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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
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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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This lecture on pearls and pitfalls of anterior and posterior cervical spine surgery
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is using
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in choosing approaches to anterior cervical spine lesions. It's a 40-minute lecture with discussion.
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So we're gonna look at or focus on how do you make a decision as to whether or not to do an anterior operation, a posterior operation, or a
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360 on patients with cervical disease? So how do you decide which direction to do multi-level surgery in? And here, you need to look at what's called the K-line. It's the vertical line from the
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mid-C2 to 7, a positive K-line, which I'm showing you here. You go mid-C2, you put a dot in the spinal canal. You go mid-C7, you put another dot in the spinal canal. You put a line, or a
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vertical line between the two. If your pathology is in front of that line, anterior to that line, okay? You have a choice. You could actually do.
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That's called a positive K-line by the way, anterior surgery, posterior surgery, or 360 surgery. And what I'm going to discuss and argue later,
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if you have that option, doing a posterior cervical procedure does not incur many of those risks and adverse events that you see with anterior cervical surgery. So why wouldn't you choose that?
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Okay, on the other hand,
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okay, you may have the negative K-line. What are you seeing with that, the negative K-line? Here's the top, the bottom.
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If your disease extends behind that line or posterior to that line, like in this instance, this would be, looks like OPLL, it's likely, more likely than not, you need to do an anterior operation.
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And the reason, I always say likely this, that, and the other, because there may be other circumstances where you may modify your technique
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Many surgeons, by the way, don't even know that this line exists. I was just gonna ask you, how many people use the K-line as a deciding factor? Is it common or is it not common? It's very
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uncommon. And I can't tell you how many times you come to depositions where the person being deposed has no idea what this is, has never encountered this. And they just say, oh, I just gestalt it.
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And hey, I go for it Or the other day, I was speaking to a relatively new surgeon who said, well, I know how to do the anterior discectomy infusions. I don't know how to do the posterior cervical
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- in this case, it was the laminopharaminotomy. So I'm just going to do what I know how to do. So you used this for years, right? Yes, yes. And it's been up for years. I mean, this is
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published. I'm not making this line up, OK? But again, here is your negative K-line disease. is posterior to that line seen over here and here. And here was the study that I'm quoting here, the
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negative K line, you're likely to choose an anterior surgery for discs, spur, spondylosis, stenosis, andor OPLL. That was a paper from
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2012. Yes. That's 12 years ago. Oh yeah, and there are many more that have discussed this since then. It warrants single versus multilevel anterior-corpectomy infusion So here's just a figurative
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diagram of a one-level anterior-corpectomy infusion. And then you have your plate and you place your screws, okay? And here's an example of a multilevel anterior-corpectomy infusion, plate and
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screws. But I'm showing you here that if you have done more than a one-level anterior-corpectomy, a two or more level, this graft and plate has to be stabilized by a posterior fusion.
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do a company post your fusion, that graft is going to extrude at least 20 of the time if it's a two-level corpusctomy and at least 50 of the time if it's a three-level corpusctomy or more. Could you
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mention that? That's really an important point. Yeah, and I'm going to repeat that actually. So here, I'm just going to show you again, you know, your anterior corpusctomy infusion By the way,
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watch out for those instances, instead of doing the one-level corpusctomy, some people are going to say, Well, I'm not so good at the one-level corpusctomy. I'm better at the discectomy. Well,
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two-level anterior discectomy, and I'll show you a case at the end, can leave disease behind that vertebral body, especially OPLL. Okay? And if you're taking off a good portion of that end plate,
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you have to watch out for pistoning of the graft between those end plates So you're going to have it. with the 2-level ACDF, you're going to have more subsidence, body fractures, and graft
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extrusion. So here's your 2-level anterior dyschectomy infusion, okay? And I'm showing you this again. You have your grafts that are placed here. But again, you've taken off a portion of the end
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plate here, portion of the end plate here. You can weaken that end plate by up to 50, depending on how much of the end plate you've taken out. If you do that, what you can risk is that the graphs
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start pistoning into the cancelous bone of that intervening vertebral body, and it can result in the vertebral body fracture and graft extrusion. So how do you avoid that? Do your one-level
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corpusctomy. You have also two interfaces here to fuse. Here you're going to have four interfaces to fuse And remember, I had just said before where the two-level anti-dissect me in fusion. Your
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pseudothorosis rate there is going to be about 24, and it's much less with a one-level core pectomy. Good, good, okay, terrific. And here's an example of where you have to really evaluate the
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images, understand your images, read your images, don't just believe whatever your radiologists are telling you. But here's a midline sagittal and more. Here's C2, here's C3. Well, certainly
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looks like a big huge soft disk by the way, that's coming down. And look, it's extending to the mid C3 body level. But it's also going down to the C3-4 level,
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not further below, OK? Your stenosis, your disease is anterior. By the way, look on the MR. Your cord markedly compressed in a high signal that you're seeing in the cord. And so this would be a
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good patient for one level of corepectomy, where here's C2 And cheerily, you take off the vertebral body of three. Then you have no trouble accessing the entirety of this disk extrusion that's
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going at least to the mid-aspect of the vertebral body. You're coming down directly on it, you can see it. It's ending at the C34 disk space. So you can do a C2 to C4 anterior core-pectomy
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infusion, put whatever graph and plate you're going to put in. And then this might be your x-ray post-op where you have your core-pectomy, plate and graft are in place. And this is just showing
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you, this is your vertebral body graft. You see here, this is where that graft ends, and then you've got your ridges posteriorly here and here, preventing that graft from going further back.
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Yeah, good. And you have to measure and shorten your anterior, posterior dimension of your graft to take that into account, because again, you don't want that graft to be pistonned into the canal
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by forgetting to put in those posterior ridges. And then here's your plate, et cetera.
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Well, here's an example where if you just did the MR alone, you could be in big trouble because on the MRI scan, it was misread that this is C2, this is C3, this is C3, four was misread as a
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soft disc herniation. Just to focus on that, misread as a soft disc by the way, note on the MR how you can see, look at the high signal in the cord opposite this level of compression. Here's the
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cord coming down, here's the cord coming up, high cord signal marked cord compression as well. Okay, you do the CT scan and this is the same patient, and look at your calcification, ossification,
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this is actually OPL, a version of OPL, called the other form that often looks like a disc or mimics a disc,
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and it's mid-body to mid-body. Well, to do this, you're going to have to go probably C2 to C5
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in order to adequately remove and resect. all this calcification in front of the cord. Okay, so good use of your CT and your MR and how you can be led down the garden path if you just do that MR
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alone. You know, some people are gonna say, Oh, the CAT scan, it's too much radiation. That's usually not the reason. Some of them say, Well, I really don't want to delayby getting a CAT scan
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'cause I want to send that patient inand get the surgery done really quicklybefore they go to somebody elseor change their mind or something like that. CAT scan can give you so much information and
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CAT scan can just be smarter than you are. If you just obtain more of them, it can keep you out of trouble. You don't have to be brilliant to order it. Again, emphasizing that CAT scan does not
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show you definition of the cord itself, cannot show you the high cord signal, but shows you the bony changes. That otherwise, this is the negative image that you're gonna see on an MR where bone
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appears hypo-intense, and here it is on the CAT scan, hyperdense Yeah, ask you a question, go back to that picture. I'm in the operating room and I get a lateral C-spine to see if my graft is in
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accurately. Is that gonna be a good determinant? Is a magnification gonna be missed? Is that,
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do I, can I feel comfortable with that? I mean, to get a lateral cervical x-ray to determine if you've taken out a sufficient amount of the OPLL? Yes, in that I put a graft in it and it didn't go
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in too far. Is that gonna be helpful or is there some error in that and with the technique and everything else? Well, I think if you've planned to do your corpectomy and do the resection that we've
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discussed, I think the lateral cervical x-ray will probably do. I mean, a lot of us are using, you know, the intraoperative ORM, you just bring that in, swing it around, boom, there's your
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CAT scan to tell you if you've adequately resected the pathology So that's preferable if you have access to that. If however, you're doing an anterior discectomy infusion here, you're going to be
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shaving more and more of the vertebral body. You're going to end up with less than half of the vertebral body above, half of the vertebral body below. Remember, if you're taking off that end plate
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and you've taken off that end plate completely, you've got a 50 strength left in this body and that body and you have a good chance that if you put a graft in there, that it may fracture out, plus
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the fact that you have not adequately and accurately, completely decompressed the degree of chord compression above and below that disc space level.
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Okay. By the way, though, a lateral cervical x-ray, if you have ossification of the anterior longitudinal ligament, can, on the other hand, be very, very effective to see the calcification
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directly anteriorly. But I'm just wondering, we're about relying on it 100, oh, it says I'm Okay, I mean, you can't. And it's a good reason to get a post-op CT scan if you have any question
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about it, or to actually presumptively get a CT to confirm that you've adequately resected disease. And we used to, with multi-level OPLO, all the time get post-operative CAT scans to see what we
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have. This is just to re-emphasize that if you're doing multi-level anterior-corpectomy infusions, you have to accompany it by a posterior fusion to stabilize your anterior graft. So this is a
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study of Accaro did a study in '98 I had to study also Journal of Spinal Disorder in 2000 for a three-level anterior-corpectomy infusion of 50 risk of extrusion without an accompanying posterior
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fusion. And this is not something you want to do one day and then come back the next day. Ideally, you're doing one, you're flipping the patient over and you're doing it immediately to avoid
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getting that graft extruding in the first post-op day or keeping them intubated overnight, et cetera. So that's a C3 to 7 anterior-corpectomy infusion, Here's a two-level anti-corpectomy effusion
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C2, C3, 4, 5. This is down to six, obviously that's a metal construct, but without that posterior fusion, 20 risk of extrusion. Alternatively, here you have your anterior strut, graft, et
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cetera, and that posterior fusion is gonna help stabilize your anterior graft.
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Again, same anesthetic, very good idea If you have to do it flipping it overnight, keep that patient intubated overnight. I can't emphasize how critically important that is because if you then
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have to re-intubate that patient the next day, that's a good opportunity for that anterior plate and graft system to extrude or for you to injure the patient in some other way. Here's an example
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where you did a two-level corepectomy and put it in a metal strut graft with a plate. Here's C2, C3, C4. Five and six have come out, and here's C7. Now this is an immediate post-op study. And
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here everything is there, that's a two-dimensional CT. Here on the other hand, this is your two-dimensional CT scan when, look at your C4 body, that graft is completely fractured out and C7,
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forget it, that's more salated and completely fractured out as well. Here's your plate and your screw, everything is anterior to the retubobody in this instance. So that's what can happen if you
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don't do that simultaneous posterior fusion in these cases.
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Now, I just want to introduce, you know, ossification of the posterior longitudinal ligament, too often in the states in particular. People say, well, that's a disease that they're seeing in
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Asia, but we really don't have it here. And I'm just emphasizing, you see this in the United States in about at least 25 of our patients. It's another reason to get that CAT scan in addition to
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the MR. If you fail to read OPLL on the MRI scan and the findings can sometimes be more subtle. So this is just figuratively what OPLL looks like. It's behind the vertebral bodies that single or
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multiple levels and it compresses the cord and it's defined as four types. I actually visited here a Bayashi in Japan and we went over this. Continuous is when it goes behind multiple vertebral
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bodies. The next kind, it's called segmental, is you have ossification just behind the vertebral bodies. Here, continuous, it crosses the interspace. Here, it does not. But then you have the
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mixed form up here, where you have continuous in one area, and you have the segmental in the other. So that's the third form of the mixed form. And what they may be completely baffling, maybe the
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final one, which is the other form, which is it's at the disk space, or appears to be at the disk space, but in actuality goes above and below the disk space, just like the example that I had
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just showed you. This can be the most risky, because surgeons will typically go in based on an MR, assuming that they're going to encounter a disk, and before they know it, they're in the middle
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of a spinal cord, and that patient's quadriplegic, because they forgot to get a CAT scan, and to acknowledge or to look for more extensive disease. So,
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here you're looking at a patient with a negative case sign, a multi-level
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OPLL, that's what we're going to look at here.
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Unlikely requires, this patient is going to likely require an anterior operation because if you put in the line C2 to 7, all this OPLL is going to be in front of you and you've got to resect that.
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So here's in color, the same diagram, basically, these were actually drawn by Joe Epstein, my dad, who was a neurosurgeon, and another example, though, where you may have OPLL and the patient
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has kyphosis, and you can see the anterior angulation
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here. And there's clear reversal of the cervical or dose is another reason to do an anterior procedure, because if your k-line is here and your k-line's down here, all of this bone is going to be -
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is going to go behind that line indicating you're going to have to go from the front.
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When you get a CAT scan or you add a CAT scan to the MRI scan that you're getting in patients. It may show you. any one of these three signs of OPLL extending to and through the Dura, and
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especially the double layer sign will give you 80 plus leak if you do enter operations, which you may still have to do, but you can then be prepared to deal with it. So here, this is a typical
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single layer sign, where you know where this is, it's a little, it can be very regular, sometimes a little irregular, but the C sign often will accompany the single layer sign, and it means that
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there's sort of a chunk that goes off to the side I had described this years ago. And what happens is the dura on the side can become implicated or unfolded in OPLL. So you've got to watch it with
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this. But very much so, the double layer sign in these two images, you see how you have bone, the vertebral body, and then that hypodense area, and then that hyperdense ossification, That
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ossification is inside the Dura.
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that hypodense area is the dura. So in these cases, there is going to be no interface, no dural margin that's going to allow you to avoid a CSF leak. It tells you if you have to go anteriorly,
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because look at the size of this compression. If you have to go anteriorly, be prepared to deal with that leak and be prepared ahead of time. Prepare your patient. Make sure your OR has the
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equipment that you need Again, an example of a negative K-line. Here's your K-line going cephalide caudad, OPLO's behind that K-line. And here's an actual two-dimensional CAT scan. Look at this.
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This is all OPLL. Continuous, C2, C3, C4, and then a little discontinuity at the C4 or FIVE level. But you see the way it becomes hypodense and hyperdense again. This chunk is
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interdurally, as is this chunk as is this entire chunk here. So that's going to be, you know, your. negative K sign with OPLL and multiple foci here, here, here, here of your double layer
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signs. So you're not only going to have an anterior leak, but it's going to cover many, many levels and you've got to be prepared to deal with that. On an MRI scan, this may be what you're going
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to see, C2, C3, C4, but look at 5, 6, and 7 This is actually OPLL, how do I know that? Because the hypo-intense area not only crosses the disk space and goes up half the body, but look at the
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separation between the posterior aspect of this entire vertebral body, this is C2, 3, 4, 5, this
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is C6, and coming all the way down to the, you know, 6, 7 level sort of almost midway. In this instance, this is going to be OPLL, and you really need to get a CAT scan to get more definition
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and also look at the MR showing you the high signal in the cord. So you're going to have to be prepared to do a very extensive resection in this case. Here is your single layer sign of OPLL.
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Everything behind here is ossification of the posterior longitudinal ligament on your axial image. This is a case where you can see this is the double layer sign, calcification here, intraderial
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here. This may be a single layer sign over here with a C sign because it's going off to the side But in short, the CAT scans your friend, it's going to show you this. It's going to tell you how
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you might have to prepare to deal with this interoperatively because it's going to be extensive. And these are just some other cases of negative K-lines, MR scans. This is C2, look at 3, 4, 5,
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high signal on the cord. Look at the MR scan showing this hypo-intense mass behind multiple levels. Okay, that is showing you, that is telling you. This is opiled up. These are not discs, these
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are misread as discs.
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All the time, but wrong decision.
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On your axial studies, you may see a mass that's this big. Do yourself a favor, get that CAT scan. And plan according to where the disease is. And both of these M-words are gonna show you the
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high core signal for this O-PLL with, you're gonna have to do a core pectomy of C3 to get this. It's going, it's all the way like three quarters of the way up the body and all the way down to like
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C5-6. And you're gonna have to do a strut from C2 after you've taken out three, four, and five, strut to C6 and then do a posterior fusion to stabilize that.
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Okay. And here another example of multi-level O-PLL, seen here. Again, figuratively, here's your old PLL. OPLL drawn here. Here's your anterior graft that you may be placing into your graft and
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strut here, or you may be using a cage to put in your strut graft and your cage and your plate and your screws, et cetera.
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Again, when you do the multilevel core pectomy infusion, you have then decompressed the spinal cord through that entire extent, entering in posteriorly, and your cord can then migrate posteriorly
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away from where your anterior OPLL used to be. It's removed. The damage, the risk, the negligence of doing an ACDF is that you end up stretching or damaging the cord over residual OPLL left behind,
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behind the individual vertebral bodies. So I showed you this before. You're doing the discectomy, discectomy, discectomy But what about the OPLL here, just figuratively shown in here? that
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you're not accessing. You may have some surgeons say, Oh, I can access that
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with a curette. Well, no, they can't. Or they access it with a curette, they damage the cord, and they get a massive CSF leak doing so. But here, leaving behind that OPLL, you're gonna end up
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with an anterior dyschectomy infusion, literally stretching your cord over this residual disease. This is a very complicated case that involved multiple, multiple issues. This patient
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pre-operatively had actually an MR similar to this 'cause I couldn't use the exact images, okay? Pre-operatively, the MR was misread, misinterpreted, by the surgeon as discs, as multi-level
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disease, and he did a multi-level dyschectomy infusion. By the way, he did not follow the advice of his radiologist who questioned whether there was OPLL and told him to get a casket and he didn't.
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He failed to diagnose a OPLL. Did the multilevel anterior discectomy infusion stretch the cord over multilevel residual OPLL? He also incurred massive anterior cervical CSF leaks, and I'll show you
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how he did not correctly deal with that. And even sustained a vertebral artery injury because it was too far off to the side. And this patient was called a plegic post-op.
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Well, what should he have done? He should have done a multilevel anterior corepectomy infusion with a strut and a plate and then done a simultaneous posterior fusion, okay? But that unfortunately
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was not what was done in this case. Instead, I'm just showing you he did a multilevel dyspectomy infusion, putting a bone graft at two levels and stretching the cord over the residual OPLL which
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I'm showing you figuratively here. And then here, I'm trying to illustrate to you with your ACDF graphs. You put the graphs in at these multiple levels, but look at the OPL that's still gonna be
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left over behind that. That's where you're stretching the cord. That's where you're damaging the cord. Okay. And in some instances, other surgeons, they're actually just getting down to the OPL
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and leaving it behind completely. I remember visiting Leuven in Europe, and I was talking to them because the surgeon had done an artificial disreplacement. And he said, Look at this post-op scan.
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Look at all the calcification post-op. And I looked at the study and I said, This is OPLL. You never took it out in the first place. So you have to be very careful when doing these procedures, do
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the right operation for the right reason. Spinal fluid leaks with the anterior cervical surgery with an ACDF, very low risk, 'cause 02 to 17, but you get to OPLL, it's as high as 6 to 12 So
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anticipating this leak. should be part of your modus operandi. And again, if you get that pre-op CT scan and you see a single layer sign, as I'm showing you here, and the positive C-sign and
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your double layer signs, then you know that there's a problem in these cases.
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And again, here's your CT, this is a post-op CT, kind of like what the CT showed in this patient. The CT showed a double layer sign, post-operatively at multiple levels, and that's your
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intervening Dura, and this is basically here, where only some of this was removed and most of this was basically left behind. And again, right to and through the Dura. When you have a patient
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where you suspect you're going to get an anterior cervical leak, the best thing to do is to prepare and drape at the very beginning of surgery, you mark your anterior incision, but you then prep
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and drape out. a wound peritoneal shunt, where you can put a shunt right in the neck with a dome, bring it down subcutaneously to the parabolic region, well parabolic region is here, but maybe
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just over the liver, where you can actually put in a distillent of a shunt here, if you have to do that intraoperatively, and you want to do that, because if you don't do that, and you just put
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in a lumbar drain, CSF, just because it's easiest for it to egress into your wound, may asphyxiate that patient, much less cause that wounded to hiss and fall apart. So in the early days, we use
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a uni-shunt, these days you can use whichever shunt you want, but track the shunt catheter from the neck to the abdomen for that wound parrot, Neil shunt. Also, postoperatively prepare to have
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available to you the placement of a lumbar drain. It's like belt and suspenders, you can control the amount that you're going to drain with the system that you're using. And by the way, when you
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put in,
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The wound peritoneal sunt, you're going to have a horizontal vertical valve to control the amount that's draining if that patient happens to be upright. The other alternative too is here to just
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immediately go to a lumbal peritoneal sunt because what's going to happen is you're going to be draining CSF in this patient. It's still going to be draining and you're going to want to take that
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drain to the outside out in about seven days so you don't get an infection. That's just at the point where your leak may be in full force And so a lumbel parent will shunt from the get go or in a
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delayed fashion, maybe what you then choose to do.
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Now, in this case, I actually was allowed to use the actual post-operative CAT scan. Post-operative CAT scan, easy to get quick, but what's that going to show you? It's going to show you the
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location of the graft, the screws, plate, etc. It is not going to show you what's happening to the cord. This is what the MRI scan showed. By the way, both of these studies were done in a
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delayed fashion. They waited a number of hours with this patient quadriplegic post-op This is your post-operative actual MRI, and here is your that is your duroseal. They put in duroseal anterior
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to the cord. It is contraindicated on the package insert to use duroseal anterior to the
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spinal cord because it can cause a mass, and in this case, cause massive cord compression. Seeing these findings, the radiologist said, wow, there's a lot of anterior cord compression And,
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instead, the surgeon did a laminectomy.
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Alaminectomy from behind here was not gonna really solve this patient's problem because it was such massive anterior cord compression and this patient ended up remaining quadriplegic.
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Hostoperatively, unfortunately, the surgeon, or fortunately, the surgeon left town for a while and left associates in town for three weeks. They did no other studies. Three weeks later, patient
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was transferred to another institution. They re-operated on that patient It was too late, you know, nothing came back. So it's a combination of errors. It may be the surgeon themselves. It may
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be the associates. It may be the adjunctive personnel in the hospital, but everybody should be.
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The other thing we want to include here, I think, Jim, is just the references that people can look at. Okay. The neurological recovery after traumatic surface. Spine injury, this is talking
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about when you re-operate on patients. the earlier the better, less than 24 hours. But if they have a significant deficit, you don't wait that period of time. It's like zero to 24 hours, six or
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12 hours. So here's in this study from Neurotrauma 2015, decompression and fusion, eight to 24 hours. At six months, you're gonna have better AIS grades. That's like Asia grades, essentially.
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So, suggest that patients with spinal cord injury undergo surgical studies and decompression within eight hours after injury, and they're gonna have better outcomes. Here's another study from
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Burkidol in neurosurgery, surgery within less than 12 hours. You're gonna get relative improvement in these patients. Another study from Lancet 2021, early surgery, you're gonna see greater
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recovery versus the late operations. And they said, There was a steep decline in changesin total motor square with increasing time duration the first 24 to 36 hours after the injury. and in Kuwait
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all 2021, early surgery less than 24 hours compared with late surgery, acute spinal cord injury, early surgery, greater recovery.
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Global spine 2017, this is Wilson at all, and it included failings who is one of the promoters of time is spine, early surgery supports improved neurological recovery amounts, spinal cord injury
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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
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for better recovery, very critical, except for those with longer. And here is failing's article, global spine, time is spine, all spinal cord injuries, pre-colonical evidence suggests early
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limited secondary injury, reduces damage to the neural tissues and improves function, ultra early surgery. they couldn't make a comment on, but all of these factors are important in trying to get
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the best results. Okay, we hope you enjoyed this presentation.
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