0:01
SNI Digital, Innovations and Learning, a 3D Live video journal with interactive discussion,
0:12
now offering this program and others as podcasts on Amazon and Spotify, look for SNI
0:20
Digital, in association with SNI Surgical Neurology International, a 2D internet journal, are pleased to present another in the SNI Digital series on Controversies in Spine Surgery. This
0:38
series is presented by Nancy Epstein, who is a professor of clinical neurosurgery at the School of Medicine, the State University of New York at Stony Brook, and the editor-in-chief of Surgical
0:52
Neurology International. This program is devoted to lower cervical spine trauma. surgery at the C Four C seven levels so part one is going to be a short review of the diagnosis and treatment of
1:10
lower cervical spine fractures on undoing this in conjunction with our gymnasts men Ah Who's the head of surgical neurology International Digital recordings and we've done many of these together so we
1:27
decided that we would approach the lower cervical spine today I'm going to briefly go over the anatomy the classification of these fractures some of the M R C T and X Ray findings of these fractures
1:38
and the operative intervention that accompanies so many of these injuries I think everybody's pretty familiar with lateral cervical spine filmed front and back the anatomy of the cervical spine here's
1:49
a preview again don't forget those ritual arteries out in the transverse for AMNA axial image vertebral body Anteriorly spinal cord within the confines of the spinal canal, dorsolateral, you have
2:02
the lamina, you have the spiniest process, and then the bilateral facet joints. Plus again, the vertebral artery. Important, sometimes on an MRI scan, you're gonna see actually an aberrant
2:15
vertebral artery coming right into the spinal canal. So sometimes an MRMR may be important to get before operating on some of these individuals, so you don't have a surprise The anatomy of the cord,
2:29
again, the vertebral body anteriorly, circumferentially, you have your spinal epidural space anteriorly, as well as posteriorly, you have the dural sac and the spinal cord in that dural sac with
2:41
the roots coming bilaterally. And then posteriorly, you've got the laminin spines processes. Interoperative monitoring, I stress as a very important adjunct to cervical spine surgery. As I
2:55
mentioned in the other lecture, we were discussing earlier. When I was president of the cervical spine, research society in 2001, I looked at cases of quadriplegia after cervical spine surgery in
3:05
the states of New York and California. 60 of those quadriplegics were from one level anterior dysctomy infusions. So there's no such thing as, we're just doing a one level ACDF, simple. No,
3:17
nothing simple. Antirely, you have motor evoked potentials, post-jurly, somatosensory evokes, and then laterally and firmly of your EMGs from the nerve roots bilaterally. When you do these
3:31
operations, you need Tiva, totally intravenous anesthesia, rather than relying on inhalation agents and nitrous oxide, because those will knock out your potentials. And here is motor evoked,
3:43
your anterior cord, post-jurly, you're gonna have the somatosensory evokes, and then laterally, you're gonna have the motor and the sensory portions of the nerve roots, When you do these
3:53
operations, you must speak to your anesthesiologist ahead of time to make sure they're using Tiva anesthesia or you will get no recordings. If anesthesia slips in, a vacuronium or a paralytic,
4:06
your motor evokes and your EMGs are gonna disappear. So there are various and sundry factors here, but I always found it extremely important to communicate with the anesthesiologists ahead of time
4:18
as to what your plans were and what you were looking for We're all looking at images here of the cervical spinal canal, the front to back dimension being mid vertebral body to the posterior laminar
4:30
line. Here you have the lateral cervical x-ray measuring the front to back of the canal and here on an MR. You have a reading CT scans though where these readings are gonna be more reliable than
4:44
MRIs or x-rays and you can measure directly on the CT scanner exactly the AP diameter of the canal. The deficits that we deal with, cervical radicular deficits, C5, deltoid and biceps, C6,
4:58
you're going to have biceps extensor to the wrist and a position, thumb and index finger, and C7 roots, thumb and pinky, extensor the phalangees and the triceps. So these are the neurological
5:09
findings that are going to go along with the deficits that you see. Patients may have myelopathy, unilaterally, bilaterally, upper versus lower Here is an MR scan of a central disc herniation,
5:22
and here's a myelogram CAT scan of a large central disc herniation. Again, motor findings, weakness, unilateral, bilateral, incomplete, complete reflex changes can hyperactive reflexes,
5:34
Hoffman signs in the, in the, from the hands and Babinski responses, sensory loss, pain and temperature from the anterior spina thalamic tract, vibration in position from the posterior columns,
5:45
and then also loss of bowel and bladder function So the out one for part one, the lower fractures of the cervical spine, and here you're saying yes, that suggests that you may need back surgery
5:58
right away to the crash test dummy. So many of our patients are getting recommended for surgery that they don't need in any shape, manner, or form. Always go for that second opinion. We're gonna
6:11
define the three columns of Denise. We're gonna look at burst fractures, the wedge, the teardrop, the slit, the incomplete and the complete. Look at the compression fractures and the four
6:22
delineations there. Facet dislocations, unilateral and bilateral. So this is a short review of some of the lower cervical spine injuries, the most prominent ones that we're going to see. But here
6:35
you enter your column, your middle column, and your posterior column. And here is a rendition of exactly what's in these different columns So. the anterior column, you have the anterior
6:45
longitudinal ligament, the intervertebral body and the disc. the middle column, seen here in green, you're gonna have the posterior longitudinal ligament coming here, the posterior aspect of the
6:57
vertebral bodies. And then finally, the third is the posterior column in blue above and below. You're gonna have the pedicles, the lamina, you may get to have the yellow ligament, the
7:07
interspinus ligament, the supraspinus ligament, the spinous processes, the pisetruins, et cetera. We're gonna
7:14
look at the four types of compression factors And the first is the wedge or the teardrop compression fracture, shown here, the split fracture of the vertebral body, shown here vertical up and down.
7:29
And then we're gonna see the incomplete burst fracture, and then the complete burst fracture. And I'm gonna repeat this in a different format as well. So you can have these alone without posterior
7:40
ligament, injuries without posterior fracture dislocations But very typically you're going to see. An anterior wedge compression fracture, maybe no surgery because the posterior ligaments are still
7:50
intact. You may have no surgery required, or if it's a
7:57
lot of that particular body, you might have to do
8:04
a corepectomy. But the A1 fractures within tacked posterior ligaments, you know, likely stable, not have to diffuse these, unless there's more ligamentous injury than meets the eye, and then
8:09
you're gonna look at that. Here's an anterior tear-dark fracture, but with posterior ligamentous injury, so this is an unstable A1 fracture. A2 is a split fracture, you can see that, but that's
8:22
a lot of vertebral body that's now damaged. You have a chord injury here, and you also have disruption of the posterior ligaments, so that you're gonna have to do a 360 fusion in this case. And in
8:33
this case, you've got, you know, multi-level vertebral compression fractures. Didn't show the posterior fractures, but assume they're there, and that's gonna be a 360 as well. So here's an
8:45
example of an A1 unstable wedge fracture. You're gonna see a problem here, and then you're gonna see the posterior ligaments disrupted. Circumferential surgery, what are you going to do here?
8:57
Well, an anterior corepectomy infusion. This is your corepectomy graft and your rod, screws, plates, whichever device, there are a bunch of different devices that we'll just briefly look at.
9:07
And the cervical spine, C3456, you're gonna have lateral mass fusions, medical screw fusions, C2, C7, and T1 are gonna be used instead. A2 split anterior fractures. Here you can see that the
9:25
A2 coronal split fracture but your ligaments posteriorly are intact. So you might get away with an anterior corepectomy infusion. However, in this case, you have the fracture of the rotable body,
9:37
but you have this tremendous fracture dislocation as well. So you're gonna end up having to do a 360 fusion that in that case.
9:45
Spectrum of compression fractures, again, but seen a little bit differently. Here's a compression fracture. You're gonna have to, without, you're gonna have to consider whether or not there
9:56
needs to be an anterior fusion. It depends on the severity of the compression fracture. And certainly if there's ligamentous destruction, you have to proceed. Here's a, secondarily, a burst
10:07
fracture, and you're gonna need a 360 fusion with this because of the extent of disease. Flexion distraction, you're gonna need that 360 fusion and fracture just location, again, likely the 360
10:18
fusion. But you're gonna look at the MR and the CT findings for both of these to determine how much disease there are, how circumferential it is, and whether or not you need anterior andor
10:27
posterior or posterior surgery alone.
10:31
Anterior burst fracture, again, and sometimes they do it by the point system, two points for the burst fracture of the vertebral body, but there's also the retropulsion that you may see with it,
10:42
and then you get another two points, as for the fracture and dislocation of that scene in the post your elements so here you're going to need that three sixty operation here a three injuries city NM
10:55
or incomplete burst fracture or with retro repulsion and ligamentous disruption and post -it element disruption so here the A three the city incomplete Anti burst fracture but the amar shows the Anti
11:08
reverse fracture plus the anterior disc body Red repulsion plus the M are shown the acute cord injury plus you see the ligamentous disruption as well so that's going to give you your three sixty
11:21
effusion in this a three group of fractures a four complete burst fracture flexion distraction injury and with rupture and disruption of the post your elements again three sixty fusion is what's going
11:35
to be needed here but again your MMR your city you can do a quick M R first to get all the bony information and then the amour to follow to get the soft tissue data that you need. Here is a C5 burst
11:49
fracture. You may think that you can just do an anterior procedure here, but look at the posterior ligamentus injury here. This was an instance where with the posterior element disruption, you did
12:03
a one-level corpusctomy anteriorly,
12:05
and then the posterior lateral mass fusion posteriorly
12:11
Anterior burst fracture dislocation, again, with posterior ligament injury, seeing it multiple levels. This is your amor, and here is your CT different case, showing essentially the same kinds
12:23
of findings.
12:28
Selection distraction injuries, anterior wedge fractures, et cetera, you may end up in some of these cases with a one injuries without ligamentus injury, doing a one-level anterior core pectomane
12:39
fusion. once you start doing by the way a two -level into your core packed me those become very unstable and the graphs often fracture out at least twenty percent of the time if you do a three level
12:51
at your Quebec domain fusion fractures at about fifty percent of the time so you're going to have to do more extensive fruit fusion in those instances but here's a tutor for a two level correct me
13:02
anteriorly and you're going to likely supplement it with the lateral mass fusion has surely or your pedicle fusions were here you have a multi -level and your quebec domain fusion actually they did an
13:13
additional sort of discectomy and fusion here with your here's your pedicle screw it's easy to see three four five and six are going to be your lateral masses and then your pedicle screws are really
13:25
the levels below that is an example of an ant you're correct them infusion or you may use autographed like we've been illustrating but there are all kinds of different metallic implant devices that
13:36
are available at this point in time, so you've got lots of things to choose from. Posture laterally, you're going to use the lateral mass screws, typically C3 to 6, and pedicle screws at C2 and
13:49
C7 and T1.
13:52
And here's just an example of front to back 360 procedures, multi-level anterior procedure with a posterior fusion. Again, you can see the anterior plate and graft fusion with the lateral mass and
14:07
here are your pedicle screws actually of C2. And again, just another example of here is C3, C3, 4, C4, 5, C5, 6, 6, 6, 7, and then your posterior fusion and done as well. So all kinds of
14:22
different 360 fusions that you can use. Again, your lateral mass screws, C3 to 6 with your pedicle screws, C2, C7 and T1
14:33
cervical fracture with facet dislocation injuries. Well, it's a unilateral jump facet. This has always been a point of contention. Do you have to operate on these or not? Well, the first thing
14:44
you want to do is you want to do your distraction with your attraction. It's a unilateral jump facet or a perch facet and you want to get realignment with the distraction to reduce the facet joints.
14:57
And then you have to decide is it stable or unstable if there's a lot of ligamentous disruption and or a significant fracture of the unilateral facet, then you probably want to consider doing a
15:08
fusion. But here's your perch facet and here's an x-ray of your perch facet. So just to sort of, you know, have this cartoon in your mind of what you're seeing radiographically as something to
15:20
reference back to. It's just like, you know, you do a redo lumbar operation and you have to work in your brain from what is normal versus what am I actually seeing here. Here's your typical jump
15:30
facet, and that's a CT scan of a classical jump facet. So you have to diagnose this first. And once you've done this, here's your unilateral perch facet. And again, illustration of your perch
15:43
facet on these different images. And so open reduction and perch facet reduction. And again, if there's a marked disruption of that unilateral facet, you may well wanna use that patient.
15:55
Sometimes you don't have to fuse the patient, it varies But here is an unilateral jump facet and there's no court injury in these cases typically. Again, whether or not you're going to need any
16:07
post-urefusion depends on the amount of disruption that you think you're seeing and or ligamentous injury that you may be documenting on that MRI scan. So you have to look at the studies carefully to
16:18
make that determination. Flexion extension studies have to be done very judiciously and carefully because you don't wanna cause an injury the patient doesn't already have. So here, we're going to
16:29
get into,
16:32
again, jump facet, posterior ligament injury,
16:37
and whether or not you're gonna have to fuse these, this is you're gonna have to fuse because you have the unilateral facet dislocation, your MR showing your posterior ligamentus injury, and
16:46
obviously the CAT scan showing your perch facet. So in this case, you're gonna wanna do a fusion. Bilateral facet dislocations, this is, you know, fusion territory, here's a, here's a
16:57
figurative 3D image of a
16:59
lateral view, an oblique image, and a posterior image. That's what it's gonna look like when you have the full dislocation. Three column injury, the locked right facet, the fractured
17:15
dislocations on the central images, and then the locked left facet is what you're gonna see radiographically, especially on the CT scans. And you can get that quickly We're also always going to
17:26
want to clear the C6-7. and the C721 levels to make sure you don't miss another injury. And here with the bilateral facet dislocation, you're going to need oftentimes a 360 procedure to stabilize
17:40
not only anteriorly but posteriorly as well
17:44
in order to decompress that canal and stabilize it. Here's an MR of a bilateral facet dislocation. You can see the anterior disc and vertebral fracture seen there with posterior facet fracture
17:55
dislocation in your posterior ligamentus injury. Again, 360 effusion is going to be appropriate here. And again, you have that presence of the cord injury. So monitoring these is a big plus. Let
18:07
me ask
18:09
you a question here. And that is, it's obvious that surgery is needed. And in most of these cases, you've talked to a 360. What's the timing? If a patient is neurologically intact, I could see
18:24
where you could say, Okay, we can wait. What's going to precipitate this in tomorrow? Emergent procedure or is this so complicated that you have to do a lot of planning and you can't do this
18:37
emergently? I think you have to look at the images, especially in that intact patient and you have to plan to do it emergently. That's essentially what failing's article in 2010 in Spine was
18:48
discussing. The faster you can stabilize these patients the better because they can go to neurologically intact and you transfer that patient from a bed to a stretcher or you roll them in some way
18:59
and then all of a sudden you can convert and incomplete into a complete injury. So emergent surgical intervention and planning is what you really need to do here. So on the other ones that you've
19:10
shown before that you've shown a number of them, all of those should have emergent surgery? If at all possible because you can't be certain that there isn't going to be inadvertent motion That's
19:25
going to convert. an incomplete injury to a complete injury. Now, there used to be the discussion, Well, the patient's complete. We're really not gonna do it. And then there was the discussion,
19:34
Okay, the complete patient, they've got all kinds of other medical issues. Obviously, if they've got major medical issues or other abdominal trauma, all kinds of other life-threatening things
19:47
going on, hemone, pneumothorax, et cetera, cardiac contusion, then you're gonna have to time it and taper according to what the patient has But if you have an incomplete injury, very important
19:58
to try and do these as quickly as possible. And if you can obtain adequate alignment as soon as possible in these patients, especially the ones presenting with a complete injury, you may gain at
20:13
least a few levels of neurological function, if not complete function in occasional cases. Really importantly, as you know, we talk to people in different parts of the world where they can't do
20:25
that.
20:27
And I remember we just talked to people in Africa a month or two ago, where the patient came, I think, with a quadaquena syndrome, they didn't know it. And you could tell. And when he got there,
20:40
he took him three hours to get there or something or three days or two weeks, I can't remember the exact timeframe, but he said he treated it as an emergency the minute he got to the hospital,
20:53
regardless of when it started Right,
20:57
I think that's a really important message. You can't fix what's happened before you've gotten that patient unless you're the one who is communicating with the field, but once you get these patients,
21:09
if at all possible, depending on life-threatening circumstances, et cetera, the sooner the better is basically still what the dictum is at this point. The image that you have in front of us now,
21:21
I mean, it's just a disastrous injury here. And, but again, now it's gonna take a lot of time, a lot of work, you're gonna have to do it emergently. It's putting a team together and getting
21:35
everybody on board.
21:39
It's challenging enough during normal hours, much less emergency hours. Right, right. But I think it's really important. We've seen in other cases where, you know, surgeons say, oh, well,
21:51
I'm gonna wait until the morning 'cause I have my other team coming in Well, this is not a case where you should be doing that. You should be doing this emergently. Other cases where patients
22:03
present with, you know, epidural spinal abscesses and they say, Well, you know, let's just operate the next morning 'cause I have my primary team here in place. There have been studies done, by
22:13
the way, that said, you know, do you operate emergently that night or wait until you have the better team in the morning? Most of those studies end up concluding, you know, you do it that night
22:23
because that's what neurologically. The patient really needs, deserves, and that results in the better outcomes. The others can be operations of convenience, but not the right thing. Just trying
22:34
to construct another circumstance. Let's say that a patient is two or three hours away from a major referral center. You know you're facing, if you have to do this, you know it's gonna be
22:49
transportation and all the rest is gonna be, let's say, several hours. I mean, probably the reflex and smart thing to do would be to refer the patient. I can see the counter-argument saying, oh
23:05
we can do them here, which is okay if you have enough equipment and resources to do it, but
23:12
it gets to be kind of a sticky decision, doesn't it? Well, I think, you know, the data have shown that referral to major spinal cord injury centers is better for the patient And if you're
23:23
referring them out. to a team that is more experienced in doing these operations. That's probably the wise thing to do. And it's often a mistake to undertake a major operation, especially a 360
23:37
front to back where you're not familiar with doing that procedure. So you're gonna be better off transferring that patient, get the helicopter or whatever you need to do to get the patient to the
23:47
facility that's going to do the better operation because you've got a more experienced team Okay, time is
23:56
neurons, time is brain, time is fine. Right, right. So hopefully you've got a good helicopter pilot to get the patient there,
24:06
ASAP. This is again, these are flexion distraction injuries with bilateral facet dislocations and again more CAT scans showing you these injuries. And this is C721 on the right, on the left is
24:21
C6-7 set dislocations. Here was a paper on a fractured dislocation at 67, a case report, literature review of a 41-year-old male. It was a motor vehicle accident. I thought this was interesting.
24:34
He was traveling at 100 miles an hour when he hit a camel on a desert road.
24:41
That's propitious for our discussion in Africa. It was a C-67 fractured dislocation. Right up her extremity weakness. It was amazing. He wasn't completely quadriplegic These are the actual films
24:53
from that study. You can see anterior fracture dislocation posterior total disruption on the CAT scan. You're seeing two vertebral bodies at one level. If you take your image right through here,
25:05
that's the image that you're gonna have. So bilateral facet dislocation. And what they did is they, here's the MR by the way. Again, stir images look absolutely terrible. You have a spinal cord,
25:17
it's sort of squeaking past here, but obviously a spinal cord injury with a high signal and a posterior ligamentus injury as well. Oh, and again, a better image on the
25:31
MRI. Oh, one of them was on the wrong road. Yeah, yeah. So they did the anterior corpuschomy infusion. They did a corpuschomy
25:42
of C7, a C6 to T1 fusion. And that's it. Now, I looked at this case and I'm thinking, Wow, you know, the guy went on to fuse. They were very lucky Usually when you fuse C6 to T1, if you don't
25:55
accompany that with a posterior fusion, they are very subject for that to extrude out and not to work and not to go into fuse. In this case, it happened to have gone on to fuse. But again, this
26:08
is an instance where you look at those studies and a 360 would have been the better way to go. The lessons of this cervical fracture dislocation article is that most occur at the C6-7 level, which
26:19
is why I was saying when you're screening The survey will spine that Cascans important to make sure you don't have. a C6-7 injury that you may miss. Motor vehicle accidents and falls, the
26:30
compression head and neck flexion injury age, often less than 40 years of age. Mortality can be very high in these patients up to 10. And most are going to require upper open reduction and 360
26:43
fusions. These are cases where you're gonna need 360 fusions, bilateral lock to sets. I'm just giving you different instances Here's a two-dimensional CAT scan, two-dimensional CAT scan, but seen
26:56
laterally at the facet joint level. Here's a 360 anterior and a posterior fusion. Here's another example of an anterior and a posterior fusion.
27:08
And again, another example of a multilevel 360 fusion. This is C3, 4, 4, 5, 5, 6, 6, 7 with anterior and posterior stabilization having been performed in these patients Sometimes, you know,
27:23
what they try to do, Jim, is. You know, oh, well, we did the anterior now. Let's bring them back tomorrow and do the posterior, keep them in bed, keep them in the brace, et cetera. If the
27:34
patients are really unstable, that can be very dangerous because any manipulation, any movement by, especially the nurses in the recovery room can end up being a disaster. So you have to, you've
27:45
got to temporize and template and see who you have available and what you're monitoring is, et cetera, to try and determine what you're going to do. Again, the current practices and the timing of
27:55
surgical intervention for spinal injury is failing study in 2010 is basically time of spine for both complete and incomplete injuries, surgical time from presentation, six hours, the sooner, the
28:09
better. Many favored decompression within 12 hours, especially incomplete deficits, except for central cord injury. But again, surgery in six hours was better if possible. So if you've
28:20
summarized the different, fracture dislocations, et cetera, and the different kinds of spinal cord injuries we've just spoken about. We've got the three columns of Denis that we reviewed. We
28:30
looked at burst fractures, the wedge, the teardrop, the split, the incomplete, and then the complete burst fractures. We looked at the different kinds of compression fractures, compression
28:40
burst, flexion distraction, and fracture dislocations, discussing the need for 360 fusions as you get to the more complex injuries. For set dislocations, unilateral, you may get away without a
28:51
fusion, but you have to consider a fusion if you have ligamentous disruption and injury, and certainly bilateral facet dislocations are gonna end up with ligamentous injury, disruptions, posterior
29:02
element problems, you've gotta do 360 procedures in these. So the early diagnosis and treatment, less than six hours time is spine, is critical to achieve the best outcomes in these patients
29:17
Wow, I'm purviewing in my mind the number of talks. you've given about injuries to the neurologic components of the spine spinal cord
29:32
and roots and so forth. And the answer is the same. The answer is when do you do this? You do it as soon as possible.
29:43
Any doubts you have to do it as soon as possible? Is that right? No, no, I mean, that's the quandary I mean, you have literature out there, spinal cord injury literature, et cetera. Some will
29:55
say, oh, you have up to 48 hours, you have up to 24 hours. And the answer is you have the patient in front of you. If you have the patient in front of you and you have the diagnostic studies you
30:07
need to design the correct operative procedure, you should do that operation as soon as possible to try and provide that patient with the potential for the best recovery. Any delay in that It may be
30:21
delayed by life-threatening attendant problems, especially in major trauma. But the sooner you can decompress the neural tissues, the better off that patient's going to be. I was reading an
30:32
article about - I think it was Delmortar had an article about beagles. And this was an experimental article. And it was talking about the timing of injury. And then there were sacrificing beagles,
30:47
which we like dogs But the time of injury, if you decompressed within an hour, or you've got the injury within an hour, the best outcomes, anything over six hours, the income started
31:01
deteriorating markedly. And so there is basically anatomic evidence, as well as clinical evidence, that supports operating
31:16
the sooner, the better in these patients. You brought up the fantastic point of if you are in a facility that can't handle this surgically, you know? surgically as well as postoperatively,
31:23
transferring that patient, yes, might have to be done, but it's gotta be done stat. Alternatively, if you have the capability of doing that operation in your center, and you have the ability to
31:35
do that operation stat in your center, then that operation should be done as soon as possible in that original facility. If you have to transfer them to a spinal cord injury center secondarily, you
31:47
could always do that But you don't want to have an incompetent surgeon doing a major operative procedure, but you have to get them to a competent surgeon as soon as possible. Unfortunately, we have
32:02
instances where the surgeons don't recognize that this is not within their bailiwick, this is not their capability in their operating outside of their areas of expertise, and that's not going to do
32:12
that patient any great service So, all of these factors may go into it, but overall, Most of the time these spinal cord injuries are brought to spinal cord injury centers. I guess the more rural
32:26
you become, the less likely that happens to be. I mean, if you have certainly level, you know, level one in two trauma centers, have to have surgeons ready availability in-house, et cetera,
32:38
general surgeons at least, often neurosurgeons. But as you get to level three and below, those neurosurgeons in level three, the neurosurgeons have to be available within 30 minutes And in this
32:51
kind of surgery, lots of these are often basic operations that are done on a daily basis, anterior-corpectomy infusion, and multi-level posterior fusions. But again, if your staff, including
33:05
your surgeons, they're not capable of it, you've got to transfer and get them to the best facility possible. Okay, well, I think it was an excellent coverage of a traumatic injury to the upper
33:18
lower cervical spine with the fundamental principle that you're just elucidated, which is time of spine, get them to treatment right away. And I think you've done the best for the patients you're
33:32
gonna do if you can't do it yourself.
33:37
We hope you enjoyed this presentation.
33:40
The views and opinions expressed in this program were those are the author interviewee and do not necessarily reflect the official policy or position of SI digital or its management. The information
33:55
contained in this program should not be considered to be medical advice. Patients should consult their own physicians for advice as to their specific medical needs.
34:07
On the homepage, please fill out your evaluation in this video using this sliding rating scale to help us improve the information. we bring you on SI Digital.
34:20
This recorded session is available free on sidigitalorg.
34:25
Click this icon at the bottom right of the homepage for questions, comments, and requests
34:35
for CME credit or
34:39
email at osmoonsidigitalorg. Foundation supporting these programs believes there are many ways to learn. Foundation supports surgical neurology and international known as SI. It's a web addresses
34:50
SIglobal. It's a 2D internet journal and Nancy Epstein is its editor-in-chief. It also supports SI digital innovations and learning, a 3D live video journal which is interactive with discussion.
35:06
It's web addresses SI digitalorg and both are available free on the internet 247, 365.
35:16
Surgical Neurology International is read in 239 countries and territories over its publication range of 14 years. It's the third most widely read 2D journal and neurosurgery. SI digital innovations
35:32
learning is a new 3D video journal. It is seen on 145 countries in the last 10 months. The goal of the foundation is to help people throughout the world
35:47
Podcasts of this program and other programs in SI digital are now available on Amazon and Spotify. Look for SI digital. Foundation also supports the medical news network to bring truthful medical
36:03
and science news to the world. Copyright, this program is copyrighted by the James I. and Carolyn or Austin Educational Foundation. All rights are reserved.
36:16
Thank you very much, we hope you enjoyed the program.
View Transcript
