Nicholas’ progress reflects a combination of intrinsic motivation, family advocacy, and long-term multidisciplinary care. “He’s never been comfortable accepting ‘no’ as a final answer,” said his father, Cameron. “We’ve always approached challenges with the question: How can this work? — and Nicholas has embraced that mindset.”

Early diagnosis and coordinated care

Cerebral palsy presents across a broad clinical spectrum, with variable impacts on movement, posture and function. Nicholas’ early symptoms were relatively mild, including lower‑extremity stiffness and limited spontaneous movement in infancy. He was evaluated and diagnosed by a Children’s Mercy team and connected early to speech, occupational and physical therapy services.

He also established care with the Children’s Mercy Orthopedic Clinic, where he has been followed longitudinally for gait, growth and functional mobility.

Kathryn Keeler, MD, Department Chair of Orthopedic Surgery, has served as Nicholas’ orthopedic surgeon since he was 6 years old. At that time, he primarily relied on a wheelchair and reverse walker for mobility.

“Nick has exceptional mental toughness,” said Dr. Keeler. “He underwent multiple orthopedic procedures to address hip, leg and foot alignment with the goal of improving functional mobility and reducing long‑term dependence on a wheelchair.”

Surgical intervention and rehabilitation

Over the years, Nicholas has undergone five orthopedic surgeries. Each procedure required months of recovery and rehabilitation, often accompanied by temporary functional regression. Despite these challenges, he remained highly engaged in physical therapy and home exercise programs.

“Every recovery period felt like starting over,” Cameron recalled. “But Nicholas was fully committed to the work. Our role was to support him — he was the one driving the effort.”

Dr. Keeler noted that Nicholas’ progress reflects an evolving understanding of CP management. “While spasticity often receives primary attention, addressing muscle weakness through targeted strength training is equally critical,” she said. “Nick exemplifies how strength-focused therapy and athletics can meaningfully improve function and confidence.”

School-based supports and independence

As Nicholas gained strength following surgery in elementary school, his family recognized that reliance on a wheelchair for school navigation was limiting opportunities to build endurance and independence. Through advocacy and collaboration with the school district, accommodations were made to allow him to ambulate more frequently with crutches.

Now a high school senior, Nicholas actively participates in his Individualized Education Program (IEP) meetings and works with school staff to align academic, athletic and personal goals. He competes with his school’s track team using a racing wheelchair and trains year‑round with creative, adaptive strength and conditioning strategies.

Functional gains and future goals

Nicholas’ commitment extends beyond formal therapy. In clinic, he often challenges himself to exceed baseline gait assessments, and he works closely with coaches to develop off‑season training tailored to his functional goals. He has also incorporated guitar playing into his routine to improve left‑hand strength and dexterity.

As he prepares to attend the University of Central Missouri this fall, Nicholas is focused on independence and continued growth. He plans to double major in Communications and History, with aspirations in radio, podcasting or broadcasting.

“I want to live as close to a physically typical life as my CP will allow,” Nicholas said. “That’s always been the goal.”

A model of longitudinal partnership

For Dr. Keeler, Nicholas’ story underscores the impact of sustained, collaborative care. “Sports, therapy and surgery all played a role,” she said. “But above all, it’s his discipline and engagement that have made the difference.”

With a demonstrated ability to translate care plans into meaningful, real‑world outcomes, Nicholas’ future goals — academic, professional and personal — are well within reach.

The eastern Missouri teen’s trouble started in March 2023. “My back was hurting any time I did anything,” said Kyndall. “I didn’t even know how to explain it; it just started hurting one day.”  

Her local pediatrician ordered an X-ray and MRI, then referred her to an area orthopedic specialist who confirmed her spine was fractured. She wore a brace for 12 weeks and started physical therapy, but the pain continued. And continued. And continued.  

“Her back hurt all the time,” Kyndall’s mom, Destayne, said. “She went to volleyball practice, but she came home crying. She couldn’t sit at a desk. Something was wrong.”   

They kept pressing for answers but weren’t finding any solutions. By early 2025, Kyndall was beginning to experience numbness in her legs. They had more lab work and tests done — all negative, no cancer, no lupus — and were told to do more therapy and talk about pain management.  

“I said, ‘Absolutely not,’” said Destayne. “That’s when I started Googling ‘top spine doctors in the U.S.’ I came across Dr. Shaw’s name.”

From a web search to spine surgery 

After 2 years of pain and no progress, Kyndall’s mom searched for “top spine doctors” online and found Dr. Shaw. They booked an appointment and drove across the state to meet with him.

Aaron Shaw, DO, FAAOS, is a physician on the Orthopedic Surgery and Spine Care teams at Children’s Mercy. Destayne called Children’s Mercy, had an in-depth conversation with the Spine Care team and scheduled an appointment for Kyndall with Dr. Shaw. They drove 4.5 hours to get to Kansas City in late April. 

“She'd been through a lot: 2 years of chronic back pain and still trying to push through it to help her team,” said Dr. Shaw. “I think she's very selfless in that approach.” But no kid should have to suffer pain to play the sports they love. They started talking about Kyndall’s options.  

“He was super nice and told me a lot about all the steps we could take to fix it,” said Kyndall.  

“He sat with us and actually listened to us,” agreed Destayne. That same morning, the team was able to get Kyndall a CT scan, which showed what they had suspected.  

"She had stress fractures on both sides of her spine, but they hadn’t healed — and didn’t really look like they were going to heal,” said Dr. Shaw. 

Stress fractures can occur in young, active people, especially athletes who use repetitive hyperextension movements. “Certain athletes are more at risk: gymnasts, volleyball players and football players, especially the linemen,” explained Dr. Shaw. Most of these stress fractures will heal on their own with rest and therapy. But sometimes, like in Kyndall’s case, they just ... don’t.  

“We talked about all the things you could do, which is what she had already been through,” said Dr. Shaw. “If we can avoid surgery, that's always the goal. But when we're getting to the point where they’re unable to do the things that they enjoy, and it's starting to affect quality of life and mental health, we have a good team that can help take care of those patients.” 

Kyndall was a good candidate for a spine surgery technique developed by Children’s Mercy Section Chief John T. Anderson, MD, and Richard Schwend, MD, FAAP, FAOA, who recently retired from Children’s Mercy. Dr. Shaw and other spine surgeons here perform 10 to 15 of these procedures a year to help young athletes like Kyndall. They place a screw across the area to stabilize the fracture, clean out any scar tissue that has formed, then place a bone graft material to stimulate healing. 

“We’ve had really good success with this particular technique,” said Dr. Shaw.

Pain-free for the first time in 2 years 

Kyndall had spine surgery and stayed overnight at Children’s Mercy to recover. Local patients often have this surgery outpatient, but her team didn’t want her travel home — a 4+ hour car ride — right after surgery.

Kyndall had the 3- to 4-hour surgery in mid-May. KC-area patients can have this surgery outpatient and go home the same night. But Kyndall stayed overnight to be better prepared for a long car ride home. She and her family raved about the inpatient care she received, including the team members who took the time to braid her hair.  

“They were just there, and anything we needed or wanted, they got,” said Destayne. “It was truly an amazing experience.”  

Dr. Shaw checked on her repeatedly until she was cleared to go home, in a pillow-filled car with detailed instructions for pain medicines, planned stops and making the drive as comfortable as possible.  

Kyndall was blunt about her recovery: It was painful and hard for several weeks. “Then about 3 weeks after surgery, I stopped having pain,” said Kyndall. “I was confused because I've always had the pain there!”  

“It was the first time she’d been pain-free for a day in over 2 years,” said Destayne.  

It was a new experience for Kyndall, who was excited to get back to normal teen life. “I just wanted to go shopping every day,” laughed Kyndall, teasing her mom. “She wouldn’t take me.”

“Listen to your kids” 

Technically, shopping isn’t prohibited post-surgery, but intense sports are. 

“For the first 6 weeks after surgery, we don’t want patients to stress the area,” said Dr. Shaw. “We want the body to do its work, heal and grow that bone. No bending, lifting or twisting — just take it easy.”  

After 6 weeks, patients can start increasing activity as they work on strengthening their core and lower back muscles and increasing their flexibility. 

Slowly, Kyndall began to get back to the activities she loved this summer, including volleyball camp, even though she wasn’t able to participate fully. She has continued physical therapy with a local therapist and has follow-up visits with Dr. Shaw both in-person and virtually. She reports her back is feeling “amazing”! 

Kyndall’s back is now feeling “amazing,” and she’s looking forward to a school year full of volleyball, friends and sporting events.

Kyndall’s advice for other teenagers with chronic back pain? “Go see Dr. Shaw,” she laughed. “No, really, just find a good doctor and make sure you’re doing all your physical therapy. And don’t push yourself too hard!”  

“Trust your kids and their bodies and what they’re saying,” added Destayne. “Listen to your kids. Get a second opinion if you need to. She would not be where she is today without that.” 

Kyndall is playing for her 8th grade volleyball team now and hoping to play with the travel volleyball team that supported her through her spine surgery journey. She’s looking forward to a no-pain school year, including being able to do things with her friends, enjoy sporting events and maybe even run track in the spring.  

“Kyndall is an amazingly resilient young lady,” said Dr. Shaw. “I'm very proud of the recovery that she's made so far and look forward to seeing what she's going to do in the future.”

Kathryn Keeler, MD, has been named Chair, Department of Orthopedic Surgery, at Children’s Mercy Kansas City. She has served in an interim capacity for the past nine months and brings a wealth of experience as a pediatric orthopedic surgeon.

Dr. Keeler received her medical degree from the University of Pittsburgh School of Medicine and completed her training in Orthopedic Surgery at Washington University in St. Louis. After a 12-month Clinical Fellowship in Pediatric Orthopedic Surgery at Washington University, Dr. Keeler completed another six-month Clinical Fellowship in Pediatric Orthopedic Surgery at DuPont Hospital for Children in Wilmington, Delaware.

Dr. Keeler was a faculty member at Washington University and St. Louis Children’s Hospital before joining Children’s Mercy in October 2013 where she has served as the Medical Director of the Complex Movement Disorders & Spasticity Clinic for the past five years. She is also an Assistant Professor of Orthopedic Surgery at the University of Missouri-Kansas City School of Medicine and is certified by the American Board of Orthopaedic Surgery.

During her tenure, she has helped Children’s Mercy achieve Level 1 Pediatric Trauma Center designation from the American College of Surgeons (ACS), becoming the only ACS-verified Pediatric Level 1 Trauma Center between St. Louis and Denver, and one of only 35 in the county.

“Dr. Keeler has been instrumental in our success,” said Doug Rivard, DO, Executive Vice President and Physician-in-Chief. “She is an inclusive leader dedicated to advancing care delivery and training the next generation of medical professionals, all while keeping our patients and families at the center of everything we do.”

The Department of Orthopedic Surgery and Musculoskeletal Science at Children’s Mercy Kansas City performs approximately 100 surgeries to improve function for cerebral palsy patients each year, utilizing the single-event multilevel surgery (SEMLS) approach.

SEMLS incorporates several procedures into one surgical intervention. For example, bilateral proximal femoral varus derotational osteotomies are often combined with other lower extremity procedures. Doing so reduces the number of surgeries and hospitalizations for these patients, streamlining their postoperative care, reducing length of stay and helping patients advance to rehabilitation faster.

In pediatric hospitals where the team is highly skilled in SEMLS, outcomes have been very good and patient/family satisfaction superior.

Improving Pain Management for SEMLS Surgery

Epidural catheters are currently the gold standard when cerebral palsy patients undergo bilateral multilevel orthopedic surgery.

However, one of the challenges for those who receive an epidural is that it must remain in place postoperatively, usually for two days. This often requires the patient to be immobile, affecting the physiology of recovery, including lung function and mobility. A longer hospitalization also affects the family dynamic, requiring parents to take more time away from work or other caregiving responsibilities. Additionally, patients may have comorbidities that preclude epidural catheter placement.

This patient population also presents with additional medical challenges, including the fact that many are taking anti-spasmodics, may be on a baclofen pump, or may be on anti-epileptic medications.

To improve upon the patient’s experience, Kathryn Keeler, MD, Children’s Mercy Pediatric Orthopedic Surgeon, and Nichole Doyle, MD, Pediatric Anesthesiologist, collaborated to develop an Enhanced Recovery After Surgery (ERAS) protocol.

ERAS Protocol for SEMLS Patients

The ERAS protocol Dr. Doyle and Dr. Keeler developed is used for cerebral palsy patients undergoing bilateral lower extremity surgeries. 
Key elements of the protocol include:

• Use of peripheral nerve blocks instead of epidural catheters.
• Earlier mobilization of patients, with an earlier start to physical therapy.
• Discontinued use of the Foley catheter before arrival to the post-anesthesia care unit.
• Use of dexmedetomidine infusion for the first postoperative day as part of a multimodal pain management plan.

To determine the effectiveness of the protocol, they performed a pilot study of 10 consecutive cerebral palsy patients undergoing bilateral lower extremity surgery from May to July 2020, comparing them with 10 controls from 2017 to 2019. The groups were matched by Gross Motor Function Classification System (GMFCS) score, procedure performed and age. The biggest difference between the two groups was in the type of pain control used. The control group received epidural catheters.

The ERAS group received peripheral nerve blocks in the operating room with clonidine or dexamethasone added to prolong the blocks based on the surgical procedures planned.

Preoperatively patients were counseled about the protocol and what to expect. Some high-risk patients were started on gabapentin at this visit. On the day of surgery families were instructed to continue clear liquids until two hours before surgery. If gabapentin was not started at the preop visit, patients were given a dose preoperatively.

Intraoperatively, the ERAS patients received intravenous (IV) acetaminophen and ketorolac. They also had intraoperative dexmedetomidine and/or ketamine infusions. A short-acting narcotic was given as needed.

At completion of the surgery the Foley catheter was removed. Upon transfer to the floor, the patients continued on a dexmedetomidine infusion 0.1 mcg/kg/hr-0.2mcg/kg/hour and they were placed on scheduled acetaminophen, ketorolac, gabapentin and a bowel regimen. They received valium, narcotic, ondansetron and diphenhydramine as needed. If needed, a PCA/NCA was started.

Key Outcomes

This pilot study showed that following an ERAS protocol can help minimize the variation of care and enhance the patient and family experience with bilateral lower extremity surgery. Results showed a decreased length of stay of almost a full day and a reduction in postoperative narcotic consumption for the ERAS group. Side effects such as nausea, vomiting and pruritus also decreased in the ERAS patients.

Overall, performing single-shot peripheral nerve blocks at the beginning of the surgery has the potential to substantially increase the value of care delivered to this complex patient population, but further study in a larger patient population is needed to confirm results.

ERAS Pilot Study Highlights

• 10 ERAS protocol patients; 10 control group patients.
• GMFCS 4 for both groups.
• Decreased postoperative narcotic use in ERAS group to 0.12 morphine equivalents/kg per day compared to 0.19 morphine equivalents/kg in control group.
• Postoperative need for a PCA/NCA pump was zero in the ERAS group compared to four in the control group, two of which occurred after discontinuation of the epidural catheter.
• Time to postoperative discharge from physical therapy was 1.70 days in the ERAS group versus 2.44 days in the control group.
• Hospital length of stay was 2.20 days for the ERAS group versus 3.0 days in the control group.

Collaborate with us to study the ERAS protocol

Children’s Mercy is seeking to study the ERAS protocol in a larger patient population by collaborating with other pediatric institutions performing single-event multilevel surgeries for cerebral palsy patients. To work with our team, contact:

Kathryn Keeler, MD, Pediatric Orthopedic Surgeon 
kkeeler@cmh.edu

(816) 234-3696

Nichole Doyle, MD, Pediatric Anesthesiology 
nmdoyle@cmh.edu

(816) 234-3464

For consults, admissions or transport call: 1 (800) GO MERCY / 1 (800) 466-3729.

Reference:

1. Schendel DE, et al. (n.d.). Public Health Issues Related to Infection in Pregnancy and Cerebral Palsy. PubMed - NCBI. National Center for Biotechnology Information. Retrieved 9/18/2020 from: https://www.ncbi.nlm.nih.gov/pubmed/11921385.