Lori Karol, Department of Orthopaedic Surgery, Texas Scottish Rite Hospital, Dallas, USA, has conducted extensive research into scoliosis, which includes a focus on chest and lung development in early onset scoliosis. She talks to Spinal News International about the importance of personally managing the care of a child with scoliosis and the rewards of helping patients with scoliosis to lead fulfilling lives.
Why did you decide to become a doctor and why in particular, did you decide to specialise in orthopaedic surgery?
I decided to pursue a career in medicine when I was a senior in high school; I applied for admission in a combined premedical/medical school programme at the University of Michigan at the age of 16. There are not many decisions one makes at that age that end up being wise ones, but I was lucky! During my clinical rotations in medical school, I found myself enjoying nearly every specialty. I was fortunate to be assigned to a dynamic orthopaedic service for one month as a third year student, and the residents I worked with engaged me as a member of the team. I assisted in surgery, reduced fractures, rolled casts—all these little experiences showed me how much fun orthopaedic surgery could be! I am more of a “doer” than a “thinker”, and orthopaedics is an active profession. I chose orthopaedic surgery because it was fun.
Who have been your career mentors and what influence did they have on your career?
My first mentor was a wonderful, kind man named Dick Lamont. He was the chairman of orthopaedics at my residency programme, and championed me as an orthopaedic resident. I was, up until the last year of my residency, the only female resident (and there were no women on staff). Dr Lamont had several daughters, and he looked out for me like I was a daughter.
The two physicians who are responsible for me choosing paediatric orthopaedics are David Aronsson and Randy Loder. They were young, enthusiastic, and eager to teach. They took great care of children. As a senior resident, I wanted to be just like them. After my residency, Tony Herring became an important mentor for me. He was a father figure to all of the fellows who trained at Texas Scottish Rite Hospital and was our greatest advocate.
During your career, what have been the most important developments in spinal surgery?
I have just enough grey hair to remember the Harrington rod era. Improvements in implants have allowed us to move the children the evening after their surgery, and to discharge them to home cast and brace free. This was an incredible advance for scoliosis patients. And of course, the ability to monitor the spinal cord intraoperatively has enhanced the safety of millions of scoliosis surgeries and allowed the safe correction of deformity.
What do you think have been your most important findings in your work on early onset scoliosis?
The major advance in the area of early onset scoliosis has been the focus on chest and lung development championed by Bob Campbell. I am lucky to have played a part in documenting the need for pulmonary growth in early onset patients.
You have also looked at bracing compliance in patients with scoliosis. What are your recommendations for ensuring compliance in these patients?
I do not think we can ever ensure compliance, but I think we can and should encourage it with the use of objective information. I am using “wear” monitors now in many of my patients’ orthoses, and sharing that information with the patients during their follow-up visits.
Male idiopathic scoliosis is another one of your research interests. Does the presentation and management of male idiopathic scoliosis differ from the presentation and management of female idiopathic scoliosis?
Boys typically present two years later than girls with scoliosis. Since scoliosis is known to progress during skeletal growth, and boys grow later into adolescence than girls, curve progression may occur later in adolescence in male patients.
What are your current research interests?
I continue to work on brace compliance, but have many research interests outside of spine deformity. I am active in clubfoot, paediatric amputee, and gait analysis research.
Outside of your own research, what do you think has been the most important paper published in the last year?
The results of BRAIST (Bracing in adolescent idiopathic scoliosis trial) from Weinstein and Dolan published in The New England Journal of Medicine validated the efficacy of orthotic management of idiopathic scoliosis.
Overall, what do you think are the key questions in spinal surgery that still require answer?
The area of molecular genetics will hopefully answer the questions of the aetiology of scoliosis. Now that candidate genes have been identified, the next question is what do those genes encode? What tissue (ie. vertebral bone, spinal cord, muscle, or disc) is affected by that gene? And once those questions are answered, how do we “fix” the process? Those are the huge key questions that I hope we can answer in the future.
Of the spinal meetings you are planning to attend this year, which ones are you most looking forward to attending and why?
I am most looking forward to attending the Scoliosis Research Society (10–13 September, Anchorage, USA) this year. Through my involvement as chair of the education committee, I have been involved in creating interesting symposia featuring some of the best and brightest minds in scoliosis work in the world.
Given that so much medical education is now accessible online, what are the additional education benefits of attending a medical conference?
I am a bit “old school”; I prefer—and always will—to learn by attending a medical conference rather than to read information online sitting at my computer. Firstly, by travelling to a conference, I am offsite from my practice and dedicating my time towards my continuing education. Secondly, the audience at a meeting becomes an educational entity—furthering the information given at the podium through the discussion period. Thirdly, there will always be something inspiring about being in the same room with the greatest minds of our specialty.
What has been your most memorable case?
It is of course hard to choose one when you are a paediatric orthopaedic surgeon as it is sort of like being asked who your favourite daughter is!
However, one memorable case was that of a young teenager from West Texas who had severe scoliosis and restrictive lung disease secondary to Marfan’s syndrome. She presented at our hospital malnourished and cyanotic. After we placed a gastrostomy tube and halo traction, and started her on bilevel positive airway pressure, we were able to successfully perform a posterior spinal fusion.
A few months after surgery, she met Justin Bieber (back when he was an adorable teenage pop star!) and sent me a photograph. She went on to become Homecoming queen, graduate high school, and is now attending college [University].
Her case is not just memorable because she was high risk and her perioperative care was difficult; it also is memorable because of her overwhelmingly positive outlook on life.
She accepted the challenges of her medical condition and dug in to fight. She accepted the surgical placement of the feeding tube—a difficult process for a teenage girl. She flourished in traction here in the hospital. She never once voiced regret, discouragement, or even pain.
Although she, and other patients like her, freely voice their appreciation and love for us as medical professionals, the truth is that these children are WHY we chose to become doctors, and WHY we keep working to improve care for paediatric patients with scoliosis.
There seems to be far more male spinal surgeons than women. Do you think that this is an issue and what you would recommend to encourage more women to specialise in spinal surgery?
I used to joke that there are more deceased scoliosis surgeons than women in the specialty. Although I cannot speak to adult spinal surgery fellowships, we are seeing more female applicants for paediatric orthopaedic surgery fellowships. These young women are trained in scoliosis management and surgery, and will play an expanding role in spinal research over their careers. Already we are seeing the new generation of spinal surgeons—such as Amy McIntosh, Noelle Larsen, and Lindsay Andras—speaking at conferences.
What advice would you give to someone who was starting their career in spinal surgery?
The best advice I can give is “it is all about the patient”. You have got to be there personally to manage that child’s care. The parents have entrusted their child’s life to you. Therefore, it is not about how fast you are; it is not about the X-ray—it is about that child.
A career in spinal surgery will lead to some sleepless nights and more worry than you’d think, but the rewards for a job well done are great. It is a gift to be able to help these young girls. Enjoy the ride.
Outside of medicine, what are your hobbies and interests?
My hobbies over time have been linked to the activities of my three daughters. I have facilitated a Destination Imagination team, been a dance mom, been on the board of a drill team, and coached volleyball. I have spent more hours in bleachers [stands/terraces at sporting events] than I can count.
My youngest will be a senior  in high school next year, so I will be busy watching her dance and attending all the senior festivities. I love to travel, and am looking forward to many trips abroad with my husband in the future.
2006–present Professor of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, USA
1994–present Staff orthopaedist, Texas Scottish Rite Hospital for Children, Dallas, USA
1999–2005 Associate professor of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, USA
1991 Fellow/paediatric, Orthopaedics and Scoliosis, Texas Scottish Rite Hospital, Dallas, USA
1990 Resident/Orthopaedic Surgery, Wayne State University School of Medicine, Detroit, USA
1986 Hospital Training (Intern/General surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
1985 Doctor of Medicine, Integrated Premedical/Medical Program, University of Michigan, Ann Arbor, USA
- Vice president, Pediatric, Orthopaedic Society of North America (member since 1994)
– Member, American Academy, of Orthopaedic Surgeons
– Member, American Medical Association
– Member, American Academy for Cerebral Palsy & Developmental Medicine
– Karol et al. Journal of Bone and Joint Surgery 2008; 90-A: 1272–81
– Milbandt et al (including Karol). Journal of Pediatric Orthopaedics 2008; 28: 234–38
– Karol et al. Journal of Bone and Joint Surgery 2007; 89-A: 1504–10
– Karol et al. Spine 2001; 26: 2001–05
– Karol et al. Journal of Bone and Joint Surgery 1993; 75A: 1804–10