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SNI Digital Innovations in Learning is pleased to present
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Nancy Epstein, who is the Professor of Clinical Neurosurgery at the School of Medicine at the State University of New York at Stony Brook, and also Editor-in-Chief of Surgical Neurology
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International
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Dr. Epstein will present a lecture, and we will have a discussion on the subject of cervical laminophoremonotomy,
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which he believes is safer than an anterior discectomy or fusion
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for lateral cervical disease.
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The lecture is 20 minutes, the discussion is 20 minutes
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Epstein has been doing spine surgery for over 30 years in the United States. as a broad experience with all kinds of spine disease, and is among the top people who have written more papers on the
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subject of spine disease than others. Thank you, Jim, and thank you for that introduction, and cervical laminophuram anatomy. I'm gonna call it CLF, because it's really a mouthful. And actually,
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the article is entitled, is safer than anterior cervical discectomy infusion for lateral cervical disease And when I talk about lateral cervical disease, I'm actually including disc disease, soft
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discs, spondylosis, hard discs, unsanet hypertrophy, spurs, osteophytes, whatever you wanna call it, but it's basically located in the lateral cervical spine. I'm a major advocate for open CLF,
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and I'm gonna show you why. It's much preferred over minimally invasive or tubular approaches or endoscopic approaches. because I think it's critical to see what you're doing and have enough room to
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work around the nerve root extending for aminoleum, essentially, bilaterally. It's a much safer open operation and much more effective to perform this with the open procedure versus the minimally
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invasive or endoscopic. It's critical to surgical success and very importantly, it's gonna limit errors and mistakes This is an example of a figurative diagram. We're gonna use what we use in the
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MRs and CAT scans. We're gonna call this the right. This is the left side. And basically, I'm gonna be talking about ventral osteophytes. There could be a soft disc or an osteophyte that you see
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here. On the other hand, dorsally, it could be a dorsal facet hypertrophy or arthrotic or arthritic changes or ossification of the yellow ligament extending for aminole CLF
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avoids the major risks associated with ACDF entirely. the vascular injuries associated with the carotid and the jugular vein, tracheal injuries, esophageal and some of the neural injuries. So I'm
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just giving you a diagram here of the here is the ventral cervical spine, the longest calle musculature is seen over here. In front of that, you're gonna have the esophagus and trachea, but here
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are your bilateral carotid arteries. You're gonna have your internal jugular veins that are gonna be present Whether you're going from the right or left side, you're gonna have these vascular
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structures to deal with, your trachea is gonna be anterior and centrally, your esophagus is going to be dorsal to that, and you certainly want to avoid any esophageal perforations or compression
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that can result in significant dysphagias that is often seen about 30 of the time, at least transiently with anterior approaches. Also, you've got vagal nerve injuries, of nerve injuries that can
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result from these procedures. Just to go over this again, CLFs avoid these major risks and complications. Here is an example of an anterior cervical exposure. Let's pretend we're approaching it
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from the left side. Beneath this lateral retractor going from the left side, you're gonna have the carotid artery. You're gonna also have the internal jugular vein. You have to be very careful in
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older patients. Watch out for that carotid. You don't want to spew off any emboli giving the patient a stroke You have under the medial retractor, the esophagus and the trachea. Lots of times
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you're going to want to release that. Retractor intermittently to avoid esophageal traction injuries. You've got your anterior bone graft. Anterior bone grafts can be mistakenly impacted into the
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cord, resulting in quadriplegia. They can also dislodge postoperatively as well.
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And then of course, you have the anterior cervical plates and you've got the risks of the screws where those I've gone into. If it's too far laterally placed, they might go into the vertebral,
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then you also have the extrusion of the plates and screws that can result in other complications. So in short, CLFs result in fewer cord and nerve injuries, less of an opportunity for quadriplegia
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and injury to the recurrent laryngeal nerve that can result in hoarseness Forensic nerve injuries resulting in phrenic paralysis, unilaterally, although there are some cases where it's bilateral.
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Horner's syndrome, vagal nerve injuries, and very importantly, they avoid instrumentation failures because CLFs do not involve the
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placement of instruments. When you are approaching the cervical spine with a CLF, you're going to be doing your decompression over here, medial to the vaset joint on one side or the other You
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basically have muscle to deal with. Whereas anteriorly, as we've just gone over, you've got the trachea, you've got the esophagus, you've got the carotids on both sides, you've got the internal
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jugular veins, and you've got the
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series of nerves that I've just described.
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CLF also markedly reduce other risks associated with ACDF. They don't entirely eliminate them. But this is just a figurative diagram of a CLF being performed You're going to be removing the medial
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aspect of your facet joint and a laminotomy of the superior and inferior lamina.
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CLFs have many fewer cord and root injuries because you're predominantly working over the nerve root with minimal decompression of the cord involved. You're gonna have fewer dural tears and spinal
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fluid leaks. You're not going to have the same rate instability requiring fusion, and The risk of adjacent segment disease is there, but it's extremely small. Furthermore, your risk of vertebral
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artery injury is less. If you're going anteriorly and you're off to any degree to one side or the other, it markedly increases that risk of vertebral artery injuries, plus you may have aberrantly
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located vertebral arteries. I had one case in which it would actually looked like a disc herniation, but you're gonna largely avoid this with your posterior approaches. And here I'm just showing
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you where
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the vertebles are located. I thought this would be a great opportunity to give you a very quick introduction as to how to do a cervical laminophoremonotomy. It's being performed for
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unilateral cervical soft disc disease or osteopithe formation. Okay, you choose this. It could be at single or even multiple levels. It will preserve stability almost completely. Avoid the risks
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that I've already told you about for anterior dyschectomy infusions. but it's essential to provide adequate exposure and adequate exposure. Again, I'm emphasizing you need to do a partial
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hemilaminotomy of the superior lamina,
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partial hemilaminotomy of the inferior lamina. You want
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to visualize the course of that nerve root extending laterally and then for eminently because you're going to be working in the axilla of that nerve root in order to remove a disc or osteophyte with
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your dampening curette So here is a review of the first step. You're going to do the partial remover of the superior and inferior lamina. And here I'm showing you a diamond bit. Do not use a
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cutting burr. The cutting burr risks going right through the lamina too quickly, right through the oleigment and injuring the cord or the nerve root. It can also spit off or skive off and is not
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the way to go. You should perform your partial hemilemonautomies of the superior and inferior lamina.
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Use an operating microscope. This is not an operation you wanna do all by yourself without an assistant. You want your assistant to be able to see what you're doing. If you're not using a
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microscope and you're using loops, chances are, they're not gonna see what you're seeing and you're gonna see it better under the microscope. Furthermore, what everybody dismisses is the use of
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intraoperative monitoring. But intraoperative monitoring, I think, is critical not only to use your somatosensory evokes and your motor evokes and make sure you're not insulting the cord is, one
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would say, but also electromyography because you don't want to be over-retracting or over-manipulating the nerve root on that side
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and getting a deficit that you could otherwise avoid using the monitoring appropriately. So the next thing you're gonna do is perform your medial facetectomy for amenotomy. That's your partial
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hemilemonotomy above, partial hemilemonotomy below, exposing the nerve root. You can do this by shaving down the lamina until it's really paper thin. Use a one millimeter kerosene punch, even
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better than the two millimeter. And once you've done that, you can also use your up-biting caretts, sometimes to remove tiny residual fragments of bone. You want to preserve the lateral 23 of that
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facet joint, because that will allow you to provide stability or maintain stability and not end up having to go and fuse that patient Plus, you have the intact facet joint on the other side. The
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third thing is under the microscope and using monitoring, you want to carefully remove the yellow ligament. The yellow ligament removal is essential in order to adequately expose the nerve root
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laterally and foraminally. And here is just a figurative diagram of where your, here's your hypertrophy dual ligament and extends underneath the facet joint. That's actually where it starts. You
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remove the yellow ligament and then you end up with your. adequate and safe exposure of the lateral and foramidally extending nerve, which is your entire aim in this procedure is to expose that. By
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the way, doing anterior discectomy infusions, oftentimes you are not actually resecting or removing the lateral and foraminal disease at all. You may be distracting that level and hoping that the
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patient's symptoms improve, but that is by far and away not guaranteed whatsoever The fourth thing you're going to do, and this is carefully, is introduce a downbiting curette through the axilla.
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That's almost like the armpit of the nerve root to safely remove lateral dyskonostia fight. So you're going to dissect under the axilla of the nerve root. You can use a pen field dissector or a ball
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tip dissector.
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Introduce your downbiting curette very slowly and very carefully. Make sure you're not going to get a spinal fluid leak. Watch out for the motor root. Sometimes the motor root looks separate from
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the sensory root. outside the dural sleeve rather than inside the dural sleeve. And sometimes it's in its own dural sleeve, but it's a very, very thin one. The arachnoid, by the way, does
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extend out laterally and firmly, and you certainly don't want to end up with a CSF leak. You're going to then remove with your downbiting carette, the disc and osteophyte. Very importantly, when
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you use that downbiting carette, two hands. You will use one hand as a stabilizer. I'm right-handed So you use your left hand as a stabilizer, leaning on the patient, and then the right hand.
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Very tiny movements with that downbiting carette. You're typically not going to get out a super large free fragment. You're going to be scraping away a disc, osteophyte complexes. There was a
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morbidity mortality conference. I attended the other week, and they were talking about removing ossification of the posterior longitudinal ligament with a downbiting carette. Don't go there. Don't
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try that that is not the way to remove that.
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So now you've basically done an open cervical laminophoraminotomy. You've exposed and removed your lateral foraminal soft disc herniation or osteophyte. Here again is the illustration. It could be
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a soft disc or osteophyte. It is compressing the root laterally and foramily. Note how it's really not compressing the cord. So your dissection is going to be out here. Your anterior discectomy
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infusion is going to expose basically there And lots of times you're going to miss this lateral inframidal pathology. And again, just to repeat, this is your partial hemilamidotomy. You're taking
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off a portion of the lamina above a portion of the lamina below. So that's just showing or illustrating for you your bony decompression. And you're laterally inframily exiting nerve root.
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I would avoid, if I were you, the
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minimally invasive approaches, Neuroendoscopic approaches. They typically provide rather poor exposure and increase the risks of neurovascular, dural, and other injuries. I'd also emphasize that
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you should do that partial removal of the lamina above. And some studies will say, oh, you don't have to remove the lamina below. I think that's wrong. You need adequate exposure of both,
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especially if you're going to work in the axilla of that nerve root. So this is the approach that I would not do I went to some of the cadaver studies. Your ability to manipulate in a 360 degree
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fashion is totally limited if you're doing this. And there are lots of reports out there of cord injuries, root injuries, vascular injuries, you name it, not good. CSF leaks. So in summary,
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the pros for a cervical lamina for an anatomy, you will avoid the following risks that an anti-dissectomy infusion has. What are these? You can avoid the carotid. and the jugular injuries,
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because those are anterior structures. They're not posterior. You're gonna avoid the recurrent laryngeal nerve injuries. You're gonna avoid the phrenic nerve and the vagal injuries, the Horner's
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syndromes. You're gonna avoid the tracheal injuries. And you're also not gonna have the adverse events associated with implanting anterior instrumentation. It's not gonna extrude, it's not gonna
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go through your esophagus And it's not gonna cause anterior compression of the cord, dysphagia, difficulty swallowing, very common after ACDFs reported, and probably at least 20 to 30 of cases,
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at least transiently, post-operatively for up to several weeks. And very importantly, esophageal perforations. And here is an MR and a CAT scan of the same patient, C2, C3, C4, C56, ACDF,
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plate and graft But you can see here, these are your collections associated with your. esophageal perforation with this one-level ACDF. So everybody's very cavalier. They say, oh, it's just a
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one-level ACDF. These are higher-risk procedures, and they could be extremely high-risk procedures. You get an esophageal perforation. It could be a life-threatening procedure.
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Other pros for CLF over ACDF, it's gonna limit the chance for cord injuries and quadriplegia. You're not gonna be impacting a graft on the cervical cord if you go from posteriorly because there is
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no graft. You're not gonna have as many vertebral artery injuries because the risk of exposing it, you have direct visualization posteriorly. You know that your vertebral is way off to the side and
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you realize how far out you are off to the side. Whereas anteriorly, if you get off the midline, you'd be surprised how quickly you can find a vertebral you didn't wanna see. Dural tears and CSF
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leaks are going to be much, much less frequent. And instability requiring fusions, very, very rare with posterior procedures. Adjacent segment disease, since you're not doing a fusion, a much
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lesser risk of having problems at adjacent levels. Here's a typical example of a one-level ACDF. And here, years later, sometimes even months later, you have
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an antiserbical disc arthroplasty or disreplacement that had to be placed. This is not what you're going to get with a cervical laminophoraminotomy.
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Other major pros for cervical laminophoraminotomy and up here, you can see, again, I'm illustrating the very foraminal spur that you may have and the adequate decompression you're going to have,
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taking a portion of the superior and inferior lamina We're going to have less tissue damage. And all of these factors are going to be in the article that's going to be coming out shortly in SI.
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You're going to have reduced operative time. There's going to be less blood loss involved. You're going to have a shorter length of stay. And very importantly, it's going to be much less costly.
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ACDFs, the implants for an ACDF graft can be5 to7, 000. And
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the plate is another5 to7 or more So in short, my major message today is choose an open cervical laminophoremonotomy to deal with lateral cervical, dis-disease, or spondylosis. It's going to be
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much safer than performing anti-servical discectomy infusion. Step
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A, you do your partial hemilemonotomy above and below. Step B, you're going to remove the laterally extending yellow ligament. you're going to expose the forammonly extending nerve root. You're
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going to use a nerve hook or a ball tip probe to get underneath the axillary portion of that nerve root. And then you're going to introduce your downbiting curates underneath that nerve root and
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ventrally remove effectively the lateral soft disc or calcified spur. I hope that this will help everybody learn how to do this procedure It's been a forgotten procedure. Everybody goes for an ACDF.
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There can be major risks and complications associated with this, which are much reduced with a cervical laminophoremonotomy. I hope you will all try
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to do this procedure or learn from your older colleagues as to how it's done. Thank you.
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Okay, that was terrific. The questions I think the audience might want to know about
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First of all, and I think you mentioned that.
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Most programs, and I don't know about outside the United States, but my guess is it's the same, are teaching the ACDF. And so, I remember when we had some residents who were training,
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they weren't exposed to that. And so,
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also another comment, I'm sure you've heard this, I've talked to people who've been in practice a number of years And they've done 1, 000, 2, 000, 3, 000 ACDFs, never had a complication. And
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so, they swore by it. So, if you look at it from your perspective, which actually I agree with, it is the risk of having a possible complication or injury is far less with a posterior approach
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than with an anterior approach than you related out. And you know, the esophagus, you know, the trachea, don't have the vascular structures. I mean, there are all of these things can get in the
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way. And you do have visualization. One of the comments people are gonna say is, well, I can't get, let's say two things. One, I can't get medially because there's a spur, and look at the scan,
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and they see a spur which not only is lateral, but it extends medially. Or the second thing they're gonna say is if there's a laterally placed disc or spur, I can't get to it This way, what's your
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answer? Well, I think if you have anterolateral disease that's significant, this is not going to be the operation that you should be doing, because you're not going to have adequate
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maneuverability for the medial portion of that spur disc or osteophyte. It's excellent for the lateral and foraminal portion of that disc osteophyte complex. And in fact, anterior exposures I often
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completely miss. resecting the lateral forameral disc or osteophyte complex. And you can see on the post-operative CAT scans that the borders, the trough of the ACDF is medial to where this
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osteophytic complex may be. You know, your other comment about, well, you know, it's something that you're used to. The ACDFs rely on distraction of that interspace. And then they're hoping
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that the distraction will reduce the compression or traction on the nerve root. But that's not necessarily always going to be the case because some of these nerve roots are actually stuck to these
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ventral disc osteovite complexes, either by soft tissue or calcific tissue that's extended, you know, into and sometimes to and through the Dura. But just because you've done many, many, many
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ACDFs, the problem is not only are the people coming out in experience in doing cervical laminopharaminomies, but those who've trained them. no longer had to do them. It's really become,
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unfortunately, a lost art. But it is something that really should be rejuvenated because, first of all, we speak to and interact with a lot of people from the developing countries, so to speak,
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and this involves very little cost. There's no instrumentation that you're putting in.
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Other than using a microscope, which we've spoken to some colleagues recently where the microscopes that they have just sits in the corner and they don't end up using it, but other than that,
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you're not leaving an implant behind. So it has the advantage of cost, the advantage of a safer approach, basically through the muscle posteriorly, good visualization,
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you can make enough room to actually do this safely As I said, if you're using a. a tubular retractor or any of the endoscopic minimally invasive procedures, they end up inadequately exposing the
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nerve root and the people who are trying them basically swear off of doing it because they may end up with some nerve root injuries.
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That's probably a long-winded way of answering questions. No, I think that's all important information Another thing you mentioned is a cost, I'll come back to another question in a minute, is
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cost. I didn't realize that the cost of the plate was so high and the graft was, I mean, there's10, 000 in there, if you're really interested. There's a lot more than that answer, yes, yes.
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Okay. But one of the problems there, Jim, is the institutions may favor doing the ACDF because They take that. 5, 000, 6, 000, 7, 000 cost of instrumentation. And they're multiplying that
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four to five to six times in terms of billing out. So there's a financial motivation that may be actually twofold, both in the part of the spine surgeon who can choose to actually charge more for
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the operation and the institution that it can also charge more. Oh, comes the devil. Okay, so, okay, now what about the reimbursement to the surgeon for an ACDF versus a cervical laminol for
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immunotomy, is it the same or similar or not? The, actually in my review article, I have some figures there. It's, the reimbursement is essentially at least twice or what I had read about twice
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for the anterior cervical dyschectomy infusion as opposed to the CLF, the posterior approach. So it's much more, I thought I'm sure it's varied by state by state and insurance carrier
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but it's basically higher for the ACDF. So I remember talking to Vernon Mark who was a professor at Mass General. And he said, you know, Jim, the one of the ways we can probably change behavior
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and costs is if we paid a lot of money for the simple operation and less money for the more complicated operation. 'Cause what you've just outlined are incentives for the hospital and for the doctor
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to do this procedure, although what you're saying is the complications are higher and they can be more disastrous, really. I mean, these are not insignificant injuries.
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And so then you've got to measure that against what the malpractice payments would be and so forth and so on. And the malpractice cases, many, many more malpractice cases, into your cervical
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approaches. I can't recall a cervical laminoframanotomy case that I've ever seen, and I've seen multiple antisertical discectomy cases over the years. That makes sense. Now let's say, I'm
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thinking from
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the mass of neurosurgeons who's out there. If I'm in a
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country that has compromised resources and I can do the procedure without putting in a plate, without putting in a graft, get 'em home quicker, get 'em out of the hospital, that's a
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procedure I can offer that has a lot of advantage. The other procedure and many of these people are paying for it by themselves. The other procedure has much more cost to it and you've said how
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those costs get absorbed. Let's say - The other thing too is a lot of the present dictums. For a single level ACDF, a lot of the companies, insurance companies are requiring that those be
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performed as out of patients. So not only are they getting an inter-dissectomy infusion that is associated with higher risk and complications, but these patients are being sent home. Many of them
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the same day, many of them within 23 hours. Years ago, I reviewed a case in the United States. Patients actually didn't even have cervical disease of significance, had a single level ACDF,
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discharged home, had a cardiac arrest within two hours, died.
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I could. I remember when I was in my residency, one of the fellows in practice came in and was doing an ACDF and reported a quadriplegia. Yeah. 'Cause the bone graft went in too far. I mean,
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that was a terrifying complication. I just, I couldn't imagine myself experiencing that That's just terrible.
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Well, one of the things, another argument they're going to say as well, if there's a spur that's extending more medially, what are
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the indications that the symptoms you're saying are just lateral and root causes, even though they have a spur extending more medially, I could see where somebody would say, Well, that's the
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excuse. Let's go anteriorly. But how would you approach that? Okay, well, that's where changing your operation from a laminoframanotomy to a laminectomy may be the appropriate approach. Good,
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yeah. By doing a laminectomy, you're going to take into account that patient's cervical or dodic curvature, and you're going to determine how many levels do I have to decompress posteriorly with a
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full laminectomy to get that cord to migrate away from that ventral osteophyte, And that can then be an effective alternative.
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Interesting, interesting. Okay, let me see. Now, we also read in the past that you get a C5 for nerve-red injury. Is
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that, well, what is the truth and what is the myth? 'Cause people are sick from behind, you get 10 more. First of all, part of that is that they say, well, it's an injury to the C5 root, a
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deltoid parisis because the root is the longest root But actually, if you end up looking at a lot of studies in more detail, you have C6 and C7 root injuries as well. So it's really not just the C5
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nerve root. What they argue, especially if you do a laminectomy and you allow that cord to migrate posteriorly, that then you can get essentially a traction injury to the C5 nerve root. Anything
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at the C4 or 5 level will help facilitate that And that is the reason for the parasees occurring. particularly involving C5, but they can involve other routes as well. Okay, what if there's a
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laterally and a laterally placed cervical disc? It's basically mostly in the frame, and can you get it out with this approach? It's great operation for that. And you just have to be very patient.
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You have to make sure you have adequate lateral and for terminal decompression. You're gonna be using the downbiting correct One thing you have to realize is that the amount of discs that you're
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going to get out is tiny, compared with doing an ACDF, where you're taking out essentially the entire disc. But you get that fragment out. You then use your dental tool or your nerve hook
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underneath the root to make sure it's adequately and for amyloid decompressed, you make sure your EMG is quiet. If your EMG is making a lot of noise, you better back off, slow down, start all
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over again, give yourself more room. to maneuver in, but it's a fantastic operation for that. Good, good advice.
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And you're using, I remember when we first did these, this is a long time ago, I date myself, but they would do these sitting. And I know, and then you put the G suit on the patient and so forth.
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And then people, we even did this, I think we did the first microscopic cervical disc, and we put it in a journal, and I think people didn't see it, but you could do that a prone, and you have
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to flex and neck a little bit, so you get double-pump the spaces, and you could do it that way. I'm sure that's what they're doing outpatient. It's trying to do outpatient, and this is a
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procedure that could be done fairly quickly outpatient-wise. And people go home, what is the recurrence? people come back with a recurrence of lumbar discs. What is the recurrence? in cervical to
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cervical root spine surgery? Right, well, they say that the incidents of having to re-operate after a cervical laminar for aminotomy for either instability or adjacent segment disease is like 1
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over a five-year period, something like that. It's extremely rare, but if you do a cervical laminar for aminotomy, is there a chance that you're gonna be back there within a few years doing an
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anterior discectomy infusion? The answer is, yeah. But if you do an ACDF, the risk of recurrence or problems at that level versus adjacent segment disease is 5,
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so it's gonna be a higher rate with an anterior approach rather than a posterior approach. Okay, I think that's an important point too. Infection, I'm sure, is less posteriorly. You really
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shouldn't get it. Not so much.
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It should be less because it's a faster operation. You're not putting an instrumentation, but the problem is is the anterior cervical surgery, the risk of infection overall is like 1, or less than
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1. And just because the back of the neck, it's at least three to 5, it is higher. And one of the reasons happens to be probably people aren't washing their necks to the same extent as they're
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washing in the front of their cervical spine. So I wouldn't say that this is gonna be a lower infection rate. I think it's important pre-operatively to make sure that your patients are not only
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washing their hair, but making sure that they're scrubbing sort of the posterior cervical region. I went through a period of saying use chlorhexidine. Now I would not because it can be very toxic
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to the eyes and the ears, but you can just use a bated-on liquid, not bated-on scrub, but bated-on liquid to prepare that area ahead of time, maybe a week or so ahead of time, get some of the
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liquid and especially wash your neck. But the incidence of infection can be higher with posterior cervical surgery. What do you tell your patients on return to work? Can they go back the next day?
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Can they, may they go home? I'm going to go for an anatomy. One of the patients happened to
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be the relative of one of the fellow surgeons and he went back to work within like two to three weeks. I would say at least take two weeks You want to make sure that incision is adequately healed,
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preferably three to four weeks, something like that, but certainly at least two weeks because you want that incision to heal. You don't want undue motion. Lots of times you put them in a soft
35:01
cervical collar, actually ask them to wear the collar backwards. It's a little more comfortable and it's just more for comfort than anything else. And like a big reminder, don't do too much, let
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the muscles, et cetera heal. Because you're going through so much muscular muscle posterior,
35:18
more discomfort than often with an ACDF, but that should at least warn patients, be careful, don't do too much, let the muscle heal, and then go from there. Over the years, I think there have
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been various approaches to limiting the postoperative pain, the posterior incision either splitting the muscle or doing various things. What's your, how do you do this? How do you do this to limit
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the pain? I would still do, I would still do a midline approach and I would unilaterally just split the muscle off to the side, use a mireting retractor or something like that to do the exposure.
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I, you know, we also often inject the muscle itself as we're going in with marking to limit the immediate postoperative discomfort.
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There was a phase that we went through where we were on a pledge lit We were putting some steroid. We do not do that anymore. Do not put any gel foam in these wounds. Avotene you can use, but gel
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foam will swell and cause you a neurological deficit.
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So any of these other tricks I just wouldn't use. I know when you do the laminophoraminotomies and the endoscopic approaches, that's a muscle splitting approach, but it also can be more bloody.
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And as I said, the exposure is much poorer and the chances of nerve injuries, spinal fluid leaks, and all these other complications is much higher, or not relieving the patient's symptoms or
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complaints, not being able to maneuver underneath that nerve root. Well, I think it's terrific. I think it's a very common operation. It's not done a lot. I think you're right. It's
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almost forgotten, but if you just look at it anatomically, as you did in your first slides, It makes incredibly more sense to - to do this if you can posteriorly rather than anterior. I mean,
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your risk, your complication risks go way down. Absolutely. Well, I hope we can get you back to talk about some more things like decompressive limonectomy. How do we treat cervical spinallosis
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and some of the other things? Because these are common problems seen all over the world. And I think people need to have a factual basis on which to make a judgment And you're going to have all the
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references in the paper, right? Yes, references are there. The paper is there. Obviously, this is a free download journal. As you will know, Jim Asman brought this to the internet. It was the
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first internet neurosurgical journal. And it's out there, and it's a download for free. And I would say read it and talk it over with your colleagues and find a colleague who's done it and learn
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how to do it from them. Thank you very much We really appreciate it, okay?
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