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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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His first lecture in pearls and pitfalls of anterior and posterior cervical spine surgery 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, is there cervical stenosis here or not? What is cervical stenosis? It means a narrowing of the front to back dimension of the spinal canal.
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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 line.
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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, and
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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, the
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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 the 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
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spinal 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 size spinal canal, seen
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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 they're spinal cord or nerve or compression. Myelogram CAT scans are extremely useful, especially in patients who had previous spinal instrumentation. It might be the best
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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 spurs.
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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 study and
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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, 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 named, Jim Alstman 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 chord compression, and this is obviously a post-mortem evaluation of a disc herniation and the chord being compressed. And here's a myelogram CAT scan of a soft
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ventral disc, and the chord 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 UDC fusion of, let's have bony
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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 time.
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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 months.
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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 study at six
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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 fusion rate, you
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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 discectomy, that's
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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 saving 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 your
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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, and
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sometimes it can be misleading and Look overly 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 three
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months. Okay. So how do we fuse pretty much if it's six months? And six months you see it's instead of the irregular border it should be a more smooth border? It becomes a more hyperdense border.
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Okay, it's all hyperdense. Okay. Yeah. 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 The systems do not have a stop. device. So you
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can 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 ridge
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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 gotta leave enough of our ridge though, so. Yeah, it isn't fragile and just
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breaks 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
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and 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
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your 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
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these 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
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to 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
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very 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, I can go
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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 hinder some articles, but you should look at them very carefully, right? Absolutely. Absolutely You know, it
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can say, look, you know, this doctor so-and-so, look at the article that he wrote. 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 multi-level core-pectomies, post-op hematomas. They're not all epideral hematomas. They can be wound hematomas They can be retroferrengeal hematomas, wound hematomas.
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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 C5667, it's easier to get a Horner syndrome because the sympathetic change deviates medially as you're going
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more distally The esophageal perforation,
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again, and pseudothorosis rates, look at this, this was taken from one of the series, 43, that's with the cadaver graft, that's not autographed, 24 with the two level, up to 42 with 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 went up with a court injury or CSF leak or Horner's syndrome or
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pseudo-authorosis. I don't know what you wanna call it, but I didn't go in. Yeah, exactly. So you gotta look at it from the patient's point of view and I'm from the doctor's point of view. Yeah,
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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 around the world.
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Because what we, these lectures are available to how many people and how many countries? Yeah, 105 countries, thousands of people. Yeah. So I like to sprinkle throughout the lecture some of the
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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, patient had no disease. But it was performed by somebody
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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 no reason to operate at the second level of surgery. There was
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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 decompression safely. The patient was okay. Second level, he
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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 point where the assistant was shocked, astounded, and the patient
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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, the 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
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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
34:35
This lecture on pearls and pitfalls of anterior and posterior cervical spine surgery
34:42
is using the K-line in choosing approaches to anterior cervical spine lesions. It's a 40-minute lecture with discussion.
34:54
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, a 360 on.
35:06
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 mid-C2
35:18
to seven, 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 vertical
35:33
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, that's called a positive K-line, by the way, anterior
35:47
surgery, posterior surgery, or 360 surgery. And what I'm going to discuss and argue later,
35:54
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?
36:08
Okay, on the other hand,
36:12
okay, you may have the negative K line. What are you seeing with that? The negative K line. Here's the top and the bottom.
36:22
If your disease extends behind that line or posterior to that line, like in this instance, this would be, it looks like OPLL. It's likely, more likely than not, you need to do an anterior
36:34
operation. And the reason, I always say likely this, that, and the other, because there may be other circumstances where you may modify your technique and what you choose to do.
36:47
Many surgeons, by the way, don't even know that this line exists. I was just gonna ask you now, how many people use the K line as a deciding factor? Is it common or is it not common? It's very
36:60
uncommon And I can't tell you how many times you know you. to depositions where the person being deposed has no idea what this is, has never encountered this, and they just say, Oh, I just
37:10
gestalt it, 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
37:23
posterior cervical, in this case it was the laminoframanotomy, 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,
37:36
this is published, I'm not making this line up, okay? But again, here is your negative K-line. Disease, you see, is posterior to that line seen over here and here. And here is the study that
37:49
I'm quoting here, the negative K-line. You're likely to choose an anterior surgery for discs, spur, spondylosis, stenosis, andor OPLL That
37:59
was a paper from 2012. That's 12 years ago. Oh yeah, and there are many more that have discussed this since then. It warrants single versus multilevel anti-corpectomy infusion. So here's just a
38:13
figurative diagram of a one-level anti-corpectomy infusion. And then you have your plate and you place your screws. Okay, and here's an example of a multilevel anti-corpectomy infusion, plate and
38:26
screws. But I'm showing you here that if you have done more than a one-level anti-corpectomy, a two or more level, this graft and plate has to be stabilized by a posterior fusion. If you do not do
38:43
a company posterior fusion, that graft is going to extrude at least 20 of the time. If it's a two-level corpectomy, and at least 50 of the time, if it's a three-level corpectomy or more. Could
38:58
you mention that? That's really an important point. Yeah, and I'm gonna repeat that actually. So here, I'm just gonna show you again, you know, you're anterior-corpectomy infusion. By the way,
39:11
watch out for those instances instead of doing the one-level-corpectomy, some people are gonna say, well, and I'm not so good at the one-level-corpectomy, I'm better at the discectomy. Well,
39:21
two-level-antero-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,
39:34
you have to watch out for pistoning of the graft between those end plates. So you're gonna have it with the two-level ACDF, you're gonna have more subsidence, body fractures, and graft extrusion.
39:48
So here's your two-level-antero-discectomy 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 plate here
39:59
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 start
40:12
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 of corepectomy,
40:30
you have also two interfaces here to fuse, here you're gonna have four interfaces to fuse and remember the, I had just said before with a two level anti-dissectomy infusion, your pseudothorosis
40:43
rate there is gonna be about 24 and it's much less with a one level of corepectomy. Good, good, okay, terrific. And here's an example of where you have to really evaluate the images, Understand
40:59
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 looks like a big huge
41:12
soft disc, 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 C4-5, to the C3-4 level, not further below, okay? Your stenosis,
41:26
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 good patient for a one-level corepectomy,
41:37
where here's C2, anteriorly you take off the vertebral body of three, then you have no trouble accessing the entirety of this disc extrusion that's going at least to the mid-aspect of the vertebral
41:50
body. You're coming down directly on it, you can see it It's ending at the C3-4 disk space.
41:58
So you can do a C2 to C4 anterior core pectomy infusion, put whatever graft and plate you're going to put in. And then this might be, you know, your x-ray post-op where you have your core pectomy,
42:12
plate and graft are in place. And this is just showing 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
42:21
here, preventing that graft from going further back.
42:25
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 by
42:37
forgetting to put in those posterior ridges. And then here's your plate, et cetera.
42:45
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
42:58
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 chord opposite this level of compression. Here's the
43:10
chord coming down, here's the chord coming up, high chord signal marked chord compression as well. You do the CT scan and this is the same patient, and look at your calcification, ossification,
43:24
this is actually OPL and version of OPL called the other form that often looks like a disc or mimics a disc
43:31
and it's mid-body to mid-body. Well, to do this, you're going to have to go probably C2 to C5
43:39
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
43:53
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
44:02
'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
44:13
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
44:23
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
44:35
appears hypo-intense, and here it is on the CAT scan, hyperdense Let me 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
44:51
accurately. Is that gonna be a good determinant? Is a magnification gonna be missed? Is that, do I, can I feel comfortable with that? I mean, to get a lateral cervical x-ray to determine if
45:06
you've taken out a sufficient amount of the OPLL? Yes, in that I put a graft in it and it didn't go in too far. Is that gonna be helpful or is there some error in that and with the technique and
45:19
everything else? Well, I think if you've planned to do your corpectomy and do the resection that we've discussed, I think the lateral cervical x-ray will probably do. I mean, a lot of us are
45:30
using, you know, the intraoperative ORM, you just bring that in, swing it around, boom, there's your CAT scan to tell you if you've adequately resected the pathology So that's preferable if you
45:41
have access to that. If however, you're doing an anterior discectomy infusion here, you're going to be shaving more and more of the vertebral body. You're going to end up with less than half of
45:50
the vertebral body above, half of the vertebral body below. Remember, if you're taking off that end plate and you've taken off that end plate completely, you've got a 50 strength left in this body
46:02
and that body and you have a good chance that if you put a graft in there, that it may fracture out, plus the fact that you have not adequately and accurately, completely decompressed the degree of
46:14
chord compression above and below that disc space level.
46:19
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
46:29
directly anteriorly But I'm just wondering, I'm about relying on it, 100 of it says I'm okay. I mean, you can't Yeah. And it's a good reason to get a post-op CT scan if you have any question
46:41
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
46:52
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
47:05
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
47:18
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
47:28
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
47:41
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
47:56
cetera, and that posterior fusion is gonna help stabilize your anterior graft.
48:04
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
48:17
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
48:26
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
48:40
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,
48:54
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
49:05
don't do that simultaneous posterior fusion in these cases.
49:12
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
49:23
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
49:35
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
49:49
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
50:02
bodies. The next kind, it's called segmental, as you have ossification just behind the vertebral bodies. Here, continuous, it crosses the interspace. Here, it does not. But then you have the
50:15
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
50:28
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
50:40
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
50:50
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,
51:01
here you're looking at a patient with a negative case sign, a multi-level
51:07
OPLL, that's what we're going to look at here.
51:10
and likely requires, this patient's 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.
51:23
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 has
51:39
kyphosis, and you can see the anterior angulation
51:44
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,
51:56
is going to go behind that line indicating you're going to have to go from the front.
52:02
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
52:16
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
52:27
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
52:41
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
52:53
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
53:06
ossification is inside the Dura.
53:12
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,
53:26
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
53:36
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.
53:50
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
54:02
interdurally, as is this chunk as is this entire chunk here. So that's
54:09
going to be, you know, your. negative case sign with OPLL and multiple foci here, here, here, here of your double-layer signs. So you're not only going to have an anterior leak, but it's going
54:22
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 to see, C2, C3, C4, but look at 5, 6, and 7. This is actually OPLL
54:37
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 separation between the posterior aspect of this entire rotiural body.
54:50
This is C2, 3, 4, 5. This
54:53
is C6, and coming all the way down to the 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 and also look
55:06
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. Everything behind
55:18
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 here. This may be a
55:31
single layer sign over here
55:35
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 you might have to prepare to deal with this
55:46
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. High signal in the cord. Look at the MR
56:00
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 are misread as discs.
56:17
All the time, but wrong decision.
56:21
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
56:35
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
56:46
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.
56:58
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
57:13
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.
57:25
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
57:37
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,
57:55
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
58:07
you're not accessing. You may have some surgeons say, Oh, I can access that
58:12
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
58:24
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
58:40
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
58:52
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.
59:05
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
59:18
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.
59:29
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. But that, unfortunately, was
59:43
not what was done in this case. Instead, I'm just showing you he did a multilevel discectomy infusion, putting a bone graft at two levels and stretching the cord over the residual OPLL, which I'm
59:57
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 left
1:00:08
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 and
1:00:18
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.
1:00:31
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
1:00:42
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
1:00:56
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
1:01:12
your double layer signs, then you know that there's a problem in these cases.
1:01:19
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
1:01:30
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,
1:01:45
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
1:01:57
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 perimbilical region. Well, the perimbilical region is here,
1:02:11
but maybe 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
1:02:22
put in a lumbar drain, CSF, just because it's easiest for it to egress into your wound may exphyxiate that patient, much less cause that wounded to hiss and fall apart. So in the early days, we
1:02:35
use 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 needle shunt. Also, postoperatively prepare to
1:02:45
have 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
1:02:56
you put in,
1:02:59
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
1:03:08
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
1:03:17
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
1:03:29
delayed fashion, maybe what you then choose to do.
1:03:37
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
1:03:48
location of the graft, the screws, plate, et cetera. It is not going to show you what's happening to the cord, okay? This is what the MRI scan showed. By the way, both of these studies were
1:03:60
done in a 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 Dursio. They put in Dursio
1:04:13
anterior to the cord. It is contraindicated on the package insert to use Dursio anterior to the spinal cord, because it can cause a mass, and in this case, cause massive cord compression. Seeing
1:04:27
these findings, the radiologist said, wow, there's a lot of anterior cord compression And, instead, the surgeon did a laminectomy.
1:04:36
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.
1:04:47
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
1:05:00
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
1:05:13
be the associates. It may be the adjunctive personnel in the hospital, but everybody should be looking at it.
1:05:21
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
1:05:42
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. Do we take a
1:05:47
break here for just a minute 'cause you're gonna get into the posterior, right? Yes, yes. And I had, it was just you and I'll talk for a couple of minutes and we'll start again. I'm gonna leave
1:05:57
it run.
1:05:59
So I thought that was excellent They were really a lot of good tips and clues there. And
1:06:06
I may divide it into, it took us about an hour for that or 55 minutes. It was good.
1:06:17
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 was the introduction, which was the anatomy, the imaging and the
1:06:29
neurologic presentation. we can also have it as a four-part series.
1:06:38
Then the choice is do we use the,
1:06:42
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
1:06:54
the subsequent anterior series. What do you
1:06:59
think about all those ideas? I think you could do the anterior and up to anterior dysrectomy infusion. I think you could segment out the anterior corepectomy infusion and then do that as a segment
1:07:11
and then do the posterior as another segment. And just say this is three part series, maybe this is part A, B and C. No, okay. Okay. Because I think the images
1:07:26
that are shown with the review of the CAT scan and the more sort of critical
1:07:32
anterior and posterior surgical decision-making processes. So
1:07:35
we break the anterior cervical after it's a simple one level. Yes, yeah. Okay, I think we can find a breakdown. Yeah. I think that's, so we need the anatomy with a simple anterior
1:07:50
cervical dysctomy infusion then more complex anterior operations than posterior operations. Right, right. I think that's good. Yeah, I'm going to see, see how you feel about that The other thing
1:08:01
I was telling you too is I have also separate lectures on anterior cropectomy infusions and posterior cervical. So you can see, we could see what you think of those just as a, as maybe supplemental,
1:08:15
more detailed in the depth of the - Well, 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
1:08:26
could record it, but you could use them as a later, two later entries in the series, Mark.
1:08:33
approaching more complex cases. Yeah, yeah, okay good, because I have them. I haven't worked on them already, yeah. So it's up to you how you wanna do it, but what we're doing is putting
1:08:44
together a library. It's terrific. So this is
1:08:47
10 recorded, 10, but there are, but no, I think we're doing pretty good. That's good. Okay, you wanna go ahead with that. You can just go on and say about posterior cervical surgery, am I
1:09:01
interested? Yeah, next we're gonna 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 is,
1:09:09
and we're gonna 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,
1:09:30
of that choice is, you know, you're gonna have a easier post-operative course, easier post-operative outcome, and reduced morbidity with fewer adverse events associated with it. So I think it's
1:09:42
something that you have to look at very, very carefully. And you know, again, this is sort of your typical post-year cervical procedure. You know, you've got the patient in a three-pin head
1:09:54
holder. By the way, I always use a three-pin head holder You 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
1:10:04
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've marked out the post-year cervical
1:10:14
incision that we're going to use. By the way, SCP, somatosensory vote potential, motor vote potential, and EMG monitoring is important By taping the shoulders, watch out, you can actually incur
1:10:25
a plexus injury. break your 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
1:10:36
surgery, 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.
1:10:48
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
1:11:00
a laminophuraminotomy. 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 patient.
1:11:12
Don't you 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
1:11:23
devoted to 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
1:11:37
foraminal root compression. No cord compression here. Here is your laminoframanotomy with your medial facetectomy for amanotomy. By the way, watch out. There's your vertebral artery out there.
1:11:49
You don't wanna 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 cord exposed. That's why the morbidity of
1:11:60
these 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 wanna go anteriorly, but
1:12:13
if 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,
1:12:25
very likely you're gonna have to do it again. opening fusion at that level. You're gonna have to do a what at that level? A fusion at C721. A fusion, okay. You're doing a foraminotomy at C721
1:12:35
because of the cervical thoracic junction. But again, here's an MR of a lateral and foraminal disc where you could approach it from behind. You can use your pen field elevators to identify that
1:12:48
nerve root because the arms are typically down by the side. The nerve root in your image are typically coming down In the old days, we used to put the patient in a sitting position with their arms
1:12:59
upward so the root would go up, but now it goes down. So you have to use a pen field elevator to get into the axilla or the armpit of that nerve and then use your downbiting correct. You can use a
1:13:10
downbiting correct to remove spurs andor osteophytes that may go laterally and foramily. And again, you know, watch out if you're concerned about a vertebral artery problem here too. But we're
1:13:22
gonna go back to our discussion of the K-line and how you use a K-line. For posterior cervical surgery, you want that positive K line, okay? That means that mid between C2 and the posterior
1:13:35
elements and C7 and the posterior elements, you do a vertical line, your pathology is anterior to that line. Again, your options are gonna be multiple. You can have anterior posterior 360 surgery.
1:13:47
Use your posterior surgical options if you can. This is going to be exclusive of the negative K line, which we have previously discussed. So the positive K line means your diseases anterior to the
1:13:59
K line, your surgical options, anterior posterior 360 surgery, best to choose posterior surgery because of the more limited morbidity associated with these procedures.
1:14:11
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, Spondylosis, and here you can see your
1:14:24
pathology. is anterior to that K line, okay? So it's pretty simple to remember, pretty simple to measure. And again, your posterior surgical operations are going to limit the risk of a CSF leak,
1:14:40
much less the other risk and complications. Your posterior cervical procedures, your dysphagia, unless the patient's intubated for a very long time, is gonna be much, much less risk of your CSF
1:14:51
leaks, much less risk of a carotid injury and internal jugular injury, or current laryngeal injury, or phrenic nerve injury. I mean, all of the list goes on and on. You can choose to do a
1:15:04
laminectomy to decompress the cord. The cord is gonna migrate posteriorly. As long as you have, in this case, you have a good cervical lordosis.
1:15:14
And here's your laminectomy with posterior migration of the cord into that space that you've created.
1:15:20
ventral kyphosis, contraindication relatively for performing posterior cervical surgery. Sometimes you may have surgeons who may do an anterior discectomy graft above and below the pathology to
1:15:32
throw the patient into some degree of lordosis to do a posterior procedure. But here again a positive K-line, here's your X-ray and it's showing you, I'm showing you the stenosis here, my uncle,
1:15:44
the neuro radiologist, he's terrorized me as a 15-year-old when I would visit him over vacation in his radiology office where he was the chair, would say okay Epstein, tell me about spinal stenosis
1:15:54
and I would have to say if you measure from the mid-retrial body to the posterior interlaminar line and that arrow is shorter than the measurement front to back of your retrial body most likely you
1:16:07
have spinal stenosis
1:16:10
on a six-foot lateral film You just will never heard that before Ugh.
1:16:15
And here, again, is an MR image of this genetic spinal canal. And remember, we didn't have MRIs until the '80s, essentially. Before then, it was myelograms. We didn't even have CAT scans yet
1:16:20
until, like,
1:16:27
1976, where, as our first year resident neurosurgery, we were running around with Polaroids of CT images, because
1:16:42
we aren't only two 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,
1:16:42
straightened lordosis and stenosis. OK, lordosis here, straightened. But you could see how, if you remove the retribal bodies here, you can, with a straightened lordosis
1:16:50
and
1:17:02
some instances, get away with a posterior operation, or if you do an anterior discectomy infusion with a lordotic graft above or below this, Sometimes you can reverse lordosis. them into more
1:17:14
lordosis and get away with a posterior operation. So again, I'm going to show you just multiple examples of an MR cervical lordosis, really a hyper lordotic curvature. Look at the lordosis here.
1:17:28
C2, C3, C4, 5, and 6. Look at the ventral compression. Look at the dorsal compression. You actually have shingling of the lamina. Instead of the lamina being sort of like this, you have the
1:17:39
shingled lamina like 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
1:17:51
from behind, that cord will migrate posteriorly like a rubber band, and then you confuse the patient because you have to maintain the lordosis. Here's another example. We've already gone through
1:18:02
this previously in a previous lecture C2, C3, C4. This is not disc disease. This is ossification of the posterior laundry to a ligament going from C45 all the way behind five, C56 behind six and
1:18:17
all the way down to six, seven. There may be sometimes accompanying just with that, but if you take away all the bone back here, you may allow that cord to migrate post yearly because you do have
1:18:29
that good cervical or dotted curvature.
1:18:36
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 you Other examples here, again, curvature,
1:18:45
good cervical oridosis. Here's seen on an MR, here's seen on a CT scan. That's actually the same patient. Look in the CAT scan, see the shingle lamina. One, the leading edge of the lamina below
1:18:58
is anterior to the level above, same thing over here. And it's just like, you know, your Venetian blinds. One goes right in front of the other and the leading edge inferiorly compresses your cord.
1:19:12
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
1:19:27
underneath here. If you remove 5, 6, and 7 with a 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
1:19:39
here. On an axial image, I'm showing you that you're seeing the single lamina. It means you see actually two lamina on the same axial image, and you're seeing it in this picture and maybe a little
1:19:50
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 to know how to discern where the pathology is and how you're gonna go about
1:20:05
dealing with it. When you do the laminectomy, this is actually what you're doing removing the lamina. and the spontaneous process. You're preserving the facettes or you may be doing a medial
1:20:16
facitectomy for immunotomy. 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
1:20:27
we're not
1:20:30
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 get your
1:20:42
baseline intraoperative monitoring. 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 preoperative
1:20:53
baseline. You do not want to get your baseline after you are already positioned for surgery because you may have already compromised that patient. You may have already damaged that patient. Same
1:21:04
thing for
1:21:07
SCPs and your EMGs. Obviously EMGs are just going to get activity So here's your figurative diagram of your laminectomy. Here's your laminectomy and here's the bone that's been removed.
1:21:16
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
1:21:28
here, this is a three-dimensional CT, following
1:21:33
a 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
1:21:44
created in that patient with a lordosis. Just some figurative images of your doing your cervical laminectomy here, a C2 down here, here is three, four, five, six, seven, and then here may be
1:21:58
T1. Downbiting curates, you do your medial fascatectomy frame anatomy, and you can use your downbiting curates after you used a nerve hook and a pen-filled elevator to make sure. that you are not
1:22:11
going in and inadvertently taking out the anterior motor nerve root. Again, that sometimes is not enslaved in the dura and you can mistake it for
1:22:25
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 frame anodomies. You don't necessarily
1:22:35
have to do full facetectomies Obviously, that's going to further destabilize the patient. Too much of the time, surgeons are actually automatically taking out the facet joints, destabilizing the
1:22:48
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 anodomy. Here at one level, you're doing
1:22:57
a more extensive pherominal dissection. Here is a nerve root exiting inferiorly and downward because, again, those arms are positioned down next to the body in that prone position.
1:23:10
And here is a pin-field elevator very gently dissecting, exposing the axilla or armpit of that nerve root. And this is where you're going to then introduce your downbiting curates. Very small, two,
1:23:22
three millimeter curates. And again, every movement you do is away from the patient. You never use that curate towards the patient. That's how you're gonna damage the cord inadvertently or get a
1:23:34
CSF leak, okay? You see, you mentioned the anterior motor route sometimes it's separate. Where would you see it in that picture? Okay, well, you may see this. This could be just your isolated
1:23:50
posterior sensory route that is in Wisconsin, the door has a durable sleeve, but you may see just ventral to it, like running here, something white, but the white would be coming down like that.
1:24:05
That could be your anterior motor nerve route that is not interdural. but it can look very much like sometimes your disk fragments. That's why you have to listen to your EMGs very carefully. Use
1:24:19
that Penfield elevator, use your operating microscope to make sure you have exposed disk and you have not exposed or decided to take out that intermotor route. Okay, terrific. Okay, but it can be
1:24:38
very tricky to do that.
1:24:41
Here's just an example where this is a pre-operative MR. You've got a tight spur of 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
1:24:52
C2. 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
1:25:04
your operative wound was. You're not seeing any detail of the cord though, are you?
1:25:10
Here's your post-operative memoir. Same patient, same time, early post-op. But here's your chord. Here's your chord pre-op compressed from front
1:25:20
to back. They used to call it like the washboard. Not that I would know what that is, but anyway. But here is your chord now decompressed. You see CSF anteriorly and no CSF posteriorly here. Now
1:25:34
you see
1:25:37
spinal fluid anteriorly Now you see spinal fluid posteriorly. The chord has migrated. This is your posterior decompression. Okay, that's what you would say. You take an image that same image as
1:25:50
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 should look like this or even better. Now, if you have had a
1:26:05
very compressed spinal cord
1:26:08
and you have, let's say, just post-op edema in the cord, you may see more cord atrophy or myelomolatia, which would show you even more spinal fluid around the cord three months later, six months
1:26:22
later, et cetera. Okay, the beauty also of doing your post-op studies is let's say you had one level where you had much more anterior compression. If there is on this post-op CT, much less MR,
1:26:37
one level where you see residual significant anterior chord compression, be it a disc, a spur, an osteophyte, whatever, you could then go back and decompress that spinal cord anteriorly at that
1:26:51
specific level. But that's why post-op studies are important. You wanna know what you've done. You wanna know what disease may be remaining behind. You wanna make sure you don't have a
1:27:02
post-operative hematoma, okay?
1:27:05
And doing sequential studies is also important, especially in terms of your MRI scans, because if anything neurologically changes or gets worse, you need to study this. I see this again and again
1:27:18
in looking at medical legal cases. It's almost like they're shoving 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
1:27:29
to go back. It might say, maybe you only did a laminectomy at two 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
1:27:42
measuring that the space there is in a spinal canal, after you've decompressed them, it still looks compromised. If you look at the C6 level, there's a much wider area of CSF. It could be because
1:27:56
of the cervical enlargement, but how do you look at that?
1:28:03
Very important on the MR, you have to look at all the medial lateral images. You have to, you know, this is just one sort of mid-sagittal image. You have to go from side to side. You also have
1:28:14
to 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 cephalate and caudad
1:28:25
levels, 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
1:28:38
look at the entire study, not just one set image. So you need to know at the end of surgery, I so decompressed them, but this person may still have some potential for problems. I mean, you need
1:28:51
to come away with some conclusion. That's right, that's right. And post, I mean, there were lots of instances where, Let's say, if interoperatively, let's say hypothetically. You did this
1:29:02
operation and the patient had significant intraoperative changes. But 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.
1:29:13
Raise the blood pressure, stop your distraction, et cetera. 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,
1:29:29
I'm gonna come down and get a STAT study You keep all 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
1:29:40
adequately decompressed. Or, Hey, we're gonna come back. We need to do something more. Okay, good point. Yeah.
1:29:49
So here's another example. We're look at the multi-level, two, three, four, five, six, seven. Especially at six seven, you see the high signal in the cord. This does not look good. This is
1:29:60
your MR. It's not the best picture in the world. Here is a post-operative AP C567
1:30:09
lateral mass screws have been placed. Here's your lateral view, post-op screws are placed, et cetera. But most importantly, this is what you want to see in your post-op MRI. C2, C3, C4, 5, 6,
1:30:25
7, you've done a complete laminectomy This is more like what we typically would see, Jim. We see more of a big bath of spinal fluid all around the cord. And that's what we're more happy looking at.
1:30:39
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, the next week, the
1:30:49
next month, et cetera, or the next few days, it all depends on what that patient's neurological status is The worst thing to do is like a complicated. multi-level core pectomy patient that I
1:31:02
presented.
1:31:04
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
1:31:15
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
1:31:25
problem I'm done Okay, real good. And then posteriorly, you know, you need to do a fusion to preserve that lordotic curvature 'cause otherwise they'll become kiphotic and angulate forward.
1:31:39
Lateral 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
1:31:53
multilevel cervical laminectomy, you're going to fuse down to the T2 level.
1:31:58
to make sure you're really stabilized that cervical thoracic junction, you know? So in conclusion, in conclusion, when you are doing any of these cervical operations, you know, look at your
1:32:10
preoperative MR, I would say a preoperative CT scan is absolutely worth it. The CT scan can be smarter than you are.
1:32:20
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. I was very lucky, I still am. I have
1:32:33
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 this?
1:32:43
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, thank
1:32:54
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 thing we
1:33:11
wanna include here, I think, Jim, is just the references that people can look at. Okay. The neurologically recovery after traumatic surgery. The spine injury, this is talking about when you
1:33:22
re-operate on patients the earlier or 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
1:33:34
here's a, 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. So suggest
1:33:48
the patients with spinal cord injury undergo, surgical studies and decompression within eight hours injury and they're going to have better outcomes. Here's another study from Birk et al in
1:33:60
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 recovery versus
1:34:11
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 Kui et al, 2021,
1:34:24
early surgery, less than 24 hours, compared with late surgery, acute spinal cord injury, early surgery, greater recovery.
1:34:32
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
1:34:46
injury 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
1:35:02
than 24 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
1:35:15
early 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
1:35:28
get the best results. Okay. Terrific job, really appreciate it. Really outstanding, really, really. We hope you enjoyed this presentation.
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