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SNI Digital, Innovations in Learning, is pleased to present another in the SNI Digital series on Controversies in Spine Surgery, a lecture in discussion given by Nancy Epstein on Central Court
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Syndrome Management. What is the evidence? The lecture is 20 minutes and the questions are 30 minutes.
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Nancy Epstein is a professor of Clinical Neurosurgery at the School of Medicine at the State University of New York in Stony Brook and she is the editor-in-chief of Surgical Neurology International.
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The lecture was given on May 12th, 2024.
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Okay, it's recording.
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Okay. Okay, so I'm so you're going to talk to us about central card syndrome. You want to go ahead and and start to introduce your title and topic and go. I'm going to talk today about the
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diagnosis and treatment of central court syndrome and I think we've all seen these.
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And
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why isn't
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central cord syndromes, this is the typical anatomical
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distribution of the damage, and we're going to go over that in great detail. If you, if the outline for today's talk, and it's also called the man in the barrel syndrome because it's a significant
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upper versus lower extremity deficit that you see with these patients. And I'm going to define central cord injuries, the frequency and the etiology of these injuries I'm going to go over the
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clinical findings, the cervical anatomy, cervical MR and CT studies. I'll show you
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different images of this. We're going to go over very specifically the surgical timing and finally the surgical options and just, you know, variably the outcomes. The definition of central cord
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syndrome for adults is a central cord injury occurring in the absence of a fracture and dislocation And actually, when I was a neurosurgery resident, I collected a bunch of these cases. from a
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cervical spinal cord injury trauma protocol that we had at NYU under Joe Ransoff. And that actually was one of the first papers I wrote with my father who happened to be a neurosurgeon. So these are
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very perplexing injuries and they can produce profound deficits. They're typically associated with a hyper extension.
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Now, what does the hyper extension do? It causes an acute narrowing of the spinal canal and the narrowing acutely causes according to penning who actually wasn't a neuroanatomist in Holland at
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that point. And the thickened cord then becomes susceptible to acute core compression. And the acute core compression can be due to anterior things contributing to stenosis, disc, spurs,
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ossification of the posterior longitudinal ligament. And posterior pathology is well contributing to stenosis, hypertrophyter and large facet joints, ossification of the ooligment or hypertrophy
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and also the laminar shingling that occurs when just look at your Venetian blinds, the inferior lamina goes anterior to the superior lamina, and that can cause direct cord injury. 71 of these
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injuries, by the way, occur at up here at the C34 and the C45 levels. How frequent do we see these injuries? Well, there are about 18, 000 new spinal cord injuries a year in the US, about a
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little more than 9 are cervical, central cord
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syndromes, the total of central cord injuries that are incomplete is about 11, 000 per year. So it's the vast majority of the incomplete spinal cord injuries occurring in any specific year. Here's
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a significant MR scan showing stenosis. I'm gonna just show you here that you're not gonna see the OPL or the ossific, calcific changes that you're gonna see next on the CT But look how narrow they.
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Here's your cord coming up. You've got spinal fluid around it, anteriorly and posteriorly. Here you can still see some CSF anteriorly and posteriorly, but then you see the narrowed canal resulting
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in a very narrowed spinal cord with edema present. This happens to be the CT scan of the same patient. And you can see, sorry, on the CT scan, you've got ossification of the posterior laundry to
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the ligaments seen here in the back of the vertebral bodies Your narrowed AP diameter here being just very few millimeters.
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One of the neurological deficits, again, is the man in the barrel syndrome, upper and greater than lower extremity weakness. Sensory levels may vary. Sensory deficits may markedly vary. Also,
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there's varying sphincter dysfunction that you're going to see with these patients. It can go anywhere from mild to extremely profound. And again, it's because of the area of anatomical damage.
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loss of motor function in the upper extremities being greater than the increase loss in the lower extremities. So where are the deficits attributable to? What are the major tracks that are involved?
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Antirely, you have the spinal phylamic track deficits. That's pin and temperature loss. You also have dysfunction in the anterior gray alpha motor neurons, giving you the terrific motor deficits
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seen with these. Laterally, you've got the corticospinal track also resulting in motor function loss. And then dorsally, you have the posterior tracks, the posterior columns in particular,
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resulting in loss of position and vibratory appreciation.
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The summary of the clinical data from the different studies. And again, at the end of this talk, you're going to find references to the above. The average age is nearly 60, over 80 male. Trauma
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is the main cause 71 are going to encourage your C34 and 4-5 levels. The canal narrowing is down to about 56 millimeters, and I'll go over shortly the fact that the cord itself takes between eight
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millimeters to 13 millimeters in anterior to posterior diameter, hyper extension injuries are which are gonna see in the majority of cases. And the additional intrusion anteriorly and posteriorly is
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going to be all the factors that I just described, and we'll mention some of these as we go along. But the main factor you see is persistent weakness, upper greater than lower extremities with the
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varied sensory deficits that I discussed. Acute traumatic central cord syndromes are seen in older patients over 65 years of age. I'm just adding here what the Asia scale is for a neurological
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injury, and I'm just gonna focus on C, which is incomplete, but with motor less than three out of five, but sensory intact and D, which is incomplete, 50 motor greater than three out of five,
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but with sensory deficits present. Again, these are foals and motor vehicle accidents, But most of these patients are in grade D. That means incomplete motor deficits, but greater than three out
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of five function with sensory intact and grade C with 21 to 51 incomplete deficits, but sensory intact. You're gonna see more comorbidities in these older patients, congestive heart failure,
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coagulopathies, diabetes. You're gonna have higher mortality rates of two to 3. And very interestingly, you're gonna see less surgery being performed in these patients, only down to 40 to 45.
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What are the radiological findings for patients with these fractures and dislocations? We're gonna look at X-rays, MR and CT studies. I'm just gonna remind you that anatomically, we're speaking
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about the seven vertebral bodies, at C12, you have an odontoid process, so you don't have any problem with a disc at that level C7T1, two, three, to C7T1, you've got the disc, you've got the
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lateral vertebral artery. And here it's being shown, you have it, you're typically entering at the C6 level and the C6-7 and going up to C1. Occasionally it'll just start at five, six, et cetera.
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So they'll leave some variations. X-rays, MRCT findings of central cordial syndromes. Antirely, you've got disc, spur, and ossification of the
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olegment. Laterally, you're gonna have the lateral spurs, hypertrophyte facettes, osteophytes, et cetera. And posteriorly, you've got ossification of the olegment or hypertrophyteial ligament,
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shingled lamina, and
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hypertrophyte facettes as well. So as I mentioned, the anterior posterior dimension of the spinal cord itself is between eight to 13 millimeters. But in addition to that, the soft tissues take up
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another two to three millimeters. That's the fat, the veins, and the ligaments. And you can see these here that are figuratively added here again. bats, veins, and ligaments. The normal
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cervical canal is typically 17 millimeters in AP diameter. And here you see an illustration. And here you can see another illustration of the normal AP diameter. And here's an actual MR. You can
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see the cord is centrally located here. And you see the bath of spinal fluid around it. But in addition to that, you have stenosis. There's a definition of stenosis called acquired stenosis where
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you start out with a normal canal. It's less than 13 millimeters, though, by the time you're done because of developing over time acquired changes or arthritic changes. Congenital stenosis is a
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canal less than 10 millimeters, and that's because you're born with it. So here's an MR of a normal cervical spinal canal. You're going to measure the anterior to posterior dimension. And
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typically, you're going to go from a mid-retebral level to what's called the posterior laminar line but you don't see that well on an MR.
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but you do see it on a CT. So if you're trying to measure stenosis or other arthritic changes of the spinal canal, a lot of the pathology, you're gonna see it best on the non-contrast CT. And
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there's your anterior to posterior dimension. Again, mid-vertebral body to the posterior spinal canal, the inter-spinal ligament, or the interlaminar line is what you're gonna look for. And here
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on the sagittal image, you've got the mid-body to the interlaminar line Illustrating cervical stenosis with the canal
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diameter of just 10 to 13 millimeters. Here you have degenerative disease. Here you can have bone spurs that are contributing to the narrowed anterior to posterior dimension of the canal. And
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adjust, you know, if you have these patients with these arthritic changes, it's the traumatic injury, hyper-extension injury in particular that's going to result in damage to the canal. And here
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it's just an acquired stenotic canal front to back dimension. mid vertebral body to interlaminal line, maybe 13 millimeters, but you have that hyper extension event. And here you may have a focal
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spur present and dorsolateral ossification of the olegment. So you're just become a sitting duck for a hyper extension central cord syndrome. Here's an MR of a central cord syndrome due to hyper
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extension stenosis and hyper lordosis. So here you can see anterior to the multiple vertebral bodies. There's a DEMA of the anterior longitudinal ligament The next you're going to see T2, a
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hyper-intense cord signal here from C2, 3, 4, 5, 5, 6, down to 6, 7. And then posteriorly, you're going to see a DEMA in the ligament of NUKI. And also posteriorly, in the canal, you do
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have a DEMA
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also swelling of the yellow ligament as well. Here's an MR of a central cord syndrome due to C3-4 stenosis So you have superiorly the C3 cord.
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the four-chord edema, and you can see the high signal on the cord on that T2 study. Ventrally, this is not an acute disc herniation in this patient, but on the CT. They knew that this was a
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ventral chronic spur, and then dorsally, you have ossification, the olegment and the shingle of lamina. So in this instance, before the hyper-extension injury, the patient did not have that high
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signal on the cord, but as soon as that injury occurred, it's like a pincer effect from anterior to posterior, and that produced the cord damage. Here's an MR scan of a patient who's a set up for
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a central cord injury. Why? Because they have multi-level ventral osteophytes and dorsally, the patient is straightened, but there's no longer a lordata curvature, but you have the hypertrophy
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facets and ossification of the olegment. So the acute hyper-extension flexion that occurs in these patients, that's what can damage your central cord Here's another MROS. cervical stenosis, and
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there's a kyphotic deformity here, but there's an inferior compensatory hyperlordosis. And so at any of these points here, the anterior to posterior dimension is narrow, the cord gets damaged.
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And here's another look at how the central canal can be so narrow that all you need is that hyper extension event to then produce your cord injury. It's interesting in the Japanese literature with
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OPLL, they talk about about 10 of patients who may be neurologically intact today will within 10 years have a
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hyper extension event that become significantly quadriperetic. Here's an MR of a central cord injury that has already occurred. And you can see this is around the 56 level, the swelling in the cord,
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it's nicely seen on this sagittal image. And again, you know, this patient had a straight inward doses. Here's a patient who has a demon in the cord going from C2-3 all the way down to 67. where
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you have a straightened lordosis or actually a partial kyphosis at the level of injury.
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Again, a set up for a central cord syndrome is a patient with a quartz stenosis and that hyper lordotic cervical configuration. And here is a milo CT scan of multilevel spinal stenosis with ventral
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disease and dorsal disease. Again, a set up for central cord injury Antirely, you have the ventral spurs, osteophytes, disc, whatever you want to call them. Dorsolaterly, ossification of the
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yellow ligament, and laminar shingling. There's an increased risk of central cord syndrome also with OPLL or ossification of the posterior longitudinal ligament. It does result in anterior cord
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compression. As you can see here, figuratively drawn. Heravayashi defined the four types of ossification of the posterior longitudinal ligament continuous, which is pretty self-explanatory, and
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then segmental, which is just because. the vertebral bodies themselves, the mixed form, where it's a combination of the continuous and the segmental, and the other form that just occurs actually
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at the disc level is shown here. The CT best shows OPLL versus the MR, increase in the risk of a central cord injury because, look at the narrowed anterior to posterior dimension that you're seeing
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here. The OPLL is behind multiple vertebral bodies, continuous here, segmental here, and the front to back dimension, central vertebral body to the interliminal line is down to just a few
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millimeters.
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So that stenosis is going to markedly increase the risk of a central cord injury, and then here are some other images on a CT. You have an axial image showing you the massive ventral OPLL narrowing
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that spinal canal down. Here's a sagittal image of the CT showing you the narrowing, and I'm just throwing out here too for you. The MR in a patient like this maybe very misleading because you
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don't. you just see a hypo-intense signal where the OPLO masses where in the CAT scan is a positive image of OPLO, but does result in really severe stenosis. That's very hard to see on your MR,
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but very clear on your CT scan where you see the direct ossification or calcification. The three CT signs of OPLO that may have penetrated your dura, and I'm just showing this to you because if you
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have a patient with a central cord injury and you have any of these findings, you're gonna try to avoid as best you can anterior surgery because your risk of a spinal fluid leak is gonna so markedly
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increase. This is a single layer sign. It's a central anterior intrusion from OPLL. Here is called the double layer sign because here you have the calcification anteriorly of your vertebral body,
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and then all of a sudden you see a chunk of calcification sitting in the middle of the spinal canal And what's in between here is your dura. I used to call this the Oreo cookie sign. But if you see
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this and you go anteriorly, you almost guaranteed to get a leak, it's like 80. And then at one point I described that in addition to the anterior single layer sign, it's a positive C sign that
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means on either side, it can mean that the dura has become imprecated or unfolded in the opol. So the double layer sign has the highest risk of the CSF leak and you can see here sequentially what
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the double layer sign looks like. Again, you remember an Oreo cookie? You remember the double layer sign. A central cord injury with opol and kyphosis, though, may require that you do an
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anterior operation. And this is just to show you, because these patients may be kyphotic. Sometimes people will put in disc graphs that are hyperlordotic to try and throw the patient into some
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degree of lordosis and then try to do a posterior decompression as well. But if you go anteriorly multilevel ventral opol in these cases with. central cord injuries may require that anterior
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operation where you do a multilevel corepectomy, but be prepared to treat a spinal fluid leak if you're doing those procedures.
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The timing of surgery, overwhelmingly early versus late surgery. This is a paper by Failings in Global Spine 2017. Again, we suggest that early surgery be considered as the main treatment option
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for traumatic central cord syndrome regardless of the level involved Here is a study from JAMA 2022, early versus late, less than 24 hours, again, as early. The early group and late group,
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basically the same age as 93 patients in each group and the early surgical decompression, resulted in significantly improved recovery in the upper limb, but not necessarily lower limb function.
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Again, a study by Europeans, Spine Journal 2023, central cord syndromes, what do you see? Well, here they felt that you get more motor recovery if you operate on these patients and they were
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contrasting this with performing no surgery at all. In 2024
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or 2023 rather time is spine early surgical intervention. Again failings who's from Canada is one of the major authors in this and again surgical decompression with stabilization is the most
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effective way to minimize the damaging sequelae that follow and acute spinal cord injury and again better prognosis, better surgical outcomes in these patients and here satari at all in spine journal
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2024. Again less than 24 hours, better outcomes in these patients, higher scores with early surgery versus late decompression and fewer complications in the early group with obviously shorter
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hospital stays. So surgical options for central cord syndromes anterior dysketcamine fusion, I would say very rare. I showed you OPLL and hair of bioshies delineation. It's the other form where it
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just occurs at a disc level, but it often extends significantly above and below the disc space. So you have a big chance of leaving a lot of disease behind if you're just gonna do an anterior
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dyscectomy infusion. Multi-level anterior dyscectomy infusions, by the way, typically resulting quadriplegic injuries, and I've reviewed a number of medical legal cases with that. That's also a
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very big mistake You really have to do a multi-level anterior corpectomy infusion if you're going to deal with multi-level OPLL, and you put in your graft, et cetera, and here are different images
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of different grafts that may be used. Other options, if you have any degree of lordosis, or if you want to put in lordotic anterior dyscectomy grafts to throw the patients into extension so that
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you can do a posterior approach, do yourself a favor, that's a good thing to do and you do your decompression, laminectomy.
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and then typically you need a posterior fusion to stabilize that. Spinal cord injuries with the anterior
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OPLL. Well, how do you decide whether or not you have to go anteriorly or posteriorly? Here is what's called the positive K-sign. If you draw a K-line between C2 and the interliminal line
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posteriorly and C7 in the posterior interliminal line, and you draw a line between those midpoints, if your ventral OPLL
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falls in front of the line, then you can do it. Anteriorly or posteriorly, but let me tell you, you wanna go posteriorly if you possibly can. Sometimes you may decide to go 360, but again, if
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there's a positive K-sign and you think that you have enough of a lower doses, go posteriorly avoid that CSF leak. If on the other hand, you have a negative K-sign where that ventral OPLL goes
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behind that line. you may have to go anteriorly. You're going to get a significant risk of a CSF leak. Again, if you can go at levels Cephalatin corded to throw that patient into a lordosis to
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then do a posterior decompression, you're going to be a very happy camper at that point. So the conclusion here is that central cord injuries do occur. They constitute about 9 of
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all of your spinal cord injuries and about nine out of 11 for incomplete spinal cord injuries. Diagnose this early on, get your MRI CT studies early on. And again, don't just do the MR, get that
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CAT scan. You're looking to see, is there significant OPLL? Is there something else going on that I'm missing? Are there other fractures that I'm missing? And then early surgery, again, is
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going to get your best results in these patients.
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Let's say, I've got a, I was thinking about this, let's say, so, so many of them want to leave now, they got a summary of it and so forth, but this is the discussion part here, particularly
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today. Patient comes in, let's say, let's take a patient patient comes in, and, and he's got the findings he's very weak in his upper extremities he's got some weakness in his lower extremities
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you may have a century level it's varying And you're saying, well, I think a patient's got a central court syndrome. You send him down you want to get an MR one of your MR's there did show, I
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think several of them showed something in the court.
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But
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you want to get an MR to know what's going on at least you probably don't know if you have time to get a CT or not. So, so now the question is, I can just see this happening. Well, maybe he'll
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get better. Maybe we ought to wait 24 hours till the next morning.
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Well, because it's convenient to operate in the morning or the next day or the day after. I got to call everybody up tonight and I'm not sure it's going to work and maybe he'll get better. I'll
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give him some steroids and so far. I mean, I could just see this happening. Okay. And so from what you're saying, it's mistake number one
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Yes, I mean, this is such a common mistake that's made these days. I go to spine conferences every Friday and they're still going on with the old literature that said, oh, you know, leave them
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alone, put them on steroids, wait for them to plateau and then, you know, hey, you operate on them at your convenience. I mean, there's a lot of convenience going on in surgery these days. And
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waiting for that operative time, you may have lost the opportunity to give this patient substantial recovery, at least according to. And what I would consider the best literature out there, there
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are some smaller studies that still go, oh, you know, you've got 48 hours and yes, wait for them to get better and plateau you, you don't want to risk your precipitating neurological
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deterioration, which typically shouldn't occur unless you're really not operating very competently. It's nice to do these under intraoperative monitoring. I think it's really requisite to do them
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under intraoperative monitoring You do have to have anesthesiology in
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these patients, do an awake, nasal tracheal fiber optic intubation. I don't think actually glide scope intubation is, should be used because it requires still a certain amount of hyper extension,
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even if you do a jaw thrust at the same time. But you need all of these factors in place. You have to get, you have to make the train move and a lot of people are not doing that these days Because
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I'm reviewing a lot of medical legal cases like court. of syndromes where everything's being put off for the next day. And that's just not the right thing to do, not the right thing to do for this
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disease. Well, you answered a bunch of questions already. One was, okay, I've got them. And I made the decision to do it. I got to take them down. I put them in the operating room. You said
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you've got to fiber actively and fiber optically
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intubate him. Now I got to turn them over prone. And that's where you want to have your your evoked potentials if you can do it, obviously, because it tells you what's going on the minute
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everything you're doing. Now I put them prone. I don't want to flex them. I don't want to extend them. It's easier to do the operation if you flex them, but I don't want to do that. I just want
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to want to aggravate the situation anymore. So I've got them on there. Everything's going okay. I put the recordings in there. I go in there now.
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What do I do? Do I go from C2 to C7?
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do I do C4, C5, C3, C4, C2, C3, C3, I mean, how much do I go? Well, I think typically you look at the level of maximal compression, and you at least should go one or two levels above and
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below Okay, so you're
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trying to create space for that chord to swell, basically. So if it's one or two above, one or two below, I'm already five levels. Well, typically a lot of these cases are going to be treated
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with five level decompress Okay, so, so if I do see two to see seven, I mean, I look at the films I'm going to see where it is, but I'm going to want to go. What you're saying is, is take some
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extra room, because if you make a small laminectomy it's going to herniate out through that.
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And the fake is you're not gonna do a, I mean, what do we hear all the time? Oh, I'm mentally invasive. If you try and do a mentally invasive operation in a patient like this, you're doing a
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tremendous disservice because the operation you should be doing is a laminectomy and making room for the court to swell. And the court to swell not only at the level of the initial nitis of the
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trauma, but you know that the court is gonna swell cephalate and caudad to that. So you have to anticipate that with an open decompressive procedure Don't cry and get fancy. Don't try and do, you
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know, tiny little incisions. It's not gonna do the trick. First of all, and secondly, that's right. It's gonna exacerbate your injury. Well, okay, no, I'm in there and I see it. I'm gonna
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try to go from normal to more abnormal tissue. So I know where my planes are, I know where I got space, at least a little space. And I do this, yes, I can drill along, I can drill a trough
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along the side and then make a thinner and thinner And I don't want to put an instrument in there. I don't want to put a run,
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a run, run, run, or do that. It was a little laminectomy, I think, because I've already gotten them in its face, right? Well, what you have to do, though, is you, you know, you talk about
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it. What you do is you come down the lateral gutter on each side, just medial to the facet, okay? You use a diamond drill, by the way. I can't stand it when I constantly read reports that say,
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we use a cutting burr and then big surprise they get a spinal fluid leak And then we have a one millimeter kerosene punch. And as long as you're staying lateral, very lateral, just medial to the
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facet, with that one millimeter kerosene punch, you're actually doing your decompression, but you're going along where you're anatomically, just above the nerve roots, rather than centrally
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getting your instrument between the lamina and the cord and exacerbating that patient spinal cord injury And then you go up one lateral gutter. and then you put a towel clamp on the spinous processes
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and then you start level by level, taking off each lamina separately to minimize any trauma to the cord underlying your pathology, yeah. Good tip. Okay, so I've done that. Now I'm gonna go take
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off one at a time. I take it off, I lift it up a little bit, I gotta cut the yellow ligament and then I start over on the next side. I mean, that's what I gotta do Yeah. And all this while,
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it's the top, the time is clicking. By the way, it's the
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anesthesiologist to give these people steroids or anything to reduce swelling.
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I mean, we'll get into that later. And the whole spinal cord injury protocol. I usually give them a gram of methampredness alone and I still put them on the spinal cord injury trauma protocol
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number of, you know,
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per hour, et cetera But the most important thing that the anesthesiologist does. they do not allow that patient to get hypotensive. I was just going to ask you. Any hypotension is going to
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exacerbate your spinal cord injury. So you make sure you have adequate lines before you flip this patient over and you have an arterial line in place to make sure you're monitoring correctly what the
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blood pressure is at the level of the neck. I'm going to come back to the pathology in a minute. Okay, so now I'm going up the side and what you say we're doing a laminectomy. So that eliminates
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another argument 'cause somebody may say, well, why don't I do a laminoplasty?
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Well, laminoplasty's in theory sound good, but in practice, first of all, you're trying to just, you really directly decompress just one side. Your average decompression with a laminoplasty may
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be just like four millimeters. You may need more than that in this case. But what you worry about is the contralateral side where, you know, you are flipping it over, ah. and whatever you're
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using, your plate, your suture technique, et cetera, you have the risk of that laminoplasty closing. You have the risk of
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the gutter that you've created on that side. You have the risk that that could fracture. These are the cases where you don't want to take any of those risks. I would do a laminectomy. All of the,
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you know, you have all these studies and laminoplasty is in success. You know, you read the study, you read the study, and then you just think about it, and you just say, this is definitely the
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wrong operation in this patient, and you really have to rethink the efficacy of these patients of this operation and other pathologies. Okay, now I got my laminin off, I've done it, and I look at
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it, the dura is very tense.
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I mean, I just even feel in the court, it's very tense. Doesn't look like it's pulsating. And okay, now I gotta open up the dura No. I know. That's a dura. No, one I need space doesn't accord
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needs space to come back. It's going to be a big mistake. The Dura is still somewhat expanseil. You
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open the door. It's like it's like doing brain surgery. It's like as a resident in neurosurgery, you know, when the first things you learn, especially in brain trauma cases, is if you open the
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door in some of those cases, the brain's going to herniate out. And in this case, the dura, the cord may herniate out, and then it's going to embark along those edges. So you do not, in my
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opinion, in this case, open the dura. Okay. So we got that settled. Okay. So now I'm done with this. And now a very important point. Don't don't open the dura, because you're going to lead to
33:51
more trouble. All the studies are done with just doing a decompression laminectomy. That's where the, okay. So I know I do that. Now the next thing is, oh my God, I've done five levels. Is
34:07
this the time to fuse this guy, or is this the time to get him off the operating room table, wake him up, let him get better and come back and fuse him another day? Well, I think that's a
34:18
fantastic question. And the answer is, I think you've got to do that on a case-by-case basis. I think the older the patient is, the more likely it is that they're not that unstable. The younger
34:30
patients, you may have to, if you've got evidence of some ligamentus injury that's associated with this, which often will be the case, then those patients you might have to fuse at the same time.
34:40
It's certainly gonna be much easier technically to fuse them at the same time rather than delaying this. But I think certainly you're older and you're young and you're middle-aged patients, I think
34:52
you have to fuse them at the same time. I think some of your older patients, you can selectively choose not to do that at all And if the patient's deficit is -
35:02
very severe. Number one, if any other medical comorbidities are there, if you have any intraoperative difficulties, hypotension, whatever else it is, I think you can definitely just do the
35:17
decompression, close, come back another day, you know, put them in a collar, etc. But it's optimal, I think, in your younger and your middle-aged patients to do the fusion at the same time,
35:29
your older patients. And decades ago, we used to just do, you know, C3 to 7-laminectomies
35:38
and not fuse any of them, especially the older patients. So that's definitely an option, especially in your older patients who might be unstable. Let me go back to opening the door. Let's say I
35:49
usually argue, well, I do this if the brain is swelling, because I'm going to put a patch graft in. If people done studies where they open the door or put a pad, and they know they can't close it,
35:59
I know that there's studies in the literature where people opened with a spinal cord tumor, so it was one of the treatments. You open it up and the tumor then begins to her knee and out you come
36:09
back later and you take it up. Anybody done patch grafting at this level? And you open the door and then you know that you're gonna, you know that you gotta open it very rapidly from top to bottom
36:21
so you've got room at both ends and then you put your patch graft. Anybody done that? I can't recall reading a study to that effect. I'd have to go back and look, but I can tell you that, you
36:34
know, certainly with Joe Ranserhoff, there were multiple studies coming out of NYU talking about doing this with head trauma and study after study after study showed that you just end up infarcting
36:46
the neural tissue along the perimeter no matter how big your derolplasty happened to be. So I think it's probably something that's gonna come -
36:56
Now, I'm going to come to the pathology because I've always had this, uh, this problem. Uh, one of the, one of my concerns with spinal cord is since doing injuries is what is the vascular
37:11
deficit. Well, to do the vascular deficit, you've got to do spinal angiography, which takes a very skilled person to do it. You've got to go
37:22
Uh, penetrating artery by penetrating artery. You've got to inject each one individually. You're going to see what's there. And so it basically was not done. Yeah Now, the problem is if I think
37:34
about it, if I think about it, and particularly with people progressively who have disease and nobody knows this in the spine. There was a fellow back in the 60s at the NIH by the name of to cheer
37:46
He did the NIH and he did
37:52
the NIH and he did the NIH. on people who had spinal cord injury. And he found that there was vascular compromise and never went anywhere.
38:04
And, but I thought it was a very interesting observation. And to me, it has to be. Now, I don't know to what degree and my alopathy, that's a problem. I don't know what to degree in acute
38:18
trauma, that's a problem. It certainly could be if there's dislocation and I've crimped the vertebral arteries So now I've got a vascular injury on top of a tissue parenchymal injury, and nobody
38:31
knows. That's why when you mentioned that you gotta make sure the blood pressure doesn't go down, that was the answer to the question, because if you're not gonna do anything about it, you've
38:41
gotta maintain the blood pressure up if it goes down and farps. That's exactly true, because that's right. And then post-operatively, you also very, importantly, If you want to raise the head to
38:53
bed 30 degrees. you've got to make sure that that arterial line is at the level of the neck. Very good point. Can't be down at the level of the elbows or something like that, but you have to
39:04
maintain that blood pressure. So this continuously reinforces monitoring. Now, when we were younger, we didn't do that, but I mean, it just continuously reinforces the nature of monitoring. So,
39:17
okay, now we got to that point and - Monitoring, by
39:22
the way, you know, one of the concerns about early surgery, of course, is well, I'm just gonna exacerbate the injury. Well, if you use the monitoring, first of all, the monitoring may show
39:30
that everything is out and you get nothing. Yeah. You
39:34
know, the SEPs may be there because that's opposed to your columns, but the motor evokes may be gone. Well, then you deal with whichever parameter you have, and when we started out with
39:45
monitoring before certainly 1989, we were just doing SEPs, but you can monitor your blood pressure, should be allowing you to maintain those SCPs at the preoperative levels. So interoperatively or
39:59
positioning-wise, your SCPs, perhaps that all you have, if they drop out or they drop down, you better watch your blood pressure, that may be the problem, much less adjust your positioning,
40:10
flexion extension. You don't want to over-flex, you don't want to over-extend, you want to make it as neutral as possible. Okay, one more thing on vascular. Has anybody done any vascular studies
40:21
and with angiography that you know of in any kind of spinal injury, spinal cord, spinal cord disease? I'm sure there are many research studies on that,
40:33
but I'm not familiar with it at this point, but that. So, because I think what happens is, is one of the things that can happen, and I know there are traumatic injuries that show mechanically the
40:45
central cord is the area that's impacted periphery has got the
40:52
the periphery, the multiple vessels are on the periphery of the cord that's so fitted. The central becomes more ischemic as those fewer vessels become compressed and don't flow. So you get a
41:04
central injury, but it was interesting. Now, something else that happened, I'm gonna recall old days. One of the things that happened is people would open them up and put hypothermia, put ice
41:15
chips in there, you're in a bag, you know, how cool the cord
41:19
Just for somebody who's watching this and listening, well, here it is, and I know there are studies to do it. What's the story?
41:29
You don't use intraoperative hypothermia. And I think, you know, they've gone through this, postoperative hypothermia and, you know, look, they still use this for brain injuries, traumatic
41:41
brain injuries. They put the patient systemically under hypothermia. Yes. But treating spinal cordionaries with hypothermia, I don't think it's been shown to be that effective. Okay, so I'm just
41:53
trying to think, I'm maybe running out of my questions here. Now the other thing is you're dealing with an incomplete spinal cord injury. Right. Right? Well, a lot of the time, sometimes
42:04
incomplete, it's cold incomplete because usually there's some degree of sensory preservation. But sometimes, you know, these group Ds are really, group D is no motor, it is no motor function.
42:15
So you can have no motor function with some sensory preservation and that may be your end-to-end old baseline. No, I'm gonna go talk to the family. And I talk to the family. And that first
42:27
question, are they gonna be able to walk? Are they gonna be able to use their arms? And so the question is, obviously, I don't know, a worse mistake I'm gonna make is to tell them something
42:39
'cause I don't know what to begin with. But what is the natural history postoperatively if you take a series of these patients? What happens to them? Well, I think, you know, a lot of the
42:49
literature for the early surgery. group is you may regain, you know, one level in your spinal cord injury scale. So you may get back or may get some improvement in function, but I think the
43:01
bottom line is you have to tell them that this level of neurological function that they have may remain as such. And you have to also lay some crepe and say, you know, it's possible that there
43:14
could be further deterioration as the swelling exacerbates usually in the first, you know, 48 hours, 72 hours, whatever time frame you want to give them, but you can't get, I think it's very
43:28
dangerous or not very smart to be overly optimistic in these cases because these patients may not see any degree of improvement And one of the most difficult things I think for patients to realize is
43:44
that you may be doing an operation that just leaves the patient at this level of function and no better.
43:51
It's a terrible, terrible situation now. Let me see what else. I think I had one other question, I forgot about it, I said. So what's your post-operative management system? You obviously have
44:04
to maintain - Yeah, post-operative management, maintain the blood pressure. And maintain blood pressure. I think that, yeah, the data on the steroids, you know, they've done studies over years
44:14
and years and years and a lot of them feel that high dose protocol really doesn't do anything Michael Phalanx has been involved in all kinds of, you know, spinal cord injury trauma protocols and
44:26
there are various different drugs that they've developed over time. I think, you know, they're supported with those medications. As they start mobilizing patients, again, they have to make sure
44:37
that the blood pressure doesn't drop. If you've done a fusion, you wanna make sure that that is holding, bracing may be important. You've gotta watch for, you know, skin changes, et cetera So
44:49
you have to have them really in the very same. specialized spinal cord monitoring unit. These are not the patients that you just send out to the floor and forget about. They're going to need a lot
44:60
of intensive treatment in your ICUs and then subsequently in your rehab centers. So now that you've got a patient who's laying in bed, he can't move. So he's just set up for PE, right? Yeah.
45:03
When you're ambushed and the phobitis and so forth, you've got to put them on a coomident. No, usually they start the sub-Q heparin doses almost three weeks ago, and it's always a balancing act
45:03
because you've got to do an operation, let's say, to do a decompressive laminectomy, whether without a fusion, do you
45:24
start the sub-Q heparin within
45:38
24 hours, 48 hours, et cetera? I mean, there have been studies on either side saying, well, you start the low dose heparin and you markedly decrease the risk of a PE, but you may have
45:51
percentage points of a post-op epidural hematoma and then you're then you have the other group though where if you're starting it later they may develop that post-op hematoma and again the incidence
46:01
of
46:04
DBT in these patients is at least 80 percent so you know you're going to have a problem if you don't deal with it. There's always the option for an inferior vena cava filter but the problem the
46:12
inferior vena cava filters if you don't have a sub-couheprin that's going to be going and usually you'll do that if you already have a dv you know a clot present or you've already had a PE but you can
46:23
then develop the inferior vena cava syndrome where everything below that clot that that inferior vena cava filter can clog off and then you get tremendous swelling of the lower extremities the
46:34
morbidity mortality of that is also significant and severe so you're always going to be between a rock and a hard place in terms of some of these decisions that are going to be made So the post-op
46:45
course or the surgeon you can lay it out but the post-op course for the patient is difficult at best. Yes, yes, and you need an entire group of people who are really honed in on how to deal with
47:03
spinal cord injuries. That's why you have the spinal cord injury centers. You've got, you know, the medical people, you've got the physiatrists,
47:11
you've got OT, you've got PT, you know, obviously you have your psychiatrists who are involved in this as
47:22
well, but getting these patients as safely as possible through a peri - and post-operative period is not an easy task and can't be done typically in your peripheral hospitals. Okay, one other thing.
47:31
Let's say I don't fuse them. Do I put them in a brace? Do I put them in a collar? I'm gonna ask you, do I put them in a halo? Everybody says they're not gonna move if they're in a halo,
47:42
obviously, somebody's gonna say, well, they're not gonna move anyway So what do you do?
47:49
put them in a halo. I mean, we've we've got cervical thoracic orthoses, you know, they're Philadelphia color variants of it. There are other designs of cervical thoracic orthoses. You don't just
47:60
put them in a collar only because that really doesn't do very much. But you add the cervical thoracic portion of that vest, and it really markedly increases your stability in these patients.
48:10
Because you're mobilized, they had on the chest, you're mobilized. Yes. Yeah. I think I've asked you all the questions I can think of. It's a terrible injury. And but I think we've covered
48:23
anything else you can think of we didn't do. I think that's that's pretty much it. I think I would just emphasize that, you know, you have to be able these patients, if they come into an ER, you
48:35
should get a neurology consult stat, you should get the MRs and CT scans, not just electively, but stat get your neurosurgeons or spinal orthopedic surgeons on board This is not something that you,
48:49
as an emergency room physician or a hospitalist, should be doing on your own, get the specialists involved early. That's going to, that is what is going to optimize the patient's outcome. And
49:00
furthermore, the hospital is the medical people, the internists, all the adjunct personnel, including the nurses, the nurse, the PA's, the OT's, the PT's If a patient
49:13
has this injury and they're just sitting on this patient and not doing anything for them, there's something called going up the chain of command, which means you go to your supervisors and you say,
49:23
how come nothing's being done for this patient? And you get them treatment, you can get them a second opinion, you know, if they've seen neurosurgery, you can get them to see ortho, if it's
49:33
ortho, then you can get them to see neurosurgery. But
49:37
you don't just accept that the treating experts, if they're not doing anything for the patient or necessarily doing what is right for the patient. One other question. patient comes in at 10 or 11
49:48
o'clock at night, you will make the diagnosis, you've got the MR, you say, well, okay, I think I can wait till six or seven in the morning and take him surgery. That's that's the big mistake.
50:02
And that is the mistake that is made all the time. And the answer is, you get your experts in that, that night, at that time, you don't just accept somebody saying, Oh, yeah, see you at, you
50:13
know, six or seven am. You may lose the opportunity to enable that patient to regain even one level is huge. But any, any, regaining of neurological function can make a tremendous difference in
50:30
that patient's life. And it is worth getting whoever it happens to be out of bed to see the patient in a timely fashion, which means really, you know, they're coming in as traumatic injuries. The
50:42
legal requirements are that those specialists show up within half an hour. or they do so.
50:48
The answer that makes everybody motivated is I'm treating the patient like I treat my own family. It goes to surgery now. Exactly. And I mean, it always amazed me that patients would ask that
51:00
because it always seemed to me that whatever you're doing in terms of treating any patient should be treating them with the same level or standard of care that you would treat any family members. So
51:12
I think that's the, that's the bar And if anybody is using a separate bar then they really shouldn't be practicing medicine any longer. Okay, end of discussion.
51:28
That's just terrific. I think this was, I hope people got a lot out of this. We covered every aspect of it, I think so. Yeah, good questions. I mean, I haven't looked at a lot of the other
51:39
spinal cord injury literature recently about, you know, you know, angiography, I mean, and I know that failings in those guys have really, really useful in all kinds of other medications that
51:52
are, you know, supposed to sequester the bad ions and all this other stuff, but I haven't really read that stuff recently. Oh, I mean, sure. Well, I'm sure if somebody has done it, you'd
52:02
probably heard about it, but this is a study done in the 1960s. So I'm talking about
52:10
a study that's 60 years old I mean, that's a long time. And it was deep sex for years, absolutely, because it's very difficult to do angiography. So now people, I'll tell you where it's gonna
52:24
make a difference. And that is when we get seven Tesla MR. Oh, interesting. What'll happen is you do a seven Tesla angiogram. Mm-hmm, that one interesting. And you're gonna begin to see people
52:39
finding vascular lesions in the spinal cord They never imagined before. you're gonna find these people coming with myelopathy with multiple segmental loss of feeding vessels in a schema in the car.
52:52
I mean, just think about what's happening and what we know about the brain before angiography and what we learn afterward. I mean, it
53:00
just has to be. I just don't see any way you're gonna get around that. So I think seven test land geography and maybe a beyond is gonna tell people I've seen a higher Tesla images of the corn.
53:15
They're still not at a high definition, but they're better. I think that's one of the things that's stopping people from doing it. Okay, thank you so much. I think another terrific job. I
53:26
appreciate it. Okay. Okay, thanks, Jim. That was fun.
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