generation starting with a given letter OFF: Think of nothing
Results	Activation of middle and inferior left frontal gyri, precentral left cortex, left angular gyri, and scattered areas in the parietal lobes.
Comments	The main activated area in this phonetic fluency task is the superior aspect of the left inferior frontal gyrus.   In contrast, the main area of activation on tasks requiring generation of verbs is the inferior aspect of Broca's area, along with the anterior insula.

Case 2

Patient	Male patient, age 13. Presurgical mapping of eloquent areas.
Paradigm	Phonetic fluency ON: Silent word generation starting with a given letter OFF: Think of nothing
Results	Strong activation in left middle and inferior frontal gyri, and left postcentral sulcus.   There is no significant activation in the right hemisphere

Case 3

Patient	Male patient, age 14, with seizures
Paradigm	Tapping task ON: Alternating Finger Tapping with the right hand OFF: Think of nothing
Results	Cortex of the left central sulcus was strongly activated. The relation to the tumor is clearly depicted by the images.
Comments	The tumor was resected without postoperatory motor deficit

Case 4

Patient	Male patient, 9 years old with a neoplastic lesion in the left sylvian fissure. No language deficit
Paradigm	Verbal fluency task ON: Think of actions related to given nouns OFF: Think of nothing
Results	Obvious left language dominance. Broca's area is well depicted along with left superior frontal gyrus. Activation in the right cerebellum has been described associated with expressive language tasks. A Case of Acalculia.

Case 1

Subject	Right handed 20 year-old-man
Paradigm	ON: Passive hearing music (single notes, unfamiliar tune), in binaural-monophonic presentation OFF: Hearing the background noise
Statistics	Statistical method P Value Z score Correlation coeficient 0.0001 N/A
Activation	There is assymetric activation which is greater on the left in Heschl's gyrus and more extensive on the right supramarginal gyrus.

Case 1

Subject	Right handed 20 year-old-man
Paradigm	ON: Passive hearing music (single notes, unfamiliar tune), in binaural-monophonic presentation OFF: Hearing the background noise
Statistics	Statistical method P Value Z score Correlation coeficient 0.0001 N/A
Activation	There is assymetric activation which is greater on the left in Heschl's gyrus and more extensive on the right supramarginal gyrus.

Case 1

Subject	Right handed 20 year-old-man
Paradigm	ON: Passive hearing music (single notes, unfamiliar tune), in binaural-monophonic presentation OFF: Hearing the background noise
Statistics	Statistical method P Value Z score Correlation coeficient 0.0001 N/A
Activation	There is assymetric activation which is greater on the left in Heschl's gyrus and more extensive on the right supramarginal gyrus.

Case 1

Subject	Right handed 20 year-old-man
Paradigm	ON: Passive hearing music (single notes, unfamiliar tune), in binaural-monophonic presentation OFF: Hearing the background noise
Statistics	Statistical method P Value Z score Correlation coeficient 0.0001 N/A
Activation	There is assymetric activation which is greater on the left in Heschl's gyrus and more extensive on the right supramarginal gyrus.

Case 1

Subject	Right handed 20 year-old-man
Paradigm	ON: Passive hearing music (single notes, unfamiliar tune), in binaural-monophonic presentation OFF: Hearing the background noise
Statistics	Statistical method P Value Z score Correlation coeficient 0.0001 N/A
Activation	There is assymetric activation which is greater on the left in Heschl's gyrus and more extensive on the right supramarginal gyrus.

Conventional MR images are two-dimensional representation of intensities occurring at a given level or slice.

These images may be presented in axial, coronal and sagittal planes.

The most frequent plane used in fMR is the axial plane which shows the localization of structures or activation in a X (right to left) and a Y (anterior to posterior) axes. Since these images are usually obtained in oblique planes it is difficult to know the precise level in the remaining Z (cranio-caudal) axis.

3D MRI scans allow us to present images with a volumetric appearance. These 3D MRI images have proven to be useful to guide surgical resections.

Types of 3D MRI scans

• Orthogonal Views are the simultaneous presentation of a structure in the X, Y and Z axes.
• Surface Rendering is the presentation of a structure as if it were seen by an external observer.
• 3D-Rendering + Orthogonal View is the combination of orthogonal views and surface rendering.
• Triple Rendering is when 3 procedures are superimposed on each other, such as MRV, fMR and surface rendering.

Orthogonal Views

Orthogonal views refer to a set of mutually perpendicular images. This localizes a given region of activation to the three axes that define the volumetric shape of the brain.

Case 1

Adult volunteer generating verbs. On the axial view the exact location of activation in the temporal lobe is difficult to determine. The black lines in the axial view correspond to the location of the coronal and sagittal views. These three views allow us to determine the location of activation in the middle temporal gyrus.

Case 2

Right handed adult male patient with intractable seizures coming from the left temporal pole, performing a language task consisting of listening to a story. No structural lesion was found in this region. A left temporal resection is planned. The orthogonal views permit evaluating of the extent of the language areas and the distance between its anterior border and the temporal pole (orange line). The neurosurgeon may use these findings as a guide to tailor the temporal resection.

Surface Rendering

Surface rendering is a computer post processing method that removes the skin and the skull to allow us to see the brain surface. The anatomy of gyri and sulci are displayed in the same way the neurosurgeon sees the brain. Functional maps can be superimposed on these images. Some activation may take place deep in the sulci which may be presented on these images bleeding through the cortical surface.

Case 1

Right handed 15 year-old-boy with intractable epilepsy performing a verbal "repetition task." The surface rendition beautifully depicts the activation occurring in the posterior third of the right superior temporal gyrus and extending toward supramarginal gyrus and Brodmann's area 7. The areas of activation are better displayed than with conventional 2D MR images.

Case 2

Right handed 11 year-old-girl with intractable epilepsy who had a left frontal resection two years ago for control of seizures. Persistence of the seizures prompted this fMR exam for re-evaluation. The images demonstrated activation obtained from a "Verb Generation Task." The study depicted Broca's area and part of Wernicke's (Brodmann's area 37), which is believed to be a repository for words. A second resection was performed based on these findings. The patient experienced no post-operative aphasia and remains seizure free.

3D Rendering + Orthogonal View

Surface rendering and orthogonal views can be combined in one procedure. This allows us to see activation (or lesions) of the cortex and deep structures of the brain. The bleeding through of activation is obviated. External landmarks of the head and face may also help in surgical navigation.

Surface and orthogonal rendering of the brain is viewed in natural anatomical orientation. This means that the structures appear as if they were under direct sight. For that reason the left hemisphere appears on the right side of the left-top-rostral view, and on the left side on the left-top-posterior view. The fMR image presented here depicts activation of the angular gyrus observed in a right-left laterality decision task. The hemi-axial plane shows the activation placed in the deep portion of the left parietal sulcus.

Case 1

11-year-old right handed boy with intractable epilepsy and left hemiparesis. Patient was mapped for language as part of his work up for epilepsy surgery with a "Semantic Fluency Task."

3D-surface rendering and orthogonal views. The images show activation of Broca's area along pars orbitales, triangularis and opercularis in the left hemisphere. Activation is also observed in visual areas likely related to visual strategies. Activation of the basal ganglia is occasionally seen as in this case. Activation can be localized on one image including the cortex, the sylvian fissure, the calcarine fissure, the lateral ventricles and along the midline.

Case 2

Right handed 11 year-old-girl with persistent intractable epilepsy who had a partial left frontal resection . Patient underwent language mapping with fMR.

These images complement case 2 presented in "Surface Rendering." Activation is obtained with a "verb generation" task in Wernicke's area not only along the cortical surface but deep along the gyri.

Case 3

13 year old right handed-boy, with temporal lobe epilepsy. A multicystic oligodendroglioma was found in the left temporal lobe (black arrows). Functional MRI was prescribed to map language areas, prior to surgical resection.

A 3D-fMRI depicts the mass in the left temporal pole. The activation was obtained utilizing a "Repetition Task" paradigm (bubbles in yellow, orange, and red). The relationship between the lesion and the speech areas are beautifully displayed.

Case 4

Right handed 19 year-old female volunteer, performing a Stroop-like paradigm. This task involves inhibition, potentially useful in ADHD evaluation.

Activation is located in the cingulate gyrus, right inferior frontal, and supramarginal gyrus (red bubbles). The blue bubble located in the right frontal pole corresponds to inhibited areas. The combination of orthogonal axial and sagittal planes allow simultaneous presentation.

Triple Rendering

The neurosurgeon has a restricted view of the brain through the small window of the craniotomy. Modern neuroimaging can provide anatomy in three dimensions, and a much wider window.

Case 1

27-year-old right handed woman who underwent MRI and MRV to rule out a structural lesion. The patient volunteered to perform a verb generation task.

The image shows the fusion of three different procedures. In gray scale is the volumetric rendition of the brain obtained from the MRI sequence. In blue are depicted the surface veins and sinus of the left hemisphere from the MR-venogram. In yellow and red appears activation obtained from the echo-planar sequence used for functional MRI.

Case 2

17 year-old right handed boy with intractable epilepsy of partial motor type. MRI showed signal abnormality in the left middle frontal gyrus consistent with cortical dysplasia.

MRI of the head with partial exposure of the brain and skull. An axial view located at the superior third of the inferior frontal gyrus demonstrates in red the activation obtained with a verb generation task. The yellow spot represents the lesion and is derived from a fluid attenuated inversion recovery (FLAIR) sequence, and rendered with the rest of images, revealing the relationship between the lesion and the eloquent areas.

Case 3

15 year-old right handed girl with sensory-motor partial seizures involving the left hand since the age of 5. MRI showed a focal signal abnormality in the right postcentral gyrus consistent with a developmental tumor without changes over 2 years.

MRI of the brain appears in gray scale, functional MR activation is in yellow and red, the tumor is purple (light blue arrow), and the veins are blue. The tumor appears located in the post-central gyrus lateral and rostral to the functional activation. The relationship between the tumor and the functional activation was confirmed during awake intraoperative mapping. The venous landmarks provided useful information to the operating surgeon. The patient's tumor was removed without residual monoplegia. The patient had only transient loss of stereognosis and proprioception involving the 3rd, 4th, and 5th fingers, post-operatively.

Conventional MR images are two-dimensional representation of intensities occurring at a given level or slice.

These images may be presented in axial, coronal and sagittal planes.

The most frequent plane used in fMR is the axial plane which shows the localization of structures or activation in a X (right to left) and a Y (anterior to posterior) axes. Since these images are usually obtained in oblique planes it is difficult to know the precise level in the remaining Z (cranio-caudal) axis.

3D MRI scans allow us to present images with a volumetric appearance. These 3D MRI images have proven to be useful to guide surgical resections.

Types of 3D MRI scans

• Orthogonal Views are the simultaneous presentation of a structure in the X, Y and Z axes.
• Surface Rendering is the presentation of a structure as if it were seen by an external observer.
• 3D-Rendering + Orthogonal View is the combination of orthogonal views and surface rendering.
• Triple Rendering is when 3 procedures are superimposed on each other, such as MRV, fMR and surface rendering.

Orthogonal Views

Orthogonal views refer to a set of mutually perpendicular images. This localizes a given region of activation to the three axes that define the volumetric shape of the brain.

Case 1

Adult volunteer generating verbs. On the axial view the exact location of activation in the temporal lobe is difficult to determine. The black lines in the axial view correspond to the location of the coronal and sagittal views. These three views allow us to determine the location of activation in the middle temporal gyrus.

Case 2

Right handed adult male patient with intractable seizures coming from the left temporal pole, performing a language task consisting of listening to a story. No structural lesion was found in this region. A left temporal resection is planned. The orthogonal views permit evaluating of the extent of the language areas and the distance between its anterior border and the temporal pole (orange line). The neurosurgeon may use these findings as a guide to tailor the temporal resection.

Surface Rendering

Surface rendering is a computer post processing method that removes the skin and the skull to allow us to see the brain surface. The anatomy of gyri and sulci are displayed in the same way the neurosurgeon sees the brain. Functional maps can be superimposed on these images. Some activation may take place deep in the sulci which may be presented on these images bleeding through the cortical surface.

Case 1

Right handed 15 year-old-boy with intractable epilepsy performing a verbal "repetition task." The surface rendition beautifully depicts the activation occurring in the posterior third of the right superior temporal gyrus and extending toward supramarginal gyrus and Brodmann's area 7. The areas of activation are better displayed than with conventional 2D MR images.

Case 2

Right handed 11 year-old-girl with intractable epilepsy who had a left frontal resection two years ago for control of seizures. Persistence of the seizures prompted this fMR exam for re-evaluation. The images demonstrated activation obtained from a "Verb Generation Task." The study depicted Broca's area and part of Wernicke's (Brodmann's area 37), which is believed to be a repository for words. A second resection was performed based on these findings. The patient experienced no post-operative aphasia and remains seizure free.

3D Rendering + Orthogonal View

Surface rendering and orthogonal views can be combined in one procedure. This allows us to see activation (or lesions) of the cortex and deep structures of the brain. The bleeding through of activation is obviated. External landmarks of the head and face may also help in surgical navigation.

Surface and orthogonal rendering of the brain is viewed in natural anatomical orientation. This means that the structures appear as if they were under direct sight. For that reason the left hemisphere appears on the right side of the left-top-rostral view, and on the left side on the left-top-posterior view. The fMR image presented here depicts activation of the angular gyrus observed in a right-left laterality decision task. The hemi-axial plane shows the activation placed in the deep portion of the left parietal sulcus.

Case 1

11-year-old right handed boy with intractable epilepsy and left hemiparesis. Patient was mapped for language as part of his work up for epilepsy surgery with a "Semantic Fluency Task."

3D-surface rendering and orthogonal views. The images show activation of Broca's area along pars orbitales, triangularis and opercularis in the left hemisphere. Activation is also observed in visual areas likely related to visual strategies. Activation of the basal ganglia is occasionally seen as in this case. Activation can be localized on one image including the cortex, the sylvian fissure, the calcarine fissure, the lateral ventricles and along the midline.

Case 2

Right handed 11 year-old-girl with persistent intractable epilepsy who had a partial left frontal resection . Patient underwent language mapping with fMR.

These images complement case 2 presented in "Surface Rendering." Activation is obtained with a "verb generation" task in Wernicke's area not only along the cortical surface but deep along the gyri.

Case 3

13 year old right handed-boy, with temporal lobe epilepsy. A multicystic oligodendroglioma was found in the left temporal lobe (black arrows). Functional MRI was prescribed to map language areas, prior to surgical resection.

A 3D-fMRI depicts the mass in the left temporal pole. The activation was obtained utilizing a "Repetition Task" paradigm (bubbles in yellow, orange, and red). The relationship between the lesion and the speech areas are beautifully displayed.

Case 4

Right handed 19 year-old female volunteer, performing a Stroop-like paradigm. This task involves inhibition, potentially useful in ADHD evaluation.

Activation is located in the cingulate gyrus, right inferior frontal, and supramarginal gyrus (red bubbles). The blue bubble located in the right frontal pole corresponds to inhibited areas. The combination of orthogonal axial and sagittal planes allow simultaneous presentation.

Triple Rendering

The neurosurgeon has a restricted view of the brain through the small window of the craniotomy. Modern neuroimaging can provide anatomy in three dimensions, and a much wider window.

Case 1

27-year-old right handed woman who underwent MRI and MRV to rule out a structural lesion. The patient volunteered to perform a verb generation task.

The image shows the fusion of three different procedures. In gray scale is the volumetric rendition of the brain obtained from the MRI sequence. In blue are depicted the surface veins and sinus of the left hemisphere from the MR-venogram. In yellow and red appears activation obtained from the echo-planar sequence used for functional MRI.

Case 2

17 year-old right handed boy with intractable epilepsy of partial motor type. MRI showed signal abnormality in the left middle frontal gyrus consistent with cortical dysplasia.

MRI of the head with partial exposure of the brain and skull. An axial view located at the superior third of the inferior frontal gyrus demonstrates in red the activation obtained with a verb generation task. The yellow spot represents the lesion and is derived from a fluid attenuated inversion recovery (FLAIR) sequence, and rendered with the rest of images, revealing the relationship between the lesion and the eloquent areas.

Case 3

15 year-old right handed girl with sensory-motor partial seizures involving the left hand since the age of 5. MRI showed a focal signal abnormality in the right postcentral gyrus consistent with a developmental tumor without changes over 2 years.

MRI of the brain appears in gray scale, functional MR activation is in yellow and red, the tumor is purple (light blue arrow), and the veins are blue. The tumor appears located in the post-central gyrus lateral and rostral to the functional activation. The relationship between the tumor and the functional activation was confirmed during awake intraoperative mapping. The venous landmarks provided useful information to the operating surgeon. The patient's tumor was removed without residual monoplegia. The patient had only transient loss of stereognosis and proprioception involving the 3rd, 4th, and 5th fingers, post-operatively.

Conventional MR images are two-dimensional representation of intensities occurring at a given level or slice.

These images may be presented in axial, coronal and sagittal planes.

The most frequent plane used in fMR is the axial plane which shows the localization of structures or activation in a X (right to left) and a Y (anterior to posterior) axes. Since these images are usually obtained in oblique planes it is difficult to know the precise level in the remaining Z (cranio-caudal) axis.

3D MRI scans allow us to present images with a volumetric appearance. These 3D MRI images have proven to be useful to guide surgical resections.

Types of 3D MRI scans

• Orthogonal Views are the simultaneous presentation of a structure in the X, Y and Z axes.
• Surface Rendering is the presentation of a structure as if it were seen by an external observer.
• 3D-Rendering + Orthogonal View is the combination of orthogonal views and surface rendering.
• Triple Rendering is when 3 procedures are superimposed on each other, such as MRV, fMR and surface rendering.

Orthogonal Views

Orthogonal views refer to a set of mutually perpendicular images. This localizes a given region of activation to the three axes that define the volumetric shape of the brain.

Case 1

Adult volunteer generating verbs. On the axial view the exact location of activation in the temporal lobe is difficult to determine. The black lines in the axial view correspond to the location of the coronal and sagittal views. These three views allow us to determine the location of activation in the middle temporal gyrus.

Case 2

Right handed adult male patient with intractable seizures coming from the left temporal pole, performing a language task consisting of listening to a story. No structural lesion was found in this region. A left temporal resection is planned. The orthogonal views permit evaluating of the extent of the language areas and the distance between its anterior border and the temporal pole (orange line). The neurosurgeon may use these findings as a guide to tailor the temporal resection.

Surface Rendering

Surface rendering is a computer post processing method that removes the skin and the skull to allow us to see the brain surface. The anatomy of gyri and sulci are displayed in the same way the neurosurgeon sees the brain. Functional maps can be superimposed on these images. Some activation may take place deep in the sulci which may be presented on these images bleeding through the cortical surface.

Case 1

Right handed 15 year-old-boy with intractable epilepsy performing a verbal "repetition task." The surface rendition beautifully depicts the activation occurring in the posterior third of the right superior temporal gyrus and extending toward supramarginal gyrus and Brodmann's area 7. The areas of activation are better displayed than with conventional 2D MR images.

Case 2

Right handed 11 year-old-girl with intractable epilepsy who had a left frontal resection two years ago for control of seizures. Persistence of the seizures prompted this fMR exam for re-evaluation. The images demonstrated activation obtained from a "Verb Generation Task." The study depicted Broca's area and part of Wernicke's (Brodmann's area 37), which is believed to be a repository for words. A second resection was performed based on these findings. The patient experienced no post-operative aphasia and remains seizure free.

3D Rendering + Orthogonal View

Surface rendering and orthogonal views can be combined in one procedure. This allows us to see activation (or lesions) of the cortex and deep structures of the brain. The bleeding through of activation is obviated. External landmarks of the head and face may also help in surgical navigation.

Surface and orthogonal rendering of the brain is viewed in natural anatomical orientation. This means that the structures appear as if they were under direct sight. For that reason the left hemisphere appears on the right side of the left-top-rostral view, and on the left side on the left-top-posterior view. The fMR image presented here depicts activation of the angular gyrus observed in a right-left laterality decision task. The hemi-axial plane shows the activation placed in the deep portion of the left parietal sulcus.

Case 1

11-year-old right handed boy with intractable epilepsy and left hemiparesis. Patient was mapped for language as part of his work up for epilepsy surgery with a "Semantic Fluency Task."

3D-surface rendering and orthogonal views. The images show activation of Broca's area along pars orbitales, triangularis and opercularis in the left hemisphere. Activation is also observed in visual areas likely related to visual strategies. Activation of the basal ganglia is occasionally seen as in this case. Activation can be localized on one image including the cortex, the sylvian fissure, the calcarine fissure, the lateral ventricles and along the midline.

Case 2

Right handed 11 year-old-girl with persistent intractable epilepsy who had a partial left frontal resection . Patient underwent language mapping with fMR.

These images complement case 2 presented in "Surface Rendering." Activation is obtained with a "verb generation" task in Wernicke's area not only along the cortical surface but deep along the gyri.

Case 3

13 year old right handed-boy, with temporal lobe epilepsy. A multicystic oligodendroglioma was found in the left temporal lobe (black arrows). Functional MRI was prescribed to map language areas, prior to surgical resection.

A 3D-fMRI depicts the mass in the left temporal pole. The activation was obtained utilizing a "Repetition Task" paradigm (bubbles in yellow, orange, and red). The relationship between the lesion and the speech areas are beautifully displayed.

Case 4

Right handed 19 year-old female volunteer, performing a Stroop-like paradigm. This task involves inhibition, potentially useful in ADHD evaluation.

Activation is located in the cingulate gyrus, right inferior frontal, and supramarginal gyrus (red bubbles). The blue bubble located in the right frontal pole corresponds to inhibited areas. The combination of orthogonal axial and sagittal planes allow simultaneous presentation.

Triple Rendering

The neurosurgeon has a restricted view of the brain through the small window of the craniotomy. Modern neuroimaging can provide anatomy in three dimensions, and a much wider window.

Case 1

27-year-old right handed woman who underwent MRI and MRV to rule out a structural lesion. The patient volunteered to perform a verb generation task.

The image shows the fusion of three different procedures. In gray scale is the volumetric rendition of the brain obtained from the MRI sequence. In blue are depicted the surface veins and sinus of the left hemisphere from the MR-venogram. In yellow and red appears activation obtained from the echo-planar sequence used for functional MRI.

Case 2

17 year-old right handed boy with intractable epilepsy of partial motor type. MRI showed signal abnormality in the left middle frontal gyrus consistent with cortical dysplasia.

MRI of the head with partial exposure of the brain and skull. An axial view located at the superior third of the inferior frontal gyrus demonstrates in red the activation obtained with a verb generation task. The yellow spot represents the lesion and is derived from a fluid attenuated inversion recovery (FLAIR) sequence, and rendered with the rest of images, revealing the relationship between the lesion and the eloquent areas.

Case 3

15 year-old right handed girl with sensory-motor partial seizures involving the left hand since the age of 5. MRI showed a focal signal abnormality in the right postcentral gyrus consistent with a developmental tumor without changes over 2 years.

MRI of the brain appears in gray scale, functional MR activation is in yellow and red, the tumor is purple (light blue arrow), and the veins are blue. The tumor appears located in the post-central gyrus lateral and rostral to the functional activation. The relationship between the tumor and the functional activation was confirmed during awake intraoperative mapping. The venous landmarks provided useful information to the operating surgeon. The patient's tumor was removed without residual monoplegia. The patient had only transient loss of stereognosis and proprioception involving the 3rd, 4th, and 5th fingers, post-operatively.

Conventional MR images are two-dimensional representation of intensities occurring at a given level or slice.

These images may be presented in axial, coronal and sagittal planes.

The most frequent plane used in fMR is the axial plane which shows the localization of structures or activation in a X (right to left) and a Y (anterior to posterior) axes. Since these images are usually obtained in oblique planes it is difficult to know the precise level in the remaining Z (cranio-caudal) axis.

3D MRI scans allow us to present images with a volumetric appearance. These 3D MRI images have proven to be useful to guide surgical resections.

Types of 3D MRI scans

• Orthogonal Views are the simultaneous presentation of a structure in the X, Y and Z axes.
• Surface Rendering is the presentation of a structure as if it were seen by an external observer.
• 3D-Rendering + Orthogonal View is the combination of orthogonal views and surface rendering.
• Triple Rendering is when 3 procedures are superimposed on each other, such as MRV, fMR and surface rendering.

Orthogonal Views

Orthogonal views refer to a set of mutually perpendicular images. This localizes a given region of activation to the three axes that define the volumetric shape of the brain.

Case 1

Adult volunteer generating verbs. On the axial view the exact location of activation in the temporal lobe is difficult to determine. The black lines in the axial view correspond to the location of the coronal and sagittal views. These three views allow us to determine the location of activation in the middle temporal gyrus.

Case 2

Right handed adult male patient with intractable seizures coming from the left temporal pole, performing a language task consisting of listening to a story. No structural lesion was found in this region. A left temporal resection is planned. The orthogonal views permit evaluating of the extent of the language areas and the distance between its anterior border and the temporal pole (orange line). The neurosurgeon may use these findings as a guide to tailor the temporal resection.

Surface Rendering

Surface rendering is a computer post processing method that removes the skin and the skull to allow us to see the brain surface. The anatomy of gyri and sulci are displayed in the same way the neurosurgeon sees the brain. Functional maps can be superimposed on these images. Some activation may take place deep in the sulci which may be presented on these images bleeding through the cortical surface.

Case 1

Right handed 15 year-old-boy with intractable epilepsy performing a verbal "repetition task." The surface rendition beautifully depicts the activation occurring in the posterior third of the right superior temporal gyrus and extending toward supramarginal gyrus and Brodmann's area 7. The areas of activation are better displayed than with conventional 2D MR images.

Case 2

Right handed 11 year-old-girl with intractable epilepsy who had a left frontal resection two years ago for control of seizures. Persistence of the seizures prompted this fMR exam for re-evaluation. The images demonstrated activation obtained from a "Verb Generation Task." The study depicted Broca's area and part of Wernicke's (Brodmann's area 37), which is believed to be a repository for words. A second resection was performed based on these findings. The patient experienced no post-operative aphasia and remains seizure free.

3D Rendering + Orthogonal View

Surface rendering and orthogonal views can be combined in one procedure. This allows us to see activation (or lesions) of the cortex and deep structures of the brain. The bleeding through of activation is obviated. External landmarks of the head and face may also help in surgical navigation.

Surface and orthogonal rendering of the brain is viewed in natural anatomical orientation. This means that the structures appear as if they were under direct sight. For that reason the left hemisphere appears on the right side of the left-top-rostral view, and on the left side on the left-top-posterior view. The fMR image presented here depicts activation of the angular gyrus observed in a right-left laterality decision task. The hemi-axial plane shows the activation placed in the deep portion of the left parietal sulcus.

Case 1

11-year-old right handed boy with intractable epilepsy and left hemiparesis. Patient was mapped for language as part of his work up for epilepsy surgery with a "Semantic Fluency Task."

3D-surface rendering and orthogonal views. The images show activation of Broca's area along pars orbitales, triangularis and opercularis in the left hemisphere. Activation is also observed in visual areas likely related to visual strategies. Activation of the basal ganglia is occasionally seen as in this case. Activation can be localized on one image including the cortex, the sylvian fissure, the calcarine fissure, the lateral ventricles and along the midline.

Case 2

Right handed 11 year-old-girl with persistent intractable epilepsy who had a partial left frontal resection . Patient underwent language mapping with fMR.

These images complement case 2 presented in "Surface Rendering." Activation is obtained with a "verb generation" task in Wernicke's area not only along the cortical surface but deep along the gyri.

Case 3

13 year old right handed-boy, with temporal lobe epilepsy. A multicystic oligodendroglioma was found in the left temporal lobe (black arrows). Functional MRI was prescribed to map language areas, prior to surgical resection.

A 3D-fMRI depicts the mass in the left temporal pole. The activation was obtained utilizing a "Repetition Task" paradigm (bubbles in yellow, orange, and red). The relationship between the lesion and the speech areas are beautifully displayed.

Case 4

Right handed 19 year-old female volunteer, performing a Stroop-like paradigm. This task involves inhibition, potentially useful in ADHD evaluation.

Activation is located in the cingulate gyrus, right inferior frontal, and supramarginal gyrus (red bubbles). The blue bubble located in the right frontal pole corresponds to inhibited areas. The combination of orthogonal axial and sagittal planes allow simultaneous presentation.

Triple Rendering

The neurosurgeon has a restricted view of the brain through the small window of the craniotomy. Modern neuroimaging can provide anatomy in three dimensions, and a much wider window.

Case 1

27-year-old right handed woman who underwent MRI and MRV to rule out a structural lesion. The patient volunteered to perform a verb generation task.

The image shows the fusion of three different procedures. In gray scale is the volumetric rendition of the brain obtained from the MRI sequence. In blue are depicted the surface veins and sinus of the left hemisphere from the MR-venogram. In yellow and red appears activation obtained from the echo-planar sequence used for functional MRI.

Case 2

17 year-old right handed boy with intractable epilepsy of partial motor type. MRI showed signal abnormality in the left middle frontal gyrus consistent with cortical dysplasia.

MRI of the head with partial exposure of the brain and skull. An axial view located at the superior third of the inferior frontal gyrus demonstrates in red the activation obtained with a verb generation task. The yellow spot represents the lesion and is derived from a fluid attenuated inversion recovery (FLAIR) sequence, and rendered with the rest of images, revealing the relationship between the lesion and the eloquent areas.

Case 3

15 year-old right handed girl with sensory-motor partial seizures involving the left hand since the age of 5. MRI showed a focal signal abnormality in the right postcentral gyrus consistent with a developmental tumor without changes over 2 years.

MRI of the brain appears in gray scale, functional MR activation is in yellow and red, the tumor is purple (light blue arrow), and the veins are blue. The tumor appears located in the post-central gyrus lateral and rostral to the functional activation. The relationship between the tumor and the functional activation was confirmed during awake intraoperative mapping. The venous landmarks provided useful information to the operating surgeon. The patient's tumor was removed without residual monoplegia. The patient had only transient loss of stereognosis and proprioception involving the 3rd, 4th, and 5th fingers, post-operatively.

Conventional MR images are two-dimensional representation of intensities occurring at a given level or slice.

These images may be presented in axial, coronal and sagittal planes.

The most frequent plane used in fMR is the axial plane which shows the localization of structures or activation in a X (right to left) and a Y (anterior to posterior) axes. Since these images are usually obtained in oblique planes it is difficult to know the precise level in the remaining Z (cranio-caudal) axis.

3D MRI scans allow us to present images with a volumetric appearance. These 3D MRI images have proven to be useful to guide surgical resections.

Types of 3D MRI scans

• Orthogonal Views are the simultaneous presentation of a structure in the X, Y and Z axes.
• Surface Rendering is the presentation of a structure as if it were seen by an external observer.
• 3D-Rendering + Orthogonal View is the combination of orthogonal views and surface rendering.
• Triple Rendering is when 3 procedures are superimposed on each other, such as MRV, fMR and surface rendering.

Orthogonal Views

Orthogonal views refer to a set of mutually perpendicular images. This localizes a given region of activation to the three axes that define the volumetric shape of the brain.

Case 1

Adult volunteer generating verbs. On the axial view the exact location of activation in the temporal lobe is difficult to determine. The black lines in the axial view correspond to the location of the coronal and sagittal views. These three views allow us to determine the location of activation in the middle temporal gyrus.

Case 2

Right handed adult male patient with intractable seizures coming from the left temporal pole, performing a language task consisting of listening to a story. No structural lesion was found in this region. A left temporal resection is planned. The orthogonal views permit evaluating of the extent of the language areas and the distance between its anterior border and the temporal pole (orange line). The neurosurgeon may use these findings as a guide to tailor the temporal resection.

Surface Rendering

Surface rendering is a computer post processing method that removes the skin and the skull to allow us to see the brain surface. The anatomy of gyri and sulci are displayed in the same way the neurosurgeon sees the brain. Functional maps can be superimposed on these images. Some activation may take place deep in the sulci which may be presented on these images bleeding through the cortical surface.

Case 1

Right handed 15 year-old-boy with intractable epilepsy performing a verbal "repetition task." The surface rendition beautifully depicts the activation occurring in the posterior third of the right superior temporal gyrus and extending toward supramarginal gyrus and Brodmann's area 7. The areas of activation are better displayed than with conventional 2D MR images.

Case 2

Right handed 11 year-old-girl with intractable epilepsy who had a left frontal resection two years ago for control of seizures. Persistence of the seizures prompted this fMR exam for re-evaluation. The images demonstrated activation obtained from a "Verb Generation Task." The study depicted Broca's area and part of Wernicke's (Brodmann's area 37), which is believed to be a repository for words. A second resection was performed based on these findings. The patient experienced no post-operative aphasia and remains seizure free.

3D Rendering + Orthogonal View

Surface rendering and orthogonal views can be combined in one procedure. This allows us to see activation (or lesions) of the cortex and deep structures of the brain. The bleeding through of activation is obviated. External landmarks of the head and face may also help in surgical navigation.

Surface and orthogonal rendering of the brain is viewed in natural anatomical orientation. This means that the structures appear as if they were under direct sight. For that reason the left hemisphere appears on the right side of the left-top-rostral view, and on the left side on the left-top-posterior view. The fMR image presented here depicts activation of the angular gyrus observed in a right-left laterality decision task. The hemi-axial plane shows the activation placed in the deep portion of the left parietal sulcus.

Case 1

11-year-old right handed boy with intractable epilepsy and left hemiparesis. Patient was mapped for language as part of his work up for epilepsy surgery with a "Semantic Fluency Task."

3D-surface rendering and orthogonal views. The images show activation of Broca's area along pars orbitales, triangularis and opercularis in the left hemisphere. Activation is also observed in visual areas likely related to visual strategies. Activation of the basal ganglia is occasionally seen as in this case. Activation can be localized on one image including the cortex, the sylvian fissure, the calcarine fissure, the lateral ventricles and along the midline.

Case 2

Right handed 11 year-old-girl with persistent intractable epilepsy who had a partial left frontal resection . Patient underwent language mapping with fMR.

These images complement case 2 presented in "Surface Rendering." Activation is obtained with a "verb generation" task in Wernicke's area not only along the cortical surface but deep along the gyri.

Case 3

13 year old right handed-boy, with temporal lobe epilepsy. A multicystic oligodendroglioma was found in the left temporal lobe (black arrows). Functional MRI was prescribed to map language areas, prior to surgical resection.

A 3D-fMRI depicts the mass in the left temporal pole. The activation was obtained utilizing a "Repetition Task" paradigm (bubbles in yellow, orange, and red). The relationship between the lesion and the speech areas are beautifully displayed.

Case 4

Right handed 19 year-old female volunteer, performing a Stroop-like paradigm. This task involves inhibition, potentially useful in ADHD evaluation.

Activation is located in the cingulate gyrus, right inferior frontal, and supramarginal gyrus (red bubbles). The blue bubble located in the right frontal pole corresponds to inhibited areas. The combination of orthogonal axial and sagittal planes allow simultaneous presentation.

Triple Rendering

The neurosurgeon has a restricted view of the brain through the small window of the craniotomy. Modern neuroimaging can provide anatomy in three dimensions, and a much wider window.

Case 1

27-year-old right handed woman who underwent MRI and MRV to rule out a structural lesion. The patient volunteered to perform a verb generation task.

The image shows the fusion of three different procedures. In gray scale is the volumetric rendition of the brain obtained from the MRI sequence. In blue are depicted the surface veins and sinus of the left hemisphere from the MR-venogram. In yellow and red appears activation obtained from the echo-planar sequence used for functional MRI.

Case 2

17 year-old right handed boy with intractable epilepsy of partial motor type. MRI showed signal abnormality in the left middle frontal gyrus consistent with cortical dysplasia.

MRI of the head with partial exposure of the brain and skull. An axial view located at the superior third of the inferior frontal gyrus demonstrates in red the activation obtained with a verb generation task. The yellow spot represents the lesion and is derived from a fluid attenuated inversion recovery (FLAIR) sequence, and rendered with the rest of images, revealing the relationship between the lesion and the eloquent areas.

Case 3

15 year-old right handed girl with sensory-motor partial seizures involving the left hand since the age of 5. MRI showed a focal signal abnormality in the right postcentral gyrus consistent with a developmental tumor without changes over 2 years.

MRI of the brain appears in gray scale, functional MR activation is in yellow and red, the tumor is purple (light blue arrow), and the veins are blue. The tumor appears located in the post-central gyrus lateral and rostral to the functional activation. The relationship between the tumor and the functional activation was confirmed during awake intraoperative mapping. The venous landmarks provided useful information to the operating surgeon. The patient's tumor was removed without residual monoplegia. The patient had only transient loss of stereognosis and proprioception involving the 3rd, 4th, and 5th fingers, post-operatively.

Case 1

Patient	2 month-old-girl with hydrocephalus
Paradigm	ON: Presentation of mother's voice, pre-recorded, using familiar words OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0007 3.4
Activation	There is bilateral activation of the precentral gyri and the right superior temporal gyrus. The activation of the motor strip occurs at the level of oral-facial representation. This is supposed to be related with the habituation-dishabituation of high-amplitude sucking in response to lingustic stimuli. This response is of great importance in the preservation of our species.

Case 2

Patient	18 month-old-boy with mild cerebral palsy
Paradigm	ON: Presentation of mother's voice, pre-recorded, using familiar words and sounds OFF: Nothing. Patient sedated with propofol
Statistics	Statistical method P Value Z score T-Test 0.0005 3.2
Activation	Activation of auditory areas are well depicted. There is bithalamic activation. The strong activation of the right parasagital frontal lobe is not well understood.

Case 3

Patient	4 year-old-boy with autism
Paradigm	ON: Presentation of flashing lights at 8 Hz, using special goggles OFF: Nothing. Patient sedated with nembutal
Statistics	Statistical method P Value Z score T-Test 0.000002 4.0
Activation	Coronal cuts. The colored areas in the figure were obtained subtracting ON from OFF. Thus, the result shows "deactivation", which represent hyper extraction of oxygen occurring in the primary visual areas (V1). This finding is consistently found in young children either awake or under sedation.

Case 4

Patient	Normal 18 month-old-boy
Paradigm #1:	ON: Presentation of mother's voice, pre-recorded, using familiar words OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0005 3.2
Graphic of Time Course	6 epochs starting in OFF
Image
Activation	There is bilateral activation on the parasagital aspects of the frontal lobes, greater on the right. The primary auditory area is activated on the left. Scattered activation is also present on the right parietal lobe. There is bilateral activation of the cuneus and precuneus wider on the left.
Paradigm #2:	ON: Presentation of flashing lights, 8 Hz OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0005 3.3
Image	ON-OFF OFF-ON
Activation	There is bilateral activation of the motor strip, and "deactivation" of anterolateral region of the calcarine fissure (periferal V1) as seen in the case No. 3. The location of this response is expected since the type of stimulus used here causes greater activation of the peripheral retina than of the fovea. The activation of the motor areas through visual stimulus is similar to the obtained with mother's voice in case No. 1.

Case 1

Patient	2 month-old-girl with hydrocephalus
Paradigm	ON: Presentation of mother's voice, pre-recorded, using familiar words OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0007 3.4
Activation	There is bilateral activation of the precentral gyri and the right superior temporal gyrus. The activation of the motor strip occurs at the level of oral-facial representation. This is supposed to be related with the habituation-dishabituation of high-amplitude sucking in response to lingustic stimuli. This response is of great importance in the preservation of our species.

Case 2

Patient	18 month-old-boy with mild cerebral palsy
Paradigm	ON: Presentation of mother's voice, pre-recorded, using familiar words and sounds OFF: Nothing. Patient sedated with propofol
Statistics	Statistical method P Value Z score T-Test 0.0005 3.2
Activation	Activation of auditory areas are well depicted. There is bithalamic activation. The strong activation of the right parasagital frontal lobe is not well understood.

Case 3

Patient	4 year-old-boy with autism
Paradigm	ON: Presentation of flashing lights at 8 Hz, using special goggles OFF: Nothing. Patient sedated with nembutal
Statistics	Statistical method P Value Z score T-Test 0.000002 4.0
Activation	Coronal cuts. The colored areas in the figure were obtained subtracting ON from OFF. Thus, the result shows "deactivation", which represent hyper extraction of oxygen occurring in the primary visual areas (V1). This finding is consistently found in young children either awake or under sedation.

Case 4

Patient	Normal 18 month-old-boy
Paradigm #1:	ON: Presentation of mother's voice, pre-recorded, using familiar words OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0005 3.2
Graphic of Time Course	6 epochs starting in OFF
Image
Activation	There is bilateral activation on the parasagital aspects of the frontal lobes, greater on the right. The primary auditory area is activated on the left. Scattered activation is also present on the right parietal lobe. There is bilateral activation of the cuneus and precuneus wider on the left.
Paradigm #2:	ON: Presentation of flashing lights, 8 Hz OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0005 3.3
Image	ON-OFF OFF-ON
Activation	There is bilateral activation of the motor strip, and "deactivation" of anterolateral region of the calcarine fissure (periferal V1) as seen in the case No. 3. The location of this response is expected since the type of stimulus used here causes greater activation of the peripheral retina than of the fovea. The activation of the motor areas through visual stimulus is similar to the obtained with mother's voice in case No. 1.

Case 1

Patient	2 month-old-girl with hydrocephalus
Paradigm	ON: Presentation of mother's voice, pre-recorded, using familiar words OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0007 3.4
Activation	There is bilateral activation of the precentral gyri and the right superior temporal gyrus. The activation of the motor strip occurs at the level of oral-facial representation. This is supposed to be related with the habituation-dishabituation of high-amplitude sucking in response to lingustic stimuli. This response is of great importance in the preservation of our species.

Case 2

Patient	18 month-old-boy with mild cerebral palsy
Paradigm	ON: Presentation of mother's voice, pre-recorded, using familiar words and sounds OFF: Nothing. Patient sedated with propofol
Statistics	Statistical method P Value Z score T-Test 0.0005 3.2
Activation	Activation of auditory areas are well depicted. There is bithalamic activation. The strong activation of the right parasagital frontal lobe is not well understood.

Case 3

Patient	4 year-old-boy with autism
Paradigm	ON: Presentation of flashing lights at 8 Hz, using special goggles OFF: Nothing. Patient sedated with nembutal
Statistics	Statistical method P Value Z score T-Test 0.000002 4.0
Activation	Coronal cuts. The colored areas in the figure were obtained subtracting ON from OFF. Thus, the result shows "deactivation", which represent hyper extraction of oxygen occurring in the primary visual areas (V1). This finding is consistently found in young children either awake or under sedation.

Case 4

Patient	Normal 18 month-old-boy
Paradigm #1:	ON: Presentation of mother's voice, pre-recorded, using familiar words OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0005 3.2
Graphic of Time Course	6 epochs starting in OFF
Image
Activation	There is bilateral activation on the parasagital aspects of the frontal lobes, greater on the right. The primary auditory area is activated on the left. Scattered activation is also present on the right parietal lobe. There is bilateral activation of the cuneus and precuneus wider on the left.
Paradigm #2:	ON: Presentation of flashing lights, 8 Hz OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0005 3.3
Image	ON-OFF OFF-ON
Activation	There is bilateral activation of the motor strip, and "deactivation" of anterolateral region of the calcarine fissure (periferal V1) as seen in the case No. 3. The location of this response is expected since the type of stimulus used here causes greater activation of the peripheral retina than of the fovea. The activation of the motor areas through visual stimulus is similar to the obtained with mother's voice in case No. 1.

Case 1

Patient	2 month-old-girl with hydrocephalus
Paradigm	ON: Presentation of mother's voice, pre-recorded, using familiar words OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0007 3.4
Activation	There is bilateral activation of the precentral gyri and the right superior temporal gyrus. The activation of the motor strip occurs at the level of oral-facial representation. This is supposed to be related with the habituation-dishabituation of high-amplitude sucking in response to lingustic stimuli. This response is of great importance in the preservation of our species.

Case 2

Patient	18 month-old-boy with mild cerebral palsy
Paradigm	ON: Presentation of mother's voice, pre-recorded, using familiar words and sounds OFF: Nothing. Patient sedated with propofol
Statistics	Statistical method P Value Z score T-Test 0.0005 3.2
Activation	Activation of auditory areas are well depicted. There is bithalamic activation. The strong activation of the right parasagital frontal lobe is not well understood.

Case 3

Patient	4 year-old-boy with autism
Paradigm	ON: Presentation of flashing lights at 8 Hz, using special goggles OFF: Nothing. Patient sedated with nembutal
Statistics	Statistical method P Value Z score T-Test 0.000002 4.0
Activation	Coronal cuts. The colored areas in the figure were obtained subtracting ON from OFF. Thus, the result shows "deactivation", which represent hyper extraction of oxygen occurring in the primary visual areas (V1). This finding is consistently found in young children either awake or under sedation.

Case 4

Patient	Normal 18 month-old-boy
Paradigm #1:	ON: Presentation of mother's voice, pre-recorded, using familiar words OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0005 3.2
Graphic of Time Course	6 epochs starting in OFF
Image
Activation	There is bilateral activation on the parasagital aspects of the frontal lobes, greater on the right. The primary auditory area is activated on the left. Scattered activation is also present on the right parietal lobe. There is bilateral activation of the cuneus and precuneus wider on the left.
Paradigm #2:	ON: Presentation of flashing lights, 8 Hz OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0005 3.3
Image	ON-OFF OFF-ON
Activation	There is bilateral activation of the motor strip, and "deactivation" of anterolateral region of the calcarine fissure (periferal V1) as seen in the case No. 3. The location of this response is expected since the type of stimulus used here causes greater activation of the peripheral retina than of the fovea. The activation of the motor areas through visual stimulus is similar to the obtained with mother's voice in case No. 1.

Case 1

Patient	2 month-old-girl with hydrocephalus
Paradigm	ON: Presentation of mother's voice, pre-recorded, using familiar words OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0007 3.4
Activation	There is bilateral activation of the precentral gyri and the right superior temporal gyrus. The activation of the motor strip occurs at the level of oral-facial representation. This is supposed to be related with the habituation-dishabituation of high-amplitude sucking in response to lingustic stimuli. This response is of great importance in the preservation of our species.

Case 2

Patient	18 month-old-boy with mild cerebral palsy
Paradigm	ON: Presentation of mother's voice, pre-recorded, using familiar words and sounds OFF: Nothing. Patient sedated with propofol
Statistics	Statistical method P Value Z score T-Test 0.0005 3.2
Activation	Activation of auditory areas are well depicted. There is bithalamic activation. The strong activation of the right parasagital frontal lobe is not well understood.

Case 3

Patient	4 year-old-boy with autism
Paradigm	ON: Presentation of flashing lights at 8 Hz, using special goggles OFF: Nothing. Patient sedated with nembutal
Statistics	Statistical method P Value Z score T-Test 0.000002 4.0
Activation	Coronal cuts. The colored areas in the figure were obtained subtracting ON from OFF. Thus, the result shows "deactivation", which represent hyper extraction of oxygen occurring in the primary visual areas (V1). This finding is consistently found in young children either awake or under sedation.

Case 4

Patient	Normal 18 month-old-boy
Paradigm #1:	ON: Presentation of mother's voice, pre-recorded, using familiar words OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0005 3.2
Graphic of Time Course	6 epochs starting in OFF
Image
Activation	There is bilateral activation on the parasagital aspects of the frontal lobes, greater on the right. The primary auditory area is activated on the left. Scattered activation is also present on the right parietal lobe. There is bilateral activation of the cuneus and precuneus wider on the left.
Paradigm #2:	ON: Presentation of flashing lights, 8 Hz OFF: Nothing. Patient sedated with chloral hydrate
Statistics	Statistical method P Value Z score T-Test 0.0005 3.3
Image	ON-OFF OFF-ON
Activation	There is bilateral activation of the motor strip, and "deactivation" of anterolateral region of the calcarine fissure (periferal V1) as seen in the case No. 3. The location of this response is expected since the type of stimulus used here causes greater activation of the peripheral retina than of the fovea. The activation of the motor areas through visual stimulus is similar to the obtained with mother's voice in case No. 1.

Please follow the links below to learn more about Language Mapping.

Auditory Verbal Activation

Passive listening to a story

Activation

Left supramarginal gyrus

Left > Right  Heschl's gyri

Auditory Non-Verbal Activation

Passive hearing of plain music (Same technical settings)

Activation

Right > left Heschl's gyri

Phonological Fluency

Subject	Right handed, 37 year-old woman
Paradigm	ON: Retrieving words starting with a given letter OFF: Think of a dark sky
Statistics	Statistical method P Value Z score Correlation coeficient 0.0001 N/A
Images
Activation	This paradigm elicits activation of the superior aspect of Broca's and Brodman's 37 areas. Some activation appears in parasagital parietal areas. The color in the left pterional fossa is due to vascular inflow.

Semantic Fluency

Subject	Right handed, 25 year-old woman
Paradigm	ON: Retrieving words within a given category OFF: Think of a dark sky
Statistics	Statistical method P Value Z score T-Test 0.00005 4.2
Images
Activation	The left hemisphere shows predominant activation. The following areas were activated: Broca's, left posterior portion of middle and inferior temporal gyri (Brodman's 37), left parietal and left premotor strip. Wide activation is seen in the inferior aspect of the occipital lobes. The main activation on the right is located in the inferior aspect of the frontal lobe (Brodman's 11), a finding consistently seen in this paradigm.

Fluency of Verbs

Subject	Right handed, 24 year-old woman
Paradigm	ON: Generate verbs related to nouns (objects) OFF: Count the letters of presented words
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images
Activation	Broca's area and left SMA are depicted. Some activation appears in the left hippocampal formation and visual areas. This last activation could be explained as the effect of picturing the objects given during the "ON" condition. There is also activation in the right cerebellum and left inferior temporal gyrus.

Automatic Speech

Subject	25 year-old woman. Right-handed Volunteer
Paradigm	ON: Saying mentally the pledge of allegiance OFF: Think of a dark sky
Statistics	Statistical method P Value Z score T-Test 0.0002 3.7
Images
Activation	Oral and facial motor strip, greater on the right. Right parietal lobe. No activation is seen in Broca's area

Verbal Comprehension

Subject	Right-handed volunteer, 32 year-old-man
Paradigm	ON: Listening to a story OFF: Concentrate on the back ground noise
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images
Activation	Left hemisphere activation is clearly greater. The activation is in the following areas: Broca's (image 5), Wernike's (images 4 and 5), left supramarginal gyrus (heteromodal associative area, in image 5), left motor and premotor strip. The primary auditory areas are also activated predominantly on the left.

Studies in Late Bilinguals

Subject	Right handed 34 year-old-woman. Native language: Spanish
Paradigm	Type: Verbal fluency task ON: Retrieve verbs related to presented nouns OFF Spell given words
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images	Spanish English
Activation	There is activation of Broca's area in both languages. The right thalamic activation is noted only in the second language. There is also greater activation of the right inferior frontal gyrus in the second language than in the mother language. SMA is more pronounced on the right in both languages.

Please follow the links below to learn more about Language Mapping.

Auditory Verbal Activation

Passive listening to a story

Activation

Left supramarginal gyrus

Left > Right  Heschl's gyri

Auditory Non-Verbal Activation

Passive hearing of plain music (Same technical settings)

Activation

Right > left Heschl's gyri

Phonological Fluency

Subject	Right handed, 37 year-old woman
Paradigm	ON: Retrieving words starting with a given letter OFF: Think of a dark sky
Statistics	Statistical method P Value Z score Correlation coeficient 0.0001 N/A
Images
Activation	This paradigm elicits activation of the superior aspect of Broca's and Brodman's 37 areas. Some activation appears in parasagital parietal areas. The color in the left pterional fossa is due to vascular inflow.

Semantic Fluency

Subject	Right handed, 25 year-old woman
Paradigm	ON: Retrieving words within a given category OFF: Think of a dark sky
Statistics	Statistical method P Value Z score T-Test 0.00005 4.2
Images
Activation	The left hemisphere shows predominant activation. The following areas were activated: Broca's, left posterior portion of middle and inferior temporal gyri (Brodman's 37), left parietal and left premotor strip. Wide activation is seen in the inferior aspect of the occipital lobes. The main activation on the right is located in the inferior aspect of the frontal lobe (Brodman's 11), a finding consistently seen in this paradigm.

Fluency of Verbs

Subject	Right handed, 24 year-old woman
Paradigm	ON: Generate verbs related to nouns (objects) OFF: Count the letters of presented words
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images
Activation	Broca's area and left SMA are depicted. Some activation appears in the left hippocampal formation and visual areas. This last activation could be explained as the effect of picturing the objects given during the "ON" condition. There is also activation in the right cerebellum and left inferior temporal gyrus.

Automatic Speech

Subject	25 year-old woman. Right-handed Volunteer
Paradigm	ON: Saying mentally the pledge of allegiance OFF: Think of a dark sky
Statistics	Statistical method P Value Z score T-Test 0.0002 3.7
Images
Activation	Oral and facial motor strip, greater on the right. Right parietal lobe. No activation is seen in Broca's area

Verbal Comprehension

Subject	Right-handed volunteer, 32 year-old-man
Paradigm	ON: Listening to a story OFF: Concentrate on the back ground noise
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images
Activation	Left hemisphere activation is clearly greater. The activation is in the following areas: Broca's (image 5), Wernike's (images 4 and 5), left supramarginal gyrus (heteromodal associative area, in image 5), left motor and premotor strip. The primary auditory areas are also activated predominantly on the left.

Studies in Late Bilinguals

Subject	Right handed 34 year-old-woman. Native language: Spanish
Paradigm	Type: Verbal fluency task ON: Retrieve verbs related to presented nouns OFF Spell given words
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images	Spanish English
Activation	There is activation of Broca's area in both languages. The right thalamic activation is noted only in the second language. There is also greater activation of the right inferior frontal gyrus in the second language than in the mother language. SMA is more pronounced on the right in both languages.

Please follow the links below to learn more about Language Mapping.

Auditory Verbal Activation

Passive listening to a story

Activation

Left supramarginal gyrus

Left > Right  Heschl's gyri

Auditory Non-Verbal Activation

Passive hearing of plain music (Same technical settings)

Activation

Right > left Heschl's gyri

Phonological Fluency

Subject	Right handed, 37 year-old woman
Paradigm	ON: Retrieving words starting with a given letter OFF: Think of a dark sky
Statistics	Statistical method P Value Z score Correlation coeficient 0.0001 N/A
Images
Activation	This paradigm elicits activation of the superior aspect of Broca's and Brodman's 37 areas. Some activation appears in parasagital parietal areas. The color in the left pterional fossa is due to vascular inflow.

Semantic Fluency

Subject	Right handed, 25 year-old woman
Paradigm	ON: Retrieving words within a given category OFF: Think of a dark sky
Statistics	Statistical method P Value Z score T-Test 0.00005 4.2
Images
Activation	The left hemisphere shows predominant activation. The following areas were activated: Broca's, left posterior portion of middle and inferior temporal gyri (Brodman's 37), left parietal and left premotor strip. Wide activation is seen in the inferior aspect of the occipital lobes. The main activation on the right is located in the inferior aspect of the frontal lobe (Brodman's 11), a finding consistently seen in this paradigm.

Fluency of Verbs

Subject	Right handed, 24 year-old woman
Paradigm	ON: Generate verbs related to nouns (objects) OFF: Count the letters of presented words
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images
Activation	Broca's area and left SMA are depicted. Some activation appears in the left hippocampal formation and visual areas. This last activation could be explained as the effect of picturing the objects given during the "ON" condition. There is also activation in the right cerebellum and left inferior temporal gyrus.

Automatic Speech

Subject	25 year-old woman. Right-handed Volunteer
Paradigm	ON: Saying mentally the pledge of allegiance OFF: Think of a dark sky
Statistics	Statistical method P Value Z score T-Test 0.0002 3.7
Images
Activation	Oral and facial motor strip, greater on the right. Right parietal lobe. No activation is seen in Broca's area

Verbal Comprehension

Subject	Right-handed volunteer, 32 year-old-man
Paradigm	ON: Listening to a story OFF: Concentrate on the back ground noise
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images
Activation	Left hemisphere activation is clearly greater. The activation is in the following areas: Broca's (image 5), Wernike's (images 4 and 5), left supramarginal gyrus (heteromodal associative area, in image 5), left motor and premotor strip. The primary auditory areas are also activated predominantly on the left.

Studies in Late Bilinguals

Subject	Right handed 34 year-old-woman. Native language: Spanish
Paradigm	Type: Verbal fluency task ON: Retrieve verbs related to presented nouns OFF Spell given words
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images	Spanish English
Activation	There is activation of Broca's area in both languages. The right thalamic activation is noted only in the second language. There is also greater activation of the right inferior frontal gyrus in the second language than in the mother language. SMA is more pronounced on the right in both languages.

Please follow the links below to learn more about Language Mapping.

Auditory Verbal Activation

Passive listening to a story

Activation

Left supramarginal gyrus

Left > Right  Heschl's gyri

Auditory Non-Verbal Activation

Passive hearing of plain music (Same technical settings)

Activation

Right > left Heschl's gyri

Phonological Fluency

Subject	Right handed, 37 year-old woman
Paradigm	ON: Retrieving words starting with a given letter OFF: Think of a dark sky
Statistics	Statistical method P Value Z score Correlation coeficient 0.0001 N/A
Images
Activation	This paradigm elicits activation of the superior aspect of Broca's and Brodman's 37 areas. Some activation appears in parasagital parietal areas. The color in the left pterional fossa is due to vascular inflow.

Semantic Fluency

Subject	Right handed, 25 year-old woman
Paradigm	ON: Retrieving words within a given category OFF: Think of a dark sky
Statistics	Statistical method P Value Z score T-Test 0.00005 4.2
Images
Activation	The left hemisphere shows predominant activation. The following areas were activated: Broca's, left posterior portion of middle and inferior temporal gyri (Brodman's 37), left parietal and left premotor strip. Wide activation is seen in the inferior aspect of the occipital lobes. The main activation on the right is located in the inferior aspect of the frontal lobe (Brodman's 11), a finding consistently seen in this paradigm.

Fluency of Verbs

Subject	Right handed, 24 year-old woman
Paradigm	ON: Generate verbs related to nouns (objects) OFF: Count the letters of presented words
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images
Activation	Broca's area and left SMA are depicted. Some activation appears in the left hippocampal formation and visual areas. This last activation could be explained as the effect of picturing the objects given during the "ON" condition. There is also activation in the right cerebellum and left inferior temporal gyrus.

Automatic Speech

Subject	25 year-old woman. Right-handed Volunteer
Paradigm	ON: Saying mentally the pledge of allegiance OFF: Think of a dark sky
Statistics	Statistical method P Value Z score T-Test 0.0002 3.7
Images
Activation	Oral and facial motor strip, greater on the right. Right parietal lobe. No activation is seen in Broca's area

Verbal Comprehension

Subject	Right-handed volunteer, 32 year-old-man
Paradigm	ON: Listening to a story OFF: Concentrate on the back ground noise
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images
Activation	Left hemisphere activation is clearly greater. The activation is in the following areas: Broca's (image 5), Wernike's (images 4 and 5), left supramarginal gyrus (heteromodal associative area, in image 5), left motor and premotor strip. The primary auditory areas are also activated predominantly on the left.

Studies in Late Bilinguals

Subject	Right handed 34 year-old-woman. Native language: Spanish
Paradigm	Type: Verbal fluency task ON: Retrieve verbs related to presented nouns OFF Spell given words
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images	Spanish English
Activation	There is activation of Broca's area in both languages. The right thalamic activation is noted only in the second language. There is also greater activation of the right inferior frontal gyrus in the second language than in the mother language. SMA is more pronounced on the right in both languages.

Please follow the links below to learn more about Language Mapping.

Auditory Verbal Activation

Passive listening to a story

Activation

Left supramarginal gyrus

Left > Right  Heschl's gyri

Auditory Non-Verbal Activation

Passive hearing of plain music (Same technical settings)

Activation

Right > left Heschl's gyri

Phonological Fluency

Subject	Right handed, 37 year-old woman
Paradigm	ON: Retrieving words starting with a given letter OFF: Think of a dark sky
Statistics	Statistical method P Value Z score Correlation coeficient 0.0001 N/A
Images
Activation	This paradigm elicits activation of the superior aspect of Broca's and Brodman's 37 areas. Some activation appears in parasagital parietal areas. The color in the left pterional fossa is due to vascular inflow.

Semantic Fluency

Subject	Right handed, 25 year-old woman
Paradigm	ON: Retrieving words within a given category OFF: Think of a dark sky
Statistics	Statistical method P Value Z score T-Test 0.00005 4.2
Images
Activation	The left hemisphere shows predominant activation. The following areas were activated: Broca's, left posterior portion of middle and inferior temporal gyri (Brodman's 37), left parietal and left premotor strip. Wide activation is seen in the inferior aspect of the occipital lobes. The main activation on the right is located in the inferior aspect of the frontal lobe (Brodman's 11), a finding consistently seen in this paradigm.

Fluency of Verbs

Subject	Right handed, 24 year-old woman
Paradigm	ON: Generate verbs related to nouns (objects) OFF: Count the letters of presented words
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images
Activation	Broca's area and left SMA are depicted. Some activation appears in the left hippocampal formation and visual areas. This last activation could be explained as the effect of picturing the objects given during the "ON" condition. There is also activation in the right cerebellum and left inferior temporal gyrus.

Automatic Speech

Subject	25 year-old woman. Right-handed Volunteer
Paradigm	ON: Saying mentally the pledge of allegiance OFF: Think of a dark sky
Statistics	Statistical method P Value Z score T-Test 0.0002 3.7
Images
Activation	Oral and facial motor strip, greater on the right. Right parietal lobe. No activation is seen in Broca's area

Verbal Comprehension

Subject	Right-handed volunteer, 32 year-old-man
Paradigm	ON: Listening to a story OFF: Concentrate on the back ground noise
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images
Activation	Left hemisphere activation is clearly greater. The activation is in the following areas: Broca's (image 5), Wernike's (images 4 and 5), left supramarginal gyrus (heteromodal associative area, in image 5), left motor and premotor strip. The primary auditory areas are also activated predominantly on the left.

Studies in Late Bilinguals

Subject	Right handed 34 year-old-woman. Native language: Spanish
Paradigm	Type: Verbal fluency task ON: Retrieve verbs related to presented nouns OFF Spell given words
Statistics	Statistical method P Value Z score T-Test 0.0001 3.8
Images	Spanish English
Activation	There is activation of Broca's area in both languages. The right thalamic activation is noted only in the second language. There is also greater activation of the right inferior frontal gyrus in the second language than in the mother language. SMA is more pronounced on the right in both languages.

Limb restoration is a gradual process that helps to restore a patient's bone and soft tissue to normal alignment, length and function. While there are many reasons a patient would choose to have this type of procedure, the primary indications include trauma, congenital deformities and bone or joint infection.

Your orthopedis uses ILIZAROV surgery to provide limb restoration. This remarkable technique uses a device called the TAYLOR SPATIAL FRAME TM to take advantage of the body's natural ability to grow healthy new bone tissue.

There are two main phases to the ILIZAROV procedure: limb lengthening/correction and consolidation.

ILIZAROV lengthening/correction refers to the period of time it takes to 'grow the bone.' This initial phase begins after the surgeon cuts the bone and attaches the TAYLOR SPATIAL FRAME fixator. During this time, you will be working with the physician and your team to make gradual adjustments to the device, which increases the gap between the bone segments, adding 'length' to the total limb. Over a period of months, new bone tissue will grow in the gap, ultimately hardening the area between the segments of the original bone.

When your surgeon is satisfied with the length and position of the new bone, the consolidation phase begins. During this phase, the bone tissue matures and becomes solid. You still wear the TAYLOR SPATIAL FRAME fixator, but you will not make adjustments. The consolidation phase is the longest part of the ILIZAROV process.

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Limb restoration is a gradual process that helps to restore a patient's bone and soft tissue to normal alignment, length and function. While there are many reasons a patient would choose to have this type of procedure, the primary indications include trauma, congenital deformities and bone or joint infection.

Your orthopedis uses ILIZAROV surgery to provide limb restoration. This remarkable technique uses a device called the TAYLOR SPATIAL FRAME TM to take advantage of the body's natural ability to grow healthy new bone tissue.

There are two main phases to the ILIZAROV procedure: limb lengthening/correction and consolidation.

ILIZAROV lengthening/correction refers to the period of time it takes to 'grow the bone.' This initial phase begins after the surgeon cuts the bone and attaches the TAYLOR SPATIAL FRAME fixator. During this time, you will be working with the physician and your team to make gradual adjustments to the device, which increases the gap between the bone segments, adding 'length' to the total limb. Over a period of months, new bone tissue will grow in the gap, ultimately hardening the area between the segments of the original bone.

When your surgeon is satisfied with the length and position of the new bone, the consolidation phase begins. During this phase, the bone tissue matures and becomes solid. You still wear the TAYLOR SPATIAL FRAME fixator, but you will not make adjustments. The consolidation phase is the longest part of the ILIZAROV process.

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There are many different pediatric orthopedic conditions where use of the TAYLOR SPATIAL FRAME◊ device is prescribed. The external fixator can be used to correct arm and leg length discrepancies and deformities including:

• Injury and trauma including growth plate fractures, malunion (where the bones heal crookedly), non-union (where the bone doesn't heal together), shortening and deformity due to bone loss.
• Congenital limb length discrepancies. These conditions are associated with many birth defects and deformities including a short femur (thigh bone), otherwise known as fibular hemimelia. Pseudoarthritis in which the bone fails to fuse together such as in a fracture healing site. And hemiatrophy, where the bones of one side of a child's body may grow smaller than the other side.
• Short stature including achondroplasia and other skeletal dysplasias and Constitutional Short Stature. External fixators can be effective in treating limb length discrepancies linked to dwarfism. Treatment may be appropriate in some cases in order to allow the patient to function more independently.
• Infection involving the bone (osteomyelitis) and joint (septic or infectious arthritis). Treatment of bone infection often requires removal of bone segment which may result in angular deformities and limb length discrepancies.
• Developmental causes which are related to the slowing of growth and limb deformities caused by illnesses such as Blount's Disease, which typically affects the bone development of overweight toddlers and adolescents.
• External fixators are also used in the treatment of pediatric hip disorders such as Developmental Coxa Vara (DCV), Perthes Disease and Slipped Capital Femoral Epiphyses.
• Joint stiffness following injury, infection or other causes can sometimes be addressed by controlled joint distraction (arthodiatasis), with the use of external fixators.
• Clubfoot (talipes equinovarus – TEV), a congenital defect where bones of the foot and ankle are not in alignment can be corrected with external fixation.
• Bone fractures in conjunction with soft tissue damage such as burns can be addressed with external fixation because it is a minimally-invasive external device that allows for skin tissue healing while correcting bone fractures at the same time.

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There are many different pediatric orthopedic conditions where use of the TAYLOR SPATIAL FRAME◊ device is prescribed. The external fixator can be used to correct arm and leg length discrepancies and deformities including:

• Injury and trauma including growth plate fractures, malunion (where the bones heal crookedly), non-union (where the bone doesn't heal together), shortening and deformity due to bone loss.
• Congenital limb length discrepancies. These conditions are associated with many birth defects and deformities including a short femur (thigh bone), otherwise known as fibular hemimelia. Pseudoarthritis in which the bone fails to fuse together such as in a fracture healing site. And hemiatrophy, where the bones of one side of a child's body may grow smaller than the other side.
• Short stature including achondroplasia and other skeletal dysplasias and Constitutional Short Stature. External fixators can be effective in treating limb length discrepancies linked to dwarfism. Treatment may be appropriate in some cases in order to allow the patient to function more independently.
• Infection involving the bone (osteomyelitis) and joint (septic or infectious arthritis). Treatment of bone infection often requires removal of bone segment which may result in angular deformities and limb length discrepancies.
• Developmental causes which are related to the slowing of growth and limb deformities caused by illnesses such as Blount's Disease, which typically affects the bone development of overweight toddlers and adolescents.
• External fixators are also used in the treatment of pediatric hip disorders such as Developmental Coxa Vara (DCV), Perthes Disease and Slipped Capital Femoral Epiphyses.
• Joint stiffness following injury, infection or other causes can sometimes be addressed by controlled joint distraction (arthodiatasis), with the use of external fixators.
• Clubfoot (talipes equinovarus – TEV), a congenital defect where bones of the foot and ankle are not in alignment can be corrected with external fixation.
• Bone fractures in conjunction with soft tissue damage such as burns can be addressed with external fixation because it is a minimally-invasive external device that allows for skin tissue healing while correcting bone fractures at the same time.

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The TAYLOR SPATIAL FRAME fixator is an external fixation device for limb correction, lengthening and/or straightening that is based on the ILIZAROV method. This ILIZAROV apparatus takes advantage of the body's natural ability to grow healthy new bone tissue and gives the surgeon the ability to accurately move bones to their correct anatomic alignment.

The TAYLOR SPATIAL FRAME device fits around your limb and is attached to the bone with pins or wires that extend from the rings, through the skin and bone to the other side.

The TAYLOR SPATIAL FRAME device is a circular, metal frame with two rings that connect with six telescopic struts that can be independently lengthened or shortened relative to the rest of the frame. This allows for six different axes of movement, which gives the TAYLOR SPATIAL FRAME device the ability to correct even the most difficult congenital deformities and trauma cases.

When using the TAYLOR SPATIAL FRAME device, your surgeon inputs information about your original bone deformity into an advanced web-based computer application. This information is then interpreted by the software and a day-by-day treatment plan is created. The software also creates an image of your deformity on screen and shows how the bones should be moving each day, until the bones are completely set in proper alignment.

You then make daily adjustments to the struts, depending on your prescribed course of treatment. As the adjustments are made, the rings of the external fixation device are repositioned with respect to each other, moving bones in the directions necessary for treatment.

Your surgeon is able to make a side-by-side comparison of current X-Rays and the projected plan of treatment graphics created by the TAYLOR SPATIAL FRAME device software. This comparison ensures that your bones are healing in the correct alignment and at the appropriate pace.

The TAYLOR SPATIAL FRAME External Fixator is a winner of the Medical Device Excellence Award.

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The TAYLOR SPATIAL FRAME fixator is an external fixation device for limb correction, lengthening and/or straightening that is based on the ILIZAROV method. This ILIZAROV apparatus takes advantage of the body's natural ability to grow healthy new bone tissue and gives the surgeon the ability to accurately move bones to their correct anatomic alignment.

The TAYLOR SPATIAL FRAME device fits around your limb and is attached to the bone with pins or wires that extend from the rings, through the skin and bone to the other side.

The TAYLOR SPATIAL FRAME device is a circular, metal frame with two rings that connect with six telescopic struts that can be independently lengthened or shortened relative to the rest of the frame. This allows for six different axes of movement, which gives the TAYLOR SPATIAL FRAME device the ability to correct even the most difficult congenital deformities and trauma cases.

When using the TAYLOR SPATIAL FRAME device, your surgeon inputs information about your original bone deformity into an advanced web-based computer application. This information is then interpreted by the software and a day-by-day treatment plan is created. The software also creates an image of your deformity on screen and shows how the bones should be moving each day, until the bones are completely set in proper alignment.

You then make daily adjustments to the struts, depending on your prescribed course of treatment. As the adjustments are made, the rings of the external fixation device are repositioned with respect to each other, moving bones in the directions necessary for treatment.

Your surgeon is able to make a side-by-side comparison of current X-Rays and the projected plan of treatment graphics created by the TAYLOR SPATIAL FRAME device software. This comparison ensures that your bones are healing in the correct alignment and at the appropriate pace.

The TAYLOR SPATIAL FRAME External Fixator is a winner of the Medical Device Excellence Award.

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As other TAYLOR SPATIAL FRAME device patients might tell you, the limb restoration process takes a great deal of preparation and personal commitment. One of the best ways to understand the process is to speak with someone who has gone through the process. Ask your surgeon to introduce you to someone who would be willing to talk to you about their experience and help you prepare for this temporary lifestyle.

Here are some points to consider before you receive the TAYLOR SPATIAL FRAME device:

• Hospitalization: You should plan for a hospital stay of at least three to four days. Ask your surgeon for help in planning what to bring with you and what to expect.
• External Fixator Adjustments: Make the commitment now to follow a schedule of fixator adjustments, which are needed daily during the lengthening/correction phase. Your prescribed course of treatment will be determined by your surgeon.
• Scheduling Considerations: Plan ahead now for the amount of time away from school or work, frequency of clinic visits, time of year and transportation issues you'll face. Your surgeon's clinic can assist you with making these plans.
• Physical Limitations: Understand ahead of time what you will be able to and won't be able to do. Talk to your surgeon about what to expect.
• Changes to Normal Activities: Preparation, more time, energy and rest will be needed to perform daily activities.
• Clothing Adaptations: Make arrangements to wear loose clothing, which will fit over the fixator.
• Insurance Coverage: Know your insurance plan and make sure to secure all approvals prior to surgery. Find out what your insurance will cover for medical equipment as you will need several medical items during your external fixator treatment time. Your surgeon's clinic can give you a list of items that you may need to give to your insurance company.
• Household Furniture and Linens: Your furniture and linens can be protected from damage caused by the fixator by wearing a protective covering over it.

◊ Trademark of Smith & Nephew

As other TAYLOR SPATIAL FRAME device patients might tell you, the limb restoration process takes a great deal of preparation and personal commitment. One of the best ways to understand the process is to speak with someone who has gone through the process. Ask your surgeon to introduce you to someone who would be willing to talk to you about their experience and help you prepare for this temporary lifestyle.

Here are some points to consider before you receive the TAYLOR SPATIAL FRAME device:

• Hospitalization: You should plan for a hospital stay of at least three to four days. Ask your surgeon for help in planning what to bring with you and what to expect.
• External Fixator Adjustments: Make the commitment now to follow a schedule of fixator adjustments, which are needed daily during the lengthening/correction phase. Your prescribed course of treatment will be determined by your surgeon.
• Scheduling Considerations: Plan ahead now for the amount of time away from school or work, frequency of clinic visits, time of year and transportation issues you'll face. Your surgeon's clinic can assist you with making these plans.
• Physical Limitations: Understand ahead of time what you will be able to and won't be able to do. Talk to your surgeon about what to expect.
• Changes to Normal Activities: Preparation, more time, energy and rest will be needed to perform daily activities.
• Clothing Adaptations: Make arrangements to wear loose clothing, which will fit over the fixator.
• Insurance Coverage: Know your insurance plan and make sure to secure all approvals prior to surgery. Find out what your insurance will cover for medical equipment as you will need several medical items during your external fixator treatment time. Your surgeon's clinic can give you a list of items that you may need to give to your insurance company.
• Household Furniture and Linens: Your furniture and linens can be protected from damage caused by the fixator by wearing a protective covering over it.

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You will need a special team of loved ones and specialists to guide you through the process of wearing the TAYLOR SPATIAL FRAME device.

Since your orthopaedic surgeon has chosen you as a candidate for limb restoration, you should know that your surgeon already has confidence in your potential for success. Knowing and utilizing your core team will help you set realistic goals so you will know what to expect at the end of the process.

Be sure to write down the names and telephone numbers of your core team to have on hand at any time that you need them during your journey with the TAYLOR SPATIAL FRAME device.

You

You are the most crucial team member because your active participation is valuable to the success of the limb correction process. You will be required to assist with external fixator adjustments, as instructed. Without your dedicated commitment and important feedback along the way, other team members cannot operate as effectively in their roles.

Significant Other

It is important that a parent, sibling, spouse or close friend – someone dedicated to your well-being – be involved in the process from beginning to end. They need to understand the procedure and what to expect as well as you do. They also need to participate in the planning process.

Orthopaedic Surgeon

Unlike some areas of medicine, limb correction requires that your surgeon be involved in every phase of the process. He or she makes the initial evaluation, performs the operation to apply the TAYLOR SPATIAL FRAME device, plans your recovery goal and closely follows your progress. The surgeon may have an orthopaedic resident, nurse or physician's assistant specifically trained to help with the surgery, and frame construction and modification.

Orthopaedic Clinic Nursing Staff

Your clinic nurse will coordinate the work of the entire team through each phase of your treatment. Your nurse is often the first person to answer questions, listen to concerns and advise you about problems as they arise.

Physical Therapist

Your physical or occupational therapist will conduct a preoperative assessment of your movement ability and will work with you throughout the process to help you stay as active and independent as possible.

Home Care Discharge Planner

A home care discharge planner will be available before and after surgery to talk about your concerns. They can also help you solve logistical problems such as transportation, temporary housing and rental of medical equipment such as wheelchairs and/or crutches.

◊ Trademark of Smith & Nephew

You will need a special team of loved ones and specialists to guide you through the process of wearing the TAYLOR SPATIAL FRAME device.

Since your orthopaedic surgeon has chosen you as a candidate for limb restoration, you should know that your surgeon already has confidence in your potential for success. Knowing and utilizing your core team will help you set realistic goals so you will know what to expect at the end of the process.

Be sure to write down the names and telephone numbers of your core team to have on hand at any time that you need them during your journey with the TAYLOR SPATIAL FRAME device.

You

You are the most crucial team member because your active participation is valuable to the success of the limb correction process. You will be required to assist with external fixator adjustments, as instructed. Without your dedicated commitment and important feedback along the way, other team members cannot operate as effectively in their roles.

Significant Other

It is important that a parent, sibling, spouse or close friend – someone dedicated to your well-being – be involved in the process from beginning to end. They need to understand the procedure and what to expect as well as you do. They also need to participate in the planning process.

Orthopaedic Surgeon

Unlike some areas of medicine, limb correction requires that your surgeon be involved in every phase of the process. He or she makes the initial evaluation, performs the operation to apply the TAYLOR SPATIAL FRAME device, plans your recovery goal and closely follows your progress. The surgeon may have an orthopaedic resident, nurse or physician's assistant specifically trained to help with the surgery, and frame construction and modification.

Orthopaedic Clinic Nursing Staff

Your clinic nurse will coordinate the work of the entire team through each phase of your treatment. Your nurse is often the first person to answer questions, listen to concerns and advise you about problems as they arise.

Physical Therapist

Your physical or occupational therapist will conduct a preoperative assessment of your movement ability and will work with you throughout the process to help you stay as active and independent as possible.

Home Care Discharge Planner

A home care discharge planner will be available before and after surgery to talk about your concerns. They can also help you solve logistical problems such as transportation, temporary housing and rental of medical equipment such as wheelchairs and/or crutches.

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• Know that the discomfort associated with wearing an external fixator is usually mild.
• Anticipate early mobility.
• Keep thinking about the vastly improved quality of life you will have at the end of your treatment.
  Actively participate in your care.
• Normal activities of daily living may be more time consuming so allow enough time for these activities to avoid frustration.
• Keep active. Go to the movies, go out to eat, attend football and baseball games, and visit with family and friends.
• Keep your mind busy by reading books, listening to music, exercising, relaxing, crossword puzzles, etc.

• Know that the discomfort associated with wearing an external fixator is usually mild.
• Anticipate early mobility.
• Keep thinking about the vastly improved quality of life you will have at the end of your treatment.
  Actively participate in your care.
• Normal activities of daily living may be more time consuming so allow enough time for these activities to avoid frustration.
• Keep active. Go to the movies, go out to eat, attend football and baseball games, and visit with family and friends.
• Keep your mind busy by reading books, listening to music, exercising, relaxing, crossword puzzles, etc.

If you are having a limb lengthened or corrected with a TAYLOR SPATIAL FRAME device, you will be required to assist in the process by making external fixator adjustments to the struts at home. This adjustment is made daily. An adjustment plan will be tailored specifically for you and it is imperative that you follow the adjustment schedule exactly.

Your surgeon will make sure that you are trained and understand how and how often to make the adjustments. Your frame adjustment schedule may change at each clinic visit depending on how you progress according to analysis by your surgeon and the TAYLOR SPATIAL FRAME web-based software.

There may be times when you experience some failure of the mechanics of the external fixator, such as broken or bent wires or pins or when you are unable to turn the strut(s). If this happens, call your clinic promptly.

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If you are having a limb lengthened or corrected with a TAYLOR SPATIAL FRAME device, you will be required to assist in the process by making external fixator adjustments to the struts at home. This adjustment is made daily. An adjustment plan will be tailored specifically for you and it is imperative that you follow the adjustment schedule exactly.

Your surgeon will make sure that you are trained and understand how and how often to make the adjustments. Your frame adjustment schedule may change at each clinic visit depending on how you progress according to analysis by your surgeon and the TAYLOR SPATIAL FRAME web-based software.

There may be times when you experience some failure of the mechanics of the external fixator, such as broken or bent wires or pins or when you are unable to turn the strut(s). If this happens, call your clinic promptly.

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Depending on where your TAYLOR SPATIAL FRAME device is placed, you will have to make clothing modifications and adjustments to your wardrobe.

If the external fixator is on your leg:

• Snap-on sports pants or shorts may be the most comfortable articles of clothing to wear. Some snap all the way up to the waistband, making them easy to get on and off.
• Pants can be altered by cutting the inside seam, up to the crotch, or the outside seam, up to the waistband, and inserting triangular pieces of fabric to widen the leg. You can secure the extra fabric inserts with hooks and loops or with buttons.
• Consider pants with many pockets for carrying multiple items throughout the day.
• During warm weather, you may wish to wear shorts or cut off pants above the external fixator.
  For women, loose-fitting dresses or skirts may be your best option. Underwear that ties on both sides at the hip can be used.
• Underwear can be altered by cutting the side seam and using hooks, loops or Velcro® to secure the cut seam.

If the external fixator is on your arm:

• Shirts can be altered by cutting the inside seam of the arm of your shirt and inserting triangular pieces of fabric to widen the arm hole.
• You can secure the extra fabric inserts with hooks and loops or with buttons.
• You can use a shawl or cape to keep warm during colder weather.
• You can cut the cuff off sweaters and shirts to enable the shirt to fit over your arm.

If the external fixator is on your foot:

• You may need to modify a pair of shoes.
• A foot ring with a rubber sole can be added to the fixator. Ask your surgeon about this.

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Depending on where your TAYLOR SPATIAL FRAME device is placed, you will have to make clothing modifications and adjustments to your wardrobe.

If the external fixator is on your leg:

• Snap-on sports pants or shorts may be the most comfortable articles of clothing to wear. Some snap all the way up to the waistband, making them easy to get on and off.
• Pants can be altered by cutting the inside seam, up to the crotch, or the outside seam, up to the waistband, and inserting triangular pieces of fabric to widen the leg. You can secure the extra fabric inserts with hooks and loops or with buttons.
• Consider pants with many pockets for carrying multiple items throughout the day.
• During warm weather, you may wish to wear shorts or cut off pants above the external fixator.
  For women, loose-fitting dresses or skirts may be your best option. Underwear that ties on both sides at the hip can be used.
• Underwear can be altered by cutting the side seam and using hooks, loops or Velcro® to secure the cut seam.

If the external fixator is on your arm:

• Shirts can be altered by cutting the inside seam of the arm of your shirt and inserting triangular pieces of fabric to widen the arm hole.
• You can secure the extra fabric inserts with hooks and loops or with buttons.
• You can use a shawl or cape to keep warm during colder weather.
• You can cut the cuff off sweaters and shirts to enable the shirt to fit over your arm.

If the external fixator is on your foot:

• You may need to modify a pair of shoes.
• A foot ring with a rubber sole can be added to the fixator. Ask your surgeon about this.

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You will have a significant number of surgeon clinic visits during your TAYLOR SPATIAL FRAME device treatment. Be sure to discuss this with the home-based team member who is helping you during treatment.

During the lengthening/correction phase, you may visit the clinic every two weeks so that your surgeon can monitor how you are progressing.

During the consolidation phase, you may visit the clinic once a month. Office visits may range from 30 minutes to two hours, depending on what work or evaluations need to be performed.

Follow-up visits may include:

• Measuring the distraction amount since your last visit.
• Assessing the range of motion of the joints above and below the external fixator for contractures. Contractures occur when the joint is not exercised. Without exercise the tendons and muscles shorten causing joint deformity, stiffness, limited mobility and pain.
• Checking the pin sites for inflammation or infection.
• Checking the external fixator frame for loose wires, nuts and bolts.
• Taking X-Rays to check the rate and progress of the lengthening/correction and assess the quality of the new bone growth.

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You will have a significant number of surgeon clinic visits during your TAYLOR SPATIAL FRAME device treatment. Be sure to discuss this with the home-based team member who is helping you during treatment.

During the lengthening/correction phase, you may visit the clinic every two weeks so that your surgeon can monitor how you are progressing.

During the consolidation phase, you may visit the clinic once a month. Office visits may range from 30 minutes to two hours, depending on what work or evaluations need to be performed.

Follow-up visits may include:

• Measuring the distraction amount since your last visit.
• Assessing the range of motion of the joints above and below the external fixator for contractures. Contractures occur when the joint is not exercised. Without exercise the tendons and muscles shorten causing joint deformity, stiffness, limited mobility and pain.
• Checking the pin sites for inflammation or infection.
• Checking the external fixator frame for loose wires, nuts and bolts.
• Taking X-Rays to check the rate and progress of the lengthening/correction and assess the quality of the new bone growth.

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Immediately after surgery, the affected extremity should be elevated above the level of the heart until there are no concerns about swelling. To elevate the affected extremity properly, place a pillow under the heel of your foot so your knee is extended fully.

To move the affected extremity, the leg external fixator must be moved together as a unit. The amount of assistance needed depends on your ability to control the leg during the move. Make sure not to place your hands under the fracture site during movement. This may cause you to apply stress and even slightly manipulate the fracture site.

Standing up and sitting down

When standing up with a leg in a TAYLOR SPATIAL FRAME device, you must use caution so that you do not fall. Always be very careful when sitting down or getting up from a chair if the external fixator is on your leg.

To stand up, move forward to the edge of the chair. Push off against the seat using the hand on the affected side. Push down on the hand piece of your crutch while raising your body to a standing position.

To sit down, back up to the edge of the chair. Hold on to the hand piece of your crutch on your unaffected side. Lower the hand on your affected side to the arm of the chair to lower your body to a sitting position.

Using the toilet

Again, while performing some daily activities with a leg in the TAYLOR SPATIAL FRAME device, you must use caution to prevent falling.

Follow the same steps used in sitting and standing for getting on and off the toilet. You may consider using an elevated toilet seat. For safety, you may consider placing a handrail beside the toilet.

Sleeping

Your body may require more sleep during the treatment process with your TAYLOR SPATIAL FRAME device, due to increased demands in ambulation. The fixator adds extra weight and increased time to maneuver as you go about your day.

Your sleep will be limited to one position – your back. Elevate the limb with the external device for comfort and security. You may want to sleep with the fixator frame cover on to avoid ripping the sheets.

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Immediately after surgery, the affected extremity should be elevated above the level of the heart until there are no concerns about swelling. To elevate the affected extremity properly, place a pillow under the heel of your foot so your knee is extended fully.

To move the affected extremity, the leg external fixator must be moved together as a unit. The amount of assistance needed depends on your ability to control the leg during the move. Make sure not to place your hands under the fracture site during movement. This may cause you to apply stress and even slightly manipulate the fracture site.

Standing up and sitting down

When standing up with a leg in a TAYLOR SPATIAL FRAME device, you must use caution so that you do not fall. Always be very careful when sitting down or getting up from a chair if the external fixator is on your leg.

To stand up, move forward to the edge of the chair. Push off against the seat using the hand on the affected side. Push down on the hand piece of your crutch while raising your body to a standing position.

To sit down, back up to the edge of the chair. Hold on to the hand piece of your crutch on your unaffected side. Lower the hand on your affected side to the arm of the chair to lower your body to a sitting position.

Using the toilet

Again, while performing some daily activities with a leg in the TAYLOR SPATIAL FRAME device, you must use caution to prevent falling.

Follow the same steps used in sitting and standing for getting on and off the toilet. You may consider using an elevated toilet seat. For safety, you may consider placing a handrail beside the toilet.

Sleeping

Your body may require more sleep during the treatment process with your TAYLOR SPATIAL FRAME device, due to increased demands in ambulation. The fixator adds extra weight and increased time to maneuver as you go about your day.

Your sleep will be limited to one position – your back. Elevate the limb with the external device for comfort and security. You may want to sleep with the fixator frame cover on to avoid ripping the sheets.

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Your therapist will design a home-exercise program encouraging you to maintain the limb's range of motion and strength. Their objective is to help you become as independent as possible to cope with the external fixator and promote healing.

Your exercise program is your surgeon's prescription. The exercise program designed for you will depend on the type of correction or lengthening treatment you are undergoing.

Aerobic activities increase blood flow and strengthen bones. It burns calories, increases resistance to disease and decreases tension. It also releases endorphins – the body's own pain-control system.

To avoid complications, your exercise program should be followed with commitment and discipline. You may be able to walk, ride a stationary bike and swim in a chlorinated, clean pool (after your sutures are out).

You must bear weight on the limb being treated with the external fixator, after you've been released by your surgeon to do so, or you may not heal properly. You must exercise your affected extremity to increase blood flow and grow healthy bone tissue. For a leg fitted with the TAYLOR SPATIAL FRAME device, that means walking. For an arm fitted with an external fixator, that means using small weights. Putting weight on the treated extremity promotes healing.

Whatever the method, exercise is critical for a speedy recovery. Check with your surgeon and your physical therapist for specific instructions.

Learn more about pediatric orthopedic physical therapy and rehabilitation services at Nicklaus Children's Hospital.

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Your therapist will design a home-exercise program encouraging you to maintain the limb's range of motion and strength. Their objective is to help you become as independent as possible to cope with the external fixator and promote healing.

Your exercise program is your surgeon's prescription. The exercise program designed for you will depend on the type of correction or lengthening treatment you are undergoing.

Aerobic activities increase blood flow and strengthen bones. It burns calories, increases resistance to disease and decreases tension. It also releases endorphins – the body's own pain-control system.

To avoid complications, your exercise program should be followed with commitment and discipline. You may be able to walk, ride a stationary bike and swim in a chlorinated, clean pool (after your sutures are out).

You must bear weight on the limb being treated with the external fixator, after you've been released by your surgeon to do so, or you may not heal properly. You must exercise your affected extremity to increase blood flow and grow healthy bone tissue. For a leg fitted with the TAYLOR SPATIAL FRAME device, that means walking. For an arm fitted with an external fixator, that means using small weights. Putting weight on the treated extremity promotes healing.

Whatever the method, exercise is critical for a speedy recovery. Check with your surgeon and your physical therapist for specific instructions.

Learn more about pediatric orthopedic physical therapy and rehabilitation services at Nicklaus Children's Hospital.

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The TAYLOR SPATIAL FRAME device is attached to the outside of your limb with pins and wires that penetrate your skin through your bone and out the other side. Pin tract sites are where the pins and wires go through your skin.

Pin-tract infections are a common problem around these pin sites, but may be avoided with proper pin care. You will have a major responsibility to make sure that the pin site areas are cleaned daily - you must take vigilant care to keep the pint tract sites clean and free of infection.

Pin site care

Your surgeon will guide you in the proper care and cleaning of the pin sites. You will need to learn how to remove dried blood and scabs from the pin sites to keep your skin from adhering to the pins and allow free drainage of your pin site. Gentle massage around the pin sites may also help to keep your skin from adhering to the pins. Be gentle when you massage around your pin sites as excessive skin motion on the pins may cause infection. If you have difficulty reaching or seeing all the pin sites, have a family member or friend help, or you can use a mirror.

Make sure that you follow your surgeon's recommendations for proper pin site care to avoid infection.

Showers with the external fixator

You may not be allowed to shower for approximately five to seven days after initial placement of the TAYLOR SPATIAL FRAME™ device. Until you are allowed to shower, your surgeon may have you clean the pin sites with cotton swabs and normal saline or other topical cleaner or antibiotic that your surgeon prescribes. During the first few days after the external fixator is placed, expect a clear yellow or slightly bloody drainage from the pin sites.

As long as there are no open wounds and your surgeon allows it, you can shower with the TAYLOR SPATIAL FRAME device in place. You may consider placing a rubber mat in the tub or utilizing a shower chair or installing handrails in your shower for safety. When you are released to take showers, cleaning the pin sites with an antibacterial liquid soap and water while in the shower has proven to be a simple and effective external fixator pin care method. Allow the soap and water to run down the extremity that the external fixator is attached to. Do not scrub. Rinse and dry the fixator and the extremity thoroughly. You can dry using a hair dryer on a cool setting.

Any activities that involve soaking the external fixator in potentially contaminated water are discouraged. That means no natural ocean waters, rivers, etc. Your surgeon may, however, allow you to swim in a clean, chlorinated pool after your sutures are removed.

Pin-tract infections

Because you will have pins and wires going through your skin into your bone, there is a risk for pin-tract infections. With proper cleaning, protection and care of your pin sites, you may never have an infection – which is the goal. Call your surgeon if you experience any of the following symptoms:

• Redness, warmth and swelling at the pin sites. A small amount of redness is normal.
• Extrememly tender pin sites.
• Persistant fever of 100.5 farenheit or higher- taken orally.
• Thick, cloudy, white, yellow or green drainage from the pin sites. Clear yellow or slightly bloody drainage is normal.
• Odor at the pin sites.

Nerve problems

If you experience pain in a place where there are no pins, this may be the first sign of a nerve problem. This is called 'referred pain.' The next sign is an increased or decreased feeling in the area of your foot or hand, depending on where your external fixator is located. You could experience these symptoms during the initial correction phase of your treatment with the TAYLOR SPATIAL FRAME fixator. Report these symptoms to your surgeon as soon as possible. They may be indications of nerve irritation.

Smith & Nephew

The TAYLOR SPATIAL FRAME device is attached to the outside of your limb with pins and wires that penetrate your skin through your bone and out the other side. Pin tract sites are where the pins and wires go through your skin.

Pin-tract infections are a common problem around these pin sites, but may be avoided with proper pin care. You will have a major responsibility to make sure that the pin site areas are cleaned daily - you must take vigilant care to keep the pint tract sites clean and free of infection.

Pin site care

Your surgeon will guide you in the proper care and cleaning of the pin sites. You will need to learn how to remove dried blood and scabs from the pin sites to keep your skin from adhering to the pins and allow free drainage of your pin site. Gentle massage around the pin sites may also help to keep your skin from adhering to the pins. Be gentle when you massage around your pin sites as excessive skin motion on the pins may cause infection. If you have difficulty reaching or seeing all the pin sites, have a family member or friend help, or you can use a mirror.

Make sure that you follow your surgeon's recommendations for proper pin site care to avoid infection.

Showers with the external fixator

You may not be allowed to shower for approximately five to seven days after initial placement of the TAYLOR SPATIAL FRAME™ device. Until you are allowed to shower, your surgeon may have you clean the pin sites with cotton swabs and normal saline or other topical cleaner or antibiotic that your surgeon prescribes. During the first few days after the external fixator is placed, expect a clear yellow or slightly bloody drainage from the pin sites.

As long as there are no open wounds and your surgeon allows it, you can shower with the TAYLOR SPATIAL FRAME device in place. You may consider placing a rubber mat in the tub or utilizing a shower chair or installing handrails in your shower for safety. When you are released to take showers, cleaning the pin sites with an antibacterial liquid soap and water while in the shower has proven to be a simple and effective external fixator pin care method. Allow the soap and water to run down the extremity that the external fixator is attached to. Do not scrub. Rinse and dry the fixator and the extremity thoroughly. You can dry using a hair dryer on a cool setting.

Any activities that involve soaking the external fixator in potentially contaminated water are discouraged. That means no natural ocean waters, rivers, etc. Your surgeon may, however, allow you to swim in a clean, chlorinated pool after your sutures are removed.

Pin-tract infections

Because you will have pins and wires going through your skin into your bone, there is a risk for pin-tract infections. With proper cleaning, protection and care of your pin sites, you may never have an infection – which is the goal. Call your surgeon if you experience any of the following symptoms:

• Redness, warmth and swelling at the pin sites. A small amount of redness is normal.
• Extrememly tender pin sites.
• Persistant fever of 100.5 farenheit or higher- taken orally.
• Thick, cloudy, white, yellow or green drainage from the pin sites. Clear yellow or slightly bloody drainage is normal.
• Odor at the pin sites.

Nerve problems

If you experience pain in a place where there are no pins, this may be the first sign of a nerve problem. This is called 'referred pain.' The next sign is an increased or decreased feeling in the area of your foot or hand, depending on where your external fixator is located. You could experience these symptoms during the initial correction phase of your treatment with the TAYLOR SPATIAL FRAME fixator. Report these symptoms to your surgeon as soon as possible. They may be indications of nerve irritation.

Smith & Nephew

After the TAYLOR SPATIAL FRAME device is removed, you may have to wear a cast or a brace on the limb that was lengthened or corrected for a period of time. This will give your bones a little longer to heal and consolidate (strengthen). The length of time that you may have to wear a brace or a cast is dependent on how well your bone has consolidated. Your surgeon will make the determination whether you will require a brace or a cast.

Your surgeon will likely recommend that you continue your exercises and increase your activity level. Motion and bearing weight on your affected limb promotes bone healing and strengthening.

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After the TAYLOR SPATIAL FRAME device is removed, you may have to wear a cast or a brace on the limb that was lengthened or corrected for a period of time. This will give your bones a little longer to heal and consolidate (strengthen). The length of time that you may have to wear a brace or a cast is dependent on how well your bone has consolidated. Your surgeon will make the determination whether you will require a brace or a cast.

Your surgeon will likely recommend that you continue your exercises and increase your activity level. Motion and bearing weight on your affected limb promotes bone healing and strengthening.

◊ Trademark of Smith & Nephew

How fast can bone grow?

Your bone can grow up to one millimeter per day.

How long do I have to wear the external fixator?

Typical external fixator patients wear the device from four to twelve months. The severity of the problem you need reconstructed, your health, weight and other factors play a role in the length of time you will need to wear the external fixator. Your surgeon will be able to provide you with a timeline for your specific case.

What are the stages of lengthening/correction?

• Correction/Distraction – This begins a few days postoperatively when you will begin the process of moving the struts as directed to create a space between your bones to promote bone growth. Typically, you will adjust the struts four times a day, every six hours, approximately 0.25mm each time, for a total of 1mm in a 24-hour period.
• Consolidation – During this time period you will wear the external fixator, but you will not adjust the struts. This allows time for the new bone growth to consolidate (strengthen) and prepare for removal of the external fixator.

How is the TAYLOR SPATIAL FRAME device attached and removed?

You will have at least two surgeries related to the TAYLOR SPATIAL FRAME device. Both the installation and the removal of the device will require a surgical procedure.

There is the possibility of serious complications with any surgery. Your surgeon will not schedule you for surgery unless he feels that you are healthy enough to have the procedure. Discuss possible complications and what to expect with your surgeon.

Only after X-Ray exams of the consolidated bone show it is completely healed will the TAYLOR SPATIAL FRAME device be removed. This will be performed under general anesthesia, usually as an outpatient surgical procedure. Afterwards, you may have to wear a brace or a cast, to give the bone more time to heal.

You may have certain physical limitations at first, depending on your bone healing progress and specific situation. Consult your surgeon about your limitations.

◊ Trademark of Smith & Nephew

How fast can bone grow?

Your bone can grow up to one millimeter per day.

How long do I have to wear the external fixator?

Typical external fixator patients wear the device from four to twelve months. The severity of the problem you need reconstructed, your health, weight and other factors play a role in the length of time you will need to wear the external fixator. Your surgeon will be able to provide you with a timeline for your specific case.

What are the stages of lengthening/correction?

• Correction/Distraction – This begins a few days postoperatively when you will begin the process of moving the struts as directed to create a space between your bones to promote bone growth. Typically, you will adjust the struts four times a day, every six hours, approximately 0.25mm each time, for a total of 1mm in a 24-hour period.
• Consolidation – During this time period you will wear the external fixator, but you will not adjust the struts. This allows time for the new bone growth to consolidate (strengthen) and prepare for removal of the external fixator.

How is the TAYLOR SPATIAL FRAME device attached and removed?

You will have at least two surgeries related to the TAYLOR SPATIAL FRAME device. Both the installation and the removal of the device will require a surgical procedure.

There is the possibility of serious complications with any surgery. Your surgeon will not schedule you for surgery unless he feels that you are healthy enough to have the procedure. Discuss possible complications and what to expect with your surgeon.

Only after X-Ray exams of the consolidated bone show it is completely healed will the TAYLOR SPATIAL FRAME device be removed. This will be performed under general anesthesia, usually as an outpatient surgical procedure. Afterwards, you may have to wear a brace or a cast, to give the bone more time to heal.

You may have certain physical limitations at first, depending on your bone healing progress and specific situation. Consult your surgeon about your limitations.

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During the correction phase while wearing the TAYLOR SPATIAL FRAME device, you may be required to use crutches if your leg is the affected limb. Your surgeon will prescribe a weight-bearing status for you to walk, either partial weight bearing or full weight bearing, which will determine whether or not you will be required to use crutches.

Before walking with crutches, it is important that you are fit properly for them and that you know how to use crutches correctly and safely. Your physical therapist will teach you techniques for standing, walking and maneuvering yourself with crutches. With a little time, practice and patience, you will learn how to walk with crutches.

Tips for Using Crutches

• Crutches should be custom adjusted to your body size.
• Make sure you have a thick foam rubber pad on the underarm piece to relieve pressure of the crutch on the upper arm and thoracic cage (ribs). Never put pressure in the axilla (armpit) when using crutches.
• Weight should be supported on the hand pieces to avoid damage to the nerves under the armpits (brachial plexus nerves), which can cause 'crutch paralysis.
• Walking with crutches can take a toll on the hands. Protect your hands from pain and calluses by using hand-piece pads in good condition.
• Long-term crutch users may benefit from new shock absorbing crutches.
• If you are getting numbness in the hands, have your physical therapist check your crutch length and crutch technique. Ask about Canadian Crutches.
• Keep your body weight down.
• Make sure your crutches have large rubber suction tips.
• Good balance and erect posture are essential for crutch walking. Learn to balance by standing next to a chair on the unaffected leg. Wear well-fitting shoes with firm soles to prevent falls.
• Stay away from wet, slippery surfaces, freshly waxed floors and rough, uneven surfaces.
• Going up and down stairs requires both strength and flexibility. Make sure someone is by your side until you have regained your strength and mobility.
• To go up and down stairs, remember – up with the good leg, down with the affected leg.

◊ Trademark of Smith & Nephew

During the correction phase while wearing the TAYLOR SPATIAL FRAME device, you may be required to use crutches if your leg is the affected limb. Your surgeon will prescribe a weight-bearing status for you to walk, either partial weight bearing or full weight bearing, which will determine whether or not you will be required to use crutches.

Before walking with crutches, it is important that you are fit properly for them and that you know how to use crutches correctly and safely. Your physical therapist will teach you techniques for standing, walking and maneuvering yourself with crutches. With a little time, practice and patience, you will learn how to walk with crutches.

Tips for Using Crutches

• Crutches should be custom adjusted to your body size.
• Make sure you have a thick foam rubber pad on the underarm piece to relieve pressure of the crutch on the upper arm and thoracic cage (ribs). Never put pressure in the axilla (armpit) when using crutches.
• Weight should be supported on the hand pieces to avoid damage to the nerves under the armpits (brachial plexus nerves), which can cause 'crutch paralysis.
• Walking with crutches can take a toll on the hands. Protect your hands from pain and calluses by using hand-piece pads in good condition.
• Long-term crutch users may benefit from new shock absorbing crutches.
• If you are getting numbness in the hands, have your physical therapist check your crutch length and crutch technique. Ask about Canadian Crutches.
• Keep your body weight down.
• Make sure your crutches have large rubber suction tips.
• Good balance and erect posture are essential for crutch walking. Learn to balance by standing next to a chair on the unaffected leg. Wear well-fitting shoes with firm soles to prevent falls.
• Stay away from wet, slippery surfaces, freshly waxed floors and rough, uneven surfaces.
• Going up and down stairs requires both strength and flexibility. Make sure someone is by your side until you have regained your strength and mobility.
• To go up and down stairs, remember – up with the good leg, down with the affected leg.

◊ Trademark of Smith & Nephew

• A cardiac monitor gives information about your heart rate, breathing, and blood pressure via stickers placed on the chest. The monitor is used during the first 48 hours after surgery.
• A pulse oximeter fits like a clip Band-Aid® or bandage on a fingertip and measures how much oxygen is in the blood. This is usually worn for the first two to three days post operation.
• An IV is usually placed in the arm or hand and sometimes in the neck. This is how your child will receive fluids and medicines until he/she is drinking enough on his/her own. One IV will stay in place for most or all of the hospital stay.
• Your child will have a PCA pump, this unit will be connected to your child’s IV. The PCA pump is the method through which your child will receive pain medication for the first two to three days after surgery. There is a button attached to the pump that your child can push to get medicine when he/she needs it. The PCA pump is programmed so your child cannot receive too much medicine. Make sure you contact the nursing staff immediately if your child does not seem comfortable enough with the current pain management plan. Your child’s nurse or doctor may have other options available.
• A urinary or foley catheter is inserted in your child’s bladder during surgery. This will drain urine until your child is able to use the restroom on his/her own. The catheter is taped to the leg and will not fall out when your child moves. The catheter will be removed three days after surgery.
• Patients will have a Jackson-Pratt, a drain placed in the incision during surgery, to help remove extra fluid from the back. This drain is normally removed the day after surgery. This does not hurt!!!

• A cardiac monitor gives information about your heart rate, breathing, and blood pressure via stickers placed on the chest. The monitor is used during the first 48 hours after surgery.
• A pulse oximeter fits like a clip Band-Aid® or bandage on a fingertip and measures how much oxygen is in the blood. This is usually worn for the first two to three days post operation.
• An IV is usually placed in the arm or hand and sometimes in the neck. This is how your child will receive fluids and medicines until he/she is drinking enough on his/her own. One IV will stay in place for most or all of the hospital stay.
• Your child will have a PCA pump, this unit will be connected to your child’s IV. The PCA pump is the method through which your child will receive pain medication for the first two to three days after surgery. There is a button attached to the pump that your child can push to get medicine when he/she needs it. The PCA pump is programmed so your child cannot receive too much medicine. Make sure you contact the nursing staff immediately if your child does not seem comfortable enough with the current pain management plan. Your child’s nurse or doctor may have other options available.
• A urinary or foley catheter is inserted in your child’s bladder during surgery. This will drain urine until your child is able to use the restroom on his/her own. The catheter is taped to the leg and will not fall out when your child moves. The catheter will be removed three days after surgery.
• Patients will have a Jackson-Pratt, a drain placed in the incision during surgery, to help remove extra fluid from the back. This drain is normally removed the day after surgery. This does not hurt!!!

• Bring a pad of paper and a pen to take notes and list questions you may have for the doctor. Doctors usually visit in the morning and during the course of a day, you may forget some of your questions.
• Bring a journal to record what happens during the hospital stay and your thoughts. This is a great stress reliever and opportunity for your child to look back on his or her experience.
• If your child has long hair, braid it before surgery.
• Bring a camera.
• Bring all needed phone numbers to the hospital.
• Set up a "calling tree" to help you update others about your child’s progress. For example, you might make one phone call to a friend or family member and then have that person call others.
• Limit all visitors until at least the third day after surgery.
• Bring comfortable clothes for you to sleep in during your hospital stay. There is little privacy.
• Bring a water bottle for yourself.
• For your child, bring button-front pajamas/shirts and loose-fitting clothing.
• Bring lip balm for your child.
• It is common for girls to menstruate during their hospital stay, so be sure to bring your own personal hygiene supplies.
• Your child may have swelling of the face, arms, hands or other areas after surgery. This is common and will decrease within a day or two.
• In the first few days after surgery, your child will receive a significant amount of medication to help him/her be comfortable. It is helpful to tell your child the date and time every time that he/she is awake.
• Do not allow visitors to sit on or bump your child’s bed. Instruct visitors to be gentle when they touch.
• Be prepared for your child to exhibit a wide range of emotions you may not be accustomed to seeing. This is very common after spinal fusion surgery.
• Limit perfumes and colognes as your child may be sensitive to even familiar scents.
• Bring several pillows for the car ride home.
• It may be helpful to use a baby monitor to help your child communicate at home.

• Bring a pad of paper and a pen to take notes and list questions you may have for the doctor. Doctors usually visit in the morning and during the course of a day, you may forget some of your questions.
• Bring a journal to record what happens during the hospital stay and your thoughts. This is a great stress reliever and opportunity for your child to look back on his or her experience.
• If your child has long hair, braid it before surgery.
• Bring a camera.
• Bring all needed phone numbers to the hospital.
• Set up a "calling tree" to help you update others about your child’s progress. For example, you might make one phone call to a friend or family member and then have that person call others.
• Limit all visitors until at least the third day after surgery.
• Bring comfortable clothes for you to sleep in during your hospital stay. There is little privacy.
• Bring a water bottle for yourself.
• For your child, bring button-front pajamas/shirts and loose-fitting clothing.
• Bring lip balm for your child.
• It is common for girls to menstruate during their hospital stay, so be sure to bring your own personal hygiene supplies.
• Your child may have swelling of the face, arms, hands or other areas after surgery. This is common and will decrease within a day or two.
• In the first few days after surgery, your child will receive a significant amount of medication to help him/her be comfortable. It is helpful to tell your child the date and time every time that he/she is awake.
• Do not allow visitors to sit on or bump your child’s bed. Instruct visitors to be gentle when they touch.
• Be prepared for your child to exhibit a wide range of emotions you may not be accustomed to seeing. This is very common after spinal fusion surgery.
• Limit perfumes and colognes as your child may be sensitive to even familiar scents.
• Bring several pillows for the car ride home.
• It may be helpful to use a baby monitor to help your child communicate at home.

Everyone’s spine has curves. These curves produce the normal rounding of the shoulders and the sway of the lower back. Scoliosis is a condition that causes the spine to bend sideways and twist.

Scoliosis can occur in:

• he upper back (thoracic)
• lower back (lumbar)
• or in the neck area (cervical)

You may also have curvature in more than one area. Scoliosis is more commonly seen in girls than in boys. Uneven shoulders or a shoulder blade that protrudes when a child bends over are often the first indicators of the condition. The most common form of scoliosis is idiopathic scoliosis, which means the cause is unknown. Your doctor may recommend surgery if the spinal curve continues to progress despite treatments, such as bracing.

The goal of spinal fusion surgery is to stop the progression of the curve. During the surgery, the doctor attaches screws and rods to both sides of the spine and the curve is gently straightened. Small bone grafts taken from the spine and ribs are placed next to the spine. These bone grafts act like cement. As the bone grafts heal, the spine will become solid and the curve will not progress. Until the bones have healed, they need support to keep them from curving again. The rods attached to the spine hold everything in place and support the spine until the bones fuse together.

Your spinal fusion surgery may be performed from the back (posterior), the side (anterior) or both. Your surgeon will determine which is best for you.

Why do it?

Some of the reasons teens say they are glad they had this surgery are:

• Less back pain
• Better posture
• Clothing fits better
• Prevention of a larger curve with larger side effects.

 

Everyone’s spine has curves. These curves produce the normal rounding of the shoulders and the sway of the lower back. Scoliosis is a condition that causes the spine to bend sideways and twist.

Scoliosis can occur in:

• he upper back (thoracic)
• lower back (lumbar)
• or in the neck area (cervical)

You may also have curvature in more than one area. Scoliosis is more commonly seen in girls than in boys. Uneven shoulders or a shoulder blade that protrudes when a child bends over are often the first indicators of the condition. The most common form of scoliosis is idiopathic scoliosis, which means the cause is unknown. Your doctor may recommend surgery if the spinal curve continues to progress despite treatments, such as bracing.

The goal of spinal fusion surgery is to stop the progression of the curve. During the surgery, the doctor attaches screws and rods to both sides of the spine and the curve is gently straightened. Small bone grafts taken from the spine and ribs are placed next to the spine. These bone grafts act like cement. As the bone grafts heal, the spine will become solid and the curve will not progress. Until the bones have healed, they need support to keep them from curving again. The rods attached to the spine hold everything in place and support the spine until the bones fuse together.

Your spinal fusion surgery may be performed from the back (posterior), the side (anterior) or both. Your surgeon will determine which is best for you.

Why do it?

Some of the reasons teens say they are glad they had this surgery are:

• Less back pain
• Better posture
• Clothing fits better
• Prevention of a larger curve with larger side effects.

 

What can you do to prepare for a back surgery?

You can do yourself a huge favor by exercising and being physically active before your surgery. Daily stretches, stomach crunches, and leg stretches are all examples of exercises that help you heal faster and recover more easily. Exercising is also a great way to relieve the stress that may be building up inside you.

In the months or weeks before your surgery, it is very important to maintain a positive attitude. Try not to dwell on what is ahead. Have as much fun as you can, safely. Stay active, keep busy, and most of all, don't feel sorry for yourself! Try to think of things to do that you may not be able to do right after your surgery. Some suggestions include swimming, horseback riding, water park slides, roller coaster rides, rollerblading, ice skating, dancing, golfing, and driving. The night before your procedure, you may want to spend some time by yourself. It will be awhile before anyone lets you do something by yourself again.

Donating Blood Before Your Surgery

It is normal to lose blood during surgery. The surgeons will use multiple advances in medicine to reduce the blood loss during surgery, despite the use of this technology, some patients will require blood transfusions during hospitalizations. There are different ways of preparing blood donations for your surgery:

• You may donate your own blood before your surgery (lots of kids and teens do this!).
• Your family or friends can donate their blood for you.
• You may get blood from the blood bank here at the hospital.

To donate blood prior to the surgery, please refer to OneBlood at www.oneblood.org or call 954-777-264 for locations, hours of operation and to schedule an appointment online. As a reminder, please take the prescription for blood donation with you to the donor center.

Medications

To decrease the risk of excessive bleeding during surgery, you will be asked to avoid taking aspirin-containing medications or non-steroidal anti-inflammatory medications (Advil, Ibuprofen, Motrin, Aleeve) starting at two weeks prior to surgery. You may not resume taking these medications again until instructed by the surgeon.

 

 

What can you do to prepare for a back surgery?

You can do yourself a huge favor by exercising and being physically active before your surgery. Daily stretches, stomach crunches, and leg stretches are all examples of exercises that help you heal faster and recover more easily. Exercising is also a great way to relieve the stress that may be building up inside you.

In the months or weeks before your surgery, it is very important to maintain a positive attitude. Try not to dwell on what is ahead. Have as much fun as you can, safely. Stay active, keep busy, and most of all, don't feel sorry for yourself! Try to think of things to do that you may not be able to do right after your surgery. Some suggestions include swimming, horseback riding, water park slides, roller coaster rides, rollerblading, ice skating, dancing, golfing, and driving. The night before your procedure, you may want to spend some time by yourself. It will be awhile before anyone lets you do something by yourself again.

Donating Blood Before Your Surgery

It is normal to lose blood during surgery. The surgeons will use multiple advances in medicine to reduce the blood loss during surgery, despite the use of this technology, some patients will require blood transfusions during hospitalizations. There are different ways of preparing blood donations for your surgery:

• You may donate your own blood before your surgery (lots of kids and teens do this!).
• Your family or friends can donate their blood for you.
• You may get blood from the blood bank here at the hospital.

To donate blood prior to the surgery, please refer to OneBlood at www.oneblood.org or call 954-777-264 for locations, hours of operation and to schedule an appointment online. As a reminder, please take the prescription for blood donation with you to the donor center.

Medications

To decrease the risk of excessive bleeding during surgery, you will be asked to avoid taking aspirin-containing medications or non-steroidal anti-inflammatory medications (Advil, Ibuprofen, Motrin, Aleeve) starting at two weeks prior to surgery. You may not resume taking these medications again until instructed by the surgeon.

 

 

Your Hospital Room

In the hospital, you will be assigned to a room where you will stay throughout the duration of your admission at Nicklaus Children's Hospital. This is your room and you can bring items with you to make it feel "like home." In addition to essentials, you may want to bring some sources of entertainment, as well as special items that make you feel comfortable. Here is a list to get you started:

• Pillow
• Favorite blanket or comforter
• Personal items:
  • toothbrush, toothpaste, lotion, deodorant, hair ties, hair brush or comb, sanitary pads, etc (Yes, the hospital provides these, but it is nice to have your own)
• Stuffed animals, toys
• Books
• Pictures of your friends, family and pets
• Laptop/tablets/cell phones and battery charger
• Lip balm
• Slippers with a non-slip bottom

What Clothing Should you Bring?

• Choose shorts or pants with a loose waistband. Boxers work great!
• Button-up or oversized shirts are good choices that will eliminate the need to lift your arms over your head when changing.
• You may also wear hospital gowns the entire time, if you prefer. It’s your choice!

More Helpful Hints

• Do not wear any jewelry the day of surgery.
• If you have long hair, try to avoid leaving it loose. A good way to prevent the tangles associated with lying in bed for several days is to part your hair down the middle and put it into two French braids. Regular braids also will work.
• Bring things to help pass the time (music/headphones, magazines, card games, etc).
• If you want to keep a journal, this is a great time and place to work on it.

Your Hospital Room

In the hospital, you will be assigned to a room where you will stay throughout the duration of your admission at Nicklaus Children's Hospital. This is your room and you can bring items with you to make it feel "like home." In addition to essentials, you may want to bring some sources of entertainment, as well as special items that make you feel comfortable. Here is a list to get you started:

• Pillow
• Favorite blanket or comforter
• Personal items:
  • toothbrush, toothpaste, lotion, deodorant, hair ties, hair brush or comb, sanitary pads, etc (Yes, the hospital provides these, but it is nice to have your own)
• Stuffed animals, toys
• Books
• Pictures of your friends, family and pets
• Laptop/tablets/cell phones and battery charger
• Lip balm
• Slippers with a non-slip bottom

What Clothing Should you Bring?

• Choose shorts or pants with a loose waistband. Boxers work great!
• Button-up or oversized shirts are good choices that will eliminate the need to lift your arms over your head when changing.
• You may also wear hospital gowns the entire time, if you prefer. It’s your choice!

More Helpful Hints

• Do not wear any jewelry the day of surgery.
• If you have long hair, try to avoid leaving it loose. A good way to prevent the tangles associated with lying in bed for several days is to part your hair down the middle and put it into two French braids. Regular braids also will work.
• Bring things to help pass the time (music/headphones, magazines, card games, etc).
• If you want to keep a journal, this is a great time and place to work on it.

The first two or three days are the most difficult. After that, each day gets better.

You probably won’t have as much privacy as you are accustomed to during the first few days. Not being able to do some things for yourself may be embarrassing or it may not bother you as much as you think. Remember, you have more important things to be concerned about.

There are a lot of things you may have to do that you may not want to do or may not feel like doing. You may feel agitated because so many people are telling you what to do. Because you are frustrated and uncomfortable, you may feel emotionally explosive. Try not to take it out on the people around you.

Remember, they are doing everything they can to help you feel better and get you home faster. When you are feeling frustrated, try to think about what you can do today that you were unable to do yesterday. You have already come a long way!

The best way to make this an easier experience is to work together with the nurses, therapists, doctors and your family. Communicating with the care team will greatly benefit you and will help them take better care of you.

Everyone’s experience with pain after spinal fusion surgery is different. Your doctors, nurses and family all have the same goal: to help you be as comfortable as possible. Tension in your body and tightening of your muscles can make you hurt more, so it is very important to help yourself relax and stay as calm as possible. It is okay to ask for medicine for your pain when you need it. In fact, the medicine works best if you receive it before the pain becomes unbearable!

Pain After Spinal Fusion Surgery

Your nurse will frequently ask you the level of your pain. He or she will use what we call a "pain scale" from 0-10. The 0 represents no pain, while the 10 signifies pain that is the worst you’ve ever experienced. Your nurse may ask you to describe your pain with words such as sharp, burning, throbbing or dull. Please be honest with your nurses at all times. They are here to help keep you comfortable.

Here are some suggestions that have helped other kids and teens relieve pain after scoliosis surgery:

• Change your position.
• Channel your pain. Think about the pain moving out of your body or concentrate on another part of your body such as your thumb or elbow.
• Listen to relaxing music.
• Have someone wash your face or hair. Feeling calm and fresh makes a world of difference.
• Have someone read to you.
• Change the look and feel of your room. For example, turn off the lights, close the blinds and turn on a fan to cool you.
• Use breathing techniques. Taking slow deep breaths sometimes helps your body to relax.
• Get up and move around.
• Go for a short walk (with help of course!).

The most important thing you can do is to identify what helps you relax and then make a plan for yourself. Share your plan with a family member who will be at the hospital with you or write it down. Always keep a positive attitude; each day will get better!

 

The first two or three days are the most difficult. After that, each day gets better.

You probably won’t have as much privacy as you are accustomed to during the first few days. Not being able to do some things for yourself may be embarrassing or it may not bother you as much as you think. Remember, you have more important things to be concerned about.

There are a lot of things you may have to do that you may not want to do or may not feel like doing. You may feel agitated because so many people are telling you what to do. Because you are frustrated and uncomfortable, you may feel emotionally explosive. Try not to take it out on the people around you.

Remember, they are doing everything they can to help you feel better and get you home faster. When you are feeling frustrated, try to think about what you can do today that you were unable to do yesterday. You have already come a long way!

The best way to make this an easier experience is to work together with the nurses, therapists, doctors and your family. Communicating with the care team will greatly benefit you and will help them take better care of you.

Everyone’s experience with pain after spinal fusion surgery is different. Your doctors, nurses and family all have the same goal: to help you be as comfortable as possible. Tension in your body and tightening of your muscles can make you hurt more, so it is very important to help yourself relax and stay as calm as possible. It is okay to ask for medicine for your pain when you need it. In fact, the medicine works best if you receive it before the pain becomes unbearable!

Pain After Spinal Fusion Surgery

Your nurse will frequently ask you the level of your pain. He or she will use what we call a "pain scale" from 0-10. The 0 represents no pain, while the 10 signifies pain that is the worst you’ve ever experienced. Your nurse may ask you to describe your pain with words such as sharp, burning, throbbing or dull. Please be honest with your nurses at all times. They are here to help keep you comfortable.

Here are some suggestions that have helped other kids and teens relieve pain after scoliosis surgery:

• Change your position.
• Channel your pain. Think about the pain moving out of your body or concentrate on another part of your body such as your thumb or elbow.
• Listen to relaxing music.
• Have someone wash your face or hair. Feeling calm and fresh makes a world of difference.
• Have someone read to you.
• Change the look and feel of your room. For example, turn off the lights, close the blinds and turn on a fan to cool you.
• Use breathing techniques. Taking slow deep breaths sometimes helps your body to relax.
• Get up and move around.
• Go for a short walk (with help of course!).

The most important thing you can do is to identify what helps you relax and then make a plan for yourself. Share your plan with a family member who will be at the hospital with you or write it down. Always keep a positive attitude; each day will get better!

 

Admission

The first place you will go the day you are admitted is to Patient Access, located on the first floor. This is where you will check into the hospital.

Once you have checked in, you will be sent to the laboratory for blood and urine tests. This does involve a needle prick, but it only hurts a little and is over quickly. The information we get tells us how your body is working on the inside. You will also be given a small container and asked to give a urine sample. This tells us how your kidneys are working.

Next, you will go to the Radiology Department, also located on the first floor. Here you will have X-rays taken. X- rays are special photos taken of your body. X- rays do not hurt!

You will then go up to the second floor where you will be given your room assignment. You will be assigned to a room. This is your "home away from home" for the next few days. You will be introduced to your nurse and will have the opportunity to ask him/her any questions you may have at that time. You may change into a hospital gown or stay in your clothing, whichever you prefer. Your family can stay with you until you fall asleep for the night. Your room includes a "sleeper chair" so that a member of your family can spend the night with you. You may ask your nurse for extra pillows and blankets.

Remember: NO FOOD OR DRINK AFTER MIDNIGHT!

The Day of Your Surgery

On the morning of surgery a technician will come and tape electrodes on your legs. These electrodes are just stickers that have a plastic wire glued to them and will be used during surgery to measure the small electricity signals that our body makes to communicate with the brain. This does not hurt! The stickers peel off easily and will be all gone by the time you wake up.

The nerve pathways that are normal for you are recorded as wavy lines on a piece of paper. During your surgery, these pathways will be monitored to detect any changes.

Before you leave for the operating room, you will be given a medicine that will make you a little sleepy and a lot less nervous! This is not the medicine that helps you to fall asleep for your surgery.

You may bring something comforting to the operating room with you such as a stuffed animal, music, photo or other familiar item.

Once you are in the operating room, you will be given special medicine through a mask. This medicine is called anesthesia. The anesthesia mask will be placed over your nose and mouth. You will need to take a couple of deep breaths and you will be asleep in no time! All IVs and cathethers are put in after you’re asleep, so you wont feel a thing!

Recovery Room

When your surgery is finished, you will be taken to the PACU (Post Anesthesia Care Unit). You will still be sleeping. In this area, we will take an x-ray of your spine and obtain labs after surgery. You will also be monitored by a nurse who will determine when you are awake enough to return to your room. Your parents will be allowed to come and see you briefly. When you wake up in your room you will be connected to a vital sign monitor, IVs for fluids and pain medication and have a plastic drain to collect fluid from the incision.

Admission

The first place you will go the day you are admitted is to Patient Access, located on the first floor. This is where you will check into the hospital.

Once you have checked in, you will be sent to the laboratory for blood and urine tests. This does involve a needle prick, but it only hurts a little and is over quickly. The information we get tells us how your body is working on the inside. You will also be given a small container and asked to give a urine sample. This tells us how your kidneys are working.

Next, you will go to the Radiology Department, also located on the first floor. Here you will have X-rays taken. X- rays are special photos taken of your body. X- rays do not hurt!

You will then go up to the second floor where you will be given your room assignment. You will be assigned to a room. This is your "home away from home" for the next few days. You will be introduced to your nurse and will have the opportunity to ask him/her any questions you may have at that time. You may change into a hospital gown or stay in your clothing, whichever you prefer. Your family can stay with you until you fall asleep for the night. Your room includes a "sleeper chair" so that a member of your family can spend the night with you. You may ask your nurse for extra pillows and blankets.

Remember: NO FOOD OR DRINK AFTER MIDNIGHT!

The Day of Your Surgery

On the morning of surgery a technician will come and tape electrodes on your legs. These electrodes are just stickers that have a plastic wire glued to them and will be used during surgery to measure the small electricity signals that our body makes to communicate with the brain. This does not hurt! The stickers peel off easily and will be all gone by the time you wake up.

The nerve pathways that are normal for you are recorded as wavy lines on a piece of paper. During your surgery, these pathways will be monitored to detect any changes.

Before you leave for the operating room, you will be given a medicine that will make you a little sleepy and a lot less nervous! This is not the medicine that helps you to fall asleep for your surgery.

You may bring something comforting to the operating room with you such as a stuffed animal, music, photo or other familiar item.

Once you are in the operating room, you will be given special medicine through a mask. This medicine is called anesthesia. The anesthesia mask will be placed over your nose and mouth. You will need to take a couple of deep breaths and you will be asleep in no time! All IVs and cathethers are put in after you’re asleep, so you wont feel a thing!

Recovery Room

When your surgery is finished, you will be taken to the PACU (Post Anesthesia Care Unit). You will still be sleeping. In this area, we will take an x-ray of your spine and obtain labs after surgery. You will also be monitored by a nurse who will determine when you are awake enough to return to your room. Your parents will be allowed to come and see you briefly. When you wake up in your room you will be connected to a vital sign monitor, IVs for fluids and pain medication and have a plastic drain to collect fluid from the incision.

For the first three days after your spinal surgery, you will be on a special bed that turns you continuously, this bed is called a Hill-Rom Sport bed. The turning is done very slowly and you will usually stay in each position for about 15 minutes. This can be adjusted according to your comfort level. The only thing you have to do when being turned is RELAX, and tell us how we can position you more comfortably. Turning keeps you from getting stiff and helps to prevent pressure on your skin which can cause sore spots and the changing of position also helps your lungs stay in good condition.

Your Diet

You may not feel like eating at first. The day of your surgery, your nurse and your family may keep offering you something "clear" to eat or drink such as water, apple juice, popsicles, Jello® or Gatorade®. Eating and drinking helps you regain your strength more quickly.

The next morning, you will begin to eat regular food. You may eat whatever you like from the cafeteria or from outside the hospital. It is important that you eat because the pain medication that you will take by mouth will cause stomach pain, nausea and vomiting if taken on an empty stomach.

In order to prevent constipation and dehydration, it is important that you drink lots of fluids while in the hospital and at home.

Sitting, Standing, and Walking

Immediately after your scoliosis surgery your nurses will be helping you with any necessary movement, but by the time you are ready to go home, you will be walking out the door. How can this happen in less than a week? Your physical therapist is the key. He or she is the person who will help you and your family learn the correct way to move in bed, as well as to sit and walk properly. Together, you and your physical therapist will set goals for moving in bed, sitting up and walking.

You will meet your physical therapist the day after your surgery. Your physical therapist will talk to you and your family about moving in bed, sitting, standing and walking. Your therapist will assist you in sitting up on the edge of the bed. You will sit for several minutes to become accustomed to the change in position. The therapist will then help you to stand. You will stand for a few minutes while holding on to something to stabilize yourself. Deep breathing is often helpful when standing for the first time after surgery as it helps to relax your body and keep you calm. Day two is also the day you will begin to walk. The therapist will hold on to you to help keep you steady as you take a few steps. Your therapist will not make you walk farther than you can, but will ask you to set a goal to walk a little farther each time you get out of bed.

You will be walking more each day and will be able to venture out of your room, walk around the nurses’ station, down the hall, to the activity room located on the third floor, or as far as you can go.

Because the physical therapist will only visit you once or twice a day, your nurse will often be the one helping you to do these things. Try to remember, the key to feeling better faster and returning home sooner, is to get out of bed and keep moving!

Once you are able to get out of bed and walk with the help of your family, you will be able to get up when you want to and soon will no longer need assistance each time you want to go for a walk.

Respiratory Therapy

It is important to keep your lungs healthy after surgery. When you return to your room after surgery, you will meet another important team member. The respiratory therapist will provide you with breathing treatments (medication you breathe in) to help you expand your lungs. Your nurse will also be reminding you to take deep breaths for several days after your surgery. You will be given a device called an incentive spirometer. This helps your lungs expand and keeps them clear and working at their best. You may get tired of everyone reminding you to use the spirometer. Please remember that it is important that you do as requested. Regular use of the spirometer is the best way to prevent fevers and avoid complications such as pneumonia.

The best way to make this an easier experience is to work together with the nurses, therapists, doctors and your family. Communicating with the care team will greatly benefit you and will help them take better care of you.