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SNI Digital Innovations in Learning is pleased to present.
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Another in the SNI Digital series of Controversies in Spine Surgery,
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with the lecture and discussion by Nancy Epstein, part two of this lecture on synovial cyst is entitled Should Patients Be Carefully Selected for Lumbar Synovial Cyst Surgery?
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Spine surgery tips to avoid complications
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Nancy Epstein is a professor of clinical neurosurgery at the School of Medicine at the State University of New York at Stony Brook and she's the editor-in-chief of surgical neurology, International.
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She's internationally and internationally known spine surgeon, has been in practice for 40 years and has one of the most extensive bibliographies of anybody in doing this work.
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Patients should be carefully selected for lumbar synovial cis surgery. Patients who are not great candidates for lumbar synovial cis surgery or any spine surgery, you have to look at the major
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comorbidities. Some patients are not going to be surgical candidates. You're going to have to sift out those with a recent MRI scan within the last six months. Decorate direct contraindication.
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Those with coated stents still in their aspirin clavics, especially in that first year, peripheral vascular disease, COPD, those with stroke. So these are some factors that you have to look at
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very, very carefully. On the other hand, as I was telling Jim this morning, I have a patient who I saw up north via telemedicine who was extremely quadriperetic in a wheelchair. He had very bad
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cervical disease. And basically I said, why not consider him for a cervical laminectomy without a fusion if he can pass medical clearance. So you've gotta be very careful in terms of who you choose
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to operate, but don't just really nearly say patients are not candidates if indeed they could benefit from surgery. Before you do that, can you go back, is that a patient, go back to the other
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side? Is that a patient you're doing on outpatient center? Oh my God, no Okay, that's a fantastic question.
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Basically, there are many too many operations being done for insurance purposes and financial purposes and expediency and because many surgeons actually own pieces of outpatient spine centers, these
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are being done in outpatient centers and they're putting patients' lives at risk. And the older the patient, the more the comorbidity, the more likely than not, they should be done in patient
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centers where they have intensive care units, they have monitored beds and stepped down units. Patients are not gonna come back at midnight because they were unable to urinate. The patient with a,
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especially a cervical problem comes back with a hematoma that patient may be dead. And that's, I've seen cases like that. So you have to be very careful as to where you're gonna have an operation
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done the older you are, the more you should question where certain is trying to do your surgery. Let me ask you this. There's one thing that's not on your list. 50 of the world is overweight or
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has a major obesity. What kind of problems does that bring to doing surgery or even this kind of surgery?
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If a patient is really morbidly obese, you have to see what the neurological deficit is. In other words, in those patients, you're gonna try not to operate on them unless they're really paraplegic,
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in which case you're gonna have to try and operate on them. But the obesity and the morbid obesity, in particular, are going to increase your risks of phlebitis, pulmonary embolus, respiratory
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depression. There's also reported increased intraoperative risks of spinal fluid leaks, visualization, wrong level surgery in particular, because it's hard to get a good lateral view and determine
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exactly where you are and especially at wrong level surgery.
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The obesity is a factor. It definitely makes the surgery more difficult. If you read any papers saying obesity is irrelevant, go back and reread the paper, and very likely it's not a study that's
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been well done. Okay, and it even increases the argument for not to use minimally invasive. In these
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patients, it's invariable, especially because of the potential for wrong level surgery You're gonna have to do laminectomies in these patients. You need to really know where you are. You're gonna
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have to put a pen field elevator, not only in the interspace, but in the disc space itself to make sure you're at the correct level. And you may have to get several films with your radiologist in
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the OR with you to identify exactly where you are or are supposed to be. And also I would emphasize that pre-operatively, you have to have that X-ray, not only AP lateral X-rays, But let's say
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your patient has four lumbar hernomer. you should have gotten AP in lateral, not only lumbar films, but also chest films, to count how many, you know, thoracic ribs you have. So doing wrong
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level surgery can be a major problem in your obese patients, and it's whatever it takes. Get whatever room you need to do the best operation possible, because boy, if you have a CSF leak, it's
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gonna be miserable in terms of repairing it, and then miserable postoperatively, if they have recurrences in terms of the trouble that they can get it to Terrific advice, just terrific.
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The
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multiple surgical choices. You can do an open laminotomy, hemilaminectomy, laminectomy here, I've illustrated, or actually my father did the illustrations. Here's an illustration of an L4-5,
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partial laminectomy of L4 above, partial laminectomy of L5 below. That's your left L4-5 laminotomy. On the right side here, and going all the way down here. This is L3-4, L4-5, L5-S1. This is
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an L3 to S1 hemylaminectomy. Now that may be good for stenosis, but not in your patient who is really severely stenotic because you're not gonna deal with stenosis adequately on the other side of
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the spinal canal. So when the patients who are severely stenotic, you're going to wanna do your full laminectomy as I've illustrated here, okay? This is L5, this is L4 You've done a complete
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laminectomy taken out, the spinous process, medial vasotectomy frame anatomy, and you can be compressed both sides. So I'm gonna go over this point actually again, and again, and again. So here
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are L4 final. Can you go back to that for just a minute, I'll ask you a question. Sure. Okay, I've
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learned that I should only take the medial aspect of the facet. Can you show me where that line is, where the medial aspect is? Okay, actually, it's easier here in the Laminotomy.
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Okay, you see I've taken a portion of the laminar above. Yes. And here's your facet joint. So you take a little more of the facet. So, and then you take a little more of the facet below. We're
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here, let's take the intact. You do a partial laminectomy here, laminotomy. See where I'm drawing there. You take that much of the facet joint. You leave the lateral two thirds of the facet
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joint and that should leave you with stability. Here's another example Here is at the three, four level. That's the L4 inferiorly exiting nerve root. You've taken a partial laminotomy. You've
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taken the medial aspect of the superior reticular facet and inferior reticular facet. And that has now given me adequate exposure of that L4 root.
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Okay. Okay, you're - If I go - Your caressant punches are critical for this. If I go on, I have to follow it out and I destroy the facet. I go further than that Is that mean? definitively the
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patient has to have an instrumented fusion there or not? No. In your older patients in particular, if you have to go laterally, for amylae, for laterally to make sure you define the nerve tissue,
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you save that nerve root, you decompress it, you do not have to fuse all of those patients at all. The other thing is, as you're doing these decompressions, you can save the bone that you're
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removing You can have your nurse clean off the bone, because you're going to have your transverse processes out here and out here. So once you're done with the decompression, if you've taken off
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the full facet, you can actually do a non-instrumented postural lateral insight to fusion, non-instrumented fusion. You put your bone chips, they coalesce out here. And actually, if you look at
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your CAT scans three and six months later, a lot of these patients will go on to fuse about 86 of the time.
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You just leave the chips there and you have to roughen up the cortical margins. The transverse processes, you take a cutting burr to rough up the cortical bone, exposing the cancelous bone, and
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then you apply the bone chips directly to the cancelous bone. Terrific, okay, terrific, great. That's how you do a non-instrumental fusion, actually.
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Okay, so here, examples of laminotomy.
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Here you have not much arthritic change here. Here are tremendous arthritic changes via a reticular facet L4, 505S1. Here
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you've done a laminotomy at each of these levels. Note at L5S1, it's a much wider interspace, and you can actually get out much further laterally without knocking off the entire facet because here,
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you see 23 of the facet is still intact. Okay.
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Then here's another illustration of the same thing You've got the
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L4-5, I don't know what's going on here.
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Sorry, we're going to just go back. No, it's okay. You've got the laminotomies over here, L4-5, and down here, L4-5-1. Okay. See that? Okay. Here, let's look at an open hemylaminectomy
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This is, it's going to expose.
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This is L5, hemilaminectomy here on the right of L4. Okay, at the four or five level, this is gonna be L5 inferiorly. The voraminally exiting nerve root is gonna be actually L4,
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okay? As opposed to
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over here, this is the L4 level as well. You're looking at dorsily here on the left. It's just been illustrated. This is the L4 hemilaminar and the
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inferior articular facet. So we're gonna plan to do a complete facetectomy here, but this is what it's gonna look like over on the right side. Once you've done that, you've exposed the foraminally
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exiting nerve root. That's the dorsal root ganglion. You're gonna see the inferiorly exiting nerve root. And this might be your disc or synovial cystic stusion that you're decompressing.
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A coronal hemilaminectomy is also a very good way for decompressing stenosis. And here it's, you remove a portion of the lamina on both sides above, including the spanish process, half of the
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spanish process of L5 below, and half of the lamina below. It exposes your dura and the L5s, the L5 nerve roots, extending laterally on both sides So this is an excellent alternative, you
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preserve the lateral 23 of the set joint, and therefore stability in most of these cases. And here is an example of what it's going to look like if you do it in true color. So the beauty of this is
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you see this space here, your pedicle is lateral, it gives you room to work on both sides. And if you take off your spanish processes and the interest spanish ligament, you can have much more
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maneuverability to look at that synovial system. decompress the stenosis on both sides simultaneously. Again, emphasizing, getting yourself enough room, sparing the nerve tissue. That's really
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what your aim is in any of these.
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Okay.
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Here is an operative photograph. Here is Cephalad Caudad. All of this tissue, this is yellow ligament And remnants of synovial cyst capsule here, and that's what you're trying to show.
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And here's the surgical removal of a lumbar synovial cyst.
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There's your synovial cyst. And then here is your synovial cyst pathologically that you've actually removed. So here you can see this is a kerosene punch underneath here, but this is the cotenoid
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that is defining the,
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the rim between the overlying synovial cyst and the underlying dura. Otherwise, you would never put a kerosene punch underneath a synovial cyst like this, unless you clearly have that plane
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demarcated. Otherwise, you're gonna get a massive CSF leak. And in some cases, you're not gonna see that plane and you can't do this kind of decompression, in which case, you then go right into
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the synovial cyst to do the procedure.
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Here's a decompressed nerve root and the thicosac after you've completed your synovial cystere section. Your decompressed dur is medial and here is your decompressed nerve root scene to the side.
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Sometimes going into these cases you only see the nerve root after you've adequately decompressed everything. It may be the last thing that you're going to see. That's why you can never blindly go
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in without enough room and just start taking things out. I think you really emphasized here you really have to understand the anatomy and delineate the anatomy of the lesion and I was just going to
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ask you from the previous slide because and that slide you said you couldn't see the mirror root to the end. It's like taking out a meningioma and getting to the vascular supply at the end you have
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to go around it and go around it and maybe you go inside you decompress it and I think is that what you were referring to and you're kind of collapse it so you can see more. Is that right? Yes,
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absolutely. And actually, if you are inside the Synegulist capsule, you may just like taking out a meningioma. You may be, uh, hyphricating the capsule, taking your Penfield elevator, getting
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a little few millimeters, maybe seeing a little more dura, and then you keep going around and around and around and around. You may get lucky and be able to completely resect that capsule. In
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other cases, you may get to a point where it's densely adherent. Let's say you've done all that, you've done a great job, but there's just some, it's just adherent to the nerve, redura, and
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sleeve. You know, obviously, you don't want to go in there. If you left a little bit of capsule left, does this recur, or do you have to worry about it? What do you do? You hypercate whatever
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capsule you can. You make sure that there's adequate decompression around so that you're not leaving any nerve tissue really compressed. The synovial cyst is not going to recur under those
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circumstances. You just have some residual scarring in and around the dural on your post-operative studies. You're an etyplurinee, excuse me, you don't have to put any agent or chemical agent in
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there to kill the remaining cells in the cyst wall or you just leave it alone. You just leave it alone because that could be disastrous and you certainly don't want to put any steroids in there
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because, you know, there were the old days where we would actually take a pledge late and put some steroid on it and leave it in the wound and that kind of thing. You don't want to do that. You
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want to leave it clean and clear. Because the steroids is going to endow, say, an inflammatory response, or? It
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can, but worse than that, it can cause the tissues to break down and increase the risk of a CSF leak. Oh my, okay. Good point. You really don't want that. Good point.
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they're more risk with the minimally invasive procedures for these synovial cysts. And here, you know, you're trying to work, you know, contralaterally, you know, certainly
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taking out stenosis, working contralaterally. This is well described with the minimally invasive approaches. But again,
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that maneuverability is what you're going to lose in these, with these tubes, because if you look at the size of the tubes, look at what I have here, the tube widths vary typically from 14 to 26
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millimeters, 26 millimeters is an inch. If you're trying to manipulate within these tubes, it's going to markedly limit what you can do. Now you can move the tubes around, but it's still not
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going to give you the maneuverability that you often need. The tube lengths, by the way, often vary from three to nine centimeters. So actually, you can use those in some of your more obese
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patients. But Basically, the tubular approaches give you higher risks for all kinds of problems, limited exposure, more neural injuries, more neural injuries, more infections, longer OR times,
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more CSF leaks.
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You have to ask yourself, is it really worth it because the patient wants a smaller scar? They would be much better off having a bigger scar and much bigger scar and no CSF leak than having a CSF
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leak that can really cause them a problem. Excellent advice, excellent.
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There's increased risk for minimally invasive resection. This
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is just another example of what it
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looks like through your minimally invasive approach and your tube. So here's an illustration, there's your synovial cyst. This may be ossification or your hypertrophy of your ligament and right
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down here is your dural sac but you're coming right down on it. How are you going to get that maneuverability to get in and around to be twixt in between? What about the nerve root that's ventral to
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it and extending superiorly or the nerve root that's ventral to it and going inferiorly? And then again, what about that dural sac? Are you going to end up tearing that because there is an adhesion
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there that you didn't think you had? So again, not worth it. Do an open procedure if you need to The increased risk for minimally invasive surgery. Here's your classic T-lifts, steep learning
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curves, by the way, for T-lifts, a learning curve. We just wrote an article on that. You can also read that in SI between 33 to 44 cases for a T-lift before you are proficient. But also, the
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T-lifts are going to increase your risks substantially of everything I've been talking about, your residual synovial cyst, nerve damage, corticoidous syndromes, continued nerve compression, CSF
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leaks, everything else.
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You get more CSF leaks with the minimally invasive approaches to
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synovial cysts and this is what it can look like on a post-operative MR. It was an L45 level procedure. This wasn't my procedure, but this is pictures that I've gotten off the Internet. Large
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dorsal CSF leak and here it is and it's coming right sub-Q. Unfortunately, a lot of people don't even believe it because some of these people go back and forth to an emergency room. It's only when
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it finally leaks out That they figure out they better do something about it. I can't tell you how many cases. They may have plastic surgery, close these patients for them, and when they show up in
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an emergency room, they send down plastic surgery just put in a stitch. Well, if you can't see any fluid, then maybe it doesn't exist. They even fail to do often MRI studies and just send them
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home again,
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and again and again. This is what the Dural Leaks can look like when you get those MRI scans, but then you have to do something about them. just sit there and not do anything at all. This was a
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series that I had written about in 2015,
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336 laminactamines and non-instrumental fusions, the kind of fusions that I just spoke about where you can decordicate a transverse process and you can put the patient's autogenous bone chips in.
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It's going to fuse like 86 of the time with instrumentation might fuse like 90 to 95 of the time. Six of the CSF leaks in this series were due to synovial cysts.
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And here were the other reasons for these leaks. Seven previous epidural injections. Well, some of those were probably attempted percutaneous procedures. Three were intradural tumors. Of course,
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you're going to get, you've got to go through the CSF to do that. Three had ossification of the olegment, and three had post-operative scar formation. But again, these are going to be the cases
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where you don't want to get this post-op CSF lead. where it's this massive. You know, you want to not only not get the leak to start with, okay? If you get that leak and you're doing a minimally
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invasive approach, I would recommend highly. You convert to an open procedure because the only way you're gonna get a good, durable repair, it usually is going to require that open surgical
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procedure. Otherwise you're gonna be back here again and again and again with the recurrent leak and all the problems that go along with it. Some of which can include life-threatening infections.
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Can you go back to that? If you come back to that for just a minute. If you look at the slide or the complications, you've got 24 CSF leaks, okay. So it's maybe 8 or something like that. You've
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got six synovial cysts, that's 2. Now you're up to 10. What's the
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ESI? Epidural Stearnger. So these patients have epidural injections prior to surgery, and unfortunately it resulted in, you know, like holes all over the place that you have to repair. Probably
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some of those were also attempted percutaneous aspirations
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So, and, and, and OIL, what's that? Ocification of the yellow ligament. So you're into it, intradural tumors you anticipate anyway, and then postoperative scar, you know, it's going to be
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another big. So you're into at least 10 complications right there, and this is in open lumber laminating activation non instrumented fusions That's from 2015 so it's a microscope and everything else.
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Yeah, this is already 10 that's you're already in trouble. Yes. Yes. And then there's some additional problems that you've caused which are another probably another 10
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So, okay, I mean that puts it in perspective so you got to cut that number down. That's the point. exactly. And that's why realizing that synovial cysts are such a common reason for an
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intraoperative CSF leak, you have to be even more vigilant if you encounter a synovial cyst to say, hey, I'm just going to do a partial resection of this if I manage to get out the entire capsule
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great, but I'm not going to risk a CSF leak trying to do that. So it's like a mental error in baseball. You're prepared with all the different options that you have to try and avoid getting a CSF
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leak if you can.
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And then of course you have what's the best dual closure technique.
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You see too often people are using a proline suture. A proline suture is going to curl back on itself and loosen. Interrupted sutures are critical. Running sutures, the worst way to repair a CSF
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leak, even though you see studies that say, oh, they're comparable But think about it. If you have an interrupted stitch and one stitch blows, you still have the other stitches that are there and
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working, whereas if it's a running suture, the whole thing is going to open up. The other thing is the type of stitch, really seven-o-gortex sutures, and I don't have any stock in this company,
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but they're the best because the needle is smaller than the suture itself. So the suture is going to block up the hole that you're creating while you're doing these repairs. The microdural staples,
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you actually put in your sutures every few millimeters, and then you have to bring up your dural edges with a, you know, a pen-filled elevator or something like that, old it up, and then take
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your staple and go over the dura. So you, you avert the edges of your dura and then come across it with the microdural staples. You always do a vasavumad over and make sure that it's, you know,
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it's watertight. Always,
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I would always use a pipe and sealant. Dura seal FDA approved, but there've been too many reports where it's glommed together and formed masses, making patients paraplegic or quadriplegic. I've
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used something called Taseo, many, many, many times, and that seems to work very nicely. And Resorbs in about a week, the Duroseo takes usually months. What is the name of the thing again,
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that absorbs within a week? What was the name of the substance? Taseo, T-I-S-S-E. Taseo, okay. Yeah, and then over that, you use Durgin or what's called microfibular collagen So you want to
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create a watertight dural closure. That means you do a foul few valsabra maneuvers to make sure it's watertight. You use your sutures and your staples that you can see here in the images that I've
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provided. You're gonna add the fibrin sealant to seal. You're gonna use a sandwich technique. You do layers. The first layer, you put a thin layer of your to seal or your
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fibrin sealant. Don't put in huge glom of these layers because they can cause compression. you can make it a thin layer of this. And then the second layer is going to be what's called microfibular
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collagen. It's easier to sedurgeon. There are different kinds of this now. And then the third layer is you put more fiber and sealant on top of that. And actually you put a drain in on top of that.
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Very important, too many people are still putting gel foam into wounds, spinal wounds. And if you read the insert, it's a direct contraindication because it swells and can cause compression of
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nerve tissues, paraparithosis, quadriparasis, whatever. If you're going to use any version of gel foam, like sergephome, you should irrigate it out so you don't lose it behind. By the way,
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this is what the microfibular collagen looks like. Here, your dirge and strips and you can put them together. If there's been a really significant CSF leak, there's actually a version of this that
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you can suture down to with your seven-o-grotech sutures in a circumferential fashion. You can use this on the first layer and then put a final second layer of duragen on top of that. And seeing,
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let's say again, I'm in a resource-limited environment, either rural, the United States or whatever it is, or someplace else. And I may not have a lot of these things available. What is the best,
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what's my best alternative to significantly? Your best alternative, if all you have
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is silk suitors, use the smallest ones you can find, and put in a whole bunch of them, and take some muscle from the surrounding muscle. Sometimes you can make it a pedicle. I just take a piece
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of surrounding muscle, tamp it down with a mallet, lay that over the dural site, and sew that muscle to the dura. Do not use fat. Fat will shrink up, disappear, and go away.
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Your muscle patch graft is your best way to go. And in addition to that, let some blood come in.
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Not a whole lot of blood, but enough blood. So that can be your blood patch. So forget your fiber and sealant, forget your duragen and all this other fancy stuff. But if there's any question,
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use your finest,
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smallest silk suture And a muscle patch graft. That will do very well. Terrific,
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terrific information. And it's also the cheapest, actually. But don't use fat, it's not gonna work. Okay, terrific. This is a study where they looked at 13 studies showing the benefit of,
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showing no benefit rather, of instrumented versus non-instrumented poster lateral fusions for rhombar spinal stenosis. We're on a roll here. You could do a decompression.
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If you need to, you've taken a full facet, you could also save your bone. I always save the bone. And you could always do a poster lateral effusion, but just laying that bone over your transverse
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processes out here. But you don't necessarily need to do an instrumented fusion.
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And here's your laminectomy for your stenosis. This, by the way, is what your poster lateral non-instrumented fusion is going to look like on a post-operative CAT scan. So here are your transverse
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processes and here are your bone chips that now have coalesced. You know, if you have the money for it and you want to really confirm it, this is a three-dimensional CAT scan documenting that that
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level has very nicely fused. So anybody tells you that - How long does that take? How long does that take? Six months or so? Six months, six months. And sometimes it can take even up to a year.
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Okay pens and patient factors. You throw in a patient who's diabetic. Their risk of having a pseudothrosis is about 25. It also takes them much longer. You also take your smokers. You get them to
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stop smoking, but still it's gonna take them longer to fuse. And then the older the patients, the longer it's gonna take them to fuse as well. Okay. So there are some patient factors that you
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have to take into account. The efficacy and safety of laminectomy versus T-lip fusions for stenosis I wrote this up in 2018. Open laminectomy is two to three levels and four to six levels. You can
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see one is 58, the other 79 patients. It really minimized the risks and complications for these patients. There were no re-operations, no infections, no instability.
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And here's just an example of your decompressible laminectomy.
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Another example shown here.
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Because the complication rates in the same paper, looking at a vast literature on this was 83 for T-LIF fusions, transfer them into lumbar interbody fusions versus about half of that, 48 for
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laminectomy.
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And here with the T-LIFs, you've got the pedicle screws on both sides, you've got the rod, you've got the bone chips, dorsally, you've got the
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interbody device, and you put bone chips in the spinal canal When your interbody devices extrude into the canal, of course, they can do that close-quarter coin of syndromes, of course, they do.
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How often do you read this in studies that are published? Almost never. But they do occur. And actually, your European literature often better demonstrates these complications.
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Your screws, sometimes they don't go where you want them to go Here's a screw that's basically kind of traversing
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the medial aspect of the on both sides. So that can actually be right next to the pedicle is where you have your superior nerve root coming down right next to the pedicle and then going for amylane
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for laterally. So you may be compressing or destroying those nerve roots. Here, inferiorly,
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that's your screw. Here's your pedicle. You have to measure your pedicles. These smaller women, sometimes your pedicles, are going to be too small for that size screw. So you cannot be doing
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pedicle instrumented fusions in those patients. And in this case, it completely missed the the pedicle out here, okay.
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There are more adverse events with the T-lift fusions, and what are these other adverse events that you're going to see? More root and dural injuries. Poorly placed pedicle screws are into body
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devices, traction injuries. This is denied all the time. Oh, well, but I didn't do anything. Well, your patient woke up with a foot drop. Well, did you use intraoperative monitoring? No,
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it's not standard of care. I don't have to. Well, if you use the monitoring, even if it's not standard of care, could it have a signal to you that you were putting too much traction on a nerve
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root? And would it have helped you avoid that foot drop? Oh, you know, I don't have to. That's not the answer that you want to hear. And that's certainly not what the patient wants to hear.
34:57
If you look at the overall adverse event reports, 77 to 23 with T-lifts And here is an inexplicable example of your screw just completely traversing the canal.
35:13
But here, 83 risk of infections, derotomy, 6, permanent weakness, sensory deficits, all
35:22
of these factors are there with transferaminal lumbar antibody fusions, which are probably
35:29
one of the most common operations that's done in the spine.
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I would watch out if you're going to university for the RVU-driven surgeon who wants to do an instrument of fusion for your lumbar synovial cyst. Oftentimes, the laminectomy is going to suffice.
35:49
There's questionable efficacy of adding, even non-instrumented, but certainly instrumented fusions. So this may be a good chance where you should run.
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It's important to avoid unnecessary surgery. I did study in 2013 and I looked at about 180 patients over, over, it was a 20 month period.
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All of the patients had seen a first opinion surgeon, spine surgeon, I was the second opinion.
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The first surgeon said 60 needed an operation where I said they didn't need anything, nothing, nothing. Looking at the pictures, everything else. Half of them said, well, they never even
36:34
examined me. The other half said, well, they didn't even bother looking at the pictures, they just read the report, which just underscores the fact that many don't even know how to read the
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pictures and don't bother doing an exam. 33
36:48
were offered the wrong operation.
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In that group, actually, there was a patient. I called him Jaws because he was being offered a C34 anterior discectomy infusion, whereas he really needed an operation from the back of his neck.
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And I kept saying to him, did he ever mention how he was going to get there? Because this guy had this huge joy There was no way you were gonna get there from here.
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And about 6 of the time, in my opinion, the surgeon's got it right. So this is really very important information for patients. And it's why I say, go get a second opinion. If there's a
37:30
tiebreaker, go get the third opinion. And here's the patient saying, I already diagnosed myself on the internet. I'm only here for a second opinion.
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So, in conclusion for part two, choose the right operation on the right patient for your synovial cystic vision, avoid unnecessary surgery, and unnecessarily extensive surgery. And we're going to
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thank ourselves at that point. That's absolutely outstanding, a terrific lecture and
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just terrific job. Thank you very much. Okay. Take care References for this talk can be found as follows. You can take a screenshot of each of the pages and use those to find these references on
38:25
any appropriate source.
38:28
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39:17
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
39:32
for consulting a licensed medical professional.
39:38
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40:06
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