0:00
SNI Digital, Innovations in Learning,
0:05
an association with SNI,
0:10
Surgical Neurology International,
0:15
is pleased to present another in the SNI Digital series on Controversies in Spine Surgery,
0:24
340-minute lectures with discussion
0:28
They're given on the topic of pearls and pitfalls of anterior and posterior cervical spine surgery by Nancy Epstein.
0:39
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.
0:53
She's been in the practice of spine surgery for 40 years, and has a bibliography that's one of the most extensive
1:07
A series of lectures on pearls and pitfalls of anterior and posterior
1:13
cervical spine surgery are focused on how to choose the correct approaches to lesion in the cervical spine, with attention to the K-line.
1:24
Part one is on the anatomy imaging clinical presentations of cervical spine neurologic disease in one level ACDF, 40 minutes
1:35
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
1:55
And this part three lectures is on pearls and pitfalls of anterior and posterior cervical spine surgery is on the K-line and choosing posterior approaches to cervical spine lesions.
2:09
It's also a 40-minute lecture and discussion. Should be looking at these cases saying what should be done, this patient is paraplegic. This is a problem this should be dealt with
2:20
I'm going to take a break here for just a minute because you're going to get in the post-year, right? Yes. Yes. We'll just, you and I will talk for a couple of minutes and we'll start again. I'm
2:31
going to leave it run.
2:33
So I thought that was excellent. Really a lot of good tips and clues there. And I may divide it into, it took us about an hour or further for that or 55 minutes Please go.
2:51
I think we will divide it into anterior and posterior, but I also may do two things. I want your input on that is the first part with the introduction, which was the anatomy, the imaging and the
3:03
neurologic presentation. We can also have it as a four part series.
3:12
Then the choice is do we use the,
3:16
do the shunt separately or not? If you have it as a separate talk, I'm thinking out loud here. I'm not sure it's as meaningful as if you attach it to the subsequent anterior series.
3:33
Think about all those ideas. I think you could do the anterior and up to anterior dysectomy infusion. I think you could segment out the anterior core rectomy infusion and then do that as a segment
3:45
and then do the posterior as another segment.
3:49
and just say this is, you know, three part series, maybe this is part A, B, and C. No, okay. Okay. Because I think that the images that are shown with the review of the CAT scan and the more
4:03
are sort of critical to the anterior and posterior surgical decision-making processes. So we break the anterior cervical after it's a simple one level. Yes, yeah. Okay, I think we can find a
4:16
breakdown. Yeah I think that's, so we need the anatomy with a simple anterior
4:24
cervical discectomy infusion, then more complex anterior operations than posterior operations. Right. I think that's good. Yeah, you know, CC, how do you feel about that? The other thing I was
4:36
telling you too, is I have also separate lectures on anterior-corpectomy infusions and posterior cervical. So you could see, we could see what you think of those just as a, as maybe supplemental
4:49
more detailed in depth. We could do those. We could go through what you're going to do. And we could, it's up to you, 'cause you're the one who's doing this is you could, we could record it,
5:00
but you could use them as a later, two later entries in the series, more approaching more complex cases. Yeah, yeah. Okay, good. 'Cause I have them. I haven't worked on them already, yeah.
5:14
So it's up to you how you want to do it, but we're doing this putting together a library It's terrific. So this is
5:21
10 recorded, 10,
5:25
but there are, but no, I think we're doing pretty good. That's good. Okay, you want to go ahead with that? You can just go on and say about posterior cervical surgery. Am I interested? Yeah.
5:38
Next, we're going to look at posterior cervical surgery. How do you make a decision for a posterior cervical operation And? one of the main points that I'm going to emphasize here,
5:50
And we're going to integrate what's called the K-line as to how we make this decision. If you have the opportunity to do a posterior cervical procedure rather than an anterior or a 360, the
6:03
morbidity of that choice is, you know, you're going to have an easier postoperative course, easier postoperative outcome, and reduced morbidity, fewer adverse events associated with it So I think
6:16
it's something that you have to look at very, very carefully. And you know, again, this is sort of your typical posterior cervical procedure. You know, you've got the patient in a three-pin head
6:28
holder, by the way, I always use a three-pin head holder. You do not use the face masks, you can get pressure on the eyes, the actual position of the neck can change, you can end up with jugular
6:38
compression, et cetera. Here you have absolute control, you can get a cervical x-ray to make sure the patient is Completely neutral and here you can see we marked out the your cervical incision
6:49
that we're going to use. By the way, SCP, somatocensory vote potential, motor vote potential, and EMG monitoring is important. By taping the shoulders, watch out, you can actually incur a
7:00
plexus injury, a brachial plexus injury. So you want to make sure that you have your monitoring going while you're positioning the patient for cervical surgery, much less posterior cervical surgery,
7:10
because it can save you from creating a disaster from the get-go, much less hyper-extending the patient or hypoflexing the patient. Terrific points.
7:22
It's best to choose a posterior operation if you can for a cervical disc. As I said, I spoke to a young colleague the other day and he said, You know, I was never trained to do
7:35
a laminophoremonotomy. I'd like to learn how to do those. I was trained to do an ACDF, so that's what I do. And I said, But you're talking about doing a C67C71 ACDF on a pretty large don't you
7:47
think the morbidity would be much reduced and the patient would be happier if you did a laminophuraminotomy at those levels instead. We have in the SNI digital series, an entire lecture devoted to
7:58
laminophuraminotomies that Jim and I discussed. So we will just gonna refer you to that, but just as a refresher. This is a lateral, an image here of a lateral spur and lateral and foraminal root
8:12
compression. No chord compression here Here is your laminoframanotomy with your medial facetectomy for amanotomy. By the way, watch out. There's your vertebral artery out there. You don't wanna
8:24
get into that. So you have to keep your wits about you when you're doing these procedures. You have root exposed. You often have very little chord exposed. That's why the morbidity of these
8:34
procedures is minimal. And typically you do not have to fuse these patients. Here is a figurative diagram of a disc herniation. If it goes too medially, you might want to go anteriorly, but if
8:47
it's very foramidal, as in this case, you don't. And this is what that frame anatomy it translates to a window procedure that you may be performing. By the way, if you're doing this at C7T1,
8:59
very likely you're going to have to do an accompanying fusion at that level.
9:03
You're going to have to do a what at that level? A fusion at C7T1. A fusion, okay. You're doing a foramidotomy at C7T1 because of the cervical thoracic junction But again, here's an MR of a
9:13
lateral and foramidal disc where you could approach it from behind. You can use your pen field elevators to identify that nerve root because the arms are typically down by the side. The nerve root
9:27
in your image are typically coming down. In the old days, we used to put the patient in a sitting position with their arms upwards so the root would go up, but now it goes down. So you have to use
9:37
a pen field elevator to get into the axilla or the armpit of that nerve and then use your downbiting correct. use a dampening curette to remove spurs andor osteophytes that may go laterally and for
9:49
amily. And again, you know, watch out if you're concerned about a vertebral artery problem here too. But we're gonna go back to our discussion of the K-line and how you use a K-line. For
10:00
posterior cervical surgery, you want that positive K-line, okay? That means that mid between C2 and the posterior elements and C7 and the posterior elements, you do a vertical line, your
10:13
pathology is anterior to that line. Again, your options are going to be multiple. You can have anterior posterior 360 surgery, use your posterior surgical options if you can. This is going to be
10:25
exclusive of the negative K-line, which we have previously discussed. So the positive K-line means your disease is anterior to the K-line, your surgical options, anterior posterior 360 surgery,
10:38
best to choose posterior surgery because the more limited morbidity associated with these. procedures.
10:45
So here's an example of a patient who has a positive K-line, and you may choose to do a laminectomy and a posterior fusion for discs, spurs, stenosis, or spondylosis. And here you can see your
10:58
pathology is anterior to that K-line. Okay? So it's pretty simple to remember, pretty simple to measure. And again, you know, your posterior surgical operations are going to limit the risk of a
11:12
CSF leak, much less the other risks and complications. You know, your posterior cervical procedures, your dysphagia, unless the patient's intubated for a very long time, is going to be much,
11:23
much less risk of your CSF leaks, much less risk of a carotid injury, an internal jugular injury, recurrent laryngeal injury, or phrenic nerve injury. I mean, all of the list goes on and on.
11:36
You can choose to do a laminectomy need to decompress the cord, the cord is going to migrate posteriorly. as long as you have, in this case, you have a good cervical lordosis.
11:47
And here's your laminectomy with posterior migration of the cord into that space that you've created. The ventral kyphosis, contraindication relatively for performing posterior cervical surgery.
11:60
Sometimes you may have surgeons who may do an anterior discectomy graft above and below the pathology to throw the patient into some degree of lordosis to do a posterior procedure But here, again, a
12:11
positive k-line. Here's your x-ray, and it's showing you - I'm showing you the stenosis here. My uncle, the neuro radiologist, he's terrorized me. As a 15-year-old, when I would visit him over
12:22
a vacation in his radiology office, where he was the chair, would say, OK, Epstein, tell me about spinal stenosis. And I would have to say, if you measure from the mid-retrial body of the
12:32
posterior interlaminar line, and that arrow is shorter than the measurement front to back of your material body, most likely you have spinal stenosis on a six foot lateral film. You've just never
12:39
heard that before. And here, again, is an MR image of a stenotic spinal canal. And remember, we didn't have MRIs until, you know, the '80s, essentially.
12:47
Before
12:50
then, it was myelograms. We didn't
12:60
even have CAT scans yet until, like, like 1976, where as our first year resident nurse earlier, we were running around with Polaroids of CT images, 'cause we aren't only two
13:15
machines in all of New York City. But here you can see, look at the MR, a cord compressed opposite these levels, three, four, four, five, five, six, and six, seven, straightened Blordosis
13:20
and stenosis.
13:22
Okay, Blordosis here,
13:27
straightened,
13:29
but you can see how, if you remove the retrieval bodies here, you can, with a straightened Blordosis and some instances, get away with a, posterior operation, or if you do an anterior discectomy
13:42
infusion with a lordotic graft above or below this, sometimes you can reverse the lordosis, put them into more lordosis, and get away with a posterior operation. So again, I'm going to show you
13:53
just multiple examples of an MR cervical lordosis, really a hyper lordotic curvature. Look at the lordosis here, C2, C3, C4, 5, and 6. Look at the ventral compression. Look at the dorsal
14:06
compression You actually have shingling of the lamina. Instead of the lamina being sort of like this, you have the shingled lamina like
14:16
that right beneath it. But if you have a good lordotic curvature, as in both of these images, and in this third image of a myelogram CAT scan, okay, you remove the lamina from behind, that cord
14:27
will migrate posteriorly like a rubber band, and then you confuse the patient 'cause you have to maintain the lordosis. Here's another example. We've already gone through this previously in a
14:38
previous lecture, C2, C3, C4. This is not dist disease. This is ossification of the posterior neural injury to a ligament, going from C4-5, all the way behind five, C5-6, behind six and all
14:51
the way down to six-seven. There may be sometimes accompanying disc with that, but if you take away all the bone back here, you may allow that forward to migrate post-yearly because you do have
15:03
that good cervical or dotted curvature. And then this is an example of spondylosis, where actually you have a high signal in the cord, but again, that good lower dotted curvature is going to save
15:09
you. Other examples here, again, curvature, good cervical oridosis, here seen on an MR, here seen on a CT scan. That's actually the
15:25
same patient. Look in the CAT scan, see the shingle lamina. One, the leading edge of the lamina below is anterior to the level above. same thing over here. And it's just like your Venetian
15:38
blinds. One goes right in front of the other and the leading edge inferiorly compresses your cord.
15:46
Another example of shingled lamina here. This is C2, and this is C3, 4, and 5. And the lamina are shingled under each other here. C2, C3, here's C4, 5, 6, and 7. They're all shingled
16:01
underneath here If you remove 5, 6, and 7 little laminectomy, it allows your cord to come down, and then you can do a posterior fusion to preserve that anatomical alignment, and get away with it
16:13
here on an axial image I'm showing you that you're seeing the shingle lamina. It means you see actually two lamino on the same axial image, and you're seeing it in this picture and maybe a little
16:24
bit better in this picture So you need to be able to read your own scans, do not just rely on the radiologists, you need how to discern where the pathology is and how you're gonna go about dealing
16:39
with it. When you do the laminectomy, this is actually what you're doing. You're removing the lamina and the spanish process. You're preserving the facettes or you may be taking doing a medial
16:50
facetectomy for a monotomy if you have spurs. You're going to have that patient when you do these operations in the prone position. Usually we would do nasotracheal awake intubations to make sure
17:04
we're not flexing or extending the neck. You numb up the nose and the throat. You snake your way down with the nasotracheal tube and the fiber optic device. You intubate them then safely and you
17:16
get your baseline intraoperative monitoring,
17:20
motor evokes with them supine before you even turn them over. You can give them a short dose of propathol and get a motor evoke. So you have a good pre-operative baseline. You do not want to get
17:30
your baseline after you are already positioned for surgery already compromised that patient. You may have already damaged that patient. Same thing for SCPs and your EMGs. Obviously, EMGs are just
17:41
gonna get activity. So here's your figurative diagram of your laminectomy. Here's your laminectomy, and here's the bone that's been removed.
17:50
Again, you remove that bone. This is actually patient with OPLL, and look at the massive OPLL that's there, but the cord on this image could be sitting here, especially if you did an MRI And here,
18:03
this is a three-dimensional CT following the
18:07
laminectomy, where you just have C2 and C7 are still in place, but all the other bones have been removed, so your cord on the MRI is gonna have migrated posteriorly into the space that you've
18:18
created in that patient with the lordosis. Just some figurative images of your doing your cervical laminectomy
18:27
here is C2, down here is three, four, five, six, seven, and then here may be T1. Downbiting curates, you do your medial facetectomy frame anatomy, and you can use your downbiting curates
18:40
after you used a nerve hook and a pen-filled elevator to make sure that you are not going in and inadvertently taking out the anterior motor nerve root. Again, that sometimes is not enslaved in the
18:54
dura, and you can mistake it for a disc. So this is the section that you're going to want to be doing, and you can remove your spurs with your downbiting curates by doing this. You can do your
19:07
frame anodomies. You don't necessarily have to do full facetectomies. Obviously, that's going to further destabilize the patient. Too much of the time, surgeons are actually automatically taking
19:20
out the facet joints, destabilizing the patient. But this is what it actually can look like. So you've done a laminectomy. This is actually the dura multiple levels, medial facetectomy frame
19:29
anodomy Here, at one level, you're doing a more extensive peraminal dissection. Here is a nerve root exiting inferiorly and downward because again, those arms are positioned down next to the body
19:41
in that prone position. And here is a pin-filled elevator, very gently dissecting, exposing the axilla or armpit of that nerve root. And this is where you're going to then introduce your
19:54
downbiting curates. Very small, two, three millimeter curates. And again, every movement you do is away from the patient You never use that curette towards the patient. That's how you're going
20:06
to damage the cord inadvertently or get a CSF leak, OK? You see, you mentioned the anterior motor root sometimes is separate. Where would you see it in that picture? OK, well, you may see this.
20:21
This could be just your isolated posterior sensory root that is in sconce in the door It has a dural sleeve, but you may see just ventral to it.
20:35
like running here, something white, but the white would be coming down like that. That could be your anterior motor nerve root that is not interdural, but it can look very much like sometimes your
20:47
disc fragments. That's why you have to listen to your EMGs very carefully, use that Penfield elevator, use your operating microscope to make sure you have exposed disc and you have not exposed or
21:04
decided to take out that intermotor route. Okay, terrific. Okay, but it can be very tricky to do that.
21:15
Here's just an example where this is a preoperative MR. You've got a tight spro the canal. You've done a laminectomy here. Here's the post-op CT scan. That's a pre-op MR, post-op CT, here's C2.
21:26
You're taken at the lamina of three, four, five, six, and here's an intact lamina of seven. And here on the CAT scan, you're just seeing some air, et cetera. That's because this is where your
21:38
operative wound was. You're not seeing any detail of the cord though, are you? Okay? Here's your post-operative MRI, same patient, same time, early post-op. But here's your cord. Here's your
21:50
cord pre-op compressed from front to back. You know, baboom, baboom, baboom, baboom, baboom, baboom. Kind of, they used to call it like the washboard, not that I would know what that is,
21:59
but anyway But here is your cord now decompress. You see CSF anteriorly and no CSF
22:08
posteriorly here, no CSF anteriorly here. Now you see spinal fluid anteriorly. Now you see spinal fluid posteriorly. The cord has migrated. This is your posterior decompression. Okay, that's
22:20
what you would say. You take an image, that same image as your last image, MR image, three months later. Do you, is it different or does it look like that? Okay, let me just get through. It
22:33
should look like this or even better. Now, if you have had a very compressed spinal cord originally, and you have, let's say, just post-op edema in the cord, you may see more cord atrophy or
22:50
myelomylation, which would show you even more spinal fluid around the cord three months later, six months later, et cetera. Okay, the beauty also of doing your post-op studies is let's say you
23:03
had one level where you had much more anterior compression. If there is on this post-op CT, much less, MR, one level where you see residual significant anterior cord compression, be it a disc, a
23:17
spur, an osteophyte, whatever, you could then go back and decompress that spinal cord anteriorly at that specific level. But that's why post-op studies are important You want to know what you've
23:30
done. You wanna know what disease may be remaining behind. You wanna make sure you don't have a post-operative hematoma, okay? And doing sequential studies is also important, especially in terms
23:43
of your MRI scans, because if anything neurologically changes or gets worse, you need to study this. I see this again and again in looking at medical legal cases. It's almost like they're shoving
23:56
everything under the rug. The last thing they wanna do is a post-op study to document where the problem is. It might say you have to go back. It might say, maybe you only did a laminectomy at two
24:07
levels and you need to do another three or four levels to decompress the cord. Well, when I look at the film and I go back to your measuring that the space there is in a spinal canal, after you've
24:20
decompressed them, it still looks compromised. If you look at the C6 level, much wider areas. Oh, CSF, it could be because of the cervical enlargement, but how do you look at that?
24:36
Well, very important on the MR, you have to look at all the medial lateral images. You have to, this is just one sort of mid sagittal image. You have to go from side to side. You also have to
24:49
definitely look at the axial studies to document that you've adequately decompressed the court. But you're absolutely right, what can often happen, especially at the most seplen and caudad levels,
24:60
you may find, hey, I've got residual compression, I've got to go back and do that, or add that to the fusion and do a laminectomy, or maybe I have to go back anteriorly. But you need to look at
25:12
the entire study, not just one set image. So you need to know at the end of surgery, you have to decompress them, but this person may still have some potential for problems I mean, you need to
25:25
come away with some conclusion.
25:28
And post, I mean, there were lots of instances where let's say, if interoperatively, let's say hypothetically, you did this operation and the patient had significant intraoperative changes. But
25:40
you know, then they came back and you didn't think that you had to change your operative plan, which lots of times you'd have to do, you know, raise the blood pressure, stop your distraction,
25:51
etc. You keep the OR clean, you reverse the anesthetic, but keep them intubated in the OR. You call down to MR or CAT scan or both and say, I want to come down and get a STAT study. You keep all
26:06
the instrumentation in the OR ready to come back. You go get your STAT study. You then can call back to the OR saying, Oh, it's okay. We're adequately decompressed. Or, Hey, we're going to
26:16
come back. We need to do something more. Okay, good point
26:23
So here's another example where look at the multilevel. Two, three, four, 567 especially at 67 you see the high signal in the core. This does not look good. This is your MR. It's not the best
26:35
picture in the world. Here is a here is a post-operative AP C567
26:43
lateral mass screws have been placed. Here's your lateral view, post-op screws are placed, etc. But most importantly, this is what you want to see in your post-op MRI. Okay, C2, C3, C4, C567,
26:59
you've done a complete laminectomy. This is more like what we typically would see, Jim. Okay. We see more of a big bath of spinal fluid all around the cord. And that's what we're more happy
27:12
looking at. And again, if you look at the other one, you've done the best you can do, but it's something you just have to keep track of. That's all. Right, right. And sequentially, you know,
27:23
the next week, the next month, etc, or the next few days,
27:35
It all depends on what that patient's neurological status is. The worst thing to do, it's like a complicated multi-level core-pectomy patient that I presented.
27:38
The worst thing to do is you do post-op studies, you do one operation or whatever it is, but you don't do any sequential follow-up studies, especially if that patient remains quadriplegic or has a
27:48
significant deficit. You have to continue to do studies. Surveillance is critical. Decision making is still critical You can't just abandon the patient and just say, Hey, it's everybody else's
27:59
problem. I'm done. Okay, real good. And then posteriorly, you need to do a fusion to preserve that lordotic curvature, 'cause otherwise they'll become kyphotic and angulate forward. Lateral
28:13
mass screws, you can use those. C3, 4, 5, 6, C7, T1, and also it's C2. It's gonna be pedicle screws. So you can decide which of these you need. Sometimes when you're doing multilevel
28:27
cervical laminectomy, you're going to fuse down to the T2 level to make sure you're really stabilized that cervical thoracic junction. So in conclusion, when you are doing any of these cervical
28:41
operations, look at your pre-operative MR. I would say a pre-operative CT scan is absolutely worth it The CT scan can be smarter than you are.
28:54
Make sure you learn how to read these studies yourself in addition to listening to your radiologist. I highly recommend conferring with your neuro radiologists. And I was very lucky. I still am. I
29:07
have a neuro radiologist who's absolutely brilliant. And I would never operate without conferring with him. And just bouncing back and forth, do you see this? Do you see that? Do I need to repeat
29:16
this? Do I need to get a better image of that? Is there a problem someplace else because. you want to, based on these findings, do the right operation for that patient and your patient. Well,
29:28
thank you. Okay, that's terrific Nancy, really a tour de force of cervical spine surgery, pros and cons, just as you said, and really appreciate it. That's just an outstanding job. The other
29:45
thing we want to include here, I think, Jim, is just the references that people can look at, neurologically recovery after traumatic surface spine injury. This is talking about when you re
29:56
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 12 hours. So here's
30:09
a, in this study from Neurotrauma 2015 decompression infusion, eight to 24 hours. At six months, you're going to have better Asia gray AIS grades. That's like Asia grades, essentially. So.
30:22
Suggest the patients with spinal cord injury undergo, you know, surgical studies within, and decompression within eight hours after injury, and they're gonna have better outcomes. Here's another
30:32
study from Birkidol 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
30:44
greater recovery versus the late operations. And they said, There was a steep decline in changes in total motor score with increasing time duration, the first 24 to 36 hours after the injury. And
30:56
then, Quiet all 2021, early surgery less than 24 hours, compared with late surgery, acute spinal cord injury, early surgery, greater recovery.
31:06
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 spinal cord injury patients
31:21
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 for better
31:32
recovery. Very critical, except
31:40
for those with longer. And here is failing article, Global Spine, Time is Spine. All spinal cord injuries, complete clinical evidence suggests early limited secondary injury, reduces damage to
31:52
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 the best results. Okay. Terrific job,
32:06
really appreciate it, really outstanding. Really, I hope you enjoyed this presentation The
32:14
material provided in this program is for informational purposes and is not intended. for use as diagnosis or treatment of a health problem, or as a substitute for consulting a licensed medical
32:28
professional.
32:31
At the end of this video, please fill out your evaluation of this program.
32:36
And these are recorded sessions available free on
32:42
snidigitalorg. If you have questions, comments, or want to request CME credit right to
32:53
osmondidigitalorg.
32:56
There are many ways to learn foundation supporting these programs as one of its journals, a 2D internet journal with Nancy Epstein as the editor-in-chief. It is SI, also known as Surgical Neurology
33:13
International It's web address is SIglobal.
33:21
The other journal is a three-day live, new video journal of neurosurgery and neuroscience, interactive with discussion. It's SI Digital Innovations and Learning. And the web address is
33:36
sidigitalorg.
33:40
The information on both of these journals is free on the internet to everyone everywhere, 247, 365
33:52
Surgical Neurology International is read in 239 countries and territories. It's been published for 14 years. It's the third most widely read 2D journal in neurosurgery. SI Digital Innovations and
34:07
Learning is now seen in 106 countries in five months. It's a new 3D video journal.
34:18
The goal of the foundation is to help people throughout the world.
34:24
Also it has a medical news network dedicated to bringing truthful medical and science news
34:34
These programs are sponsored by the James IN. Carolyn Erausmann Educational Foundation. They're copyrighted in 2024. All rights are reserved.
34:47
Thank you for watching the program. We hope you've enjoyed it.
View Transcript
Listen to Podcast