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SNI Digital Innovations in Learning is pleased to present in association with SNI Surgical Neurology International,
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another in the series of SNI Digital Controversies in Spine Surgery,
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a lecture in discussion with Nancy Epstein, who is the editor-in-chief of Surgical Neurology International on the topic of diagnosis and treatment of thoracic disc herniations.
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Nancy is the professor of clinical neurosurgery at the School of Medicine at the State University of New York at Stonybrook, has been in practice for 40 years doing spine surgery, is the
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editor-in-chief of Surgical Neurology International.
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This is another in the series of talks on
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diseases of the spine and neurologic involvement by Nancy Epstein. And this one is on the diagnosis and treatment of thoracic disc herniations, a very troubling subject for many neurosurgeons who
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handle it. So Nancy, go ahead. Thank you, Jim Yes, the diagnosis and treatment of thoracic disc herniations is becomes very specific because it has to be tailored to where that disc herniation
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originated from. So pathologically and atomically, MRCT, et cetera, you're looking for the large central disc herniations, you're looking for the large anti-lateral disc herniations seen here.
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And then you're looking for the very lateral andor foraminal disc herniations because it's gonna be completely different as to how you may approach some of these. Just looking at the anatomy, we're
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all familiar with ventrally. You have the vertebral body and you have the annulus fibrosis, nucleus pulposis located centrally. Then lateral to this in the thoracic spine, you have the rib as it
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is anastomosed to the thoracic vertebral body. You have the thoracic pedicle. You then have the laminoposturally, but you also have the transverse process as it affixes to the rib laterally. So
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all of this anatomy is very specific to the thoracic spine and it becomes crucial to understand that when essentially understanding and seeing what the different approaches happen to be. Just
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emphasizing the anatomy anteriorly, yes, here's the anterior longitudinal ligament, the vertebral bodies, here is your head of the rib being affixed to the lateral thoracic spine posterior, your
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laminar, your spanish processes, and obviously your transverse processes that are basically enastomos to that rib laterally. And here's just a figurative diagram of the thoracic spine, T1 to 12,
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looking at the anterior and posterior portions of the vertebral body, the spinal canal where the spinal cord is living in the dorsally, the spanish processes in lamina. So what are your options for
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thoracic disc herniations? Well, the lateral disc, the trans-particular approach, was really devised to deal with this very specifically and very vocally, interlateral thoracic discs. You're
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going to need a costar trans-resectomy or lateral extra-cavitary approach. And for anterior central thoracic discs, you can use the lateral extra-cavitary or the anterior trans-thoracic procedure.
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And here's just a brief summary of what these produce approaches are going to show you. Here's your lateral thoracic disc herniation. And here is your illustration of the trans-particular approach.
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You're not doing alaminectomy here, you're actually just exposing enough bone to expose the pedicle to then do the trans-particular resection. Then for your anti-lateral discs, you're going to have
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a costo-trans-resectomy as your option, where you're going to remove the transverse process as it affixes to the rib, the pedicle, and also where the head of the rib enastomoses to the
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thoracic vertebral body Also, before you go on and see what you do, and even all the back and forth we've done, how common are in the disc pathology and the spine, how common are thoracic dicks?
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It's like one out of a thousand. Oh, it's really low. Yeah, the frequency of your lumbar disc
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is obviously the highest, about 10 of those are going to be cervical discs and thoracic discs are really quite rare. Like one in a thousand is basically the.
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figure that we're typically given. Obviously, you can see these that are asymptomatic on amorous and CAT skins, but the symptomatic ones are rare. This is just, again, to illustrate the costar
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transeresectomy, where you're doing a combination of removal of the ribs or removal of the pedicle, rather, and a portion of the vertebral body with the head of the rib, and then a portion of the
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rib itself
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Interlateral or anti-essential disc herniations, the extra-cavitary approach can be used also for this. Now, what makes it extra-cavitary? Because not only you're doing what you're going to do
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with the costar transeresectomy, but essentially, you're also taking out the vertebral body laterally, which means that you have to peel away the pleura from the lung in order to have this lateral
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exposure of the vertebral body. And again, all of your dissection It has to be with a downbiting curret away from the canal. that's the whole point. You can't be putting in anything underneath the
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lamina that's compressing the already compromised spinal cord 'cause that's what makes patients paraplegic from the laminectomy, which I'm gonna show you shortly.
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And then anterior central discs can also require a trans-thoracic approach or a thoracotomy, where you're coming in laterally, you're taking off the rib, the head of the rib, and you're removing
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the ventral aspect of that vertebral body. This is classically what's used for your calcified ventral disc herniations, but the extra-cavitary approach can also be effectively used for that. One of
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the
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main points of the talk, and if everybody falls asleep for the rest of the session, don't do a laminectomy with a thoracic disc. It shouldn't be used for a lateral, an interlateral or a
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central-destion anterior thoracic disc, where you should use a trans-pidicular, cost your transversectomy, extra-cavitary, or trans-cavitary. thoracic approach. And here, again, to emphasize,
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don't do the laminectomy. Here are your options, the trans-particular, the costar trans-resectomy, the lateral extra-cavitary, or the trans-thoracic approach. So if you're listening to this talk
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and you're thinking, Well, what should I bother remembering? Just remember this picture and everything else you can forget. But if that thoracic comes along, just re-consult the literature and
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re-consult this talk to try and reorient yourself as to how it's handled. This is a typical illustration of a thoracic laminectomy. You're removing the Spanish process on the laminar on both sides.
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Here, you know, you can see the facet joints are being preserved.
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I've provided you with summary of the literature. I'm just going to show you there are multiple papers that we're going to summarize shortly. But there's a lot of literature out there. And it's
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going on for years, and I'll show you one going back to 1985 at least, which emphasizes For decades, it has been known. Do not do a laminectomy to treat a thoracic disc herniation. And this is
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just gonna keep coming up again and again. It doesn't matter if you're doing it minimally invasive, microendoscopically, et cetera. It is the wrong operation for a thoracic disc. And again,
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here's your illustration of your typical laminectomy and your removal of the lamina. No matter what technique you're using to remove the lamina, you're still more likely than not going to damage the
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spinal cord in doing that. Here is a study by Arsenal in 1985. And to summarize their findings, neurological worsening was attained with a laminectomy, rustle it all in '89, '67 cases.
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Transthoracic and
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costotransversectomy procedures were equally effective. Laminectomy, not advised.
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Okay, and again, here's your laminaectomy, illustrated here and here. oftentimes you're combining it with a fusion to maintain stabilization, but again, contraindicated procedure for a thoracic
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disc. Syngunis is study in '92, 14 cases. Again, here, cost of transversectomy and some of the other approaches were equally affected. Laminectomy, contraindicated. Fessler, 1998 in surgical
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neurology. Morbidity was similar for most procedures other than laminectomy, quote, laminectomy does not provide adequate access for the safe removal of these lesions, these lesions being thoracic
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discs. Channadol, 2000 laminectomies are, you know, not being performed, chew it all, 2002.
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Hosture laminectomy was abandoned currently as it's too likely to result in neurological loss and then they favored doing these other approaches that we're talking about. Here's an example of why
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laminectomy is the negligent operation Here's a Mylogram CAT scan. Okay, here's the CT of the vertebral body's 10 and 11. And you can see the ventral disc herniation. There's a myelogram CAT scan.
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You can see the dye and the dye is disappeared and is compressed by the ventral disc herniation. Here you can see CSF is present posturially. You do a decompression posturially. You're not doing
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anything for the anterior compressive lesion. So just in case you don't believe the image that I'm showing you here, here is a figurative diagram of basically illustrating a massive anterior disc
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herniation, okay, compressing the cord dorsally, okay. And the reason I'm showing you that other than to again show you with these different papers, again, that laminectomy is not the option
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that you wanna use. Laminectomy has not been a viable option for decades. So there's a high risk of paralysis. But that basically when you do a laminectomy or you do any operation you're doing a
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laminectomy. The kerosene punch or the kerosene rungior has a typical three to five millimeter bite. And this is the bite that we're talking about. It's right at the end here. This happens to be
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four millimeters in this illustration, but there are others. I mean, we had one millimeter kerosene punches as well. But the problem is with these, no matter which kerosene you're using, no
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matter which bite, you are introducing with a laminectomy. You are introducing that device below the lamina, okay? You already have a very compromised, compressed spinal cord, no matter what the
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bite plate of that kerosene punch happens to be, you're going to be compressing or you're adding to the compression of that cord and potentially damaging the cord. You know, lots of cases, they're
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using somenocensory evoke potentials and the SCPs will just directly drop out and typically won't come back. But a roger placed under the lamina directly injures cord. That's why you do not do a
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thoracic laminectomy. Here's the myelocete image that I showed you. Here's the figurative diagram of the large central disc. Here's the rosior bite, in this case, an illustration of four
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millimeters, but it could be smaller. But here's what's happening. What you're doing is you're placing the bite underneath the lamina. Okay, you're compressing the cord, you're manipulating
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dorsal to that very compromised cord. Your scps are going to drop out. Your cord is going to be damaged by doing this. So a bite of any rosor doing
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a laminaectomy with a thoracic disc is going to compromise your cord and it's going to produce or contribute to cord damage, not the way I do these cases. And here's just some information. Now I
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had summarized this in 2023, the average age for patients with thoracic discs between the age of 48 to 56
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with some other references thrown in, but you can just look at the SI article downloaded for free, all of our articles, are free to download. And what, Jim, two 34 countries at this point? Yeah,
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239, sure. Wow, okay. So the clinical presentations for thoracic discs. Pain, myelopathy, myeloridiculopathy, and bladder loss. So pain between 50 to 75 myelopathy, between essentially 50
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and 99 and myeloridiculopathy 61, with about a third, at least showing radiculopathy in a quarter, showing bladder dysfunction So a lot of these patients have a lot of symptoms. They don't have to
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exhibit all the symptoms at the same time. It's just like when you talk about quarter coin syndrome, they can have a partial quarter coin syndrome. Here you can have partial loss of neurological
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function. It doesn't have to include all of the factors at the same time. So the first operative procedure we're just gonna review is the trans-pidicular resection of the lateral disc. And here you
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just see that this is the pedicle, the lateral aspect of the pedicle, and you're going directly down that pedicle. you're going to drill down the pedicle. And for the lateral disc, you're going
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to start using your downblading curate to morselate, not only the remains of the bony pedicle and resect that with the pituitary, but also components of the disc itself and the annulus.
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And here again, trans-particular approach, you're only removing the bone really over the facet. You're not really doing a laminectomy. So you're not really doing laminar removal over the cord.
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It's just very lateral over the facet, just where the pedicle is. This figurative diagram is not absolutely correct. Just so that you can expose where the pedicle is very, very laterally So the
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transverse process and that picture remains. The transverse process, yes, that remains, the rib remains, the rib affixation to the vertebral body remains. You're just removing the pedicle here,
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because the disc herniation is supposed to be just next to or adjacent to the pedicle This is, again, for a very lateral or foraminal disc, and you're going to use that down biting carette, you
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know, to just more so late, the remains of the pedicle, as well as the disc herniation that you're encountering. You use a diamond drill in this also or? Oh yeah, oh yeah. In fact, I would
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always use a diamond drill. You don't want any of the cutting burs to ratchet out and then all of a sudden take a piece of your spinal cord by mistake. So the runger is just to take additional bites
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and pieces out. That's right, very, very minimal. But you use curates. Sometimes you'll use the up-biting curate in the pedicle itself. Once you get to the base of the pedicle, you'll use a
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down-biting curate To essentially deliver fragments of disc into the discal region here and then to remove it directly. But every move is away from the cord, not towards it.
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Again, here is your lateral disc. You can use your down-biting curate for that lateral excision. This is, I'm just using this diagon. This is actually a cluster transverseectomy, but here I'm
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just emphasizing to you
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that we're going to remove from here down to here. That's to remove the pedicle here. And the ribonie removal is only very laterally over the facet and really not over the cord. Again, not
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perfectly illustrated, but that's as close as I could get. When you look at trans-particular procedures, the average OR time, blood loss, length of stay and re-operation rates, here was a study
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by SAWA at all in 21, 43 thoracic discs, average operative time, a little more than three hours, average blood loss, 238 cc's, average length of a hospital stay, 44 days. I mean, these days,
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you know, it's very rare that we have patients who are really staying that long. Re-operation rate, 14. Well, probably if you choose the correctly extensive operation the first time around,
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you're gonna have fewer re-operations So that's what I would say for here. It says to be a very lateral. a remedial disc to choose a trans-pidicular approach. And I ask you a question here. One of
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the problems is how do I know I'm at exactly the right level where the disc is? Because before surgery, you put a needle in, you take a
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lateral x-ray, do you put some dye in there? How do you know? Because I think there are reports of people who actually go to the wrong level. Yes, yes So how do you know that? Yeah, a very
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common mistake in the thoracic spine. First of all, before you ever go to the operating room, you're supposed to get chest x-ray, as well as a lumbar x-ray. And
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you look at the AP views to make sure you have 12 thoracic vertebrae, and you've got five lumbar vertebrae. Now, 5 of the time, you may have four lumbar vertebrae or six lumbar vertebrae. So you
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have to make sure that your count when your pre-absis studies is correct. Preoperatively, get an MR and a CT scan and even a Milo CT scan to make sure you are correctly localizing where the
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discrimination is before you even go to the operating room.
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Some people will, prior to doing any thoracic procedure, do a localizing film that morning, use methylene blue or some of the other things or actually sometimes they put a small pledge lid of metal,
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write opposite the pedicle of interest. But then in the OR you have to prone, do fluoro and count up, you have to count up the ribs. Now that's why you have to make sure you've counted the ribs
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correctly and you have your preoperative chest x-ray to help tell you that in your preoperative lumbar film to make sure you're not making any numerical mistakes. Sometimes injecting the interest
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minus ligament at that level can help you out also. And just using methylene blue, is that 100 certain? Absolutely not, it can spread. They can inject too much. And you can end up, you know, a
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level above, a level below. So that's why you have to, the best way is to correctly count the
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thoracic pedicles on your AP fluoro image. As you sequentially go from the 12th rib to the 11th to the 10th, et cetera, you have to count your way up. Okay, that's really important. Yes, but it
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is a very common adverse event associated with these procedures. And it can be avoided, but it takes a lot of planning pre-operatively as well as intraoperatively to make sure that you're not at the
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wrong level. A lot of the trans-particular approaches, you know, look, you do have the thoracic spine and the rib cage you together, many still think that you need an inter-body fusion if you're
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going to do a trans-pobicular approach and some will place, you know, different kinds of inter-body devices in the site itself and then put the pedicle screws posteriorly as well. This may be true
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as you get closer to the thoracolombra junction. In the mid thoracic spine, it may be certainly less necessary to require that. And more scans. They're the best at showing the location of your
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thoracic discs. Myelogram CAT scans, I'm going to show you next, or also excellent, for doing that. Non-contrast CAT scans may be unreliable. But where your disc is going to be located, about
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30 of your discs in the thoracic spine are going to be central or anterior. Interlateral of some series vary, 50 to 100. And lateral has a huge variation, 6 to 70 percent. So. depends on the
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study, you read the size of the study, but the locations can vary markedly. Certainly, I think the majority are gonna be your inter-lateral disc herniation. And again, the custer
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transverseectomy here and your lateral extra-cavitary approaches are gonna be the safest. Choosing just to do the trans particular is probably the least safe in terms of giving you very limited
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access and maneuverability. And many people think these days that the trans thoracic has a very, very high morbidity. So cost of transeresectomy and the extra-cavitary are going to be really the
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favorite choices to a large degree. Can you come back a minute? That slide said there was six to 70 lateral. That's a kind of big range, why is that? That's huge. I think it's the size of the
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different studies that are submitted. And they just said, hey, we have a series and all six of our cases were thoracic, you know, were six out of seven were lateral thoracic deaths. So it's a
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variation in terms of the size of the different groups. I think that the truth is probably somewhere in between around 30 or 40 percent. Okay.
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Interlateral discs, typically, as I've already mentioned, cost of trans-resectomy is very popular. You remove the pedicle, the head of the rib, and then the rib itself. And here, again, is
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your large, interlateral thoracic disc herniation. It's impinging for amolee when you're exiting root, but there's also some compression on your cord as well So you need more room to go through the
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cost of transversectomy approach to dissect that disc laterally. So for the cost of transversectomy, you're going to remove basically the transverse process and the lamina will vary laterally over
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the facet and the transverse process. Well, it's really a transverse process here more so than just the facet. And then you're going to do remove the pedicle and you're going to remove the lateral
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aspect of the vertebral body, but in this area up here. So again, an illustration of the interlateral disc, and this, again, showing you, pedicle removal, the head of the rib, and also the
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rib itself, and also the transverse process of fixing to that rib. And once you have done the resection, you should have a pretty good, very lateral view. And here, then you can start dissecting
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material laterally away from the cord, away from the nerve tissue, and into the sort of the crevice that you're creating, or the defect that you're creating. And here is, again, just to remind
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you, you're taking off the pedicle, the head of the rib, the rib itself, as well as the transverse process. And then this is what it's gonna look like on a post-operative CAT scan. So here,
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really your lamina is intact. You're going lateral to that, okay? You're taking off the rib is coming in here. You've removed the transverse process You remove the pedicle. and you remove the
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head of the rib and the interlateral portion of the vertebral body. It's not the custer transversectomy that comes all the way down where you dissect it all the way down here through the soft tissues,
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but this gives you a very lateral exposure for that interlateral disc. Again, all of your maneuvers are away from the cord. That's why when you do these procedures, you should be using not only
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somatosensory about potentials which monitor the back of the cord, position, vibration, the posterior columns, but motor vote potentials are going to monitor the alpha motor neurons, anti-lateral
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spinal thromatrix, but basically motor. So you need motor vote potentials as well as somatosensory vote potentials when you do these cases. If you start to get changes, you halt, you stop, you
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raise the blood pressure, you can hyperoxygenate your wound with peroxide. If there's any distraction or manipulation, you stop whatever you're doing. If you have not created enough of a
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decompression, Make yourself more room. Okay, and wait. Probably give a bolus of a gramosolumidrol. Sometimes you wanna give two, but you don't just keep working your way through, okay? Oh,
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good, very good image.
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So what's the difference between CTs and MRs? I mean, pretty much include this in almost every lecture, just in case we have other folks who are not familiar with this. Basically, MR scan is
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gonna show you the soft tissues in the thoracic spine, you've got disc, you've got CSF, you've got fat, you've got ligament, you've got cysts, et cetera. CAT scan is gonna show you calcium or
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the heart candy shell, the calcified disc and the bone itself. So again, on an MM, you've got the chocolate on the inside, the heart candy shell on the outside, and that's your MR and your CAT
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scan, just in case any of your colleagues are forgetting that The most thoracic discs herniations are the way. by the way, between T11 and T8. And the MR is gonna best show the soft tissue
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findings for this. And here is your anterior thoracic disc scene on this sagittal MR. And here's an axial MR that excellently shows you the chord compression. So here's the thoracic disc. And
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here's your chord tethered over it, okay? In some cases, you may have a lot of CSF posteriorly. In this case, you also have some epidural fat In other cases, there's going to be less room
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present. But the MR best show you, soft tissues, the disc, the stenosis, the ligament, the cysts, high chord signals are seen in the chord, indicating the severity of the compressive changes.
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You may see edema associated with it. It may document for you the chord compression, the best, which you're not going to see on, certainly, on a non-contrast fat CAT scan. And MR scans, it's
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not going to show you the calcification. It's going to show you a negative image anything that is calcifying. and that's very different from having a positive image. Positive image you're gonna see
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on a CT or a Milo CT, Milo CT, obviously, by placing dye into the, you know, thickle sac, you're gonna get the best delineation of this. It also helps you very importantly prevent wrong level
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surgery because you know exactly where that is. And you're doing the laminectomy here. I mean, I brought wrong, you're doing your Milo CT, you're doing it from the bottom up so that you can count
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correctly as to where you are. Cat scan alone can show you the calcified thoracic disc. And in this case, this was colored in one case. Here's the vertebral bodies anteriorly calcified disc,
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opposite the disc space, lamina posteriorly. And just look at this, look at the, there's no room left here. Because again, you're gonna have a millimeter or two or three of epidural fat and dura
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and hypertrophy ligament, et cetera. You put a kerosene punch underneath here with a laminectomy, you're going to come. or demolish what's left of the cord in that case.
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So fully calcified discs, you know, about 40 to 65 of the time, partially calcified up to 27. So you're going to see some calcified discs. Also, sometimes your myelocyt is gonna show you that
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the disc has herniated interdurally. That's a good reason not to pursue necessarily the anterior thoracic or thoracotomy approach because then you're gonna have trouble dealing with this CSF leak
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component of that. A CT scan, this is just an example of a CT showing calcification of a thoracic disc herniation. The MR does not show the calcification of this disc herniation 'cause on this MRI,
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you're just seeing a hypo-intense signal for what is ossified or calcified. You do see the compressive effect, And here you can see the cord is vastly indented from this ventral thoracic.
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discrimination. But again, a good example of where it's judicious to get a CT scan, much less a mile of CT in some of these cases, basically all these cases. Extra-cavitary approaches, so can,
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again, if you've
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been out there and sleeping, join us. Large anterior lateral thoracic disc can also be approached through a extra-cavitary procedure. And here, again, is your large central anterior disc again.
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Extra-cavitary procedures. That's where they are on this schedule here. Here's an interlateral disc in your myelocyt. And here's on a myelocyt. This is not the best study I could find, but it is
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not the worst. So you can see here is the disc herniation. You can see here barely a little bit of spinal fluid in the dural sac. And here you can see DCSF in the Durl-SAC, and then it disappears.
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but here is your large interlateral disc just like you're seeing it on the figurative diagram. You do not have a lot of room to work in. And obviously the choice of which side you're gonna go into
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has to deal with the side of the major component of that disc because that's where the resection is going to have to be. So again, your extra-cavitary, you're gonna go from here, take out this and
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this so that you're working all throughout there And that's what I'm showing you here. You're taking out not only the pedicle, you're taking out the transverse process, you're taking out a good
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portion of the rib and where the rib affixes to the thoracic retinal body and a huge portion of that retinal body itself. And that's why in many of these instances, you're gonna put in an interbody
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graft to make sure that you can shore up that level, make sure it doesn't, you know, kifos. So again, extra-cavitary approaches, you have to take off the lateral muscles, From underneath the
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rib, you're going to have to take down the pleura in order to expose that vertebral body adequately.
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This is with the muscles removed. You're going to see your transverse process. You're going to see the rib.
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And then you're going to proceed from there. Okay, you're going to take out the rib and you're going to disarticulate and take out the head of the rib
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You have to cut the rib first in order to do that. And then what you're going to do underneath here is you're going to dissect the pleura away. But again, this is probably a better diagram of some
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of this but see where this retractor is it really should be more medial because you want to take some of the transverse process, where it affixes to the rib where it affixes to the pedicle here as
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well The diagram is not perfect but it just shows you the separation of the plural once you've completed the extra cafeteria approach. You should have an excellent anti-lateral decompression of the
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cord, as well as the nerve roots. So you have much, much more room here to work in. Okay, and you know, hopefully you've kept the plural in tax so you're not compromising along in this case.
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Transthoracic approaches, on the other hand, may be dealing with your anti-lateral discs, as well as with your large central discs. Everybody argues that
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the
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morbidity of trans-racic approaches makes many people avoid them favoring the extra-cavitary procedures. So, and here, just on showing you - in my low CT scan showing you a giant intra-dural disc
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herniation, here on the non-contrast CT alone, here on the MR, you never would have anticipated that. And a my low CT is going to show that to you very well. Giant thoracic discs are seen about
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30 to 40 of the time that means that they're arguing that they're taking up 30 to 40 of the canal. And the frequencies vary markedly. It depends on, again, the series that you're looking at in the
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literature. And here are some of the different series that report different frequencies. Here's an illustration of a anterior thoracic disc I'm representing to you that this is a disc herniation
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ventrally, centrally at T1011.
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And then here is an MRI scan of a large thoracic disc, central anterior And then here are the image that I showed you previously of the large central myelocyt of that disc herniation. So figurative
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diagram to MR, to myelogram CAT scan. Okay, here, figurative diagram over here, actual myelocyt here.
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And again, just remember the big blue disc herniation, you have to get that out safely. And that's where you're
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trained You're a transterastic. procedure may come in. You have to choose which side you're going to go from. Here is just a figurative diagram of everything you have to go to to get there. So
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it's a long way in.
34:09
Transthoracic approach requires, you know, theipsilateral thoracotomy. You're going to be taking out rib, disarticulating the head of the rib. Lots of times you're taking out the pedicle as well
34:19
to get all of the approach. You've got to do a retroplural dissection of that lung to try and then expose the lateral aspect of that vertebral body. And again, you're going to be trying to go after
34:33
that calcified CSF a avoid to trying, carette down-biting your with disc
34:37
leak. And again, you have to be prepared in some of these cases. Are you going to need a lumbar drain once you're done with this? Sometimes people will put in a wound pair of no-sunt for this.
34:48
They certainly do in the cervical spine. But for the trans-thoracic resection, We'll put in. basically screws into the virtual body in order to distract that interspace and get down to the spinal
35:02
canal. This is the resection. You're going to go through the pedicle, the head of the rib and take out the base of the canal itself. Here's a lateral view of your exposure. Using your downbiting
35:15
current, everything, the oldest section is away from the cord itself.
35:20
Okay, and then at the end, you're gonna place some kind of an interbody device as well as a lateral plate on the vertebral bodies, which, of course, you can do the same facsimile of this with the
35:34
cost of transeresectomy. Again, here's an example of a large central disc herniation on an MRI scan. Here you have removed it and you've got the graft here and then the plate and then this is what
35:48
your plate may look like on that MRI, obviously with artifact, but now your cord is decompressed at that level. There may be a residual high signal in that cord associated with that. But here your
35:60
post-IPMR shows your graft and plate in place. And here again, your post-operative view of your procedure, you've done your resection as best you can, and you have a view of the cord and the nerve
36:13
roots. What are the outcomes of the trans-thoracic and trans-facet procedures? In Korea series, they were all anti-relateral discs and they did trans-thoracic approaches This was back in 1994.
36:26
Good to excellent outcomes, 86 of the time. Silverman at all, this was later in 1998. Study 87 approved and most of these 60 were trans-thoracic procedures. And what were some of the adverse
36:41
events where one patient died, there was one cardiac event and one patient developed paralysis. So they're not without risks and complications. Again, somatosensory vote potentials as well as
36:51
motor evokes are critical to use in these cases.
36:56
Here is another study of trans thoracic 70 good results actually from both of these studies That minimally invasive trans thoracics, you know may have more complications Longer surgery more blood
37:10
loss and longer lengths of stay Kapoor study of mostly trans thoracic, but some other trans-particular You know a little more than half a little less than half improved half stayed the same and a
37:23
subset of patients Became worse the major events. Dural chairs massive blood loss Interoperatively and delayed complications can be delayed pleae ger herniation of the cords final fluid leaks
37:37
infections etc. So these can really present with some significant morbidity again a lot of these thoracic procedures are going to be supplemented with a pedicle screw instrumentation medical screws
37:51
can be placed percutaneously, minimally invasively, or open. And again, you have to remember if you're putting minimally invasively these screws, the tubes are three to nine centimeters long.
38:05
Tubes themselves vary between 16 to 26 millimeters wide and one inch is 25 millimeters. So here's your, you know, your thoracic pedicle screw instrumentation. And this is what it's supposed to
38:19
look like. You know, your screws nicely placed bilaterally, et cetera And here, screws may be nicely placed. And in this case, I just, you know, chose to borrow actually from the lumbar
38:31
literature. And here is a screw coming across this spinal canal. That's not good form. This is a thoracic study where the CT scan on the parasaginal images showed a screw beyond the retrieval body.
38:46
And it was confirmed on the axial study and they did a swallow, a barium swallow, a esophogram and they diagnosed that that screw head. penetrated the esophagus, so obviously it had to be removed,
38:58
and the entire patient had to undergo a major revision surgery. So basically, when you're talking about thoracic discs, stop, think, look at the literature. Choose the right surgeon to perform
39:11
the operation. If it's not you, if you haven't done it before, don't do it alone. Do it with help. Watch, learn. Don't just have that patient be your first patient, where it's like you go to a
39:25
meeting, and you're ready to go ahead and do it at home. And choose the right operation for that thoracic discrimination based on your studies. I just want to point out to you that if you look in
39:38
surgical neurology, International 2023, I have a summary article. Look at the reference list. And this is just one of the - that's half the reference list. Here's the other It goes back to 1995
39:51
and it goes up to 2023.
39:54
You know, again, laminectomy is the wrong operation for thoracic discs and here are the multiple references that I'm giving you in this reference. It was 67 cases. Trans thoracic and costar
40:10
transversectomy are the most equally effective. Laminectomy is ill-advised. 14 cases in this study in '92. Laminectomy is contraindicated. Fessler study in '98 Laminectomy contraindicated. Chen
40:23
study 2000. Again, the other procedures are effective. None are a few patients underwent laminectomy. World neurosurgery, 2018. Seva komara, said, Basically, don't do the laminectomy. And so
40:40
on and so forth, this was 2023. Laminectomy is no longer considered a viable option for treating thoracic disc herniations. And here it just happens to be one talking specifically about cost to
40:52
trans-resecting. You know, so in short, you know, basically these are very difficult operations. Make sure you have the correct monitoring going into these procedures. Make sure you have the
41:06
appropriate preoperative studies, MR, NCT,
41:11
andor myelogram CAT scan. Make sure you actually mark, as Jim and I were discussing, mark that patient preoperatively that morning before you go to the operating room to try and make sure you're
41:21
going to be in the right place at the right time. Watch out if you're using methylene blue or any of the others, don't inject a lot of material because you have to inject it into the intraspinus
41:32
ligament, very punctate, very focal, and again, it does not take the place of counting up the ribs on an AP fluoro image from the lumbar spine all the way into the thoracic spine to make sure
41:44
you're operating at the correct level But this is what it takes to do these operations correctly and safely, and if you follow these directions that should really help you do these well and get the
41:58
best results for your patients. Thank you. And Nancy, it's just a superb review of a
42:06
subject. Let me ask you a few questions that I had as I was going. It's pretty obvious that once you get this disease, which is rare, so you're not going to see it a lot. You got yourself a very
42:20
complex problem that's difficult to manage. All the things I'm going to ask are going to follow up on that. Obviously, you've got to get a CT and MR. Should you also get a Milo CT? I mean, if
42:34
you go with what people used to say before, is you need all the information you can get before you do the surgery. Would you do them all or what would you do? I think, you know, Milo CT might be
42:46
great for lateral or for abdominal discs. Once you get into these bigger disc herniation. central or interlateral, you can start to worry that you do a monogram and that patient could decompensate.
42:60
Oh, okay, very good. So you have to be very circumspect in terms of where you choose to do that. That's where you might just get the non-contrast CAT scan. Talk to your radiologist. I can't
43:11
emphasize to you how many cases are lost, you know, medically legally or botched because nobody took the time to go to their neuroradiologists, go over the MR, go over the CAT scan, go over, you
43:25
know, just plain x-rays. Did you get everything you needed to localize that problem before you did anything? And then when, before you go to that OR, do yourself a favor in the thoracic spine,
43:38
have that level marked by the radiologists. And then in addition to that, you want to make sure that you are counting up the ribs correctly to that you're sure make
43:51
Okay, that's good. And then the next thing you talked about is, as we talked about it is emphasizing counting because I just can't
44:03
forget in my training, people would always say, geez, I was at the wrong level. Yeah. And I've seen that happen in the lumbar level. So you've got to really be sure about that. Now, the next
44:14
thing is, let me get to this subject first The next thing is, if you're going to do a costo transferectomy, do you
44:24
need to talk to your thoracic surgeon or not? I mean, in other words, when do you need to ask for somebody to come in? 'Cause the risks are going up as I start talking about all these things. You
44:39
need some supporter or somebody who at least can help you through this.
44:45
Yeah, I mean, you need definitely to talk anesthesiologist. Sometimes they will separately intubate the main bronchus on the right and the left, because if your lung is collapsed down on one side,
44:59
because you get it interplurally, then you have to be ready to anticipate that and deal with that. So definitely, you have to talk to anesthesia. What about the thoracic surgeon? And what, for
45:10
what would you do it for a costo transferectomy? You
45:16
could, I don't think it's absolutely essential. I think it's certainly helpful because they're used to peeling ribs off the pleura. So that's a good job. If you, if you don't have an experienced
45:31
surgeon who's done thoracic discs before, and you have not done these well, definitely a thoracic surgeon is, it behooves you. I mean, it's just like for any surgery, you know, certainly the
45:45
anterior lumbar, anterior body, fusions, et cetera, to have an access surgeon
45:50
ready to help you and also they know how to prepare and speak to the anesthesiologists because They're doing this kind of exposure all the time. Yeah, that's a very good idea Yeah, now it would
46:02
also because you would you convert the cost of transfer sectomy and to more of an anterior procedure? So you may have to do a more dissection would be another reason you need to have somebody there
46:18
You know, I didn't have on my use not there. I had to do it myself. I couldn't quit. Yeah Yeah, and you you really you really need the experience of a qualified really thoracic surgeon to be to
46:32
be there to help you Also in case you get extra bleeding that you're not used to dealing with I mean, that's that's a That can be a real problem and how to get the lung out of the way safely
46:44
Definitely.
46:47
And a vote potential is also, you mentioned that early on, but these are all things along the way that ensure that you're going to have a successful outcome. Yes, yes. But it's all the planning,
47:00
in other words, how many, you know, if you look at malpractice cases, how many of the errors, or it's like the mental errors in baseball, they didn't have an arterial line in place, that was a
47:12
mistake, they didn't have the SCP and motor evoked potential monitoring, 'cause the motor evokes are gonna show you if the anterior portion of the spinal cord is being damaged, SCPs may never drop
47:24
out, so you really have to have the two of them there. They've been studies in monkeys where they actually removed the anterior two thirds of the spinal cord and they left the posterior one third
47:37
intact and the motor evokes dropped out, but this amount of sensory is stayed intact, so you have to have all of these other adjuncts in place. I think emphasizing the thoracic access surgeon is a
47:49
very good emphasis. The minimally invasive surgery. I'm not, you can help me out here because I'm not familiar with that. Are people trying to approach these with minimally invasive surgery and
48:02
tubes and all that kind of stuff? All the time, all the time. And all I can tell you is it just seems to me that a lot of these approaches are fraught with a lot more risks and complications. If
48:13
you can't see what you're doing and you're getting less than adequate exposure and trying to do, I mean, the literature basically shows after a year, you know, with the smaller incisions versus
48:25
larger incisions, a lot of the results tend to be relatively similar. But the comorbidities seen with some of these endoscopic or microendoscopic or minimally invasive procedures, the risks are
48:39
higher. I mean, it's just like in the lumbar spine, minimally invasive discectomies, more CSF leaks, infections because it's taking you longer to get where you have to go because you can't get
48:49
there as readily and quickly, you know, mistakes in terms of localization mistakes and residual discs, recurrent discs, that kind of thing. So I think you've got to be very careful in terms of
49:04
when to apply a minimally invasive, much less a micro endoscopic approach. So you don't go to a course and do a endoscopic approach and come home and do that in your next patient. Well, that's
49:17
done all the time, unfortunately, right? It's, you know, see one, do one, teach one, but that's a real mistake. In other words, if you go to a course and you see this done, there have been
49:28
instances where in the same hospital, let's say you had neurosurgery and orthopedics and, you know, all you had to do was ask your orthopod in the next room to come and do a few cases with you to
49:42
make sure that you know how to do it at So you do with them as co-surgeon, so you really learn how to do the case correctly. Instead, ego gets in the way and your patient suffers for it. Well,
49:56
you know, I look at it as this is, this is really a procedure front with a lot of risk here into parts of the anatomy. You don't see all the time. You're into an area where there's very little
50:09
room for, for error And it would seem to me, if I was just thinking about it, I'd want as much visualization as I could get. If I was using a tube, I'm really pretty restricted. I'm not an
50:22
expert in that. I don't mean to criticize people, but I'm just looking at it from what are the statistical chances of having a high degree of success rate. And I'd have to have a lot of vision,
50:36
particularly if this is not a common procedure. You don't do this often. as in a center where you do 20 a year or something like that, it's a you've got a different argument, but this is this is
50:47
this is trouble waiting to happen. Yeah, well it's it's like going to the courses with the cervical for melanoma, you know, microscopic or cervical for melanotomies and your maneuverability, even
51:02
if it's it's a relatively short,
51:06
you know, travel from the skin to actually the bone itself, your restricted ability to maneuver your nerve root that's extending laterally and superiorly typically, getting the maneuverability
51:21
under that nerve, getting your dissector, dissecting away from the pathology, getting your keratin safely, these techniques, especially through the tubes, can be very, very limiting. And if I
51:34
got, let's say, it was taking the, taking this central disc out and the process, I tore the dura and I got a CSF leak. Now what do I do? Well,
51:49
number one, doing a repair is gonna be very difficult. Number two, you should not put in dura seal or your fibrin sealants because they're gonna be cord compressive. So that's not a smart way to
52:03
do it. You can always, you know, use a artificial dura or, you know, some fascia on the weigh-in. But the main thing is,
52:18
lots of these cases can be treated with wound parrots, neils, shunts. So you directly divert CSF into the pareneal cavity. And then once you're done with the case, you can put in a lumbar drain
52:31
or immediately put in a lumbar pareneal shunt with what's called a horizontal vertical valve. So that as soon as they stand up, They don't lose all this CSM.
52:41
I'm thinking about this and I look at surgery and I pack some stuff in there and hope it's going to get better. And after surgery, I got a CSF leak, I got to take the patient back to surgery, I
52:53
got to go through everything all over again. Then I got to put a drain in. I probably have to inspect where the leak is and see what I can do. I've still got my thoracic surgeon with me That's the,
53:06
I don't want to go down that road. So that's complicated life. Yeah. Well, one of the biggest mistakes though is that everybody then to occlude the leak, they throw in the kitchen sink. You know,
53:17
yeah, you're throwing your derogen. Well, then you throw in some gel foam, gel foam's the worst thing to leave there because it swells like 12 in all directions. And then before you know it, the
53:28
patient postoperatively is paraplegic because they all compress the spinal cord. And Dura seal is well known to do that as are the other five instillants. So you have to be prepared. to deal with
53:41
this and typically, you know, putting in a diverting shunt is gonna be the way to go. Well, you've gone over this procedure. It's obviously a complex procedure. It has risks and if you do your
53:58
homework and do all the preventative things before you get in there, I don't think you're trying to discourage people, but it's something you just have to be prepared for and it can be done But if
54:11
you need to all these extra support, there's nothing wrong with asking a thoracic surgeon, getting multiple films, making sure you're at the right space, getting the evoked potentials and motor
54:21
and sensory
54:24
and being careful on your user instruments because each one of those things can get you in trouble. Yes, yes, and again, most importantly, if you haven't done it before, find a surgeon who has.
54:38
Okay, just another terrific summary, the terrific graphics and it made it really understandable I think for the audience and for me and really appreciated. Okay, my pleasure. Okay, we hope you
54:54
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