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SNI Digital, Innovations in Learning, is pleased to present
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another SNI Digital series. This one is on Controversies in Spine Surgery, a lecture in discussion
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held on February 25, 2024, with Nancy Epstein, who is the Professor of Clinical Neurosurgery at the School of Medicine at the State University of New York at Stonybrook. She is the Editor-in-Chief
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of Surgical Neurology International, SNI.
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And this lecture that Nancy is going to give is on how do we limit harm to patients during Spine Surgeon's learning curves for a minimally invasive surgery. The lecture is 21 minutes, the discussion
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is 17 minutes
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Hello, everybody. I'm Jim Osmond. And here today with Nancy Epstein, who you know is that her surgical neurology international and has been highly regarded as a spine surgeon for 30 or 40 years.
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I don't want to say too many years Nancy, but 30 or 40 years has written probably more papers than most people and worked in spine all over the world and is well known for having a well thought out
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and well documented views, which may not necessarily be support everybody to agree with, but that's the purpose of SI Digital is to bring you the controversies in spine surgery, which Nancy is
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leading, so that you can hear both sides of the evidence and then make your own decision So Nancy, anything I missed?
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I think that pretty much summarizes it. I've been doing this at least for 38 plus years. And I think going into SI digital is really bringing it into a completely new venue. I would just emphasize
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to everybody, they can listen to today's talk, but then they should go back to SI and look at the papers because some of these papers are just about to be published. And they should, you know, if
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that's the way they learned, they can learn by SI digital plus also reading the papers, or having their colleagues read the papers. So this is what you're gonna present is a paper that you're is in
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process, is that right? Correct. And so they can read it there. Well, we'll have references at the end where you can - I just put SI 2024, it's about to be published. Yeah, so we'll have some
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key references at the end which Nancy has in more detail in the paper, but at least it gives you a start. And so Nancy, why don't we go to your talk we'll have some discussion afterward. So the
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question started to ask, and actually Jim and I had discussed this, is how do we limit harm to patients during spine surgeons' learning curves for minimally invasive surgery? You know, one of the
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most frequently performed procedures is the transferaminal lumbar antibody fusion, and out of that has arisen the minimally invasive transferaminal lumbar antibody fusion and many, many other
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minimally invasive procedures. You can see here, illustrated is the metrics column device, and here is the interbody device as part of the T-LIF, and here you can see the pedipal screws that are
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introduced precutaneously that goes along with the minimally invasive transferaminal lumbar antibody fusion. I'm going to start by defining minimally invasive spine surgery, and I think everybody
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pretty much knows what we're talking about here. you have illustrated the classical midline approach where you retract the muscles to both sides. This may be your exposure for typical open
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laminectomy or even discectomy. And here you have the metrics tubular retractor for a mastectomy. If you have this on both sides, it could be for minimally invasive laminotomies bilaterally to
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address stenosis Off here to the right, classic image of a minimally invasive X-lip being performed. And here the instrumentation for your minimally invasive anterior lumbar antibody fusion. So
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we're going to discuss these different procedures in different contexts. But basically, what's common for the minimally invasive surgical techniques? Less tissue disruption, muscle splitting
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procedures. The aim is smaller incisions with shorter operative times, reduced post-operative pain, shortened post-operative recoveries, and more rapid return to work.
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We're going to define the learning curve for these minimally invasive operations. And again, here are your minimally invasive tubular retractors, different systems have different sizes. But the
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classical sizes are that they come in lengths 3 to 9 centimeters. The 9th centimeter may be for your morbidly obese patient. And different widths 26 to 14, retractors are those of
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millimeters being classically used But we're going to use the following definition and we can discuss later if you have a better definition. But how many cases does a spine surgeon need to do to
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perform the surgery safely and efficiently? Others may say to become proficient in doing that operation. But the main measurements that are taken is to define this by reductions in the following In
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other words, how many cases does it take before the operative time is reduced, before you have less intraoperative blood loss? to reduce the length of stay of that patient post-operatively, to
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result in fewer adverse events, to result in less frequent conversions to open surgical procedures. And by the way, I think when you're talking about minimally invasive operations, there should be
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more conversions to open procedures when people run into trouble. And very importantly, how long does it take in order to get better outcomes?
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One of the first questions people are gonna ask is, let's just take for a discectomy. If you have a question of an open laminotomy to take out a micro disk or to do a micro discectomy,
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the answer is most studies show really no learning curve for the conversion. So here's your open laminotomy for the discectomy one day and the next day could you do a minimally invasive metrics
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discectomy? I did a review of this in 2017,
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it appeared to be no learning curve for the conversion.
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Vashnavidal in 2022, found also there was no conversion that was required before they did 114,
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then only a base of gesquecanese.
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Next, the T-lifts. And I'm going to show you five or six different studies. It's going to go in a time from basically 2014 to 2022.
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Learning curve in this study, the first 33 cases versus the next 32 cases beyond the learning curve. So what did they find in the first group? More drill tears, need for greater volumes of
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intravenous fluids, higher blood loss, longer OR times and anesthesia times, medial pedicle will breach documented on the CT scan, two instances post-op where it failed to fuse, one graft
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migration, and two re-operations. That is as opposed to the next group of 32 cases where they were considered beyond the learning curve, fewer adverse events were encountered, one infection, two
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pseudo-authorosis, three re-operations.
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And to your right, what you're seeing here is your classic derral tear, and you can see that there's a huge collection that's subcutaneous going all the way down into the canal. And then here's a
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figurative diagram of a derral tear So within the learning curve, you have more derral tears requiring repair. Again, I would just emphasize, if you have a derral tear, and you're not sure that
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you've got a good derral repair, you should convert to that open procedure, repair it adequately to avoid recurrent post-operative derral fistulas, adhesive retinoiditis, and everything else that
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you can get into in terms of trouble
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Also 2014 is another study of 44 cases, the first 44 cases versus the next 46. Again, more dural tears were required in this group and also more cage migrations. And here's an example where you
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can see a cage migration. So the first 44 cases of one dural tear, two cage migrations, longer OR times, fluoro times, poorer outcomes, as opposed to the next 46 cases where there was just one
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cage migration And interestingly, they found that for both groups, it was similar fusion rates and none converted to open surgery. Again, they're using not converting to open surgery as a badge of
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honor. I would just re-emphasize do what is right for that patient to correct the problem that you've created.
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2017, this was a review article that I'd written. 32 to 44 cases, that's the learning curve for the T-lifts. but it was for other operations between 20 and 30 cases. So the learning curve for
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conversion from open to minimally invasive laminectomy was 20 to 30 cases. Remember for your discectomy, it was none. But here your typical classic open laminectomy is illustrated. And the other
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operations include minimally invasive cervical procedures, anterior lumbar interbody fusions, percutaneous pedicle screw techniques, et cetera And on study in 2022, nine articles, over 750
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patients, T-lifts, the first 31 to 43 cases. That was the average number seen between these different articles. And again, here's your classic T-lift with four percutaneous pedicle screws being
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placed for the minimally invasive T-lift.
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And there is actually your exposure into the canal. Taking off the facet joint, actually rendering patient unstable. And more importantly, Here's your post-op study, that patient who has a unique
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new-sided, right-sided foot drop in this case, and there is your screw going across the spinal canal. By the way, this just underscores the fact, if you have a patient post-operatively with any
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of these procedures, and they have a new deficit, by all means, do a post-operative study. Try and find out what the reason is for that deficit to see if you can correct it I just ignore it
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because that is a problem that is commonly being pursued. In this study in 2022, 31
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cases were part of the learning curve for T-LIFs, and what were some of the adverse events, cage migrations, and screws in the canal. So here for this minimally invasive T-LIF, you have the
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normally placed inter-body device, and you can see it's not in the canal, the free space between the back of the device and the thegal sac, whereas here. your device has extruded into the spinal
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canal, as shown here by the arrows, figurative diagram of the screw across the canal, probably pithing a nerve root as it goes. And here is an example where they pith the nerve roots on both sides
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with the percutaneous placement of the pedicle screws. So again, if you have a patient with a new post-operative deficit, do a study document where the problem is to see if you can fix it Now,
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this is looking at the minimally invasive oblique lumbar antibody fusion, her olives. And this study looked at the first 24 cases for the olives versus the next 25. And what did they find? Well,
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here's your oliph exposure seen here. 375 of your adverse events occurred in those first 24 cases, whereas the latter 25 cases is only 20. And what were those? adverse events, more motor and
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sensory deficits. Typically, ilius hose quadriceps, more nerve injuries, more fluoro time, longer OR times. And
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I'm just gonna say emphasize, look at where your A-lift device, your X-lift device is here because we're gonna discuss this now.
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This was a study looking at learning curves for minimally invasive volus versus minimally invasive extreme lateral lintobody fusions. And here is your typical illustration of an X-lift device being
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placed. And it's the first 30 cases pretty much for both. That was your learning curve. But a 10 rate of adverse events for X-lifts versus 333 for olives. And the olives had more neural and
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vascular injuries, although they had, both groups had similar ages, clinical findings, blood loss, over times, et cetera. And here is another study looking at minimally invasive interlumbar
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interbody fusions The first 25 cases. And I think this was pretty staggering. 32 of your major vascular injuries that required repair and packing occurs for these first 25 cases. The last 20, next
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25 cases, none. So look at the mic difference between that for major vascular injuries. And it's no surprise for A-LIFs that you have some of these major vascular injuries because your access for
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the A-LIF is right in front of the vertebral bodies and right really between, typically youriliacs. In
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Schlefani's study in 2014, there were 14 articles looking at five minimally invasive spine operations and said that the general learning curve is 20 to 30 cases, and they looked at laminectomies,
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percutaneous screw placements, cervical operations, T-LIFs and A-LIFs. And here's your classical minimally invasive laminectomy with your tubular retractors used bilaterally. Here are your
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percutaneous placed pedicle screws. Here's your cervical laminophurambinotomy.
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Here's your typical X-LIF or T-LIF device, rather. And here's your typical minimally invasive A-LIF. So I'm summarizing here the different learning curves that we've just gone over. And if you
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look at surgical neurology international, it's still improved, but it's about to come out This discusses all these different learning curves. We already discussed the fact that for open discectomy,
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there's versus lean, no learning curve, and you switch to the minimally invasive discectomy. For minimally invasive laminectomy, it's 20 to 30 cases, T-LIFs, 31 to 44 cases, A-LIFs, 30 cases,
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O-LIFs, 24 to 30, and X-LIFs, 30 cases. So that's a lot of cases, basically, you're talking pretty much a minimum of 20 cases. and often 20 to 30 cases for all of these different varieties of
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minimally invasive procedures during which time patients can sustain injuries.
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One of the authors, Ferry, looked at the learning curve for minimally invasive spine surgery and actually asked what's the impact of training and experience here? And they found that only almost 60
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of studies discuss surgeon experience, you know, what happened to the other 40. Only about 40 looked at the number of years in practice as perhaps impacting this. But here is a staggering
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statistic. It's just 167 of surgeons, okay? Refallorship trained. Ever had done any kind of cadaver course or workshop on these newer procedures before performing them. And ever did the actual
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open operations. So here's like a classic open operation as a coronal hamilam anatomy. where you can see, particularly at the four or five level, as illustrated here, you have bilateral access,
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you can do a bilateral discectomy, a laminectomy, et cetera, but only, again, 16 ever did this open procedure, according to these, the statistics from ferry at all. Now, when you're a
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resident, the learning curves are basically satisfied under your attending surgeon and supervision. But what about after residency? Well, we just learned that only 167 of surgeons take cadaver
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courses to learn new operations. And here is your typical, you know, sagittal view of a cadaver, lumbar spine. But in fact, most surgeons just take the course, go home, and then they do the
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operations. But why shouldn't they have surgeon mentors or inpatient surgeons experience surgeons in the operating room? Certainly the sources of these experts can be industry, can be academia,
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and can be well-trained colleagues Why no mentors? Well. competition. Oftentimes in the same institution, you may have, you know, you may be the neurosurgeon and you just went to the course and
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the orthopedists have already been doing the operation. Why not scrub with them ahead of time? Why not have them scrub with you? Is it pride? Is it arrogance? Is it greed? And certainly is it
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financial?
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But these factors shouldn't be your major factors. It really should be the safety of the patient
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And if you summarize the risk to the patients of the lumbar of the learning curve for minimally invasive surgery, look at the different groups, T-lifts, more durable tears, blood loss, pedicle
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breaches, pseudothrosis, re-operations, poorer outcomes for the O-lifts, 20 to 24 cases versus the excellent 30 cases, more motor and sensory deficits, more major vascular injuries, for the
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learning curve for the A-lifts, major vascular injuries that are often life threatening, learning curve for the minimally invasive. Laminectomy, pedicle screws, A-lift, T-lift, et cetera, 11
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adverse events, more durable tears, implant male position, nerves, injuries, and suitarthrosis. So the main message is here are 20 to 30 cases required to satisfy the learning curves for the
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vast majority of these operations. For T-lifts, it's even higher, 31 to 44 cases. Well, shouldn't these learning curves be addressed to minimize the risk to patients?
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So can we summarize of how we could reduce the learning curve for minimally invasive spine surgery? If you look at different papers, some suggest mentoring, cadaver labs, models, and simulators.
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In 2017, I suggested mentoring programs. Sharif et al looked at structured training with cadavers and lots of practice. This is a quote, preferably while working under the guidance of experienced
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surgeons. And Kim Chi at all looking at 230 open versus minimally invasive thoracic and lumbar operations, education program, reduce the learning curve, educational aids, models, virtual and
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augmented reality aids, surgical simulators to reduce the learning curves for the spinal surgeons.
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So our major question at the end of all this, instead of answering something, we're actually asking, you know, how do we limit harm to patients during spine surgeons' learning curves from
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minimally invasive surgery? The answer should not be for the surgeon to go home and do the operation and get into trouble and end up doing exactly this, where you have the surgeons in the operating
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room saying to the nurse, nurse, get on the internet, go to surgerycom, scroll down and click on theAre You Totally Lost? icon. Thank you It was a very good concise lecture. I'm going to
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take the position of
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neurosurgeon and practice who is looking at some of these things. And I've got a series of questions here. If we look at this, you said the learning curve per procedure is at a minimum of 20.
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Could be 30. I'm in a residency. In my residency program, I work as fine surgeons, cranial surgeon, stereotactic, unless I get a fellowship.
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Is my exposure ability to get that experience with 20 cases per procedure? Is that likely for me to get that in just a regular residency program, or do I have to go get a fellowship to do this? I
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think that's a great question And I think most residency training programs at this point. in order for you to graduate from these programs, the ACGME requires a certain number of cases be done per
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category. So I bet many of these have 20 to 30 to 40 to 50, I mean, antiserbical discectomy infusions, probably has a requirement of 25, 30 plus, probably lumbar laminectomies and numerable
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numbers. For these minimally invasive procedures, I would think that now, as opposed to 20, 30 years ago, when there were really no fellowships available, it would really behoove those who
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really want to be spine-surdens to spend that extra year or two, taking these fellowships, take the opportunity, because once you go out into practice, you're never gonna get that opportunity
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again. And if I were they, I would take the fellowships to get that experience Otherwise it's going to be doing it by yourself, or if you're in an institution, an academic institution in
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particular, or in an institution where you have colleagues who are well-trained surgeons, at least take advantage of their expertise in terms of learning how to do these. I mean, I would just give
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you my experience. I mean, obviously this was back in the 1980s, and actually my father was a spine surgeon, and I came out of a residency at NYU Bellevue, where I would say almost 999 of what we
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did was brain surgery. And I was just lucky that I spent years operating with a really fantastic spine surgeon to become more of a spine specialist. And then as time went on and other procedures
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became available,
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I went to courses, my colleagues went to courses, we scrubbed together on a lot of these cases. to learn how to do these procedures, but now that you have these fellowships available, I would
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definitely take advantage of it and get as much training as you can. I think once I calculated the number of cases that you see your chief resident, or chief resident would do, is that you're
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actually the first surgeon or the first assistant. Right. And if you're talking about 200 days without the weekends, I know that some people got on print on weekends, but let's just take that.
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Yeah. And you're spending in the operating room, and most you're gonna do two major cases a day, and
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most, or it's a major case and then a smaller case. So
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if, and that's gonna be distributed, if you're in a residency between a whole different category of cranial and spinal procedures. Yes. If you're in a fellowship,
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you probably hit that number. in a, I guess, certainly in a year or so. Now, that's 200 total cases, but if there was 30 cases required for each, one of those categories you had,
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I think you may have had five categories. I'm up to - Easy, yeah. I'm up to 150 cases already. Yeah. You haven't done anything else. Yeah. And you haven't talked about anterior fusion or
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typical or straightforward laminectomy for a desk or something like that. Yeah So it would be, you'd get your numbers, but it would be, you'd be working to get that. Yes. So I think if you went
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to a fellowship, you'd have a higher chance of doing that. So now, let's say a lot of these things came out. I was trained, let's say 10, 20, 30 years ago. And I've had to go back and learn
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myself, either I go to a cadaver meeting in the Spine Instrument Company sponsors this. And I have a chance to work on the cadaver. and go through that, it may take a weekend. I can't take a
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whole bunch of time off of practice. Is that gonna be good enough to learn? And I think that's where the question that you're raising comes up, my father always said the pages don't bleed.
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And so you really don't have a chance to don't if you get a perforator or you've got this or that or the next thing. And you certainly don't see any post-operative complications if you're working on
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a good average. So it's obviously compromised as your time and then different manufacturers have different instruments and you might want to learn the technology with one which may or may not apply
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to the other and so forth. So the learning curve applies. Now you mentioned one of the things quick and quick passing. And that's - so how can I get more experience? Well, one is I'll say, well,
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I'm not
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But yet, what if I wind up doing it, you're into the high risk category and then the higher chance of a complication Yes, you mentioned early on, if I have a, I do a
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T. T left, and I may get to two to two migrations of the artificial implant I place, and maybe a couple of CSF leaks. I can see a group of people saying, well, okay, that's goes along with the
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procedure And
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everybody knows that I've talked to the patient about that as a complication. So what am I fussing about? How would you answer that? Well, I would say, first of all, if you're a surgeon and
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you're having those frequent complications. Number one, you should stop doing the procedures until you scrub with more surgeons who don't have those complications. Number number two. When you've
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gone to these courses, if you don't know how to do these procedures, these companies can identify surgeons that you could scrub with to see in an OR, what and better how to do it. You can make
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arrangements for other surgeons to scrub in with you in CITU. And very importantly, screen your patients more carefully Do they actually need the procedures that you're offering them? Furthermore,
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if you are having trouble and you have created, let's see you're having major bleeding or certainly if you're having major bleeding, then you know, call in your vascular surgeons, don't hesitate
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to get that kind of help. If you have a CSF leak and there's no way you're actually going to adequately treat it, then open that patient up and do the open procedure that you're familiar with But I
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would say if you're doing these operations and you're having high complication rates go back to doing the open procedures that you're more familiar with. So I've done my first procedure and I know I
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got a dural tear and I have some CSF in the way you name. Well, what's the best thing for me to do is put some jaw foam or something in there or some muscle and hope it goes away
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or maybe I'll get the microscope in there and see if I can sew it up or
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what do you advise? Because
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I'm in trouble. What do you advise? I would advise getting out your microscope. You should have had the microscope probably in the first place, but I would advise if you can't repair it and I've
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read these descriptions of trying to do a microscopic repair of a CSF leak and I don't really believe what I'm reading. I would say open the patient up and do a good repair because that's the patient
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who's going to get from the recurrent CSF leaks and end up with an adhesive arachnoiditis, they're gonna end up
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with intracranial hypotension and everything else that goes along with that. Open the patient up, put your ego aside and do what's right for the patient. Okay, it makes sense. Now, let me give
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you another one 'cause you're a direct experience with this. There's some orthopedic people in the community and they do the same thing
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You've worked with orthopedic surgeons and actually good ones. And
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another solution would be take up a conversation with your orthopedic colleague, the one who's got a good reputation and so forth in the community. And maybe you can wind up doing a number of
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procedures jointly. What do you think about that? I think that's a fantastic idea. I mean, I spent probably more than a decade doing into dyspectomy infusions with an orthopedic colleague. And I
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think we both learned a lot from each other. And what's interesting is, you know, it's not just the technical portions of the procedure, but I remember, actually, my orthopedic colleague was
30:05
doing an ACDF by himself at one point, and I was called into his room, and he said, look, we have semantic sensory vote, the motor vote changes, and I just put in the graft and it looks perfect.
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And I said, take the graft out, you have to downsize it, but take the graft out, wait for the SCPs and motor evokes to change and come back to normal and then put in a smaller graft. I would
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still say two heads are better than one, and you can actually teach each other to be better surgeons, and it's great to have the perspective of two disciplines looking at the same case. It's
30:43
perfect, I think one of the answers as well, Gee was I have to divide the charges for the case, But on the other side of it, what you're doing is providing a quality outcome which attract more
30:57
cases to you that you do with less complications and you should make it up on the other end. Was that reasonable? I think that's absolutely the case. I mean, there's nothing worse than having a
31:10
patient do poorly. And you don't want to sacrifice the patient for your ego And it's a big mistake not to put the patient first. And if you have any question, consult that surgeon before you do the
31:26
operation. I mean, this is like, you know, you go to Morbidity Mortality Conferences and then you go to Spine Conferences and trying to get people to come to the Spine Conferences and bring in the
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case before they do it. Get everybody's expertise in there. And then you can actually choose to do the case with one of your other orthopedic or neurosurgical colleagues, whatever it takes. but
31:48
get that added information so that you're gonna do the best operation for that patient and think about it ahead of time. How often are surgeons now going to the ORs and they're unprepared? They
31:60
haven't thought about it ahead of time. I mean, I trained with Joe Ranssehoff and he said, again and again and again, you do that operation hundreds of times before you ever get to that operating
32:12
room. It saves the patient time, time is infection and it saves the patient the complications. And you have to know all the parameters of how am I gonna deal with this complication or that
32:25
complication, but you have to think about it, you have to prepare and somehow preparation is gone to the wind, especially what I hear all the time is, oh well, it's the residence case or it's
32:36
from the clinic and so the attending just comes in cold without having adequately reviewed or thought about the case much less the resident having thought about the case ahead of time and therefore
32:45
nobody is prepared do it correctly. And then of course they might put up the wrong x-ray and then up doing wrong sided surgery when wrong level surgery. So I think two heads are better than one
32:58
and one should take advantage of that.
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You touched on something a little bit ago on monitoring. You do monitoring on all these cases and what does it tell you? Do you have confidence in it? When do you stop? What do you do? I think
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using monitoring in all cases is critical. Even if you're doing discectomies, when you have
33:26
exposure and you're starting to retract a nerve root,
33:32
too often you or your assistant may be over-retracting that root. I mean, what's the most common complication you're seeing with T-lifts, by the way, or minimally invasive T-lifts? You're seeing
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traction injuries, the foot drop, post-operative foot drop. If you have decent intraoperative monitoring, you're going to see changes, at least on those EMGs, to tell you something's going wrong.
33:56
You're over-retracting, change what you're doing. Too often, they're using intraoperative monitoring only when they're putting the pedicle screws in place, but really, you should be using the
34:09
monitoring when you're doing any of the decompression. When you're studying your laminotomy, when you're doing your medial facetectomy for aminotomy, when you're retracting that route, you're
34:17
taking out the disc or you're decompressing the stenosis. It's surprising how often you can get changes during these portions of the procedures that you would not otherwise anticipate, but you're
34:29
gonna use it and avoid getting the post-operative deficits. So I would definitely use them. Let me follow up on that. Let's say I'm in a place where it's not available to me or let's say I'm in
34:41
another country where they don't have
34:47
interoperability terms is easily available. What would be your suggestion to the surgeon there? Do a bigger operation? Do the open operation where you see everything?
34:59
Don't go for the thing where you're gonna have your complications. What's your suggestion? Well, I would say some of these
35:07
hospitals in other countries, 'cause I went to one a few years ago and the microscope was in the corner And I said, you use that routinely, don't you? And they said, no, rarely. Takes more time,
35:21
takes more effort. Well, the answer is use the microscope number one. Number two, make sure you have adequate exposure. If you do not have interpretive monitoring, you have to be triply paranoid
35:33
about having adequate exposure to limit the amount of retraction of that in order to do the operation correctly Okay, another question, yes.
35:46
There's a lot of technology being developed, technology to put in screws, which has been around for a while, but it's getting more refined technology that can define more the anatomy of where
35:59
you're going.
36:01
What's your feeling about that? What is, and I'm not sure that we have enough cases to know, you've seen the literature, what's your feeling at this point? I think everybody has to take a giant
36:14
step back and say, is this an operation in this particular patient that warrants doing a fusion at all? Do we need to put any screws into this person? Can we just do a decompression? Isn't that
36:28
the best operation for this patient? If we're going to put in screws, let's limit the number of levels that we're doing. How often are you seeing the 80-year-old who is getting a five-level
36:39
interbody lumbar fusion or something that's going from the thoracic to the lumbar spine that they can't possibly require, and then post-operatively big surprise, morbidity mortality is extremely
36:50
high. So I think more judgment, less surgery, and a better knowledge of the medical issues that their patients face if they choose to do the more extensive procedures, are those procedures really
37:05
warranted? And they have to also back up to basics. What's the neurological exam? Does it correlate with what they're seeing radiographically? Have they done the MR scan and the CAT scan to
37:18
adequately document the pathology to make sure they're doing the right operation at the correct levels? So all of those factors, I think, go into it. There's the whole aspect of planning. Is that
37:31
patient properly screened to have the operation that you're planning to do? And is that the right operation for that individual patient? Or are you going to hurt that patient?
37:43
It looks like if you look at all three of those operations, the actual FOLF and TLIF, the goal is the same. Has to essentially take out the lesion, take out the desk and open up the disk space,
37:57
spread the bodies apart, put
38:02
a graft in between. What would be the reasons to do something other than a TLIF? 'Cause once you get into more lateral or even anterior approaches, it seems like you're into more real estate that's
38:15
gonna be risky. Yeah. Well, I think first of all, when you're doing the TLIF, as I commented at one point, when you do a TLIF unilaterally, you're typically knocking off the facet, so you're
38:27
actually creating the Iatrogenic instability that you're then gonna treat with the pedicle screws. Do
38:33
you really need to take off that facet joint in order to get the exposure that you need? Can you just do a. a laminectomy and medio-facetectomy, frame anotomy, angle the
38:43
table, use your microscope and
38:46
decompress that patient without doing anything at all. Then if you're gonna choose to do the T-lift, can you just do the one level, don't do multiple levels if not needed. The X-lift, the A-lifts,
38:58
the O-lifts, those are ways of distracting the interspaces and putting an interbody fusion device in place And indeed, the complications that you're getting into or the adverse events that you're
39:12
encountering with these can be horrendous. If you look at the oblique lumbar interbody fusion, you're trying to go between those blood vessels and the muscle laterally. If you're doing the X-lift,
39:28
you're going straight through the SOS muscle, which contains, I think surprise, the lumbar plexus, And then you're getting a 40 risk of motor and sensory deficits. associated with that. If
39:39
you're doing an ALIF, that's to stabilize that level, but if you look at the real estate there, you're going right where the blood vessels are. The risk of the vascular injuries, life-threatening,
39:51
et cetera, are usually fairly horrendous. And with an ALIF, of course, you're not taking out a disc, you're not decompressing the nerve tissue, you're just distracting the interspace. So you
40:04
really have to take four giant steps back and say, Why am I doing this operation in these patients? And I think a lot of these procedures probably don't need to be done in most of our patients. Are
40:16
these all in-patient procedures that they can be done in outpatient centers?
40:23
Well, I think unfortunately, too many are being done in outpatient centers and they're not paying attention to the patient's comorbidities. In other words, they'll take a 30-year-old and say,
40:33
Well, I'll do an outpatient XLIF in this patient And then they'll take the 75 year old. They'll do the outpatient X-LIF or T-LIF or whatever the operation happens to be. And then that patient comes
40:45
back in a few hours later,
40:48
could be a bleed, could be with urinary distension, could
40:53
be, you know, post-operative hypotension, AFib. The numbers of complications can be endless because if they are doing an outpatient procedure, they're gonna be more hesitant to leave a draining
41:06
place. Also, during that period of time, if there was a CSF week and they repaired it, too often they're still trying to discharge that patient. And then you have no way of observing, or do they
41:21
have intracranial hypotension as soon as they stand up, is a whole lot of CSF gonna start pouring out.
41:29
I think too many of these procedures are being done as outpatients because it's convenient for the insurance companies. there's pressure from the families.
41:43
The surgeons can sell it. Well, you know, you'll be here. You're just gonna have a few hours with us, and then we're gonna send you home. And that it's not necessarily safe for the patients.
41:55
Okay. Any things we didn't discuss that you wanted to add? I think that
42:03
a lot of surgeons have to step back And everybody's more and more afraid of, you know, am I gonna be sued for this? I'm gonna be, am I gonna be sued for that? And the answer is,
42:16
the biggest thing they have to do, post-operatively, if that patient has an adverse event, they have to figure out what went wrong, and they have to treat it. They have to do the post-operative
42:31
MR, they have to do the post-operative CT scan, Whatever it takes, don't delay it. 24, 48, 72 hours, don't avoid it completely and don't do anything for a year 'cause we've seen this done.
42:46
Figure out what the problem is and fix it. Because I think that is what patients find unforgivable. And that's what most of us as colleagues as surgeons find wrong.
42:59
Yeah, that's a terrific summary of a challenging controversial issue I have no doubt that the payment for the complicated procedures like the X-Lift deal, if all of that. And I pay much more money
43:15
for the hospital and surgeon than less complicated operations, true or not true? Absolutely true. So got to be careful there. Well, okay, Nancy, we really appreciated terrific review.
43:28
Everybody can look for the article in SI, Surgical Neurology International We'll have some references at the end of this video. And you can look at that, but it should be published in the next
43:41
month or so, right? Yes, absolutely. Okay, terrific job. Thank you very much. Okay, thank you, Jim. Okay.
43:49
The references for this talk will be found in a paper on how do we limit harm to patients during spine surgeons' learning curves for our minimally invasive spine surgery.
44:02
The papers in press should be available on Surgical Neurology International, SNI, on February or March 2024. Other references mentioned in this paper should be found in the published document.
44:19
We hope you enjoyed this presentation. The material provided in this program is for informational purposes and is not intended for use as diagnosis or treatment of a health problem or as a substitute
44:35
for consulting a licensed medical professional.
44:42
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44:53
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44:58
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45:09
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45:25
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