Controversies on Cervical Spine Surgery: Anterior approaches and arthroplasty: Fact or Fiction

SNI Digital, Innovations in Learning, is pleased to present another in the SNI Digital series on Controversies in Spine Surgery, a lecture in discussion

given by Nancy Epstein

on a review of anterior cervical discectomy or fusion

versus cervical disc arts or plasti. The lecture is 50 minutes, the discussion is 30 minutes. Nancy Epstein is the professor of clinical neurosurgery at the School

of Medicine at the State University of New York at Stony Brook. She is the editor-in-chief of surgical neurology international. Okay, today I thought we would discuss reviewing indications for any

inter-servical dysctomy and

fusion, and in a very restricted way, just going over cervical disc arthroplasty, what are the, you know, clinical radiological as well as surgical indications that we're going to deal with.

We're going to go over the cervical anatomy, the MR and the CT studies, radiculopathy and myelopathy we're going to define I'm also just going to briefly throw in avoiding epidural steering

injections because they have no documented long term efficacy and big attendant risks and complications. And then I'll really focus on anterior discectomy infusion, single or multilevel, briefly go

over cervical disc arthroplasty and just managing perioperative adverse events As with many of these lectures, I usually like to start with just looking at the bony anatomy that anteriorly, you have

the vertebral body posteriorly, you've got the spinous processes in the lamina, and here's another example. you're looking at the vertebral bodies anteriorly, the cord intervening, and then the

posterior elements. Also superimposed on this, you see the vertebral bodies, but you also see the

brominatransverse area where you have your vertebral arteries coming upward and here on your axial view. Very important, by the way, for anterior discectomy infusions, you've got to say centrally,

you don't want to get off to the side and get into those verteals. But here's your anterior vertebral body. Obviously, here's the spinal cord centrally. And then you have posteriorly the lamina

and the spinous processes, your bilateral facet joints, and then the foramina transverse area. Years ago, I had looked at a case and I thought, Ooh, I wonder if that's a disc or not. And I went

to my neuro radiologist and he said, You know, let's just do an MRA and it proved to do an aberrant vertebral artery rather than a disc herniation. So, you know, keep an eye out. or any abnormal

pathology here. Anatomically speaking, anterior cord is basically motor function. Posterior is sensory function. You've got position and vibration appreciation. And then you've got the nerve

roots coming out bilaterally and foramnally. If you take away the bone, here you have the anterior cord and the alpha motor neurons anteriorly, the posterior cord, position and vibration, the

fasciculus, grassless, and cuneatus. And then of course you have your anterior motor roots and your posterior sensory roots. People, and this is what I find very helpful in terms of discussing

this with patients, much less lawyers or anybody else who doesn't understand the difference between an MRI and a CT scan. Almost everybody at least in the United States knows what an MM is. And I

just say, look, the soft tissue in the center, That's the MRI, it shows you the soft tissues, the nerve tissues, the CSF, the fat, blood, et cetera. And the perimeter is the hard candy shell.

That's what you're gonna best see on the CT scan. So these are studies that will see different things for you. If you're looking for cord pathology, you do that MR. If you're looking for bony

pathology, you do the CT. Usually prior to doing cervical operations, I think it really behooves you to get both studies because that additional CT scan may give you critical information and help

you avoid getting, in particular, an anterior cia-seth leak. So you're going to talk about doing a multilevel or a single-level anterior discectomy infusions. It might be for a central disc

herniation or a spur. And you've got to pay attention. What's the size of that spinal canal? Is it a wide canal? Do you have a stenotic canal? Because it may change your decision-making process

So let's just go over the normal spinel. the normal canal measures basically 17 millimeters. It's from the mid-vertebral aspect to the posterior interlaminar line. And the interlaminar line is

basically, if you look at my hands and my arms coming out to the side, it's where the lamina come together to form this spinous process. This you should readily see, certainly on an x-ray, a

six-foot film, and very nicely delineated on a CT scan And it's going to allow you to directly measure, particularly better, on the CAT scan, the exact dimension of the canal. Mid-vertebral body

to the posterior interlamina line, 17 millimeters is the normal canal. Relative stenosis is a 13-millimeter canal, or less, and congenital stenosis, the one that you're born with less than 10

millimeters is what your measurement is going to be So, here are three studies. You know, centrally, you have just the image where you're measuring the interlamina line between the vertebral body

to your elements, you know, what is your exact dimension of that canal. Here you can see on the x-rays, you can visualize the interlaminal line being seen here very nicely on all these images,

and then here on the MRI scan, again, this is more difficult to measure and see on an MR, but that's giving you your central canal dimension.

MR scans again best show you the soft tissue, the spinal cord, the nerve roots, the ligaments, the hematoma, the spinal fluid, etc. And here's your figurative diagram, and here's your MR scan.

Here's your cord sitting in a bath of spinal fluid, vertebral body anteriorly, lamina posteriorly, etc. And here is a figured image of an interlateral C67 extruded disc herniation, and here on an

actual MR is that extruded disc. Now, I'm just going to mention. our purpose is today, that note how this disc goes nearly to the center anteriorly. We have an alternative called a cervical

laminopharaminotomy, but you're not

going to want to do that in a case in which your ventral compression extends as far centrally as the central aspect of the spinal canal because your risk of damaging the cord becomes too high. So

here's your MR of the six, seven anterior lateral disc, not a candidate for laminopharaminotomy. And here I would do an anterior procedure.

This is just repeating these images again of the central canal dimension, but now using a CAT scan. And on the CAT scan, especially the axial views, you can measure this very, very nicely, plus

any other attended pathology. Can I interrupt you a minute? Can you go back slides to the one where you were showing the lateral disc or the one before that?

one back. Yep.

Okay. Yeah. Okay. This is a key point, I think. And you said the reason you would not do this from behind is because it looks like the disc. It's really not extending to the midline. But can

you tell us more about how you make that you make the decision here versus anterior versus posterior? Yeah.

With laminophoraminotomy, it is best if the disc is very lateral andor foraminal. This is a large disc herniation. It could be it could contain punctate ossification. It could be tough and tenuous,

especially in your younger patient. And what you really don't want to get into is trying to take out that disc from posteriorly if it extends too far anteriorly and over-manipulating the nerve root

with that down-biting cadre. That's my main concern is if it's a large disc herniation like this, and there's more central extension of the pathology, then I'm more concerned that I may over

manipulate that nerve root while trying to get in there laterally and foramidly with that laminophoramidomy. I don't want to over manipulate that nerve root because that can then cause a deficit and

root damage. Okay, that's good explanation. That's real helpful

Okay, so we went over, you know, the CAT scan and the central dimensions that we're looking at here. Here is a typical image of a calcified central disc or spur causing chord compression across

the canal. And then here's a non-contrast CT image showing you basically the same thing. Everything that I'm circling here is pathology that shouldn't be there. And you can see even on the CAT scan

that there's central cord compression. This is not going to be conducive to a laminophuraminotomy. If you

have a patient, and we're going to just briefly mention this later, where there's an excellent cervical lordosis, and this is a multilevel problem, then that patient may be a candidate for a

laminectomy. This is a figurative example of a lateral and foraminal disc. Again, a little bit too much centrally here from my taste to do it posteriorly, and here's your myelogram caskin, where

you have your dye in the subarachnoid space, and here's your interlateral disc and ridge that's sitting here. So in this case, I would go anteriorly, and you have to, by the way, watch out.

Don't go too laterally and foramidally with that anterior exposure. Don't go beyond the visualization under that microscope, because you do not want to end up napping the retrieval artery laterally,

you're more likely to do that. five, six, or four, five. Let me ask you another follow-up question here. If you looked at this posterior and we're looking instead of a laminar firm anatomy to a

laminectomy,

would that change your approach? And again, what I'm getting to is the safety, total safety of one approach versus the total versus another. Yeah. I think if you have just one level disease like

this, I would go with an anterior approach If you have a patient and that cervical lordotic curvature is excellent, and you're doing a multi-level decompression, which will allow the cord to

migrate posteriorly, and not just stay where it is. And you do a medial facetectomy, meaning you're taking off the medial 13 of the facet, and you're taking off the, let's say you're doing your

hemilaminectomy, even over multiple levels, then you can typically safely decompress that nerve root as the neurofusion. follows the chord migrating posteriorly. But if this is just a one-level

procedure like with a

laminoframanotomy, that chord is gonna stay where it is. And that chord and nerve root are gonna remain tethered over that anterior spur osteophyte. So if you go posteriorly, you have, if you

were to, let's say I'm in a situation where I can't do it, if I go posteriorly, I'd have to have exposed, have a wider exposure. So I get some mobility or at least some degree of exposure of this,

of the disc, which may be a little wider. Yes, yes, because here, Jim critically, what you were even more so than a soft, what appears to be a soft disc is with a spur, even with that

downbiting cadet taking out little morsels of spur, you may be over-minipulating that nerve root and you're also risking impinging the liqueur. So that's right, if you have a multi-level

decompression and that cord's gonna migrate posteriorly along with that nerve root into your decompression, you can do an extra-ferraminal decompression here to give it the space that it needs. Okay,

so the key is, it turns out to be an atomic anatomy and if I'm in a situation where I'm gonna wind up manipulating the cord and so forth, then posteriorly is not going to be the way to go So that

almost mandates an anterior approach. Yeah, yeah, especially if it's very focal and that's right, it's not multi-level. Okay, so I think for those who are in other countries where they may not

be able to do this or for some reason you can't do that on a patient, that's the, those are the defining characteristics here. Okay? Yes, and here I'm just, you know, integrating in briefly and

with the images, what's the neurological deficit that you're going to see with these patients with pathology at different levels? I think one of the most concerning things that we see are operations

that are being done unnecessarily at multiple levels. And in fact, I know of a medical legal case where the patient had disease at one level

is surgeon who was a skull-based surgeon, not a spine surgeon, did a two-level discectomy At the second level, where there was no pathology whatsoever, the surgeon slipped and ended up with the

pituitary, taking a bite out of the spinal cord, making that patient quadriplegic. So restrict your operations to the levels where you really need it and know something about the neurological

deficits that go along with the levels that are indicated based on your MRs and CAT scans prior to the surgery So, you know, obviously at the sea. For a five level, you have the C5 nerve root,

and that's gonna give you deltoid weakness predominantly. It might give you some element of biceps. The C6 nerve root, you look for a weakness of extensor of the rest at opposition of the thumb and

index finger, and the sense we lost that goes along with that, and the thumb and index finger as well. And for C6-7, you have the C7 nerve root, weakness of opposition of thumb and pinky, very

much so extensor, the phalangees, as well as the triceps. But you have to remember the neurological exam don't just operate on any additional level because it's convenient, or there's some other

expedient reason for doing unnecessary surgery. Here is an example of myelopathy, where you have a ventral disc herniation. This is a pathological specimen, obviously, with the cord indented,

and down below it, We have Milo CT scan of a soft central district. herniation sort of making that spinal corda boomerang configuration. And in this case, the patient may present with a diffuse

weakness of an arm, or both arms, or both legs. So it's paraparisis, cordaparisis. A more diffuse deficit rather than just a root or reticular deficit. Reflexes can be hyperactive. You may have

a Hoffman's sign indicating hyperactivity of the upper extremity reflexes, Babinski signs, et cetera, and the lower extremities Sensory loss, pin, light touch, vibration, and position. And

interestingly, sphincter dysfunction is seen relatively late in a lot of these cases, although interestingly, sometimes with a big cervical disc herniation, it might be the first finding.

One thing I wanted to go over is avoiding cervical epidural steer injections. They are handed out right, left, and center Some insurance companies mistakenly Why are these to be done before giving

permission for operations? But the problem is, is that there is really no indication to do most of these. These patients, it results in no long term improvement. They are not approved by the FDA,

which actually shocks a lot of people. They have a lot of risks and complications associated with them, including infection have done within three months of surgery And they're obviously very costly,

although some people may be lining their pockets with these procedures. So what are the risks of interlaminar or transferaminal injections? By the way, interlaminar means between the lamina and

transferaminal is going to be off to the side, but you can inject inadvertently into the cord itself. You can end up with epidural hematomas, vertebral artery injections can result in paralysis,

stroke and death That's not good.

remind us of the anatomy of the epidural compartment. We have anteriorly, the vertebral body. Next comes, you know, you've got the epidural space is obviously circumferential, but next comes

your anterior epidural space. Then you have the cord and then you have your posterior and posterior lateral epidural space followed by then, of course, your posterior elements, the spinous

processes and the laminar. So here's an example of

an interlaminar placement of the needle between the laminar. And there's the fluid collection that you're creating, typically it'd be up to maybe three cc's of your epidural steroid. And here, but

what can happen? Servical spine, cord injection, intermedular cord compression, because of the

lockulation of that collection, especially in a very stenotic canal. And certainly formation of epidural hematomas, And I'm going to give you an example of that. in just a second. But here's your

transferaminal injection. Typically, it's done

at C7T1. You're trying to avoid the vertebral artery, which occasionally, aberrantly, will enter the canal at C6-7. And again, you know, three to five CCs or one to two CCs. However many CCs

can result in an epidural clot and cord compression, nerve root compression, neurological deficit

This is an example of a patient who underwent a unnecessary epidural injection in a outpatient facility. The patient was young. The preoperative MR scans show nothing in terms of, quote, surgical

disease, no significant nerve root or cord compression, no focal neurological deficit. The epidural steroid injection, it's interestingly, you can look at the records. A lot of these are just

done in three minutes. Many of them are anesthesiologists or pain management specialists, radiologists, and lots of times they're doing up to 20 of these a day. So they can't be very carefully

selected if they're doing this several days a week and they're not carefully selected. Furthermore, a lot of the

pain management specialists don't know how to read the preoperative diagnostic studies, don't know how to do a neurological exam and can adequately screen these patients. In this case, the patient

had the study done Immediately on transfer to the postoperative care unit, the patient noted the onset of numbness, tingling, and severe weakness. The

anesthesiologists had already gone to another facility to do another bunch of epidurals there. It was delayed in terms of having a specialist show up, a doctor show up, and the transfer to the

hospital was delayed, the MRI scan was delayed, And then the surgery was delayed at least a full 12 hours. by which time the patient was completely quadriplegic. The patient then underwent an MRI

scan. This is an image similar to the hematoma. You can see anteriorly the cord is markedly compressed and that's your posterior cord compression seen here. So here you see going from C6 to T2,

all of this is postoperative or post procedure epidural clot. And if you don't believe what I'm showing you there, here's just a figurative diagram of what I'm trying to show you in terms of the

clot location. And here is the actual MR showing you where this is the cord compressed anteriorly and laterally towards the left and look at this massive epidural hematoma. These images are similar

to that patient because of medical legal reasons. We couldn't show her actual images themselves. This case settled and it's so typical of these cases it took like several years for this to come to

fruition

Again, Interlaminar injection, just an image of how you do that, transferaminal injection. You're going through the neuroferamen, higher risk with the transferaminal injections in terms of the

cervical cord. What are the risks in the complications? And multiple publications and surgical neurology international, these are the different years. Just look up Epstein and E, you'll find the

articles. About a 7 to 11 of risk of vertebral artery injections. That can result in stroke, death, quadriplegia, et cetera, and up to a 6 risk of spinal fluid leaks. So next, we're just going

to transition to doing an anterior discectomy infusion. For discs, for spurs, for osteophytes, spondylosis, and stenosis, it may be at one level, it may be a spur. And again, you're going to

pay attention to how wide is your spinal canal at these different levels? By the way, anterior discectomy infusions are the most common operations performed in the US. inside if you study in the

spine journal 2018, over 137, 000 or cases per year. Here's your classic anterior exposure and the anterior discectomy infusion. Here's your graft and plate in place. And here again, as your

plate, I don't know about you, but you know, you talk to your personnel in the OR and they say, what case are you doing next? They say, oh, just an anterior discectomy infusion. Years ago,

when I was president of the cervical spine research society, I did a paper looking at the frequency of quadriplegis in the state of New York and the state of California. 60 of patients who became

quadriplegic had single level anterior discectomies and fusions. Single level. So it just goes to show you number one, these are high-risk procedures. Number two, it's also an indication to

monitor these patients because of those risks and complications. Here's an illustration of a two-dimensional CT as well as x-rays and images of a one-level ACDF. Here is your disc herniation. Here

is your inter-body graft. This happens to be illustrating aniliac crest autograph, which still happens to be A, the cheapest and B, the gold standard because it has the highest rate of fusion.

Yes, it's a separate incision. But years ago, Medtronic was notorious for pushing articles to emphasize the high risk and complication rate of doing aniliac crest autograph, that second incision

And again, grossly, grossly exaggerated. And here is a two-dimensional CT scan. That's your anterior graph, by the way. That's anterior margin, because you're going to use a curvilinear graph,

just like the curve of theiliac crest. And the cancelous bone is going to be located here

posteriorly. And then you're going to shave it down so that it actually nicely fits into the inter-disc space. You're going to leave a posterior ridge, by the way. Posterior ridge is critical to

make your graph doesn't extrude posteriorly on here. Here is your. the plate and screws. Eventually we got from fixed screws from the cast bar system to variable angle screws to really a slotted

plate that was a dynamic plate that decreased the risk of graft

extrusions. Can I ask you, I got a slide coming up on showing taking a bone graft from theiliac crest. Is that coming up? Yes, yeah. Okay, so I'll save my question to that And then here, what

you're showing, yes. Yeah, this is an X-ray. Sometimes it's hard to see it on an X-ray. Like post-operatively, if you're trying to figure out, you know, in three months, do you take the

bracing off, et cetera, CAT scan shows you so much more definition. And so much more definitively. What you see on this is you see that the margin between the graft and the end plate is, there is

bone growth across here. There is

no lucency You're not gonna see that on the next one. the problem with an x-ray is too many surgeons. It's like, you know, beauty is in the eyes of the beholder. They look at the x-ray and they

declare a fuse because they want it to be fused. It's not fused. Patients take off their braces or whatever happens to be and the whole thing falls apart. Let me ask you a few questions here

because this has a lot of information on it. Let's say I'm in a country. I have a patient who come to me, he doesn't have any money, and it looks like he needs to have an anterior operation. I go

ahead and do

aniliac. I say, well, I'm going to do theiliac bone graft. I take it out and I'll come back to that in a minute, and I put it in here. Now, the next thing is,

what's the evidence that shows that a putting in a little, a little fusion there, a little, the metal plate, okay, three years. What's the evidence that that's going to be better than not

because I want to send this person home. He doesn't have the money for it. How do I deal with this? Well, the plate actually reduces the incidence of extrusion by only about 10 or 15. And it's

very important when you're putting in theiliac autograph, leave a ridge anteriorly just that comes down a little bit, you distract, and then you put in the graft, because if you leave that

anterior lip superiorly and inferiorly, that can help hold the graft in place. So you do not need 100 of the time to use a plate. Basically, it's become the fashion and the modus operandi in the

states to use the plate because of that extra protection of about 10 avoiding graft extrusion. But if you're in a country where all you have is theiliacrest autograph, just make sure you countersink

that autograph behind small anterior ridge and obviously keep your posterior ridge in place. And make sure the graft fits tightly. If you do a graft and you shave it down too much and that's not

fitting tightly because again you're going to distract that interspace put in the graft and then release the distraction. If that graft is not sitting in there tightly you've got to take another

graft. Now let's say I'm in the country. I

would guess that in many countries you can make these plates for a low cost but let's say it's not available to me and then what do I do after surgery or I put a person on a collar or how do I keep

track of this to make sure that I reduce this chance of extrusion? What do you tell them? Well first of all I would put them in a collar, I put them in a hard collar and you really need to use the

extension brace. If you do not use the extension brace it's been nicely shown. that just a collar alone is not gonna hold that graft, is not gonna restrict that patient sufficiently. What's the

experience in braces? This is the thing with that elevates your chin and it has something behind it. No, well, you've got the front and the back aspect of the collar and then it's plastic

typically. And then there's a plastic extension in the front and the back and a strap goes around your chest. Okay, so what you're doing is you're stabilizing the circle of thoracic, so it's

not like this. It's like this. That's right. Okay, so I have to be able in my country find the right kind of brace and I've got to impress upon the patient not to take it off. How long do they

have to leave it at six weeks? I would say I would have them leaving on for three months. Three months, okay. If they had no plate in place, I would leave it on for three months. The other thing

too is you've got it, as I started to mention, you know, these plates have gone through an evolution You had the plates? The Caspar plates had screws that were fixed completely to the plate, and

it was distracting the interspace, not allowing it to collapse down, increasing your rate of failure and suit arthrosis. And then you had plates where the screws would toggle like 17 degrees, but

that was not enough. And that also prevented the graft from fusing. So it was finally Asculab came out with a plate where the screws could actually migrate in the slots, allowing for that

compression to occur and the fusion to occur, decreasing the extrusion rates seen for the fixed plates and the 17 degree dynamic, you know, other versions of plates. Oh, okay. So now we've

covered that now that the other gets came back to the taking the graph from the hip, right, and, uh, yeah,

you want to see some of this first? Yeah And I just want to show you is, you know, here, I want to show you a few things. If you're doing multi-level anterior discectomy infusion, don't remove

the entire end plate. If you remove the end plate, you are decreasing the strength of that vertebral body by 50. If you do that, if you remove the entire end plate between the intervening

vertebral body and you put in a graft, there's a very good chance that those grafts are gonna piston into themselves and fracture out that vertebral body. Well, I've seen a lot of people go in and

scrape the end plate out. Yeah, well, that's right. And it allows for the subsidence and then the pistoning of those grafts. And then here, again, posteriorly,

you see the ridge above and below, ridge above and below. That is critically important. You know, you go to any of these medical legal cases and you see grafts pistoning into the cord. Well,

that's why they're pistoning because that ridge was not. And that ridge should be there no matter what interbody device you're going to use. It's just an extra sort of belt and suspenders measure

that really should be used. And let's see, I was just going to show you some examples where here we're going to look at a typical cervical disc here, adjacent spurs. You can see some calcification,

ossification here, by the way, there's some ossification of the

anterior longitude ligament, but two adjacent spurs may require a two-level procedure like this, two adjacent, these may be soft discs, and then here two adjacent spurs. So these are some of the

indications that prompt people to do a two-level anterior discectomy infusion, but again, you can see in the illustration the end plates have been preserved here so that those graphs will not piston

into each other. Otherwise, again, this inter-retroable body may be pistoning out and fracturing out Wait a minute, we'll come to that next slide.

I'm looking at the slide on the lower right-hand corner with the plate on and the discectomy at at least two levels there. And that question is, given all the things, all the dangers that I can

have with this operation, and I realize there's 120, 000 done and never, and people say I'm getting away with it, I don't worry. But to me, I would worry, 'cause all I have to do is have one

quadriplegia and my life is dis-devastated. Besides the patient, I couldn't live with myself, 'cause I've done something I shouldn't have done. So why wouldn't I wanna go posteriorly here? Why

wouldn't I wanna do a laminectomy, even if I go an extra level? Right, because if you see the extent of chord compression here anteriorly, I'm gonna mention a little later on, I included the

positive K and the negative K sign if you have very significant anterior chord compression.

then you really should be going from the front because doing the posterior decompression. Here where it's a straightened, there's no lordosis. This is not going to work if you do a posterior

decompression. On the other hand, this is an instance where yes, you could take off the lamina here, here, here. Those are the lamina, you know, they're inward shingling and you could actually

decompress adequately those spurs. You probably want to do a posterior fusion to maintain that lord daughter curvature But here you would have the option, this probably the degree of anterior

compression is too severe and these spurs, you want to see with the MR that goes along with it, are probably causing too much anterior compression and there may be straightening and kyphosis and

here there may be a little kyphosis. So again, if you have a cervical lordosis, completely different discussion, the other part of this discussion, which will be really in a separate lecture as

your alternative here, if you feel that you have to take off more

that intervening vertebral body, you can do a full core pectomy here and then do a strut fusion from the level above to the level below, removing this vertebral body and putting in a strut graft.

Okay, so there are multiple choices there. You're going to come up to these later. That's good. Okay, right. And here, example of aniliac crest autographed, you know, again, if you years ago,

Medtronic was

brought up on charges of basically having essentially many, many studies in which they popularized the fact that aniliac crest autographed was much too high risk, and therefore you needed to use one

of their antibody devices.

That's not correct. Actually, theiliac autographed is often very, very well tolerated, and the fusion rates are much, much higher than any of the other devices, because I'll give you some of the

numbers for pseudarthrosis rates. It's like, with autographed, it can be as low as 0 with

allograft. It can be up to four and a half percent for one level, two level, 12, three level, much higher than that. And again, we have now machined cadaver allografts. Usually it's made out

of fibula. And the problem with fibula is it's all cortical bones. So it takes forever for this to be replaced. And then small central canal, you can put in some chips of your autographed You can

put in sometimes demon-realized bone matrix, whatever it is, sometimes because it's just the one level, you'll get away with it. But a lot of these machine cadaver graphs are notiliac bone, some

are, some aren't. And the

fibula

ones just take forever to incorporate. Peak cages or plastic is becoming much more popular than the cadaver alograss. Because any of the cadaver graphs, you still have the risk of hepatitis, HIV,

et cetera, although it may be small.

And this is what it looks like on a post-operative film of a two-level here, C2, C3, 4, 5, and 6. And you can see that they put in markers in that peak so that you can see where the graphs are.

That's because if it's too far back or in the canal, you may have to redo your procedures.

And here's an X-ray of just a one-level, and that's autographed, and you can just see posteriorly And you can see that there is no loosened margin between this and the end plates.

And then here is a two-level cadavergraft. It's going to look very hyper-intense from the very beginning, but you may end up with some lucency around it, showing pseudathrosis or failure diffuse

and failure to incorporate. So each of these has pros and cons associated with it You know, the plastic is not going to incorporate the holes in the plastic can hold autographed, people will go to

theiliac crest and just do a little core of autograph to put into the central portion of that peak or plastic. Other times they'll use demineralized bone matrix, which really doesn't help an awful

lot. Again, autograph is the best So, sorry, that's what I was going to ask you so the safest and the best is autographed in the chance of, of having a pseudoarthrosis or not getting a fusion is

low. That's correct. Yes. What 5 or something or I actually published a series years ago that was 60 patients, it really act autographed again one surgeon, and based on CT finding 0

pseudoarthrosis with those patients. So, I'm

looking at all these examples are giving me and I'm sitting here and saying, this has got this complication the bone may not be replaced I've got to put bone chips in these. and these plastic things

so that you've got some fusion,

it would seem to me that the most logical thing to do is to use an autograph. Yeah, well, but you see number one, it's cheap. Number two, there's tremendous advertising for, oh, let's avoid

theiliacrest incision site. And that's, I mean, too many patients, you know, don't like that thought of a second incision. And then what have they faced with? Well, then they're given a choice

of plastic or cadavergraft. If there's going to choose cadavergraft, they're supposed to tell you there's a chance of HIV, hepatitis, or Yakub-Croitz health disease, you know? So lots of times

people are not going to choose this. And again, you can see that it can piston into the intervening vertebral bodies. By the way, the costs of these cadavergrafts can be up to 6, 000 for one

single graft. Your hospitals may like this because they multiply six times when they build it out to the insurance companies and what's the what's the

fusion percentage with the plastic or or other kinds of graphs or the peak cages as compared to an autograph? Well as I said the the autograph is going to be you know zero to two to three to four

percent or something like that. You go to the allegraft or the peak cages

the actual incidents of the anti-sudarthrosis probably five to eight percent. Some of that is going to be exaggerated as less than that because a lot of those studies were just based on x-rays alone

and not CT confirmed. If CT confirmed the risk of sudarthrosis even with a one level is higher than with an autograph. The real problem that you get into are the multi-level graphs because the

number uh the the risk of sudarthrosis really jumps So, you're telling me, right? Well, I shouldn't, you're not you're not telling me, but here's my choice, I'm looking at this. And

everybody's saying, well, you can go do it, put a cage in it or get cadaver bone. And the answer is, the chances of fusion are less. And I'm sure somebody said, well, a few percent isn't

significant. They're not the one who's experiencing it. And then I'm looking at all this, all these metal and screws in there I'm thinking about infection and then you're telling me, I can get HIV

with one of these things. I gotta ask myself, why am I doing this? Yeah, well, actually the risk of infection with theiliac crest autograph is reduced. And in the presence of infection, let's

say you're going in and somebody has an anterior cervical abscess, okay? You're gonna wanna useiliac autograph if you can

because that's gonna have a much lesser rate of infection even with the plate being put in there. whereas these other devices are gonna have higher rates of infection. Well, I'm sure people are

gonna hear this lecture and say, Well, she's really over exaggerating this. I've done hundreds of these. I never have a complication, so forth and so on. But if you just look it up what the

risks are and what you're adding in there and what you're adding in costs, that's pretty hard to justify that decision. Right, but you have to remember too, though, Jim, at these institutions,

the

cost of these devices magnified five to six times. That's what's built out to the insurance companies. So the more of these cases that are done, many of which are unnecessary, and the more

instrumentation you use, the more, quote, value that surgeon may become. And that includes academia. One other thing, and that is, I know I've heard this a number of times, and that is, oh,

patients have a lot of pain with the LA aircraft and it. plow them for years and so forth and so on.

Is that true or is that one of these exaggerated symptoms? I think it's highly exaggerated and that's what they were basically coming down on Medtronic 4 is basically, they were supporting articles

that were over-exaggerating the risks and the complications associated with the autographed. But basically you're right, if you are in a country where you can't afford all this other stuff, you're

very well, may get the better operation and the safer operation. Well, that's what I'm saying. If I'm in a country that has limited resources, there are simpler ways to do this with a much lower

risk and that'll have very good outcome. Yes. That's what you're telling me. Yes. Okay.

Okay. Other anterior discectomy fusing constructs, I mean, there are tons. peak. You've got peak and metal that looks like this with the screws going above and below. Here, a plate affixed to

the graft. This device, by the way, it was a MOBC. This was associated with some really big ROIC, actually, with some really significant pseudothorosis in some cases. What is

ROIC? I forget exactly what the this is the ROIC device Oh, it's an ROIC device, okay. It's a complication. There's all peak, and then there's

metal phalanges where you get the graft in, and then you have a device that allows you to basically, those phalanges should come out into and extend into the superior and the inferior vertebral in

place. Yeah, okay. Wow. Yeah, exactly. And then on your side, I'm sure there are no randomized studies, but among all those different things as to what's better than the other.

That is absolutely true. Here is a summary in surgical neurology international 2019 of ACDF risks. Disphasia, a difficulty swallowing. Actually, some studies it's reported 20 to 30, certainly in

the first few postoperative weeks. The esophageal perforation is a little less than 1. Postoperative clots, including wound hematomas and epidurals about 1. Spinal cord injuries occurring during

these, pistoning of grafts, again, without that posterior ridge, recurrent laryngeal nerve injuries, where they have a vocal cord paralysis on one side, and that's actually very important. If a

patient has had a prior cervical operation on one side and you're contemplating doing a second anterior approach, you better know pretty operatively that that recurrent laryngeal nerve was not

compromised 'cause otherwise you can end up with bilateral current laryngeal paralysis in a patient on a rest. greater or trachte can I make a comment here, you know, having been a patient to

multiple different operations. If if you're telling me, okay, well, these are, this is the data you showed of the patient, that's what the risks are. There's one out of 10 chance I'm going to

have dysphagia. Have you ever had dysphagia?

That is disabling and esophageal perforation. I haven't had that, but

that's life threatening, obviously. Yes, and epidural hematoma. I remember when I was in a resident and training, one of the people who were in practice in the community came back and he said I

was doing an anterior cervical procedure and I was putting in the graft and patient woke up, he was quadriplegion and it turned out the bone graft was too far in. I'm telling you it had a profound

effect on me forever Why do I need to take that risk? I mean, it's devastating because there's no return. So these are all these things and people say, well, this is common risks. That's the

risk of the procedure. And they pass it off, cord injury. Oh my gosh. Let's say I'm left with some kind of a parisis and it's my right arm and I turn out to be a surgeon. I'm disabled for the

rest of my life. Right, right. I mean, people pass them off, but the complications, even if they're small, in that person, are life-changing. Right, and actually that's interesting that

you're bringing that up, because if you can do for one level disc that's very lateral or foraminal, a laminophoramidotomy, okay? You

have none of the risks of the anterior procedure. Postearially, you may have a very limited risk of a spinal fluid leak, a very limited risk of a root injury as long as you're performing it

correctly. you have no instability as long as you're preserving two-thirds of the lateral facet and you're not necessarily putting that patient in a collar other than maybe for a week or two just for

discomfort, etc. So your risks, you are avoiding here, some of the other risks, Horner's syndrome, pseudothorosis, you are avoiding the majority of these risks if you go or have the option to

go posteriorly. Your posterior options may include a laminoframanomy for one-level disease. If you have multi-level pathology but you've got that good lordosis and you're going to do a multi-level

laminectomy for multi-level stenosis with a focal disc or a spur at one level, that posterior operation is going to be a much safer alternative. You know if you go mathematically, statistically if

you're in if all the risks, you got a 20 risk rate. It doesn't mean all are going to have to happen at the same time, but your risk is high. Your risk isn't just 95 dysphagia. You also have a

risk of hematoma. You have a risk of cord injury. All these things add into it. And the question is, if somebody's operating on you, do you want to take those risks? Do you want those risks for

yourself? And I think surgeons have to think about that. It isn't go along with the procedure that you have other choices that can reduce the risks.

So many of the surgeons today are just being taught really how to do anti-dissectomy infusions. Too many of them barely know how to do a laminar for aminotomy or have never actually done one. And

then besides that, we have the industry and companies trying to propel you into buy their product. And you just showed me two pictures there with 12 different products or different things to do.

and nobody's made a distinction of which one is better than the other that costs a ton of money. And what's the benefit and why should I do it? So - Any more consent, just think about it. If you

are in an academic institution, in particular, some of them, you have the first evaluation may actually be a whole 30 minutes, but a lot of your follow-up appointments may be just 15 minutes. You

can barely get out the patient's name during that period of time, much less have any reason to discussion about what the risks and complications are for the operation that they're going to choose.

There basically, many instances are just told, this is what I'm going to do. Go down the low way, schedule this, and we're out of there. Okay, very, very good. Just look at the

pseudo-authorosis rates though here. This is just from, you know, multiple studies. Holy cow. Level is 43, two levels, jumps a hell of a lot, and then three levels, jumps pro a real lot

Here's just an example. of a three-level anterior discectomy infusion. The first level, by the way, that you see in red, okay? That graft actually, at least it fused to the interior vertebrae.

It looks like there's some anterior fusion. If you do a coronal CT scan, you can actually see, you know, every two millimeters, whether or not that's a graft is incorporated. Here, look at the

graft, pseudothrosis. The graft is largely resorbed. You see the black line, the radiolucent line, between the graft and the superior end plate and the inferior end plate. So that's a failed

fusion. And the level below it, well, this is probably cadaver graft. And you see the cadaver graft often is fibula and it's just piston into the soft, cancelous bone of the vertebral body above.

And you see all this is pseudothrosis, the luscent line, failed fusion. And some of the graft is even extruded anteriorly. And look at the plate and the screw This is the front of the vertebral

body. that screw and plate have extruded out.

So this is just a good example of how much you can get into trouble by doing a multi-level procedure. So number one, only do the number of levels that really needs it. And number two, hopefully

choose the right operation and the right instrumentation to use in that patient. By the way, here's just an example of an epidural abscess after here's your discectomy graft in a plate and there's

your abscess extending into the retroferringial compartment. So many of these, by the way, are missed. For some reason, post-op patients have a problem. There's so much hesitancy to do that

post-operative MR, be it the immediate post-op MR that's needed because the patient's quadriplegic or several weeks or several months down the line. And here's an example where you have a fractured

screw. Okay, and a partial plate extrusion.

There's some examples of the complications, adverse events that you can have with this. You won't see, you won't see this in the literature. You're not going to see it correctly and accurately

reported. Actually where you see this, the best is the medical legal literature where these complications are brought up, but that's in a case by case basis And this is a smorgasbord of just some

of the anterior cervical disc arthroplasty or CDA alternatives. This happens to be the Bryan disc over here, but all of these different variants are being used and offered two patients. And I'm

just going to show you a MOBC. This is a two level As soon as it was released, it was almost immediately used at two levels, and the surgeons were just saying, Well, you know, I'm doing one,

I'm doing two, I don't have to wait for it to be approved for that, I'll just do it.

the graft at the antibody devices. And what do you worry about these? They can extrude.

They can end up failing to integrate into the vertebral bodies above and below. And if they loosen and have to be removed, lots of times, to retrieve these devices, you have to do complete core

pectomies, because otherwise, you just can't get these devices out. So it makes re-operation extremely difficult And again, getting reported accurately what the actual complications are is almost

impossible. Now, why do they use CDAs or disk replacements? In theory, to preserve the motion at that level. However, I can remember visiting a colleague in Louvin,

Guffin, young Guffin. And he showed me a case, and he said, look at this. And he showed me a Brian disk. And he said, what do you see? I say, I said, you know, On your post-operative study,

you have ossification of the posterior lunge or two ligament that's actually in the canal. And I would surmise that you never took it out in the first place. So you put in a device where you

actually never decompress this spinal canal in this patient, and therefore you have heterotopic ossification or OPLL actually going from one level to the other. But there are many other instances

where the body reacts by creating bone and basically fusing across these so-called motion-sparing devices. It was really created to reduce the incidence of adjacent level disease, and it has done

that, except in instances where it's just caused fusion and there you go. It's supposed to be used or was designed really for soft disks, not for spurs and spondylosis, but as you would guess as

soon as it's out there, people are using it for all indications and contraindications alike What are the components? One of the components is cobalt chromium. Now cobalt was also something used in

hip replacements. I'll just show you the rest of that. And the problem with cobalt is it can cause blindness or visual dysfunction andor cardiac dysfunction because the particulate matter will

basically separate and be systemically born to these other areas. And adjacent institution in Manhattan, a patient presented with visual loss after having any hip replacement, that had cobalt

chromium in it. Visual loss resolved once they took out the device and switched it, but again, they don't tell you about these problems.

Here's an example of a three-level procedure. And you can see already here, this sort of fish-mouthing or opening up of this device at the third level. Short-term adverse events, dysphagia was

reported in one of these studies 70 and high re-operation rates In fact, fire. re-operation rates have been reported for cervical discarthroplasty about twice as high as for anterior discectomy

infusions. And long-term complications, adjacent segment disease, that frequency is not that different for a fused level and implant failures. You're going to see, especially as those devices

loosen or some of them have polyethylene core and that's going to disintegrate The other thing that can happen with these devices is because of the metallic interface with the vertebral body, it can

cause bone to disappear. That's osteolysis or spur heterotopic ossification, too much bone forming, especially anteriorly. So you get spur formation resulting in your loss of motion at those

levels. So all kinds of problems underreported, et cetera. Now, one of the questions that's always asked How do you decide to do an anterior operation as opposed to a posterior operation? So I've

shown you here what's called a positive and the negative K signs. This is something that's often used when determining to do a multi-level anterior corepectomy infusion versus a posterior

decompression with a fusion. But here I'm just gonna go over this with you because there are many contraindications to doing multi-level anterior discectomy infusions

If you draw a line from the mid-aspect of C2 to mid-C7, this is called your K-line. If your pathology, disc stenosis, opioid, whatever it is, is in front of that line or anterior to that line,

you can have the choice of doing an anterior operation or a posterior operation or a 360 if you want to. On the other hand, the negative K-sign in here, you see a diagram basically of ossification

of the posterior lunges' religment or if you have a massive disk causing huge risk. compression or massive anterior spur, then you're going to have to with that negative case on, you're going to

have to go anteriorly and take out that mass. Is that clear, Jim? Yeah, that's clear. So that's a pretty reliable measure then of if I have to go anteriorly, I've got to have a negative case

sign. I have no other choice, right? Right. If you have a negative case sign more likely than not, you're going to have to go anteriorly because otherwise you're not going to decompress the cord.

That cord will remain tethered. If there's a positive case sign, the cord will be allowed to migrate posteriorly and be decompressed. And what the black is, is either is bone basically either.

The bone or disease in this case, it happened to be up below. Yeah, but you can have multiple spurs in this case, multiple spurs, but they're huge, then you're going to have to go anteriorly.

very good explanation. Okay, so positive case sign, the pathology is anterior in front of the K-line. Okay, anterior posterior 360 surgery, you have your options. Okay, also you have more

likely than not, you have a good cervical lordosis, that's going to make that positive. Kiphosis, you're going to get stuck with the negative case

sign. So here, a negative case sign, pathology is posterior to the A-line and likely you're going to have to do anterior surgery Sometimes, you know, they'll do posterior anterior anterior

posterior depending upon the severity of that compression. But here's an example of a positive case sign. And here, look at this cervical case. You have a really good cervical lordosis. So

definitely, even with the multi-level anterior spurs, I think I showed you this image earlier, you do a multi-level laminectomy, post your fusion, you're going to decompress that cord, that cord

is going to migrate post Even if you have a foraminal disc or spur, the cord and that root are going to migrate posteriorly, you're going to have a better chance with your downbiting curette or

removing the disc underneath that root or the spur, okay? Andor if it's just a multi-level spur, you could do your two-level anterior discectomy infusion. On the other hand, if you have an older

patient and those vertebral bodies are not great and they're osteoporotic, that might be where you want to take out the intervening vertebral body and do a corepectomy from the level above to the

level below and not leave an intervening vertebral body. If, again, you have to remove half or if you have to remove the end plate of that intervening vertebral body above and below, that's gonna

be markedly weakened. And if you put in a graft above and below, that can potentially subside and piston and fracture out that vertebral body and graft. So these are multiple judgments then when

it's conflicting, The decision is. is conflicting, there are multiple different judgments that go into choosing which way you go. Absolutely, I mean, here's another example of a positive case

sign on a myelogram CAT scan, 'cause you could see the

dye in the spinal canal. Okay, look at the lordosis, excellent lordosis. Look at the bone, you've got some spontaneous spurring and spontaneous fusion, here's C2, C3, C4. Five, six, and

seven look like they're already spontaneously fused, and here you have a diffuse narrowing in the spinal canal. Again, you've got the positive case sign, because mid here to down here, all this

pathology is going to be pretty much anterior, although posteriorly you have some shingling, but you do a decompressive, you take out the bone here, you've got that good lordosis, that cord is

just going to migrate posteriorly like this, like it's like a rubber band, if you take a rubber band and hopefully your finger through the rubber band, right? If you then take away your finger,

that rubber band's going to straighten out The court is going to do the same thing. So that's right. You have multiple things to look at in terms of your decision-making. Patient is not kyphotic.

They're not straightened. They've got a good lordosis. A negative case sign, on the other hand, is the pathology is posterior or behind the line, like

OPLL. And this is a good example where here, you're midway at C2, midway at C7, and here's your K line, and look at the OPLL behind that line. Obviously, the patient here is also kyphotic. If

you go posteriorly, you're going to still end up with a cord that's tethered over the anterior disease. You're going to have to go anteriorly. Very good example. Take off some of the pathology

that's in

this case. Very importantly, when you're choosing to do an anterior dyspectomy infusion, don't be flip. Okay? Quote, We can do this operation an outpatient basis, I'll get my bag and meet you

in the parking lot.

It's over a billion dollar industry during these anterior discectomy infusions. I would avoid using an outpatient OR and patients over 65 with major comorbidities. Major comorbidities include morbid

obesity, a diabetic, obstructive sleep apnea, and others. More than a one-level anterior discectomy infusion. And also, if they go to these outpatient ORs, watch out. If they're supposed to

keep them a minimum of 47 hours, some of these outpatient ORs are actually ambulatory centers where they'll keep them 23 hours to at least the next morning to wait for some of these complications to

occur. And there are a lot of studies out there saying, Oh, you know, these outpatient ORs, they're safe, effective. They'll give you lots of numbers. We do X number. Perfectly fine. Well,

there's some quads in between those, and I'm going to show you a few ones. Here is a patient, a one-level discectomy infusion. No indication for surgery, by the way, on the pre-op studies

morbidity, drug abuser, morbidly obese. diabetes, hypertension, obstructive sleep apnea, use the monitor at home. This patient had the surgery and was discharged from that packet within less

than four hours, coded at home in two hours and came in dead, secondary to acute clot, and in this case settled, had a combination of a wound hematoma and a

retroferringial hematoma, also an epideral hematoma

in that case. Here is another instance where a patient had a four level anterior dyschectomy infusion Mistake, why? Patient had multiple comorbidities, over 65, I think he was in his 70s. Blood

pressure, coronary artery disease, diabetes, ethanol abuser, had a multi-level dyschectomy infusion as an outpatient discharged probably within about two hours because it got, you know, they

were completed late in the day and they had to close the OR. They even noted in the notes at the time of discharge, you know, the nurse rolling into the front door, Well, there's an awful lot of

dream. drainage coming out, and some of it looks pretty clear. Patient almost immediately coded at home. It was a clot and a CSF leak. The patient was found to be brain dead. In fact, he came

back in. It was brain dead on a respirator for a little over a year. And that case took years, but finally settled.

Now, I CSF mentioned leaks. The incidence of CSF leaks with anterior surgery is relatively low, up to maybe 17 If you have a patient with OPLL, and much of the time you're not gonna know it's

there unless you do a pre-up CT along with that MR, but look how with an OPLL, that risk markedly increases. If you have a patient where you think there might be a risk of a CSF leak, because even

with an one-level procedure, you may see a lot of spur. It could be adherent to the Dura. You can just prep and drape your patient for a wound parent, you'll show it at the same time you're

draping the neck for the surgery and then if it occurs after you've done your discectomy infusion, you can actually track a shunt catheter from the abdomen, I mean from the neck to the abdomen with

a woodperitoneal shunt. We used to use uni shunt, so I'm sure there are other devices that can be used today. The other alternative, of course, and this is sort of chasing your tail, is you can

put in a lumbar drain. The problem with your lumbar drain, of course, is going to be you're going to put that into five to seven days. That leak is still not going to be resolved within those five

to seven days. And you're going to end up taking out the drain at that point because you're risking infection. And you're going to end up with a patient whose neck is going to fill with CSF. It's

going to cause all kinds of wound problems, much less respiratory decompensation. I think that the smarter thing to do is you do your wound pair at Nilsant and I would then supplement it with a

lumbar pair of Nilsant because it's indwelling. You can avoid the risk of overdrain it This is what's called a horizontal vertical valve. Uh, that makes sure that when they stand up, you know,

their pressure doesn't pull through the floor and they don't get subdurals, et cetera. Uh, the other thing that's important is one of the biggest problems we see certainly in the medical legal

cases is ignoring patient complications postoperatively Not doing that stetamor and not re-operating on the patient. And the important thing is to do this, not just within, you know, the old

literature said within 48 hours you were okay, not good. Within 24 hours. Well, that's not necessarily from the time of the onset of the deficit, nor taking into account the severity of the

deficit. If that patient is severely quadriplegic, you don't have 24 hours. You have basically as soon as possible to get something done Here is the first one of the articles from neuro trauma

within eight hours after injury, better outcomes, and if it's within eight to 24 hours, surgery within less than 12 hours from neurosurgery 2019. Early surgery, less than 24, better than late.

That's from Lancet Neurology. Early surgery, less than 24, better in the Indian Journal of Surgery. Improved neurological recovery, a global spine 2017 with early surgery, less than 24. Again,

you have to judge what that patient's deficit is. I think one of the best articles is Michael Failings in Global Spine Journal 24. Moderate evidence patients show two times more likely to recover

more than two Asia grades at six months and 12 months plus separately of surgery as well within that 24-hour period. And they looked, you know, studies four or five, eight, and less than 12 hours.

So again, and he coined the term time as spine. So in conclusion, the most important thing is, you know, have the correct indication to do an anterior discectomy infusion versus a cervical

discarthroplasty. Choose your patients carefully and selectively do not do a multi-level. procedure unless that patient absolutely needs it. Look at the posterior and safer alternatives if you have

those options in that case. And if your patient awakens with a new post-operative deficit, and again, I'd recommend strongly, wake that patient up in the OR. Don't wait until you're in the

recovery room and then wake up two, three, four hours later. And then somebody else picks it up. And by the time the surgeon knows about it, it could be six, 12, 24 hours. Get that stat

post-MR and re-operate as soon as you can because time is spine, just like brain is spine with stroke.

Okay, let's talk about the fact that time is fine. Now, here are the references that I think that if you're looking to read some of the primary sources, Journal Neurotrauma 2015, Jug et al, what

are they finding? Eight hours is better than 24 hours, so early surgery is better and they will improve more grades if the early surgery is done

The next is Burke J. Neurosurgery 2019, surgery within 12 hours, again a better, better Asia grade may be found in these patients and early decompression improved recoveries. Badwila, Lancet

Neurology

2021, early surgery, more recovery than the late operations and there was a steep decline in change in total motor score with increasing time duration You know, if it looked 24 to 36 hours, so in

short, the old rules don't apply. Earlier, the better. saying, Oh, well, I have 24 hours. I can do it the next day. Not good enough. If that patient has a severe deficit, your obligation is

really to do these ASAP. This argument that people put forth, Oh, well, I don't wanna do it in the middle of the night because there may be more risks and complications with that nighttime OR team.

There have been a lot of studies that have discounted that hypothesis. Queodal in the Indian Journal of Surgery 2021, again, touting the benefits of early surgery, acute spinal cord injury

patients who underwent early surgery, had greater recovery from spinal cord injuries. And this is Phalanx's article from Global Spine Journal. efficacy, safety, and cost early versus late surgery

is better, less than 24 hours. And existing evidence supports improved recovery among spinal cord injury patients undergoing that early surgery And here was just an article that I had thrown in

there. Looking at if patients were undergoing additional secondary tertiary, et cetera, re-operations for anterior cervical disease, 1, 100 patients, major adverse events in 35, versus minor,

a lot of readmissions, 34 and re-operations. Again, the morbidity rates were less if they had a one level versus a two level prior procedure. You really have to watch out for whether or not they

have a recurrent laryngeal nerve injury prior to choosing to redo this. Even if you're doing it on the same side than you're dealing with more scarring, but see as much as you can. And then these

are all the other references that you can see associated with these. And that's it.

Okay, let me

ask you a couple of one or two questions and that's it. The lumbar peritoneal shunt my understanding that. Basically, there's a general rule that about, it fails about 50 of the time. Is that

your experience?

In any of the cases where I used it for a CSF leak, it did not fail within the period of time that it took the anterior leak to resolve. Okay. So the answer was, I think they worked really pretty

well. And remember, we also had the Wound Parrot Nilsundt And if the Lumbel Parrot Nilsundt failed, we could actually tap the dome of the anterior shunt to divert some of the CSF. But no, I

didn't encounter that they were that. So the use for hydrocephalus is different than the use for draining a CSF leak. Yes, yes, you just need shorter term. Certainly a

few weeks is usually more than enough to do the trick. I think it was a terrific talk And you

want to - pointed out to me is that the complications, now I know the argument's gonna be, well I've done this my whole life, I've had very few complications, or no complications, so forth and so

on. But if you have a complication, it's 100 for the patient. That's a good thing. And the answer is

if you - Especially, yeah, especially if you have a patient where, you know, a laminophur anonomy is a perfect operation for that patient, you know? So, you know, I've seen multiple cases

where had the operation been done posteriorly, they would not have encountered all the complications like graft related, et cetera, anteriorly, so. When you made your list of all the things you

can get anteriorly, yes, I've only had why, yes, I've had a few patients with the phage, just phagia and motor deficit, and then, you know, you just

never know how it's reported. But the complications can be very significant from the figures you had. It was from one out of 10 to one out of 20 for sure. I mean, not one out of 10, from 10 to 20.

And imagine if I'm the patient and I'm going to a doctor and he wants to sell me a car. Yeah. And I ask him show me, tell me about the complications. Well, he said, if you add them all up, one

of them is about 10 And the rest of them, you add them all up, it's 20. Yeah. I'm sitting there saying, what the heck am I doing this for? I don't want this car. Yeah, that's right. And

nobody thinks about it that way. And the answer should be for surgeons, although everybody takes it differently, it should be zero.

Or as close to, as close, it should be as limited as possible. Well, the point is if - In sure. But he says it's okay to have one or two or four or six or eight percent.

Yeah. I went to a CPC once where the head of the department, they were presented some, they were doing a posterior fossa approach to a tumor. It was an acoustic and they had a devastating deficit

and they said, well, everybody knows that you can get this with the operation. So I don't think we have to record it as a complication.

Okay, so that's for the hospital reporting. So I think it's, these are very serious and you've got to get to be as close to zero or as close to zero as you can get. How can you sell a car and tell

them it's a, you're gonna have a move? But that's, you know, that's a really good point because, you know, if you look at almost any of the medical legal cases across the country, the arguments

that they try to use is exactly what you said. Well, it's a reported complication with this procedure. Well, it's an unacceptable complication of the procedure. Particularly A, if it was the

wrong procedure in this patient, B, it was poorly performed. C, they didn't use adjunctive measures to increase the safety of the procedure. That's why they talk about monitoring as well. It's

not part of the standard of care. It's like you'd say, well, if you were going to do an operation and you could increase the safety of it using ABCD, why wouldn't you use that? Are you presented?

I mean, I think it was now over 40 different replacements you're gonna have for discs in the front. And the answer is, and they all have complications or even complications. I think you were

talking about one when they were using cobalt and they got blind. So, oh gee, yeah, I had one out of 200 people became blind. I mean, that's just the life-changing. It's unacceptable. When you

can go and get an Oleac bone-crust graft, put it in, you get a higher rate of fusion. It's easy to do It's a patient's own graph. And you get all in, that's a lower cost. I don't see the

argument. I just don't see it. So, and I know I'm in the minority, but it just doesn't make sense. Oh, both of them were very bad. Yes. They don't even have any, they don't even get, most

surgeons do not even now know how to harvestiliacrist or graft anymore. I'm sure that's true. And a professor once who said, and he said, what you do is you're gonna get complications of

complications So what you have to do is stop the complications because it isn't just a complication you, you may get CSF leak and then you get a subdural hematoma. Now you've

got a complications or complications or you may get a meningitis and so forth. That's what you're exposing the patient to. So it isn't just a number in a journal. This is real life and real

complications. So anyway, I really appreciate it. It's really an outstanding review

of this area. And a lot of questions came up about what you can do, and we hope we answer the questions for people no matter where you are in the world. And I think you did. You don't need all

this stuff in your country. If you don't have it, you could use the patient. And yes, sometimes I may not follow directions, maybe you have to go get the proper brace or something like that. But

compare that to the cost and everything else from everything else. I just, you can't justify that to me. Yeah. Okay. Yeah. Sounds good. All right. Thank you very much. Now it's coming up.

We're going to do, you're going to do something about anti-recarpectomy. Anti-recarpectomy next, I think. Yeah. And then you have a combined talk doing anterior and posterior approaches to the

spine using case examples. So the audience can go through what your choice is and so forth, right? Yes. And that's only the first third of the spine textbook.

Thank you so much, Nancy, just an outstanding job, okay? Good, good, I'm glad. Okay, bye-bye. Okay, stay well. Yeah,

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ACD/ACDF vs Cervical Arthroplasty; Controversies in Spine Surgery; Nancy Epstein. MD

James I. Ausman, MD, MA, PhD

Nancy Epstein, MD

SNI Digital®, the Global, Interactive, Peer-reviewed, New Video Journal of Neurosurgery and Neuroscience-2024 Edition; "Innovations in Learning" for the 21st century

VIDEO EDITORIAL

NEW SNI Digital® Version 4.2

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ACD/ACDF vs Cervical Arthroplasty; Controversies in Spine Surgery; Nancy Epstein. MD

James I. Ausman, MD, MA, PhD

Nancy Epstein, MD

SNI Digital®, the Global, Interactive, Peer-reviewed, New Video Journal of Neurosurgery and Neuroscience-2024 Edition; "Innovations in Learning" for the 21st century VIDEO EDITORIAL

NEW SNI Digital® Version 4.2

SNI Digital®, the Global, Interactive, Peer-reviewed, New Video Journal of Neurosurgery and Neuroscience-2024 Edition; "Innovations in Learning" for the 21st century

VIDEO EDITORIAL