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SNI Digital, Innovations in Learning,
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an association with SNI,
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Surgical Neurology International,
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is pleased to present another in the SNI Digital series on controversies in spine surgery,
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340-minute lectures with discussion
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They're given on the topic of pearls and pitfalls of anterior and posterior cervical spine surgery by Nancy Epstein.
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Nancy is a professor of clinical neurosurgery at the School of Medicine at the State University of New York at Stonybrook, and the Editor-in-Chief of Surgical Neurology International.
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She's been in the practice of spine surgery for 40 years, and has a bibliography that's one of the most extensive in the field.
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A series of lectures on pearls and pitfalls of anterior and posterior cervical spine surgery
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are focused on how to choose the correct approaches to lesion in the cervical spine, with attention to the K-line.
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Part one is on the anatomy imaging clinical presentations of cervical spine neurologic disease in one level ACDF, 40 minutes
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Part two is on approach to two level or more anterior cervical spine lesions, also 40 minutes. And part three is on approaches to posterior cervical spine lesions, also 40 minutes.
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His first lecture in pearls and pitfalls of anterior and posterior cervical spine surgery
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is on the anatomy imaging clinical presentations of cervical spinarological disease and one level ACDF. The
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lecturing discussion is 40 minutes. Yeah, you know, whenever you start thinking anterior, posterior, you
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really start to try and figure out how do you make these decisions and what I'm going to do today is I'm going to start with basically, you know, showing you anterior discectomy infusions and then
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showing you what's called the K-line to discern whether or not you go from the front of the back and what criteria you use to do this. I'm going to look at the cervical anatomy, MR and CT studies.
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We're going to discuss briefly cervical radiculopathy and myelopathy, anterior discectomy infusions, anterior corepectomy infusions, and then posterior surgical procedures. Just as a quick
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reminder of the cervical spine anatomy, and we have other talks that go over this in greater detail, obviously on a cross-section view, you have the anterior vertebral body. This is followed by
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the circumferential epidural space that's shown here in blue. Next, you have the spinal cord, it's sitting in a bath of spinal fluid, obviously dura arachnoid pia, you know, around that. And
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then you have the posterior aspect of the epidural space going circumferentially And then posterior, you have the lamina, and then ultimately your spinous processes. When I was going over this,
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and I decided I'm going to also emphasize the anatomy, the anterior cord, the posterior cord, I thought it would be a great opportunity to tell everybody again, or remind them, when you were
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doing these operations, intraoperative neural monitoring, I don't care what the quote, standard of care is officially. You know, you have to just stop and think If you have an adjunct. that can
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make your operation safer for that patient. Why wouldn't you want to use intraoperative neural monitoring? And again, if you use the monitoring, you have to understand it, and you have to adjust
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your surgery according to any changes that may occur. Now, in terms of anatomy, the anterior core, the alpha motor neurons, motor evoked potentials, that's what that's going to subserve.
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Posterially, you have the posterior column, somatosensory evoked potentials And then obviously, by laterally, you're going to have the nerve roots, and that's why you're going to perform EMG or
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electromyography. When you're talking about looking at motor evoked potentials, anterior spinal thalamic tract, but more so, motor neurons, patients who have severe preoperative motor deficits,
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sometimes these MEPs are absent to start with, and they recur or appear during the operation itself. You certainly don't want the opposite, MEPs are there and they drop out, don't ignore them,
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don't just continue doing what you're doing. I've had a case recently where they were completely ignored. Surgeon continued doing the wrong operation and the patient ended up with paraplegia. So
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amount of sensory vote potentials, obviously it's meant monitoring the posterior columns, vibration and position appreciation may be the deficits that you see preoperatively. If you get SCP changes
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and you're doing an anterior operation and you're not doing motor vote potentials, you're actually causing a lot of damage in order to get those SCP changes to occur. And obviously then you have the
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nerve roots, the EMG for the anterior motor root, and in the cervical spine that's usually the little white root that sometimes is not enclosed in the door that sometimes you can miss or
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misinterpret as your disc and take out inadvertently. And obviously you have the posterior sensory nerve root. What are the differences between MRs and CAT scans? This is always very helpful to
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remind patients. not necessarily physicians, but everybody needs a good reminder some of the time. And basically, if you understand what an MM is, our international colleagues may not. It's
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chocolate inside what's called a hard candy shell. And what I would say is that the chocolate on the inside is like the soft tissue on an MR. It can be the nerve tissue. It can be the spinal fluid.
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It can be the cerebrospinal fluid. It can be the fat. It can be a blood clot, etc. The hard candy shell on the outside is the calcification or the ossification. Again, your MRs are going to
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underestimate the extent of stenosis because they do not quote C. Bone. Bone appears to be hypo-intense. CAT scan is going to give you a direct image that's going to be hyper dense and document
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these
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Next, you have to really understand or remember, you know, is there cervical stenosis here or not? What is cervical stenosis? It means a narrowing of the front to back dimension of the spinal
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canal. Sometimes it's just off to the sides as well. But here's the normal 17 millimeter canal measured from the bin aspect of the vertebral body to the posterior laminar line. Pustular laminar
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line. Again, if you look at my hands and my arms are the lamina, my hands are the spanish processes It's where the spanish processes take off. And then here on a lateral view showing figuratively,
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and I'm going to show you in a minute x-rays and CAT scans and MRs, normal canal 17 millimeters, something called relative stenosis is usually between 10 to 13 millimeters and congenital stenosis,
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the kind you're born with obviously is less than 10 millimeters. By the way, the minimal dimension of the spinal cord is 8 millimeters to 13 millimeters on an AP image.
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Two to three millimeters of that is taken up with the soft tissues like ligaments, like fat, like the epidural vessels. So you have to pay attention to this in terms of making your, you know,
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judgments. Here is your lateral cervical film, or here's your AP view first. Here's your lateral view going from the mid aspect of the vertebral body to the posterior interlaminal line. The
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dimensions of your canal are going to be different at different levels. The higher you are, C-1-2 very wide, C-2-3 also very wide. And it gets typically narrower as you go down, C-4-5-5-6-6-7.
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So here, you can see this is going to be very narrow opposite C-2, but C-3, C-4, C-5, C-6, and C-7. That's just on an x-ray view. Typically, this is a six-foot x-ray My uncle was under a
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radiologist and is a 15 year old in his lab and office in front of all of his crew, he would say, okay, you know, Nancy, tell me about what kind of a cervical x-ray you're going to obtain. And
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I'd have to say, you know, Bernie, it's a six-foot film and, you know, you're going to do it perfectly and you're never going to forget this because if I do, I'm going to be dead. And here is
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your classical MR scan that's going to nicely show you. These are the vertebral bodies. You are not seeing the body. You're actually seeing the fat in the bone. You're seeing the water component
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in the bone, but you're not actually seeing the bone itself. Here you're seeing the spinal fluid. That's why they call this the myelographic view. Here's your spinal cord coming down and
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posteriorly here is your CSF as well. And then your Spanish processes is what you're viewing posteriorly. Now just to jump into pathology, here is a figurative diagram. And then an actual MR is an
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axial image of a right C67 disk. Here is the spinal canal. right here. This is your lateral disc in this case, right-sided, 'cause we just used the body imaging people, call this is the right
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and this is the left. Here's an actual MR from a patient, okay? And here's the anterior and posterior, and here is your soft disc herniation scene here, okay? Here, by the way, is your spinal
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cord, and CSF is around your cord on this image
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Here is an MR, once again, of a normal cervical canal, midline sagittal view, cord is coming down, unimpeded, CSF all around it, again, your myelographic view, normal sized spinal canal,
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seen on that study. Good lord dosis, by the way, that's the normal curvature of the cervical spine. Here is an MRI scan, look at the C23 level, cord is not compressed, C34, it becomes somewhat
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narrowed, and look what's happening here then.
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C4, five, six, and seven, markedly narrowed AP diameter of the canal. And look, the lordosis is straightened and we'll talk later about how you make a decision anterior and posterior in terms of
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which direction you do the surgery from if there is a straightening of the lordosis. And I'm also going to point out to you that you saw the increased signal in the cord. So again, that is
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something you're gonna pick up on an MR. You're not gonna see that on a CT. You do not see cord detail on the CT scans This is what you're gonna see on a CT. Here's your lateral view, okay? C2,
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C3, four, five, and six. And here C2, again, the widest level, three, four, five, and six. It mid-body to post your interlamine the line. This is an actual CT scan. So the beauty of a CAT
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scan is you can directly measure from the bone, especially on the 2D non-contrast study. You can actually see the bone that you're directly measuring from and this is going to be more accurate in
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terms of measuring your canal dimensions than what you're going to get on an amor. And again as I'm emphasizing you, you're going to be able to document stenosis better on the CT than the amor, but
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you're not going to see the degree of cord compression, nerve root compression in that other detail unless you have that MRI
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Non-contrast CAT scan, a figurative diagram of a ventral spur at C-5-6, seen here, and then here is the actual non-contrast CT itself. Everything from here, posteriorly, that is all calcified
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spur. And again, on the amor, you're going to see the detail as how much cord compression there may be accompanying that image. Now a myelogram CAT scan is kind of like the Cadillac of
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how you document whether there is spinal cord or nerve or compression. Myelogram CAT scans are extremely useful, especially in patients who have had previous spinal instrumentation. It might be the
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best way to get the actual images as to what's going on. But here's your myelogram CAT scan. It's a two-dimensional study. And here is your spinal cord. C2, 3, 4, 5, 6, 7, look at the bony
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spurs. All of that bony detail, you're not gonna see like that on an MR. But again, here, your cord on that mid-sagittal image looks to be free. Here's a central left-sided disc on an axial
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study and trolateral disc herniation here, C71. Again, a difficult level sometimes in view of large shoulders to visualize on a non-contrast CT, much less even in MRI. And by looking at OPLL,
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it's a
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great study. You have to watch out though. If there's a lot of cord compression, you may just wanna get your non-contrast CT and not risk that patient's neurological deterioration. But just to
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keep in mind, MR, soft tissues, CAT scan, bone information. And if you're doing a cervical complex procedure, the two studies together are gonna show you more information than just one alone. A
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very famous colleague of mine name, Jim Alzman sent me this image the other day and said, I need a reminder about the neuroanatomy of the cervical spine. So as you may recall, C1 goes over and
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above the arch of C1 at all of the other levels, let's say it's C23, take the lower number of that level and that's the nerve root that you're gonna be dealing with. So C23, it's the C3 root and
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so on down until you get to CAT1, which is gonna be your C8 nerve root.
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What do these deficits result in? It results in radiculopathy or root symptoms and signs at the C45 level with the C5 group coming down. that patient may have deltoid weakness. You ask them to hold
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their arm out to the side, push their arm down. By the way, if you're doing a telemedicine evaluation, you can have the patient do this to themselves or you can have a relative sitting there doing
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it with them. And it's amazing how accurate some of these evaluations can be if you can't just see the patient in person. See six nerve root. You've got weakness of the biceps. You say, try and
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pull your arm down or push your own arm down and see if you can resist that. And for the wrist, you know, hold your wrist out straight and then see if you can forcibly bend the wrist or take the
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thumb and index finger and come through the thumb and index finger or not. So that may show you whether you have a C6 root deficit and C7 is basically, can you come through the thumb and pinky?
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Extents of the Phalangees is very, very C7 and the triceps is, you know, sort of a combination of C7 but a little bit of other. So these are just the nerve roots that, you know, you just want to
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remember, remember their location. Again, if you remember nothing else at any level, just take the lower number, and that's going to be the root that's going to be involved. Surgical myelopathy
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means that there is some degree of cord compression, and this is obviously a post-mortem evaluation of a disc herniation and the cord being compressed. And here's a myelogram CAT scan of a soft
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ventral disc, and the cord is deformed anteriorly on this image.
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What are the deficits that you're gonna see? Weakness of one or both sides, upper extremity, lower extremity, entire arm or leg or both. Reflexes can be hyperactive. You've got Hoffman signs.
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You may have the Binsky responses. And sensory loss could be pain and temperature from a specific level down, like a pin level. I saw a gentleman with a thoracic disc the other day, And indeed,
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he had could tell it was a pin at approximately the left the lesion was about uh t eight nine he could tell the difference between the sharp pin and just sort of adult sensation on the left side as
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opposed to the right side where the pin was clearly a pin so sometimes this is more subtle and you have to examine this very very carefully vibration and position is sort of self-evident you can ask
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them about loss of urinary or bowel dysfunction do yourself a favor and some of these patients just get yourself an ultrasound especially if it's an emergency room there was a case where we were
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discussing a patient and you know very clearly the patient had not voided all day and the ultrasound certainly of the bladder documented that anterior cervical discectomy it's because now we're going
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to switch into a discussion of surgery inter-discectomy infusions single or multi-level one of the most common operations in the US about 137 of these thousand per year. And here you have your
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classic, you have your MR, it may or may not be supplemented with a CT of your disc herniation. It's followed by, you know, you're gonna do your discectomy, you're gonna place a graph, and
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we'll talk about different graphs that can be used. And this is then gonna be followed by two-dimensional CAT scan. That might be done six weeks, three months, six months later. And obviously
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your lateral cervical x-rays that may be done immediately post-op, intra-op, and post-op, and then six weeks, three months, et cetera, with flexion extension x-rays subsequently being performed.
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And that's your plate with your screws, superiorly and inferiorly, et cetera. Could you go back to that a minute and see? Yeah. Well, how long does it take for you to see fusion of, let's say a
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bony graft? It really takes three months. Three months? People can say, oh, yeah, I mean, I've had some, cases that I've reviewed is, oh, you know, it's fused. It's six weeks, not enough
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time. Not enough time. You can see the beginning of fusion. But for that to be really solidly fused, it's really gonna take you a good solid three months. And in many instances, it could be six
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months. And it's an ongoing process. I've had patients who were smokers. They may stop smoking for those first three months and go back to smoking. And then the graph resorbs, and you do the
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study at six months and they're no longer fused. So it's typically a period of three months Now, that changes markedly. If you have a one-level discectomy, okay, certainly autographed, the
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fusion rate, you know, I had done a series where it was like 100 in about 60 patients. But other studies may be a few percentage points, three to 5 don't go on to fuse. You add a two-level
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discectomy, that's skyrocketed to like 12 to 20 that might be failing to fuse already by that time. In the upper right-hand image there, I'm gonna go back one more time.
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Right at the fusion where the blue arrow is, is the
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radio dense areas, the fusion of the cortical
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bone with the bone upper and lower levels. Well, what you're seeing here, this is the intro aspect of this, in this case it's aniliac trichortical raft, okay? But what you're seeing here, this
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sort of fuzziness, typically it's the interspace between the
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cancelous bone of the end plate, because you're shaving down the end plate to get this graft in, so it is the interface between the cancelous bone of the vertebral body and the cancelous bone of
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your graft itself, and that's what's integrating, typically here. By the way, look at the posterior ridges, I'm going to show you a better example of that shortly, but that's what you're seeing,
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and sometimes it can be misleading and look overly quote good, but physiologically it's going to take you again for those three months. So in that image is it fused or fusing? Fusing if it's only
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three months. Okay. So how will we fuse pretty much if it's six months? And six months you see it instead of the irregular border it should be a more smooth border. It becomes a more hyperdense
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border. Okay, it's all hyperdense. Okay, okay, great, great point And so here, I'm just going over, you know, multi-level anterior discectomy infusions. It's important when you do these
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operations, not only are you doing your multi-level anterior discectomy infusion, your single or multi-levels, but look at the posterior ridges. You have to have the posterior ridges to prevent
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you from pistoning into the spinal canal. Now that pistoning could be a trial spacer that some of the systems use and watch out because some of the systems do not have a stop. device. So you can
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just go right into the canal, especially if you're not doing intraoperative real time lateral flora, but you have to realize that the safest thing to do is to always have a posterior ridge. And
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it's not just a tiny little thin, you know, pledge a little bone that you're putting there, because otherwise the graft could just knock that off and knock it into the canal. But you know, this
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is a figurative diagram. But just imagine if this is thicker, which is what we usually do. But you, you typically will drill into the vertebral end plates. You don't usually want to go completely
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through it, because then you may weaken that end plate by 50. And if you've done that above and below, because that's what's going on here, you can get those graphs pistoning into each other,
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which I'm going to mention shortly. But leave that post to your ridge. Yeah. If you mentioned pistoning, does that mean
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that I could see the man flexing and forcing that graph going backwards. Is that what you mean? I mean, intraoperatively. Oh, intraoperatively. Graph can be inadvertently pushed right into the
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spinal cord. It could be a trial spacer. It could be the actual graft itself, but absolutely. Postoperatively, you know, if these grafts are in
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and there's no posterior
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ridge and they flex or extend with greater force, yes, those grafts can piston into the spinal canal. Oh, in surgery, it's operator dependent Yes, absolutely. In fact, one expert that
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I recently read in a deposition, oh, I never use a posterior ridge and the next breath is, yes, I've had, you know, grafts piston into the spinal canal. So the answer is this is a safety
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maneuver that basically all of us were taught when doing anterior discectomy infusions, at least in neurosurgery You got to leave enough of a ridge, though. Yeah, it isn't fragile and just breaks
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off, right? That's right. In other words, you see this is pretty small. I would at least bring it out, at least another 50 so that you're here. So your graft is actually gonna go in here and
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then you have a nice, wide, thick ridge that's gonna prevent you from pistoning into the canal. Okay, great points. Yeah, so this is just an example of a two level interbody fusion, here's your
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interbody graft, and then here's your two level plate and your vertebral body screws that may be placed along with that. There's a whole different discussion about what kind of plates are used these
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days. We typically use dynamic plates. We no longer use the fixed plates because the screws actually in the asculop plate, the head can actually move up and down the slots and allow the graft to
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compress, which is how it fuses. rather than having stress shielding where if you have a fixed plate and graph system, it can prevent the compression that's needed for a fusion to occur. So very
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important as to what systems you use and why. Yeah, good point.
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So Iliac autograph. This is still a gold standard. It's still the cheapest. In the different hospitals, different institutions across the country, certainly in any other country. Iliac autograph
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itself to harvest this may take you an extra half hour. The morbidity of it has been grossly over exaggerated, especially by Medtronic. And years ago, they came under scrutiny because of their
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ultra exaggeration of the complications, the risks and complications associated with autograph. Their devices and everybody else's devices basically be a cadaver, autograph, peak cages, all of
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these. are typically six or7, 000 when the hospitals buy them. But the beauty for the hospitals is the hospitals are gonna multiply that amount six or seven times before they then charge the
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insurance carriers.
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So here's just an example of a peak graft, a peak or metal device. So there are all kinds of devices out there, another peak metal device. Here you have screws affixed to the plate, and here's
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your graft. And there's a hole in here, by the way, where you can put in bone morph - you can put in - you're not supposed to use any bone morphogenic protein in front of the spinal cord, but they
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do put in what's called demineralized bone matrix. It's cadavergraft and mixtures thereof. This is a peak metal device. This is
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ROIC. There have been some major complications associated with that. They could be just all metal, or indeed, as in this instance, a metal cage. And this may be supplemented with a plate as well
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each of these devices. By the way, when you look at the literature and you review medical legal cases, they have their own risks and complications associated with them. There's no paper, let me
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go back to that for just a second. There's no paper or is there a paper in the literature comparing these devices? There are lots of papers. Usually they try to compare one device with the other.
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The classic is that they're comparing Cadaver Allograft with one of the peak devices Others, if they're well-designed studies, it's gonna choose between one or two rather than a whole slew at the
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same time. Metal cages, here you have to put in a fair amount of, they say, well, sometimes you just harvest the autograph from the operation itself, and then you put in the de-neuralized bone
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matrix. This is gonna take longer to fuse, and then there'll be the metal plate across there. This one has a very high pseudothorrhosis rate as well as slippage rate. There are tons of studies out
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there comparing one with the other and then you have to read these very carefully to say, is this a white paper? Is this really a comparison, a valid comparison between this product A and product B,
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or is it a very biased presentation? In many instances, as an editor of a journal, SNI, we get lots of papers called white papers where they're just trying to use it as a cheap way to advertise a
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new device that hasn't actually been correctly vetted. And I can't emphasize to you how many times some of these devices were never appropriately tried out in different animal models to see whether
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or not they're actually safe, much less effective. So the rep from the company may end you some articles, but you should look at them very carefully, right? Absolutely, absolutely. And then,
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you know, you can say, look, you know, this Dr. so-and-so, look at the article Well, if it's a white paper, then you can take that under advisement. One of the papers in 2019, I just
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reviewed the risks and complications of multiple papers for inter-discectomy infusions. So these are the smaller operations, swallowing difficulties. Lots of series are going to say this is up to
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30 to 40, especially if it's multilevel corepectomies, post-opematomas. They're not all epideral hematomas. They can be wound hematomas They can be
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retroferongeal hematomas, wound hematomas. Not everything is an epideral hematoma. Spinal cord injuries, recurrent laryngeal nerve pulzies.
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We used to say this is more frequent if you operate from the right versus the left, Ron Applebaum years ago said, Oh no, the rate is similar on both sides. The incidence of a CSF leak should be
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relatively small. Again, do yourself a favor, use an operating microscope to try and minimize that risk of infection is there. We all say, people can reach the front of their neck that maybe wash
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their neck, but they can never reach the back. That's why the risk of infection with posterior cervical surgery is typically three to six to nine percent. Horner syndrome, that's getting the
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sympathetic chain. As you go down lower in the cervical spine, if you start operating at C5-6-6-7, it's easier to get a Horner syndrome because the sympathetic change deviates medially as you're
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going more distally A esophageal perforation,
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again, and pseudothorosis rates. Look at this, this was taken from one of the series. 43, that's what the cadaver graft, that's not autographed. 24 of the two level, up to 42 of the three
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level. Yet you hear your colleagues all the time saying, Oh, I just did a three level ACDF. Look at these morbidities associated with anterior cervical discectomy infusion. I'm going to mention
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later on a cervical laminoframanotomy for either a single or two-level unilateral disease. Almost all of these complications, we're not going to call them complications, we're going to call them
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adverse events, can occur with that. And by the way, when you're dealing with your medical legal colleagues, these should always be, in my view, termed is it negligence that caused it? Was it a
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technical surgical error? Was a mistake? Is it really acceptable? And quote, part and parcel of the operation to have that spinal cord injury? Or was there a reason for it? Was there a mistake
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made that led to that error, that injury having occurred? And that can be true for almost anything in these categories. Otherwise, the whole notation of quote complications may be allowing
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surgeons to just
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commit egregious errors or act in a negligent fashion without any consequences. Well, I don't know if I'm the patient and I want to end up with a court injury or a CSF leak or a harness syndrome or
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pseudo-authorosis. I don't know what you want to call it, but I didn't go ahead. Yeah, exactly. So you've got to look at it from the patient's point of view and I'm from the doctor's point of
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view. Yeah, and everything we're doing here by doing these lectures and everything else is to try and enhance the safety of surgery that's being done on patients, not only of this country, but
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around the world. Because, well, these lectures are available to how many people and how many countries? Yeah, 105 countries, thousands of people. Yeah.
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So I like to sprinkle throughout the lecture some of the medical legal cases that I've seen. This was a patient who had a two level anti-dissectomy infusion done By the way, at the second level,
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the patient had no disease. But it was performed by somebody who was a brain or a skull-based surgeon, not even a spine surgeon. One day he said, Okay, I'm gonna do a two-level ACDF. There was
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no reason to operate at the second level of surgery. There was no disease on the MR. He had no neurological deficit to correlate with that. Okay, he actually did the first level in terms of the
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decompression safely. The patient was okay. Second level, he literally plunges into the canal and actually takes a bite out of the spinal cord That's the only and easiest way to put it. To the
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point where the assistant was shocked, astounded, and the patient actually jumped.
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And the patient was caught a collegiate post-operatively. This image is similar to what the patient's image might have been. You know, here's your anterior cervical disc at a single level, no
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disease at the level above or below. And this, again, is an image similar to the patient, but I couldn't medically legally take the patient's images. And you can see the cord swelling after the
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malfeasance, after pistoning into that canal and taking a bite out of it, et cetera. You see the edema, the whiteness in the cord is what you're talking about. That is the white image that you're
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seeing in the cord coming from that disc space level. Now, what you're gonna see in some of these cases is the surgeon's turn around and say, oh no, it's the white cord syndrome. Now the white
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cord syndrome is something where there is actually no explanation as to why the damage occurred. It's a quote stroked to the cord. Here you have a direct reason why damage occurred to the cord and
33:50
in most other instances, the majority, the vast majority of cases, there is an explanation as to why the cord injury occurred and or that there's residual pathology or the cord is tethered over
34:01
residual disease White cord syndrome is very rare and totally reserved. for instances where there is really no other explanation other than the spontaneous stroke to the court. So it should not be
34:14
the excuse for not only seeing this on a post-op study, but then ignoring it, not re-operating on that patient. 'Cause this is a good example where now you have a swollen cord. Shouldn't you at
34:26
least be doing a decompression from behind? Give that cord more room. Very good explanation. The other thing we wanna include here, I think, Jim, is just the references that people can look at.
34:40
Okay. The neurological recovery after traumatic surface. Spine injury, this is talking about when you re-operate on patients the earlier the better. Less than 24 hours, but if they have a
34:49
significant deficit, you don't wait that period of time. It's like zero to 24 hours, six or 12 hours. So here's a, in this study from Neurotrauma 2015, decompression and fusion, eight to 24
35:03
hours six months you're gonna have better AIS grades, that's like AIS grades, essentially. So suggest the patients with spinal cord injury undergo surgical studies and decompression within eight
35:17
hours after injury, and they're gonna have better outcomes. Here's another study from Burkidol in neurosurgery. Surgery within less than 12 hours, you're gonna get relative improvement in these
35:27
patients. Another study from Lancet 2021. Early surgery, you're gonna see greater recovery versus the late operations. And they said, There was a steep decline in changesin total motor score with
35:39
increasing time duration, the first 24 to 36 hours after the injury. And in Cuyatol 2021, early surgery, less than 24 hours, compared with late surgery, acute spinal cord injury, early surgery,
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greater recovery.
35:55
Global spine 2017, this is Wilson at all, and it included failings who was one of the promoters Time is Spine. Early surgery supports improved neurological recovery amounts spinal cord injury
36:09
patients undergo early surgery. This is a systematic review. This was a failing study in global spine 2024. Early surgery, again, overall moderate strength evidence. Early surgery, less than 24
36:25
for better recovery. Very critical, except for those with longer. And here is failing's article of global spine Time is spine, all spinal cord injuries, pre-colonical evidence suggests early
36:38
limited secondary injury, reduces damage to the neural tissues and improves function. Ultra-only surgery, they couldn't make a comment on, but all of these factors are important in trying to get
36:51
the best results. Okay. Terrific job, really appreciate it, really outstanding, really, really. We hope you enjoyed this presentation
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