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Plenty, the foundation for the treatment of neurological disorders in Buenos Aires, Argentina.
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In association with SNI,
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the 2D traditional journal, and SNI digital, the 3D video interactive journal, are pleased to present Neurosurgery Grand Rounds, South America, a global case-based discussion with international
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guests. The meeting is organized and moderated by Andre Servio, who is the head of neurosurgery at Flenny and Buenos Aires, Argentina.
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The topic of today's session is post-year approaches to the cervical spine. The speaker is Nancy Epstein,
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who is the guest speaker, commentator and international
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and the energy from Surgical Neurology International. Well, hello everybody, my name is Tomami Essentino. I'm an surgeon that works here in Fledi that does exclusively spine surgery. I'm gonna
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talk about this technique that is posterior cervical for amineotomy, when to do it, when not, and how, and some tips of how to do it.
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This will be the agenda to give a brief introduction about the topic, to talk about the indications, so as to take the patient from the clinic to the arc, the complications that are related with
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this technique, some surgical tips, and to show everything in a case example
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As a brief introduction, it's relevant to know that serica radical properties have very common pathology, but extremely strange to need surgical procedures. The three main causes of this pathology
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could be spondylotic changes through osteopies, disc herniation that could be soft or hard, or for amino stenosis due to this collapse
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We as spine surgeons have made the surgical momentum we have against this pathology is huge. We can do procedure from anterior we can do it for posterior, we can do push motion pressure. for
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serving strategies or are at releases. The idea is to choose what best fits for our patient and obviously what is best in our hands to give to that patient.
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But it seems to me that through the years, the ACDF became the standard procedure to treat everything. As you can see in these meta-analysis of big cases, this case have, for example, almost 100,
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000 patients to analyze that went an ACDF on one, two, or three levels against these meta-analysis of what aminotomies where the series are small, there are between 130 patients or 40 patients.
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And this also makes sense because ACDF is a long, well-known surgical technique. It's easy for us, we feel comfortable doing, and probably we did a lot Let me go back to that slide. I think I
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think it's important to just
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I mean, I hope you don't mind if I start interrupting. But I think if you look at the 1950s, the 1960s, the 1970s, really into the '80s, posterior cervical surgery was actually much, much more
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common at that point. You had, you know, Snyder, certainly in the '50s, introducing the laminophoraminotomy. So there was a time when a posterior approach in the laminophoraminotomy was
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predominant, and
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ACDFs were the minority. You know, obviously you had cloud, you know, showing up And actually I used to, the cervical spine society meetings, I used to go jogging with him in the morning. But,
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you know, this was not the standard of care at that time. And the fact that it's become so dominant has really detracted from people being trained to do the posterior approaches. So anyway, I
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thought that might be a good time to bring that up. Perfect.
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And that's what I want to say that how comfortable does you guys or anybody feels doing or am I not to me? How many did you do as a resident or a fellow? And you have to compare how many did you do?
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How many of the CDF you did in the upstairs? Nevertheless, they can be extremely efficient. Of course, the key is the selection of the patients. This is how clinical indications to resume the
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patient has to have a unilateral and equalopathy that could involve one or two levels with a motor or sensory deficit that corresponds to that very equalopathy and the absence of concordant reflexes.
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Clinical contraindications are really important any sign of myelopathy. Patients with myelopathy are not candidates for this kind of surgery. If they present hyperreflexia, health, mambibisci,
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patients that present bilateral symptoms or had a pre-refer for, I mean, not to me. Oh, wait a minute, yeah, sorry. I
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mean, I just want to go over this because if you have a patient with myelopathy, doesn't it depend on
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whether you're talking about a ventral compression only, if it's anti-lateral compression, or certainly lateral compression, a dorsal, multilevel decompressive procedure, maybe your procedure of
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choice in these cases. So it's not always that if they're myelopathic, you can't choose to do post-year approach, and bilateral symptoms, the same thing, it might involve a laminotomy or
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bilateral laminoframanotomies, doesn't it largely also depend on your MR and CT findings? Yes, of course, I would probably be, what I was talking about is when you talk about a disc herniation,
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and of course it has to do, if you have
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a osteopithecus ventral to the dorsal, to the medulla, and it's comprising, I think it's
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myelopathy, and there is no signs of instability, you can do, of course, a decompression, and that would be okay. But generally, we don't have those type of patients To be honest Yeah.
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What about neck pain? Because you always, when you talk about posterior cervical surgery, it's a preserved mobility. Neck pain is something that changes the paradigms. Generally, patients that
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have the neck pain started as a change in width, the onset of radicular pain are good candidates for this surgery, because it has to do with the inflammatory response of the urinated disc. But of
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course, you have to always analyze if the patients have any mechanical instability that causes the neck pain.
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Some radiological indications and contraindications, for amino stenosis secondary to spondylosis, that usually is better seen on a CT scan, as you can appreciate in those two cases. As you can see
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in this such a worldview, generally the superior articulate process is the one that does the for amino stenosis For I mean, this soft disk or post it or lateral disk as
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rule to us to decide if the patient could be a candidate for a posterior for aminotomy. We'll look at the medulla. The lateral margin of the medulla is our limit to decide if the patient could be a
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good case to do a posterior for aminotomy. And of course, if the patient has instability or alignment of normalities, you probably have to decide another technique. Can you just comment on when
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you get CAT scans in addition to your MR scans in these patients? And what trouble it can avoid by doing that? Usually when the CAT scan, the CT is very useful to us to see the herniation is, is a
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hard herniation or a soft herniation. Sometimes when you don't, I usually when I don't, I don't think that patients have for aminosterosis and in the MRI is not that clear I use a CT scan source to
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see, like in this case, the narrow, the foramen is more evident in CT than in MRI. But usually it's that my use of the CT
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is that - some other scenarios. It's ideal for young athletes. With here in Argentina, I have a - see a lot of rugby players. You can probably think they are like the NFL football players, but
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less professional here in Argentina is an amateur sport For these cases, sometimes it's ideal for them. Residual steroids post-ACDF or alkyloplasty. In an adjacent level, this is post-ACDF. And
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the patients have multilevel pathology that only present with radicular pain. In these cases, if you two are posterior for them, you know what I mean? Sometimes you can prevent this domino effect
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of preventing a two or three level ACDF when the patient only manifested radicular pain.
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I think it's really important the selective nerve root block as a diagnostic and telephyltic tool. Here we have a radiological professional that is really good to in these procedures. The problem in
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Argentina, they are that common to do cervical nerve
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root blocks, but we have a good experience and good results.
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Aren't you, go back to that slide because I've written papers about epidural injections, particularly at the C-7, you know, the C-6-7 level C-7-2-1? I mean, aren't you concerned about A, the
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vertebral artery, B, potential intra-dural injections, potential intermedular injections? Does this really give you so much more critical, useful information to validate subjecting patients to
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the risks of this procedure?
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The thing is that, as we feel comfortable, Indicating these procedures because we have a
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A rather early because Doctor that he's specialized in this and he's one of the he has a huge series of cases. Of course, he's really dangerous Sometimes he doesn't use particularly corticoids so as
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to prevent the ejection's intra arterial of the
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Zero idea. Yeah, but but also but also Nancy. It's It's necessary to remark that many many times in our in our series of patients Some patients avoid the surgery because of the selecting nerve
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block So we use this in like to me to mass So only to when I when the doctor lambda put the video kind to start the procedure again Near the the nerve root if the patients refer
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the alleviation of the symptoms, for us, it's a very good candidate for the posterior approach if the selecting nerve root doesn't function. So for us, it has two indications, this nerve root.
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To select the patients, to select the level of the surgery, but also many patients above the surgery because it's a very good procedure. I agree with you. I remember in our institutions, maybe
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Pablo Moreno, I remember how many patients, but I remember one patient who has this complication, as you mentioned, about the vertebral artery. But telling you the truth, this guy is only
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dedicated to perform nerve root, cervical, thoracic, and lumbar nerve root. He has an incredible experience. Yeah, but you know that. When you're talking about releasing an educational video,
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You have one person who is fantastic at doing this. but you don't want to be telling the population out there that this is something that should be a procedure of choice or something that should be
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done prior to like insurance companies saying, Well, then you have to have this before you have surgery. The other thing is there is a literature out there that talks about the efficacy of steroids
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alone, anti-inflammatories or just like epidural steroid injections. They compare epidurals versus IM injections, versus placebo versus everything else I think some people may look at this and say,
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this is a fairly invasive and a higher risk procedure than would necessarily be indicated. I think that would be certainly the case in the States. Jim, what would you
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think? Oh, I think you've all summarized it pretty well. It's obviously what Andreas is saying this. They know that there's a risk, but they have somebody who is extremely experienced
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And I'm sure in communication with
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you all, you select the patients appropriately for it. Are you concerned at times that, or have you gone in at times after one of these selective blocks and encountered a CSF leak?
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Andres? I don't remember.
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You're asking me if we have any patient with after the selecting a route, because it's non-audible. And you go in surgically and do you find a leak on occasion? Because, I mean, certainly that's
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true with epidural injections and find out all the time. Maybe in the lumbar spinal region, but yes, maybe
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I remember with problemarino and at other order operaticone in the lumbar spine and I'm found some liquid in the foraminal region. And sometimes we used to say maybe sing it so much really with but
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maybe it's like you are proposing an old partial repair. Yes, I think maybe I never saw it in this possibility, but you're right, maybe it's an option. There's also some literature out there that
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talks about the increased risk of certainly epidural injections within three months of surgery and increasing the risk of infection. Any thoughts about that?
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Yes, an infection, yes We have, I remember, one patient's operating on for an appendinoma in the cervical spine and then he received an
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epidural injection in the lumbar region because of pain and he developed osteomyelitis. He finished with a surgery, thoracolumbar surgery to stabilize this osteomyelitis. It was incredibly, I
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remember very well this, because it was my passion. Yeah. Yes.
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There is no pain, there are no any procedure without risk. Right. We are completely right. This is not for everybody.
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Okay.
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So we start talking about surgical setup, position in an organization of level. In the beginning of our series, we usually did the surgeries in the semi-sitting position. And as the years passed,
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we
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moved towards doing this in the prone position,
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especially when we started using surgical so as to control the epitura bleeding. That's to be on. Well, it's interesting that you're saying that because for years, decades, actually my father was
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a neurosurgeon, Joseph Epstein, and we would do them in the sitting position. And you know, you had to have the echocardiogram and everything else, but boy, you put them a little flex in these
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in sitting position And, you know, there was absolutely no bleeding and we had some kind of sensory vote, potential monitoring and everything else going like that. So, my other question is, do
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you ever use Nezotracheal fiber optic intubation in these patients? Or do you expect that in patients with myelopathy?
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Of course, because if our series, we don't have the data of every patient because they go before the electronic and
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we have the clinic in the electronic system, but there are no meelopatic patients in this series. Usually if the patient present meelopathy, we don't do a surrogate posterior for having also been.
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Okay. In truth, we do a lot of semi-cereting position because we are not a surgical institute, but I think with the surgery flow and bipolar, you can control the pedura bleeding that will be the
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best indication for semi-cereting. Do you use interpretive monitoring in these patients? Yes. What? We use.
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As you said Nancy, we have a, we are in a surgical institution. So we perform semi-sitting and city position for many procedures, mainly pinion, human regions, super-cerevela in the approach.
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But you know, to an awareness, psychologists have a very huge experience to put the patient in this position very quickly. But you know, you need a lot of things because of Transcadiaco or
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Doppler from the Sophos
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You need a lot of things. Of course, you avoid the bleeding. It's like Professor Sami always says that you have a free hand because you
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avoided the necessity to cycle completely during the surgery, the blood. But since the last maybe six years, we changed to this position because there are very,
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very good demonstrations for the venous bleeding you will see in the videos and it's very quickly. from the surgery in the. Well, I think the prone position is perfectly fine. But one thing I
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would take issue is I hear sergeaflow and really sergeaflow and gel foam. If you use them, you have to completely irrigate them out of the wound, otherwise you can get significant swelling. So I
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assume you use abatine and abatine as something that you
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might leave in place, but not sergeaflow, am I correct?
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Abatine, are you? Abatine. Use abatine? Abatine. Yeah, I don't know why he said that. Do you know on the list? It's almost like a cotton that you can leave behind as a hemostatic, but I mean,
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certainly when you use something like sergeaflow to obtain hemostasis, you know, the literature shows, you know, you must irrigate it really all out because otherwise it can cause compression.
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Yes, I agree with you. Yes, do we do
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a lot of irrigating here?
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Okay, well, I'm interrupting you. What about the microscope? Is that coming up? Yes, here is a picture of how we, for example, who's a Mohsen tailor and a galpy, so as to get the surgical
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view. Right. And it's really important to always confirm the level twice. Before the incision, and after the incision, and you can use the Mohsen tailor or put it in the interlaminal space, some
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kind of detector to check the level. That's, it's really important.
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Some anatomical considerations be, before we start talking about the surgery. You have to use the pedicles as a guide. The idea is to do a keyhole osteotomies, so as to unroof the nerve, from the
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superior articular facet. And if it's necessary to do a micro decectomy through the axilla or shoulder of the nerve. Here on the right, you can see a picture of a model Bertor up from the back.
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The red circles represent the pedicles. In yellow, you have the interlaminar B. In blue, you have, as an exit in arrow, the nerve, and this black line marks the 50 of the facet. On the right,
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you can see the red circle that shows the area to be drilled. Here on the left, you can see in this picture, the stars marks the interlaminar B, the place where we start to drill. In light blue,
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you can find the petticles and look how interesting is how the 50 of the facet that is marked by these red dotted lines marks the exit of the petticle. So if you go beyond 50 of the facet, there's
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no need going beyond 50 of the facet because there is the petticle, the nervous, already outside the petticle. So take account that you have to respect. the half of the facet so as to prevent the
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ultrasonic instability but you don't need to to restrict more than 50 percent and it's really important to use the pedicles as your guide. It's because between the pedicles is the root and outside
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the pedicles the the nerve is already loosened. The other thing too though is that nerve may not be going as lateral as you think but because you usually have the arms you know just right down by the
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body in this prone position that nerve may be coming a lot further downward rather than just straight lateral and you know so you have to be very cognizant of when you go in especially if the nerve is
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under a lot of pressure you certainly don't want to go through the nerve inadvertently thinking it's disc. And to be honest every time we do a laminotomy laminotomy not to me is different. You can
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see like sometimes you have the the nerve is closer, you have an exposed the entire axilla, sometimes the shoulder, like every case is different. So you have to be really knowledge and thinking,
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step by step,
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where the things are. Right.
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About that, what I mean, Otomi, we use the base of the interlaminar B so as to stop drilling here in the red, the black circle shows the area to be drilled. Here the triangle is the base when we
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put the drill and we start drilling, we usually finish the drilling process with a one millimeter ringer. Here on the
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top, you can see, you can identify the already the keyhole view. Here on the right, you have the medulla. Here on the top, you have the exiting root. And here we are working on the axilla. You
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can see how the assistant gently retracts the nerve and the medulla to medially so as to explore the space. And here on the bottom is something that you must always have in your mind that sometimes
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the anterior root could be separated from the posterior root and you have to always check before doing the micro disectomy that you are really over the ligaments or not touching a separated anterior
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root And that this is where your direct EMG testing can be helpful as well right. Sorry, I didn't understand you use your direct EMG probe also to help you. To be honest, we don't use that direct
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EMG probe you usually use them on search in intraduro tumors, but we don't use it here Sometimes it can be helpful because sometimes you're right that motor that motor ventral route may not even have
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a drill sleeve around it and it may be very, very white and look just like this. So you're absolutely right is a there's a good chance you can destroy that on your way in, which is not what you
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want to know
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I don't know if Andres have ever saw one but we usually spend a lot of time doing like this section over the ligament to really be sure it's ligaments and no the root. Yes, this is for us Nancy the
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most I think we always discuss with our orthopedic surgeon during the surgery the same tips we are trying to to to various slowly to to displace the dramatic to the medial side like Thomas said and
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then to look for me to identify really is the disc and not the the anterior spinal roots I never saw a case when we open an anterior spinal root but for me this is one of the most important part of
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the surgery to identify it to be completely sure that you are opening the disc and not the right and then also if you're doing any medial retraction you know you're watching these and your motor
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evokes to make sure you're not causing any problem much less your EMGs to see if you're really disturbing that route as well.
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And the other thing too is don't be afraid to enlarge your opening if you don't have enough room, right? No, of course, that's what I - The better more bone removed than more retraction, right?
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Every time we are doing the approach, we're like, I have a mind. Well, first we have to unroof the facet. Now you have to identify the lateral margin of the
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medulla, look for the pedicles. You have to really put your mind where you are because it's a small surgical window, and if you lose your north, you're in trouble. Yes, OK. That's why it's so
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technically challenging the surgery.
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There is no such thing as too identical for aminotomies. Sometimes the surgical window could be small, like in this case. Sometimes it could be bigger, like in this case. You can take a small
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fragment, like you can see in the top.
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like you see in the bottom, you have to expose the seal if you have to work from the axilla or from the shoulder. And with the use of bipolar, water, and surgical surgical, usually you can
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control the epitura bleeding. I mean, I think two things here. First of all, you know, I used to go to the cervical spine society and certainly, you know, in the 80s and early 90s, you know,
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a lot of the orthopedic surgeons would just do a firm anatomy. They'd do nothing about the disc, and then they'd get out, and I was sort of horrified as how could you just leave everything alone.
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But the other comment, too, is in the working basically
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axilla is essentially the only place, I think, to safely work. I think you start working above that nerve room. You've got your epidural venous plexus, and you don't have much control, and I
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think you really have to really work inferiorly, you sort of like between six and nine o'clock, just like your image shows on that left mode. side. Yes, of course, the majority and best cases we
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do it from the axilla, but we have some cases we do exploration from the shoulder, but you have to always be careful. The amount of traction and stress you do to the nerve root, taking an account
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that is already compressed from pathology.
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You're dissecting with nerve hooks and your pen field elevators. What about your downbiting curates? Are you using your downbiting curates? Downbiting curates, I don't know what they are, sorry.
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I'm not in isolation. Now we used to do the retraction with the very small desector, and then I like the hooks. We prefer the hooks, Nancy. We have different small hooks. But sometimes if you
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have a significant pherominal spur, that downbiting curate can be helpful in terms of getting, and obviously, you know, you have to control it and you've got I've got to work, you know, going.
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poster laterally on the left and poster later on the right, etc. But the very small down buying currents can be sometimes very helpful instruments, especially with some of the sequestrated
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fragments that might be a little more stuck
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And what about the whole notion of, you know, when to stop. If you don't have access and there's more medial, you know, lateral disease that you can't readily get to from this approach No,
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stop is most is as important as knowing when to start, right. Sure. And I think that there's nothing better than the experience of our surgeon to decide when to stop Usually we believe that both to
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such as only doing the and roof of the nerve or looking for the disc are good options. But there are cases when it's better to do less so as to prevent more damage. So, are you doing an open
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unilateral exposure, or are you doing it through these metrics? Oh, only open unilateral. Good, because I think the metrics tubes just restrict you so much. This is a difficult enough operation
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that being restricted by the tube is just going to prevent you from doing a decent operation and a safe operation. I don't have.
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Go on this No, I agree with Nancy. We used to perform some tubes surgeries many years ago at the beginning of the market in Argentina started to put some pressure because of the surgery with the
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tubes There are some colleagues we get doing the surgery, which who are doing the surgery with cubes. I think, of course, there is some point for this type of surgery because, you know, these
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surgeons said that maybe this surgery performs less muscle resection and less pain for the patient. in our experience, of course, this open approach generates some pain in the neck, but maybe for
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a couple of days, no more than this. And I think we feel more comfortable. The skinny seizure is no more than two centimeters, two and a half centimeters. It's not so much in the midline. Some
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patients used to do a tattoo in the scar after the surgery. I think, of course,
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if you feel comfortable with the tubes, it's a good option. But I think with microscope, an open approach, it's very beautiful. I think it's really important, though, because I think a lot of
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people feel that they're compelled in some of the countries I've been to, like, you know, Korea, you know, they feel compelled to, you know, it's a selling point. And I think it's a terrific
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mistake, especially with an operation like this, that you really need that maneuverability that you
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have in an open approach, which the tubes are not going to allow you. and you wanna do the best and safest approach rather than having the most cosmetic and smallest incision. So I think that's
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critical. Okay. I don't have much experience in tubular surgery, but when I spend some time in San Luis, Missouri, there was a lot of MIS surgeon and for their experience, they told me that
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cervical spine is the most difficult for them to do tubular. If you see a guy that does a good cervical spine surgery to where he probably can do any surgery, they told me so. Yeah, well also if
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you start looking at some of their results of the minimally invasive lumbar procedures, they're not so great either. So I think even if they, again, you know, this is the fashion and they can
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sell this, some of the results are a disaster. So we can discuss disasters later.
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So I'm gonna show a case example we did recently with Andres and Olamarino, this is a 25 year old female that presented a right cervical regalia for more than two months. She was an almost a
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professional athlete. She presented with a four on five deltoid weakness with no signs or symptoms of myelopathy. She has this C5, C6
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disc with no response to a selective network.
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Here's gonna show the video. The video, remember it was on the right side. So this is lateral, this is medial This is bottom. We start drilling from the base of the interlaminar B. We start to
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remove the facets. Then we use carry zones from two to millimeters. Generally, we use the one of one millimeter. Here's the source of blow. We use source to control the amputeal bleeding. We
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then start to remove what is the yellow ligament and start looking so as to recognize the important anatomical structures As you can see here, we have immediately the metula. and the exiting route.
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And here we are working on what is the
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axilla. As you can see, we previously, obviously this video is edited so as to show, but we ensure that this is the ligament and we are about to cut it with
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the. I don't know how to, I remember how to say it between. So now we start doing the de-sections carefully Remember that it was a big, a near the disc, so we are gently using a hook and a
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micro-de-sector. As you can see in these cases, the retraction is small and we start to carefully explore the space so as to remove this huge, a near the disc. Always try, remember this is
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cervical spinal lumba so you have to be gentle, no hard retractions You can see how tense everything is because of the alienated teeth. So we'll start removing what is this big fragment.
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Always take your time. Nobody's rushing you.
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And with these gentle maneuvers, you will see now how a big chunk of disk is
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retired.
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is some epithelial bleeding that shows us how compressed everything is, we'll remove this big fragment and we continue to explore so as to check if there's any losing fragment like this one.
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And now we start to explore to make sure
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that there's no residual fragments as you can see already The nerve and is more losing, it has lost this tension that arise because of the compression. We do the final check.
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Some a mustassia with sodium flow, and of course we use a lot of irrigation still we see there's no more blacks.
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And that is all
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the patient have no complications and point. Sorry, I always
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It's interesting when you look at that MRI scan, there was a very significant ventral component that even crossed the midline of the spinal canal. So I think that you may have others who would have
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recommended an anterior approach to that rather than, you know, a
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laminophuram anatomy. I think that probably nobody in Argentina will indicate that surgery And maybe it's a -
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What's the
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post-op study show, by the way? Sorry? What did the post-operative study show? Your post-operative amorous - No, we didn't do it. She, this surgery was done last month. Okay. She had no
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complications with surgery. She was discharged at the other day of surgery. And she's
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that four or five of the weakness is getting better Remember, she's a crossfit, Eliz.
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So, it's really difficult for us to really stop her from studying activities, but. Well, other than just getting, you know, cervical AP lateral flexion extension films, which I'm sure you're
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going to want to get, especially if she's involved in heavy sports. I would definitely get an MR as a baseline on this patient post op to see, you know, do you have still significant day into a
37:09
lateral disease If you never got a CAT scan, I'd probably get that too to see if there's more spondylosis there enter a laterally that you have to be aware of in the future. Yes, of course, we
37:19
generally start you doing those cuts cancer MRI that second, third month after surgery, I just wait to see how she was. So probably, of course, like we don't have much evidence in this type of
37:35
the same problem with rugby athletes because it's an amateur sport And we don't have all this serious and data, as for example, you guys up when it's about NFL. And sometimes it's difficult to
37:47
decide. decide if when a patient can start doing sports or not, because they are not the same sport as soccer or maybe going to a gym. So it's really challenging and you have to talk a lot with the
38:01
patient. Well, the more reason to have your, you know, flexion extension films available and also to decide are you gonna get a followup MR. and at some point maybe even a CT, especially if you
38:11
started out with so much ventral disease because there may be more residual disease left there then you know when at least you want to be able to have a discussion with the patient about that and the
38:21
potential risk at some point that they may need a secondary anterior procedure in the future. Of course, and the key of this and that's something I have in mind as philosophy. Sometimes there is no
38:34
right answer when you talk about surgery or not surgery or if you go talk about anterior or posterior or when you talk about other disease or motion persevering surgeries We have to talk with the
38:45
patient.
38:48
decide with them what is best for them, and also what is best in your hands. So, what are you doing for post-operative management in these patients? I mean, in the States, there's a big push to
38:57
avoid, you know, any of the
39:01
opioids, to use muscle relaxants, to use gabapentin or nurontin,
39:04
what are you using? In spine surgery, you have like a neuroscast anesthesia protocol for in analgesia patients that go for actualysis, especially in escolyosis or lung surgeries. In this type of
39:18
surgery, we usually use only opioids as ramalol
39:24
and cody and some kind of benzodiazepine, volume.
39:38
With that, we generally go to the penec pain. Let me just interrupt for a minute. Tomos, can you go to the next slide, 'cause the viewers are seeing the black side, which is your intermediate
39:44
slide there. Here, you can see the slide. Go to the next slide because they're seeing black on the screen
39:53
You still see in black because I'm changing the slice Yeah, no change to the next slide, which is number night. Maybe you have to share again to us Let's see how we show it again. Oh, okay. Are
40:05
you finished with your talk? You had you had a few more slides? I thought Add here Thomas, you know the they've done a lot of literature about opioid use post-opirally even short-term opioid use
40:19
and the risk of even short-term opioid use resulting in long-term opioid use is pretty scary I mean it ends up like six to ten percent to the point where now the max that they'll give anybody is three
40:31
days worth But nothing to follow up and they're really recommending avoiding it entirely by using muscle relaxants or The
40:39
gap of pendants and Tylenol and things like that So it's something that you guys should at least look into especially for these smaller procedures where you can just completely avoid the opioids in
40:50
the future. Okay. I do also believe there's like a great difference between, that's something I really also take in account. If you do look the spine surgery and spine patients in South America
41:04
and compare with the states, these are different Sorry, Thomas put the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the
41:09
the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the
41:09
the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the
41:09
the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the
41:09
the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the
41:15
Now you see it now yes, but it's the it's not in the complete version of the presentation. We are looking all your presentation in the in the left side of the screen. Yeah,
41:32
how many more slides you have just now, but maybe it's okay Yeah, it's okay. We'll just go ahead for discussions. Just to close a deal of disclosure is something we were talking about about the
41:44
MIS. Yes, there's a lot of series about tubular nucleoscopic and percutaneous endoscopic techniques that most of
41:52
which we don't believe in terms of the results that they report They usually, I mean I see a lot of papers for surgical neurology international I can't tell you how many come in and say our results
42:03
were perfect we had none of this we had none of that. And the first thing you do is you check those papers because you know they can't possibly be true And I think this is the point of - Especially
42:13
for the younger surgeons coming up in the system, you know, don't be so enamored minimally invasive can be minimally effective and maximally dangerous. These are not necessarily, you know, the
42:25
choices you want to make. Okay, stop the presentation So to see the, Nancy,
42:36
regarding your, your, your comments in a well institution, you used to do after the surgery, the possibility period, like Thomas said, this protocol of
42:48
pain killer because of the neck and not, not of the
42:54
arm pain The point is, we used to put a soft cola for 10 days, 15 days in order to avoid the sudden movements of the neck. Our patients remains hospital, maybe 24 hours, maybe sometimes 48 hours
43:10
and I remember having a great time. had with Natalia and Pablo Marindo, I think I remember one lady who needed the
43:19
anterior approach after several months, but telling you the truth, maybe it was not a complete right selection of the case. Maybe it was our desire to stop the pain in the arm and it's not a sober
43:35
indication of the posterior approach, but sometimes you want to resolve the problem of the patient with one surgery. I remember this lady needed the anterior approach, but in the whole series,
43:49
when we choose the posterior approach, we
43:54
had a very, very big good result. It's a very beautiful surgery for the right patient. And I think patient selection here is so critical. You shouldn't use any of these operations or any of these
44:05
procedures for pain alone. You really have to, you know, I was just at a meeting the other They were kind of berating me well, but you shouldn't know so much about infectious disease. You
44:16
shouldn't know so much about general surgery or something like that. It's like, you can't have blinders. You have to know enough about medicine overall in order to better select and care for these
44:26
patients. Psychiatry especially, I mean, how many patients, they come in, they have fibromyalgia. You know, you can clearly see that they've got so many other factors going on. There's no way
44:38
some of these patients, especially the chronic regional pain syndromes are gonna get better no matter what you do. Even if they have a surgical indication, they're not gonna get better. Exactly.
44:47
So, you know, you're a surgical acumen, you're having to have some kind of a neurological deficit on your exam, and not just choosing to do any of these operations for pain alone is, I mean,
44:58
that's exactly what you're talking about. I don't know, why do we ask? Yeah, go ahead. Sorry, sorry, James, and at my last point, last but not least, it's very important, in my another
45:09
country. and economical reasons. If you want to perform this surgery, you need a very small box of instruments. You need a very fine section tube, one carries on one or two millimeters, hooks,
45:24
maybe one or two hooks, various small hooks, and one desector. You do not need an almost different type of desectorals, carries on, and so on. It's an economical surgery if
45:36
you want to perform this. Yes, yes. Actually, that's really critical because you do an anterior discectomy infusion. In the states, almost any of your interbody devices is7, 000, that the
45:47
hospital will actually mark up five or six times and build to the insurance companies, and then you have the plate, another7, 000 to8, 000 that they're multiplying up. So some of the surgeons are
45:57
going to end up really sort of motivated to do an anterior procedure because to their hospital, they're going to look more valuable, whereas this basically costs you nothing.
46:08
terrific. When we hold here for a second, first of all, Tomas, that's a superb job, excellent presentation. And, Andraste, and my compliments to you and your team. That's the kind of surgery,
46:23
bloodless, pristine, really a nice, really, really a nice job. I'm really compliment you on the and the care with what you want went about all doing every phase of what you were doing. I have
46:37
great admiration for that. Well, we're privileged to have Pablo here and Nicholas and I think these are people with experience in italia. Maybe they want to say something
46:49
here and so maybe they would like to make some comments. Pablo, do you want to say something or in italia?
47:00
Hi, good morning everybody.
47:03
Just to share that being educated from the orthopedic side. We learned to do this surgery from Dr. Jorge Salvat and then Nandres. And from our perspective,
47:21
long time ago, it was like a new experience. And we found this surgery really challenging at first in our hands, but so useful and with such good results. And of course, we are, as Nandres said,
47:41
we are very conservative in our surgical approaches and our surgical decision making. And these are very, very carefully chosen patients. And actually, over all these years, maybe more than 20,
48:00
And the results were very, very satisfying.
48:07
I think it's a very good option. It's a very good option. But of course, you always have to have an open mind to think of the decision approach with all the alternatives. And of course, doing all
48:25
the previews who are kept as has been said with a CT scanning before just to avoid surprises, not just MRI. And
48:40
what else? I don't know, I think everything has been mostly said, but it's a very, very good option. And in our team's hands, it's
48:53
really, really good.
48:55
We are not doing the MIS procedure And I agree that there's a lot of pressure to install all these,
49:08
new techniques, mostly, I'd say, like for marketing reasons and because
49:16
it's not to save money into hospitalization time and then, but it's like,
49:28
like, like a trend, you know, like
49:31
something that people is asking us to do. Yeah, yeah, you are pressure You are under pressure, and we are very firm in our mini open and on small incisions but open surgery in lumbar spine and in
49:48
cervical spine and we are still working on that kind of Terrific policy yeah Pablo to you is Pablo there does he want to make some comments I use the one who's he's had a great deal of experience on
50:03
race.
50:08
I don't know if you can hear me there. Yes. I hear you. Okay. Well, first of all, I want to say thank you for Nancy who introduced the term Spondylosis in cervical spine several years ago. That
50:20
helped me very much to describe the problem in the people who have neck problems.
50:31
Do you want to say something else, Pablo? Yeah. I
50:39
think the spherical approach and the posterior approach in the cervical spine is the surgery that we have to do when it's really good to indicate. There is no so many problems in that type of surgery,
50:51
so I think we have
50:54
to introduce that in the young people because they prefer almost anterior approach. That is for me. Okay.
51:05
Nicholas, is he your other orthopedic colleague, Andres? No, he's our second-year resident. Oh, okay. Or
51:14
Guido, or Maria?
51:17
Yeah, he's the professor of autism here. Okay. Would you like to make some comments?
51:25
But this is a world where he did the demand, I repeat. who taught us this surgery. And another little tip, Nancy, maybe you agree with me for young people, for young neurosurgeons and orthopedic
51:41
surgeons. Every time we are operated on and we receive, after taking out
51:49
this amount of venous bleeding, of course, it's not so beautiful to see in the video, but we are very comfortable. Because you see that this is the compression of the nerve You see, in this case,
51:60
the patient will be, you
52:03
will succeed with the surgery. Right, except you must make sure there's no CSF leak. No, of course, no, no, no, yes, yes. And if there is, if there is, you have to figure out how you're
52:15
gonna deal with it, right?
52:18
Salah, would you like to make some comments?
52:22
I think you are mute, you are mute.
52:27
Yeah, we can't
52:30
hear him. Yeah. Can you tell us about Professor Sowad,
52:35
he's a neurosurgeon or isopaedic surgeon or? No, no, no, he's a neurosurgeon. He was the first chairman of our department in Glen institution. He has more than 50 years experience of
52:47
neurosurgery in Argentina.
52:50
You can hear us, Professor Sowad, right? Yep
52:56
What's connecting right now? Okay, there we go. So. Okay.
53:01
Okay,
53:03
so what? Oh, hello. Hello, hello, hello, hello, hello, hello, hello. Who's there? What's up, beautiful, beautiful presentation. Thank you for all.
53:18
Okay.
53:21
So sorry that I couldn't.
53:29
We appreciate you being here. I have my respect for what you did in difficult times. And anyone else. Andre, so you think you could talk and.
53:43
A kundo or more or do you have some questions.
53:47
I think, I think that Pain, radical pain, radical properties, cervical, radical property is a really complex subject to treat because we have so many options to use. I do pain specifically. So
54:05
for aminotomies, I left it for the
54:12
I treat the patient in the clinic. So I follow him. And when a pain have a regular pain that is caused by a discrimination. I think it's really important to take it easy because that disc's
54:28
generation, when it's soft, will probably like disappear by itself. So we have to take it easy sometimes with painkillers, we try to avoid opioids, but sometimes they are really good as well. So
54:43
when we have this kind of pain, we always try to use first under block. I know it has its risks, but in our institution, we have Dr. Lamme that he use a contrast just to check always before he do
54:57
the corticosteroid injection, just to check that he's in the epidural space near the nerve. So that's really important because when he put the corticoids and the lidocaine, this goes inside the
55:12
epidural space and around the nerve. So we check that with the contrast in the CT scan. That's really useful. We have avoided a lot of surgeries just doing some blockage and then waiting. So maybe
55:25
we can do two, three. And if after the second or the third, depend on the patient and the difficulty of that block, then we will go with the surgery. We try to avoid it. And when the surgery is
55:39
indicated, I think that it has really good results. When it's just, for example, a compression from a soft disc herniation. So I think that our philosophy just try to avoid the surgery. But when
55:51
we do
55:53
use the surgery, I think it's a fantastic tool and we have really good results as well.
56:01
Okay, Nancy's, we have a, as a video on SNI digital. I'll tell you about that in a few minutes, but on the risks of epidural, epidural injections and, and so forth. Let me see Nicholas. Did
56:17
you want to ask any questions?
56:24
All of the presentation was very key. I have no question. Okay. Do you have any, did you mention more or did you have any questions? Discernations on MRI scans. I mean, a lot of those, those
56:38
data come from lumbar. Prospective studies and, you know, they resort completely about 10 of the time. And others may obviously regress But the much lesser percentage of that.
56:52
Morrow, did you have any questions you wanted to ask?
56:56
No, no, it was a representation. I don't have any questions further to ask. I just want to make clear this particular case that it was stuck. We usually do see discounts prior to doing for
57:09
aminatomy as well. That's our fashion of studying the patients. We always have a bone image and also an MRI In this particular case, I had the
57:22
and I used to follow this patient as well. She was, as Tomás said, a cross-fitter, in training, she was a professional athlete. So she saw another
57:36
professional as prior to our concept, and they offered her a anterior ADF for that particular level, as it was mentioned, but sometimes you have to take into consideration as well what the patient
57:50
wants. And in this particular area of talking about minimal invasive approach in the scope in as well, sometimes a minimal invasive approach may be a good indication, and not only the fashion of
58:04
doing this, for instance, this particular case, she was more concerned of continuing her competition. She had a new father, a competition this year as well So an anterior ACDF with the use of a
58:19
rich neck and everything,
58:22
without millopathy in the MRI, only with a radicular pain and radicular affection, maybe the foraminotomy solved her problem. She, I saw her in the consult the couple of weeks ago. She's doing
58:37
great. She has no further pain. She's, she avoid any, any medication. She's not taking anything and she has already begun with her exercising and everything. So she's really happy with that Of
58:51
course, we have to follow her up with further MRIs and flexion extension, as Nancy said. But I think that in this particular case, I mean, selecting the patients sometimes doing less,
59:04
particularly for the symptoms of the patient, it's also like an, I mean, minimal invasive approach. You can have good results.
59:14
We're privileged to have a side
59:19
concern, As from Persia, he's always trained in. Rance and he's been at UCLA site. Do you have any questions or thoughts about today? The main point is that I think each country should go with
59:31
the way they have it. In the US, as far as I see in at UCLA, our spine growth are very good. And a spinal surgeon, although the orthopedic as their own section, they work together. I think we
59:46
have to consider each continent has its own way I mean, they are doing great job over there. But in US, most of the spine surgery is done with instrumentation because of the finance and the screws
1:00:01
and each one of them costs 500 to 1000 And inter body disc, the user artificial one,
1:00:09
5, 000. I think each country should go with their own system. I wish one of our response surgeon from neurosurgery here at UCLA was participating.
1:00:21
They have different points of view. And I tell you, there is a hospital in Los Angeles not affiliated to UCLA. They do a lot of MIS, regularly or famous for that one, their response search. So I
1:00:37
think it's depends on the condition and the situation of each institution. Although in America, finance is the major problem for the hospital to build more Unfortunately, I have to tell you, and
1:00:52
some of the response surgeries are unnecessary, as we have talked about it, almost one third of the response surgery are not necessary, but because of the finance and the insurance and the system,
1:01:07
this is the, I think each country should go with its own way. And I really enjoyed all of the, our colleague from the Argentina, and I first time to meet with Dr. Nancy, and it was a pleasure to
1:01:19
see all of you. I just like to follow up on the whole notion of unnecessary surgery because a number of years ago, I did a study where I looked at 180 patients over like a year and a half. And I
1:01:31
saw all of these patients as a second opinion. Many of them had already scheduled operations from their first opinion surgeons or they were told that they needed an operation. And after going over
1:01:44
them and evaluating them, 60 needed absolutely nothing I mean, nothing, which is exactly the point that you're making. 30, they were never gonna do the wrong operation. It's like, one patient I
1:01:58
saw actually in person, he looked like Jaws from the James Bond movies. He was supposed to, he was scheduled for a C34ACDF. There was no way you were gonna get there. He did great from a
1:02:10
posterior approach, decompression, et cetera. And like 10 of the time, they really got it right But, you know, just because an operation is being. Scheduled doesn't mean it needs to be done.
1:02:22
And then you really have to re-examine the patient from head to toe Reduce studies if you need to too much of the time studies are six months old sometimes even a year old And things may have changed
1:02:35
So the need to re-establish and re-initiate and reassess these patients from A to Z I think is absolutely critical and you really want to weed out the patients who don't need anything at all Which is
1:02:47
what your point is? Okay, Dr. Osman, do you mind if I add one thing to share with you? There was a problem in US. especially in California about counterfeit instrumentation The screws and all
1:03:03
those material they were fake from another countries and some of the hospital because of the financial seeds they let it to be used and these patients because of the broken screws and they end up with
1:03:17
severe pain.
1:03:19
And that is something I hope you don't let this happen in Argentina. And so they have been, some of the neurosurgeons, the spinal surgeon were affected and they were under investigation because the
1:03:33
federal government came in and they arrested 130 spinal surgeons. And they, some of the hospitals are closed and there was a case on Wednesday on our presentation at UCLA. There was one of these
1:03:50
victims that the neurosurgeon, our response surgeon had to go remove the instrument and to fix all the damage which was done. Just be careful about this. This is counterfeit instrument materials
1:04:04
which comes from another country which I don't mention the name. Unfortunately, damaged many patients and it wasn't the news for the last few years that how many patients were suffering Guess what
1:04:18
he wanted to share. experience. I know you don't have it, but don't let it this happen to your center and your country
1:04:26
and your mission. Professor, excuse me a minute Nancy, Professor Sowat, did you want to make any comments?
1:04:34
I think he's, I think he's muted. You're muted. Jorge, you're muted
1:04:41
Uh, you're
1:04:44
not kidding me. I would like, I'm sorry. Go ahead, go ahead Natalia. We, professors, I'm unmuted now, but why don't you go ahead and Professor Sowat, I could go, okay? Yeah,
1:04:59
thank
1:05:03
you for all my friends. Oh, okay. Natalia, thank you very much for coming Natalia, what did you want to say? Yeah, I wanted to add that we are mostly a second opinion institution in our country.
1:05:18
And we see a lot, a lot of surgical indications that we turn down. And I think that most of our practice is based on the knowledge, the popular knowledge that we do not do surgery that doesn't have
1:05:36
to be done.
1:05:38
And we are very strong about it. We are very careful about not doing surgery when it's not necessary And that's our fame maybe when I say this. Watching your surgery, that's pretty obvious from
1:05:55
what you're saying and watching the surgery. It's pretty obvious that you're extremely careful and everything you do, you've done a terrific job. This is very, very impressive. Andres, anything
1:06:08
else? What we've done here is try a new experiment and how we educate, which is, having continuous discussion as the presentations are made. And Tomás, you did a terrific job and terrific job of
1:06:22
answering Nancy and the questions she raised. And I took a lot of preparation. And Grace, do you have any thoughts here? Thank you very much for allowing us to be here. It's a really interesting
1:06:36
way of sharing experiences for us. And I think we have the obligation
1:07:05
as an assertion to put again, like Nancy said, that many years ago the posture approach was very more frequent than the anterior approach or maybe the same proportion. Now, I think we have the
1:07:06
obligation to publish our results. To put again in the literature of our results, to show our colleagues that maybe, of course, we are not the only colleagues who have performed this surgery, but
1:07:08
I think it's necessary to put again the in the department Yeah.
1:07:14
the results in order to reactivate, not
1:07:18
the knowledge, because it's like an awareness. You have this possibility, remember, and because for a neurosurgeons telling you the truth, it's not a big - of course, we spoke about every
1:07:31
complication, but it's more easy surgery than to perform an scoliosis surgery, intramedular tumor. It's a very beautiful, gentle operation A young neurosurgeon with a very good learning cue will
1:07:47
obtain very excellent results. So it's necessary to publish, to show the results,
1:07:54
to put, again, a new alert to the spinal community that this is a known procedure, but it's very useful. It's still useful. Nancy, is there a recent publication comparing the posterior lateral
1:08:09
approach
1:08:11
with an anterior approach. or are these just separate series that you have to kind of compare and then that makes them different and so forth? I mean, there are so many series over the years
1:08:22
comparing anterior and posterior and so many of them are poorly designed, not randomly chosen, et cetera. I would just say that there are many, too many anterior procedures being done where a
1:08:36
posterior laminophrominotomy would be the procedure of choice. So you have to go a series by series, but they're not great ones, but I think it's a good point. I think as an operating surgeon,
1:08:46
you should always keep a database of your patients and the results that you have, because it's the only way you can correct your mistakes in the future by highlighting them and recording them,
1:08:56
'cause otherwise you'd forget. So I think that's important. Number two, I think just before we close up today, number one, do not use any of the five-in-ceolence anterior to the cervical spine.
1:09:09
Do you see that? It closes quadriplegia, it closes quadri compression. I would not use a fibrin sealant in the posterior cervical spine either. Number three, just as a point of discussion as to
1:09:19
what your operating rooms may request of you, at one point there was a choice between two kinds of fibrin sealants. And I said to the nurse who is our head nurse, you know, type A, we've used
1:09:32
this for years, we've had no trouble with it. She said, well, we want to use type B because it's cheaper. And I went to the literature, and what did I find? As I went back to her, I said,
1:09:42
well, type B may be cheaper, but basically in the literature, it's great for rabbits and rodents, but not for people.
1:09:52
So, you have to, you know, anytime you're given any literature, look at the quality of the study, look who's doing it, what are their motivations? You know, the same thing with some of the
1:10:02
outpatient procedures. Be very careful who you choose to do any of these outpatient procedures on They're older patients, comorbidities, do yourself a favor. hour or longer stay. I never thought
1:10:16
about that. Nancy, if we looked at rodents and rabbits, the number of patients we'd have would increase dramatically.
1:10:25
Well, okay, I think, I hope everybody enjoyed this, this way of doing it. We're experimenting in SI
1:10:38
and SI digital with different ways of teaching, different ways of learning, and Thomas, you were terrific in doing this, and it was, we spent an hour, we did it a different way, and I think it
1:10:50
was an excellent, for me it was excellent, you covered everything. So we thank you very much, and this is going to be seen everywhere in the world. SI digital is now in 80, 85 countries, and
1:11:03
they're going to be looking at this, and we're going to be able to translate And we were working on this because I think. One of the doctors in the previous session we had, Andres, wanted to have
1:11:15
immediate insulation because it was more convenient for him to be able to speak in Spanish and we were translated immediately in English. We're working on that now and probably within the next month
1:11:26
we'll be able to have that. So we're trying to make things that are easy for people around the world to listen and to learn. We do translate it already all into 10 languages, Portuguese, Spanish,
1:11:39
French, Russian, many of them. So when it's posted on the SI digital, everybody can look at it and put it in your own language. And so it helps. Anybody else want to make any final comments?
1:11:53
Professor Selvat, any final comments that you'd like to make? No. Again, thank you for all of this. Well, thank you. Thank you very much for everything. And Natalia, thank you for your
1:12:05
comments I didn't call on Jasmine, I'm sorry, I didn't. I don't know if she was here or not, but Jasmine, if you're there, do you want to make any comments?
1:12:15
I guess - But once again, I will send you by any name. Okay, thank you all. Have a very nice weekend and nice to see you all. And thank you very much, Nancy. As usual, thank you for all the
1:12:31
information you provide us. It's just terrific, okay? Thank you for arranging, Ms. Jim. I think it's great. Adios, Argentina, adios
1:12:41
Thank you. Thank you. Thank you. Thank you. Thank you. Reference for this talk can be found in Nancy Epstein's video on SNI Digital entitledServical Laminophurim Anatomy for Lateral Soft Disc or
1:12:57
Osteophyte. And the web address is given below.
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We hope you enjoyed these presentations.
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Material is provided in this program for informational purposes only and is not intended for use as a diagnosis or treatment of a health problem or as a substitute for consulting a licensed medical
1:13:26
professional.
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Please fill out your evaluation of this video to obtain CME credit The recorded session is available free on snidigitalorg. Send your questions, comments, or requests for
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CME to osmondsnidigitalorg. There are many ways to learn. Surgical Neurology International is a 2D international, Nancy Epstein is its editor-in-chief, web addresses, SIglobal, or SI Digital,
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Innovations in Learning, a 3D Live video journal.
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Interactive with discussion web address is s and i digital dot org
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Thank you.
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