What follows are highlights from these studies:

Surgery Unnecessary for Most Adolescent Athletes with Lumbar Spine Stress Fracture

A new study by researchers at HSS shows that 95 percent of adolescent athletes who are diagnosed with acute spondylolysis heal with just rest, bracing, and physical therapy. These findings support treating patients with a conservative, non-operative approach and reserving surgery as a last-resort option.

“These results are important because when we sit with families to discuss treatment options, we can confidently tell them that the vast majority of patients do have resolution of their pain and are able to return to sports without having to undergo surgery,” explains Jessica H. Heyer, MD, a pediatric orthopedic and spine surgeon at HSS and senior author of the study.

Spondylolysis is a stress injury or fracture of the pars (a bone structure in the vertebrae located at the bottom of the lumbar spine) that often causes lower back pain. It is prevalent among teenage and pre-teen athletes, especially those who repeatedly bend backwards (hyperextend or twist the lower back) such as soccer players, rowers, baseball players, gymnasts, and football players.

The retrospective review included 179 children and teenagers diagnosed with spondylolysis between February 2016 and August 2024. According to the findings, 95% of the patients were free of pain and able to return to their activities after three months of rest, bracing, and physical therapy. Only 5% of this group went on to require surgery, which can involve either a direct repair of the pars with a screw, or a fusion around the pars injury.   

“We saw an excellent rate of return to sports and resolution of pain among the patients in our study,” notes Dr. Heyer, adding that the protocols for non-operative management of spondylolysis vary across the country.

“These results support our recommendation to restrict activity for a full three months and initiate physical therapy after 4 to 6 weeks of rest,” she says. “This period of restricted activity is important to allow for clinical improvement of pain and healing before deciding on whether surgery is needed.”

Growth Hormone Therapy May Increase Risk of Fractures in Children and Teens

A new study by researchers at HSS shows a strong association between growth hormone (GH) therapy and an increased risk of physeal fractures, a pediatric bone injury affecting the growth plate near the ends of long bones such as the wrist, fingers, and lower legs. These fractures are responsible for 15% to 30% of all childhood fractures and are common among adolescents who are active in sports. 

“We found that GH therapy was associated with an increased rate of physeal fractures in the upper and lower extremities,” says Emily Dodwell, MD, MPH, a pediatric orthopedic surgeon at HSS and senior author of the study. “These findings are important because they provide more data to consider as we help families weigh the risks and benefits of GH therapy.”

Previous research has yielded contradictory findings about whether exposure to GH therapy increases the risk of physeal fractures.

“With prior studies being inconclusive, we wanted to investigate the potential association between GH and pediatric physeal fractures on a national basis,” explains Dr. Dodwell.

GH therapy is used to treat children who are diagnosed with GH deficiency[EN1] , certain genetic syndromes, short stature, and small for gestational age. GH therapy can help increase a child’s height, growth rate, and bone mineral density, and improve their body composition and key bloodwork parameters used to test for metabolic syndrome, diabetes risk, and overall cardiovascular health. However, it has also been linked to orthopedic complications, such as progression of scoliosis (curvature of the spine) and increased risk of slipped capital femoral epiphysis (a painful hip condition).

Dr. Dodwell and her colleagues used a nationwide insurance claims database to identify prevalence of pediatric physeal fractures in the upper and lower extremities with and without GH exposure. Their database search included 34,196 patients aged 4 to 18 years old who were given GH therapy for at least one month between 2010 and 2022 and were followed for two or more years. The researchers compared this group to the same number of patients who did not receive GH therapy during that time, taking into account age, sex, and weight.

The analysis found that GH therapy was associated with a higher rate of physeal fractures. These included fractures at the proximal humerus (arm near the shoulder), proximal radius (forearm near the elbow), distal radius (forearm near the wrist), distal ulna (wrist joint), distal femur (thigh bone above the knee joint), proximal tibia (upper shin bone below the knee), and distal tibia (lower shin bone near the ankle).

“This retrospective study was not designed to determine whether GH actually causes these fractures,” notes Dr. Dodwell. “Physicians should bear that in mind when counseling patients regarding the risks and benefits of GH therapy.”

Further research is needed to confirm these findings, she adds.

They participated through the Perry Initiative's Perry Outreach Program. “The goal of our program is to introduce students to all the exciting careers in orthopedics on both the surgical and engineering sides,” explained Amelia Knarr, PhD, executive director of the Perry Initiative. “Students get a real hands-on feel for the different types of procedures in orthopedics and also get to hear from successful surgeons and engineers. This benefits the students by showing them they are wanted, welcome, and capable of joining this exciting field.”

Under the guidance of HSS physicians, students participated in hands-on activities using plastic replicas of bones and tools of the trade such as drills and casts. They learned techniques that orthopedic surgeons use to repair broken bones, fix torn ligaments, apply a cast and suture a wound.

“The activities highlighted various biomechanical principles in orthopedics, demonstrating the integration of engineering in this field,” said Jessica Heyer, MD, a pediatric orthopedic surgeon at HSS and event organizer. “They were excited to use orthopedic tools and enjoyed casting each other and learning how to suture.”

In addition to hands-on learning, the students attended lectures to get an idea of what it takes to become an engineer or an orthopedic surgeon and what their jobs are like on a day-to-day basis. “The students demonstrated great enthusiasm, asking thoughtful questions,” Dr. Heyer said.

Aarti Shenoy, PhD, an instructor of applied biomechanics at HSS, delivered an engaging lecture, sharing key moments in her journey to become an engineer. She highlighted the collaborative nature of her work – describing how she and her colleagues in the Biomechanics Department partner with HSS surgeons to design research studies to advance the field of musculoskeletal medicine.

“The Perry Outreach workshop was a valuable experience for the participants, as they were able to gain insight into what a career in orthopedics might entail,” she said. “Students gained a sense of accomplishment from completing tasks that may have seemed challenging at first. Through the hands-on activities, they were encouraged to envision themselves as surgeons or engineers.”

“I learned how to use a drill today, and then we drilled a bunch of screws into different bone models,” said Lina Bernatska, a junior at Staten Island Technical School, who gave the event a thumbs up. “It really inspired me as a woman to want to go into these fields where women are underrepresented, and it's so refreshing to see all these educated young women tell their stories and tell us about their journeys…to get to where they are in life.”  

Her classmate, Ava Glatman, said it was cool to learn about different orthopedic procedures, such as total knee replacements, and how to fix a broken ankle. Reflecting on the event, she said, “I think it's really meaningful, especially understanding that this is such an underrepresented field for women. Being able to see so many women that have succeeded in their field is really inspiring and motivates me to do something like that in the future.”

Students from high schools in New York City, New Jersey and Connecticut attended, including Bernards High School, Bronx High School of Science, Concord-Carlisle High School, Fairlawn High School, High School For Health Professions & Human Services, Newtown High School, Pascack Valley High School, Ridgefield High School, Saint Francis Preparatory School, Staten Island Technical School, Toms River High School South, Tottenville High School, University Heights Secondary School, Urban Assembly for Leadership and Empowerment.

Challenges of Pediatric MRIs

A typical MRI is not only loud and confining but also very sensitive to motion, requiring subjects to lie still during the 20- to 80-minute procedure, which is a major challenge for pediatric patients. Consequently, sedation is used in up to 28% of pediatric MRIs, and reports show this number is increasing.

While sedation can facilitate successful imaging—and is considered relatively safe—relying on this strategy for young MRI patients poses potential risks, including cardiopulmonary issues and allergic reactions. Additionally, the combination of MRIs and sedation can cause anxiety for children and their parents and prolong recovery.

Researchers found that avoiding anesthesia—and post-anesthetic recovery—through CCLS interventions improves the overall efficiency of the MRI process, benefiting both families and care teams.

“Without anesthesia, children can avoid the need for an IV, they don’t need to fast prior to the MRI, and they don’t need to extend their hospital-related experience to recover,” says lead study author Jessica H. Heyer, MD, pediatric orthopedic and spine surgeon at HSS. “And from a hospital perspective, it enables children to have an MRI even when an anesthesiologist is not available.”

The American Academy of Pediatrics stresses that these types of nonpharmacological interventions “must be considered as standard procedure in infants, children, and adolescents undergoing MRI,” supporting the approach taken in this study.

Benefits of Avoiding Sedation

For this retrospective cohort study, HSS researchers looked at 1,936 patients between the ages of 4 and 12 who, in total, received 2,319 MRI scans over an eight-year period. They found that no child who received CCLS intervention prior to and/or during the procedure required IV sedation during MRI.

Despite the study’s remarkable success rate, Dr. Heyer notes that there are always exceptions: “Sedation-free MRI may be more difficult for very young children, those who need longer scans, children with cerebral palsy, and for those who need a head, brain, or neck MRI."

While all children can greatly benefit from CCLS intervention, Dr. Heyer notes that children between ages 5 and 10 appear to show the strongest results. Study co-author Melissa Collins, MS, senior child life specialist at HSS, adds that this strategy is particularly valuable for children with sensory processing issues or those with a history of negative medical experiences. “For example, children who’ve been told a procedure wouldn’t hurt and then were held down or experienced pain are less likely to trust medical professionals and medical environments,” she says.

Effective Child Life Techniques

The researchers examined several CCLS techniques, including guided imagery, distraction strategies, and caregiver involvement, but the most helpful strategy is “appropriate preparation based on the patient's developmental age,” says Collins. “MRI anxiety typically stems from uncertainty, so it’s important to provide children with accurate expectations, so they’re able to prepare and cope more effectively.” Collins suggests showing children a video of an MRI that walks them through each step and what they’ll see, hear, and feel during the scan to help take away some of the fear of the unknown. “It also helps to reiterate that nothing is going to touch them or hurt them,” she says.

At the Lerner Children’s Pavilion, one or both parents are always encouraged to accompany their child into the MRI suite. Children are also invited to bring a favorite soft, metal-free toy into the MRI unit and are given mirrored glasses so they can see their caregiver or the technologist behind them throughout the MRI. To celebrate their bravery, each child receives a small reward at the end of the exam.

Looking Forward

“Our research demonstrates that with proper preparation and support, we can transform a potentially stressful medical procedure into a positive experience for children,” concludes Dr. Heyer. “By reducing the need for sedation, we’re not only reducing medical risks but also empowering children to actively participate in their healthcare journey, potentially making future medical encounters less intimidating.”

Reference:

Tracey OC, Zucker C, Wisch J, Adhiyaman A, Thakur A, Collins M, Parise J, Denneen J, Jaramillo D, Potter H, Ipp L, Heyer JH. Not Just Fun and Games: Certified Child Life Specialists Improve Success Rates of Young Children Undergoing MRI Studies without Anesthesia. Presented at: Pediatric Orthopaedic Society of North America (POSNA) Annual Meeting, 2025

Thestrup J, Hybschmann J, Madsen TW, et al. Nonpharmacological interventions to reduce sedation and general anesthesia in pediatric MRI: a meta-analysis. Hosp Pediatr. 2023;13(10):e301-e313. Accessed May 14, 2025, at https://doi.org/10.1542/hpeds.2023-007289

Uffman JC, Tumin D, Raman V, Thung A, Adler B, Tobias JD. MRI Utilization and the Associated Use of Sedation and Anesthesia in a Pediatric ACO. J Am Coll Radiol. 2017 July;14(7):924-930. Accessed May 14, 2025, at https://www.jacr.org/article/S1546-1440(17)30121-7/abstract

Spine specialists at HSS have been using a 30-camera array, called 3dMD, in the lab for several years, but the new study shows that the system produces clinically meaningful information. Because 3dMD does not rely on ionizing radiation, the technology may help adolescents with scoliosis avoid many of the repeated and potentially harmful x-rays that conventional care requires.

“Determining spinal range of motion is a lot more difficult than it sounds,” said Roger Widmann, MD, chief of the Pediatric Orthopedic Surgery Service at HSS and co-principal investigator on the new study. The conventional gold standard has been the use of x-ray imaging; however, x-ray tests are expensive, and long-term exposure to radiation from the scans has been linked to cancers.

The new technology provides a “safe, repeatable, inexpensive measurement of spinal range of motion that can be used in both a research and clinical setting,” Dr. Widmann said.

Information from the 3dMD scans can help spine surgeons determine the optimal approach to operative treatments and allow them to better track the progress of scoliosis patients following surgery. “The technology gives you objective measures of range of motion so you can improve your surgical decision-making,” Dr. Widmann said.

The HSS team presented their findings today at the 2023 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in a poster titled “3D Surface Topographic Optical Scans Yield Highly Reliable Spine Range of Motion Measurements in Adolescents.”

The 30-camera array can generate a whole-body image of a standing person in under 2 milliseconds – fast enough to eliminate any blurring from even the slightest movement in any direction.

In previous studies, the HSS team and their colleagues have shown that images generated with the ultrafast cameras match the anatomy beneath the skin. That alignment is critical for 3dMD to be useful in the clinic as a way to guide treatment for scoliosis, which affects between 2% and 3% of youth in the United States, or 6 to 9 million people.

Treatment for scoliosis frequently involves physical therapy or the use of braces to correct the curvature of the spine – a measurement called the “Cobb angle” – but in the most severe cases, surgery may be necessary.

For the new study, Dr. Widmann’s group used 3dMD to image 254 boys and girls with scoliosis and 53 without the spinal deformity as they underwent several exercises designed to work the torso in various directions.

“This is teaching us which parameters are more useful and which are not,” says Howard Hillstrom, PhD, a biomechanical engineer at HSS, senior director of the Leon Root, MD Motion Analysis Laboratory and co-principal investigator on this project.

The new study found two movements that were reliably able to differentiate youth with scoliosis from those with normal spines: bending as far to the left and right as possible while standing, and bending toward the floor as if to touch the toes.

In the first case, patients with scoliosis show significant asymmetry between one side and the other in terms of how far to each side they can bend. Meanwhile, scoliosis patients are not able to bend as far toward the floor – as measured from a point on their collarbone – as those with unaffected spines, Dr. Hillstrom said. “That’s good enough to distinguish healthy kids from those with scoliosis because most kids are so flexible they can get to the floor and those with scoliosis probably can’t.”

Although the assessments make sense both intuitively and clinically, the latest study shows that they are also an objective measure of scoliosis. The entire process, from the start of the scan to the generation of results, takes under 10 minutes, Dr. Hillstrom added.

“And now we have this system that acquires these variables and doesn’t require ionizing radiation to do so,” he said, noting that this is critically important because scoliosis patients have a significantly greater incidence of cancer, breast cancer, and cancer mortality than those without the condition – an increase many experts attribute to the radiation they receive from x-rays and CT scans.

The process of diagnosing scoliosis starts early. “The first time someone notices that a child may have scoliosis is usually when the school nurse sees it during a routine examination,” Dr. Hillstrom said. “The nurse tells the parent to take the child to a doctor, and the first thing a physician will do is order an x-ray.”

The HSS team now has imaging studies of more than 300 adolescent patients with scoliosis in its 3dMD database. “Of those, approximately 50 are a year out from surgery and 30 are two years out, providing the ability to look at the long-term benefits of the technology on range of motion and other parameters [such as angle of trunk rotation, back surface rotation, and asymmetry in lateral bending and twisting”, Dr. Widmann said. 

Authors: Alon Wolf, PhD; Ankush Thakur, MS,BS (HSS); Benjamin N. Groisser, BA, (Technion); Caroline C. Gmelich, BA; Don Li, MD,PhD; Hila Otremski, MD; Howard J. Hillstrom, PhD; Jessica H. Heyer, MD; Kira Page, BA; Kyle Morse, MD; Matthew E. Cunningham, MD, PhD, FAAOS, (HSS); Michael T. Hresko, MD,FAAOS, (Boston Children's Hospital); Roger F. Widmann, MD, FAAOS, (HSS); Ron Kimmel, DPHIL (OXON)