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innovations in learning. A 3D live video journal
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in association with SI, surgical neurology international, a 2D internet journal,
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are pleased to present another in the SI digital series Controversies in Spine Surgery, a three part lecture series in discussion on the Cotto Aquinas Syndrome.
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A title of this talk is a review of the Diagnosis and Management of Cotto Aquinas Syndrome and Related Malpractice Issues.
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It's given by Nancy Epstein, who is the Professor of Clinical Neurosurgery at the School of Medicine at the State University of New York at Stony Brook. She is the Editor-in-Chief International
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The talks in this series on Lumbar Cotto Aquinas Syndrome are part one anatomy imaging, clinical presentations, and surgical lessons in diagnosing and treating the Lumbar Cotto Aquinas Syndrome.
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Part two is avoiding malpractice issues in Lumbar spine surgery And part three is avoiding malpractice in the treatment of CSF leaks. Lumbar Cotto Aquinas Syndrome part one is on the anatomy imaging,
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clinical presentations and surgical lessons
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in treating this syndrome. This is Nancy Epstein who's going to talk to us about the failure to diagnose and treat Cotto Aquinas syndromes, one of the most common mistakes in spine surgery and we've
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divided it for your ease of
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of viewing into three parts, but it all should be looked at together because they're all related. And Nancy is a professor of clinical neurosurgery at the School of Medicine at State University of
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New York at Stony Brook and is
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one of the most prolific writers in the spine world. And
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it tells us what we want to know and tells us the truth. Okay, Nancy. Okay, thank you, Jim. Okay, so this is really brought on by wanting to go over the basics. And when patients present with
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corticwinis syndromes, we need to recognize them. You need to know how to diagnose them, how to treat them, and not to delay in any of the treatment modalities.
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During the course of this, we're gonna go over how to read MRAs and Cascans and everything else. Here's a figurative diagram on the left of a normal disc spinal canal. This is a lumbar canal. And
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here's a patient with a corticoid syndrome with a large central disc herniation. Can I ask you a question before you even start? Yeah. How common is this disease of all the spine diseases, you see
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it would be five or 10, one out of 20 to one out of 10, do you think it's more than that? I
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think it's at least one out
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of 10, one out of 20. If you ask me how frequently do I see this as a cause of a medical malpractice case, that's at least 30 to 40 of the cases that I see. Wow. It's extremely common. This is a
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subject that's commonly missed is what you're telling me.
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Codercoinis syndrome and missing codercoin syndrome, it's like
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the COVID of spine surgery, you know. It's there and it should be treated and it shouldn't be missed and the misdiagnosis is flagrant. The first thing I'm gonna go over is some of the neuroanatomy,
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just basically of the lumbar spine. You can see neuroanatomy in some of the other talks that Jim and I have given. I'm just gonna define codercoinis syndromes and then the rest of the lecture is
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gonna go over MR and CT causes of codercoinis syndromes. Part two, I'm gonna reveal some of the factors that go into negligent lumbar surgery resulting in codercoinis syndromes, how negligence
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spinal fluid repairs can result in or cause codercoinis syndromes. What's the best timing for surgery for codercoinis syndromes? And this is a great time to emphasize to anybody if you don't
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remember anything else from this lecture. If the patient has a codercoinis syndrome, You can't just look at the literature and say, Oh, I've got 24 hours before I have to operate. I'll just
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operate on it in the morning. The answer is no, the clock starts ticking as soon as the patient starts developing the first neurological deficit. And the best treatment is, quote, the sooner the
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better in this disease, up to six to 12 hours and not certainly waiting the 24 hours. But the best literature is gonna say basically day zero to one The old literature is up to 48 hours. Old
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literature, the poorest literature, not the literature that should be listened to. So in terms of just the basic lumbar anatomy, you've got here on a lateral view. This is obviously a
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post morbid specimen. You've got four, five lumbar vertebral bodies. And you've got the discs anteriorly, by the way, 5 of your patients may have four lumbar vertebral bodies or six. So they can
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have lumbar sacral anomalies that you must be aware of. And here posteriorly, you've got the spanish processes and the lamina. In between there, you have your spinal canal and you're measuring the
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front to back with the dimension, or EP dimension of the kind of canal from the mid-vergiro body anteriorly to the posterior lamina line. And if you look at my hands for a minute and you pretend
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that my arms are the lamina and my hands are the spanish processes, the posterior lamina line is where those two lamina come together to form that spanish process. You should be looking at a lateral
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six foot film. My uncle was a neuro radiologist and he hammered this into me as a 15 year old sitting in his conferences.
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Okay, so here is a diagram of where the conus is. The conus is at the T12L1 level. Below it, you have the lumbar cistern that's filled with spinal fluid. and actually the end of the cord is
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anastomose to the sacrum by the phylum terminally. This is where the quarter of a coiner lives and the quarter of a coiner basically goes from T12L1 ending typically at L5S1. And here, you can see
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figuratively, I've shown you where it's gonna be located, large disternations causing quarter coiner syndromes. And I'm going to try to integrate case studies in the midst of everything to keep
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people awake and alive, to just, you know, essentially emphasize how important it is to learn this for the patient's sake, not just to pass an exam, okay? So here's just an example of a
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figurative diagram of a big disk causing a quarter coiner syndrome. And if you can just sort of put these cartoons in your memory, it will help you remember what the anatomy is whenever you see
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patients. Here again, T12L1, L5S1. That's your quarter of a coin. Sacred roots are going to be S1 to S5, seen down here. Quarter coin of syndromes, L2 to four. That's part of your femoral
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nerve. L5S1, that's part of your sciatic nerve. And the sacred roots are S1 to S5. So from L2 to
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four, what are those nerve roots going to show you? Well, I'm just going to show you here. Here's an extruded, sequestrated disc on the sagittal image, whereas that disc herniation has extruded
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superiorly. And here you can see it's at the parapeticular level. This is the L3 pedicle that you're seeing here. It is so important as a spine surgeon that you know your anatomy and you know how
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to read your own MR and CAT scans. I would say your radiologists, your neuro radiologists are going to miss the pathology at least 5 to even 10 of the time. And I'll show you one case shortly in
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which they miss the diagnosis.
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femoral nerve, L2 to 4. What are you gonna find on the exam? You sit the patient down, you ask them to lift up their leg, you can push that leg down. That's gonna beilius ous weakness. They
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can't elevate and keep the knee up. Quadriceps, they can't extend the leg. And again, that's the biggest muscle in the body. So you have to have a lot of problems going on in order for that to
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show a deficit. Reflex loss, the patellar reflex, the knee reflex. Sensory deficit, loss of pin in the thigh and outer aspect of the calf. And here is just, you know, I'm just diagramming for
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you. L2 to 3 is on the thigh. And here, L4 is the medial aspect of the calf. Unlike lateral aspect of the calf, I'm gonna show you is L5. And lateral aspect of the foot is S1.
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So here is an example talking about the next set of nerves, the sciatic nerve. By the way, people think in the lumbar spine, all you're dealing with is sciatic nerve They forget the femoral nerve
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completely.
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but the psionic nerve is comprised of L5 and S1, and L2 to four is not included. So you have to remember this when you're looking for pathology and you're trying to correlate it with the patient's
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exam. By the way, here's a nice large extruded disc on the left at the L5, S1 level. Here's your disc herniation scene right here. Here's your theical sac, and here's the normal nerve root on
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the other side. And here you are in the OR. On the cross table here, you can see the door You've got cotnoids here that happen to be a patient who also had significant stenosis. So here you're
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taking out fragments of disc with the pituitary, trying to get the lateral and foraminal portion of the disc that you may miss if you're just on theipsilateral side. By the way, if you're doing a
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micro endoscopic discectomy or a minimally invasive discectomy through a tube, you do not have this kind of maneuverability to make sure you get the same full extent of disc excision and go into the
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interspace and empty out that disc to make sure you don't get a recurrence. Okay, so for the sciatic nerve, L5, foot drop, they can't lift their foot up. Easiest thing to do, asking to walk
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across the floor and put their toes up in the air. And if you start hearing that they're slapping the foot and you look and that foot's coming down, that's the best way to pick up your foot drop.
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They may also have a loss of the ankle response and there can be sensory loss on the outside of the calf and over the top of the foot. If you're looking for S1, they can't stand up on their toes.
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And again, they can't plant reflex or push that foot down. There's a loss of the ankle response and actually the loss of the ankle response correlates more with an S1 deficit than L5. Loss of pin
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appreciation on the outer most lateral aspect of the foot and even under the foot as well. Can I go back to that slide? You just, you guys. I don't know if we're gonna come back to this, but you
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show the large disk there and you show that you're removing the disk. And the question then comes up, how much is this debate? How much of the disk do you remove? Sometimes, you know, you look
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and I say, Oh, I take out this big, long thing and it's a big disk, could be everything. But do you go back into this space and do you look for some more? You said you're using a pituitary
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ringer so it obviously suggests you're just not shaving off the top of it. You're evacuating the loose fragments in the disk space. Do you want to spend some time now or later on that? No, no,
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let's talk about it now. I think it's a great question. And one of the biggest problems with minimally invasive surgery is lots of times they'll just go in and take out the extruded or the
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sequestrated or the free fragment. And there's a tremendous amount of disks that's left in that disk space.
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And that's why there's such a huge incidence of recurrent disc herniation with minimally invasive approaches. I can remember visiting, I
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guess it was, might have been Japan at that point. And I was talking to a surgeon and I said, wait a minute, you just did a minimally invasive discectomy, it originated from the L4 or 5 level.
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You've done your tube approach only to the mid L5 pedicle level to take out the free fragment. What about all of the other disks that's probably still in that interspace at the four or five level?
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And he said, that's for another day. I don't have time for that today. Oh my, but I remember that some time ago and you probably know we're papers, but there were some papers on 'cause there was
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a, I think a prevalent attitude at some time where you don't, you just take out what you can and leave the rest and then the recurrence rate and those people was, was significantly higher, is that
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correct? Yes, it's a very, very large number of patients who come back with dysprit occurrences. And so you have to have an angry with this patient. One more next data, one more question on that.
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Are you used the pituitary ranchers, which I think everybody understands? And sometimes they're correct. So how aggressively do you empty out the disk space? Well, I think you use a down-biting
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curate. You are protecting the nerve root with a bayonet and nerve root retractor, as well as cotenoids above and below. And with the curate, you're certainly going underneath the posterior
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longitudinal ligament, and everything is dissected downward into the disk space itself. And you're also going to shave off the cartilaginous end plate, as well as disk from the superior and
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inferior end plates. The answer is aggressive yes. With a pituitary, you've got to be very careful. I know patients who died intraoperatively because they took a bite out of the aorta with an open
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pituitary. You don't do that. I think you have to be much more careful with a pituitary in the disc space and the disc space with a pituitary, you're only taking out the fragments that you've
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already freed up with that down biting curette And these discs which often are large, the quadaquinas syndromes. Do you go to the other side and take the disc out there? If you've emptied one side,
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what's your thinking on that? In a disc herniation like this, I'd probably just do it from this side. If I had any question, I'd go in, I'd check quickly from the other side, just to make sure.
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So you have to wind up doing a laminectomy at that level? It depends on the size of the disc. If it's a disc herniation like this, I'd just do probably. anipsilateral approach. If it's a younger
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patient, you can get away with a laminotomy where there isn't that much in the way of stenosis and as long as you have enough room, sometimes you may switch it to a hemilaminectomy. If it's a much
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bigger disc, then the bigger the disc, the more exposure you need. And that's one of the most common mistakes that's made is you don't wanna end up over-retracting the nerve and damaging the nerve
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tissue while trying to make a smaller incision In fact, this is one of the things that, I mean, I always used SCP and EMG monitoring for lumbar discs. It can tell you when A, you're retracting,
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they coat a coin a too much 'cause your recipes will start to drop out. And if you're doing too much in terms of retracting the nerve root as well. So you've got to be very careful in any of these.
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One last question, I'm sorry for the diversion to wants looking everybody know think I..
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I'm, let's say I'm in a part of the country where I can't get SSEPs, I can't, and I can't have
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monitoring. Was there, just persons unavailable, we don't have them there or so forth. What do you
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change or do you change anything if that's a problem?
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I think you have to be very aware of whether or not you are providing undue retraction. And if you're retracting too much, you're going to cause some nerve damage. It's interesting because I've
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read some of these medical regal cases where number one, they have no assistant, which is a big no-no. Number two, a lot of people are just using loops. If you have access to a microscope, use a
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microscope You need less retraction under the operative microscope than you do if you just have loops And the other thing is you can't see what you're doing and can't assist you if you don't have a
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microscope. And lots of times they don't have loops to assist you. So the answer is monitoring is great if you can get it. If you can't get it, at least use a microscope if you have access to it.
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If you don't have access to a microscopic. You know, using your loops, you're gonna need a bigger exposure and don't spare the exposure. Some of these exposures you go back and you look at post-op
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CAT scans in patients who end up with spinal fluid leaks and nerve damage and their entire exposure ends up less than, you know, 10 millimeters by 10 millimeters. I mean, there's a lot of them are
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even less than that. You can just see what the bony removal is and
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that's hazardous for the patients and for their outcome. So I think that's the key point I wanted to bring out and that is if you don't have that, you should go up for more exposure.
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Yes. Because your job, your job is not to cause more harm and to have enough room to do the adequate decompression to get out the extruded sequestrated just that you're going after and to get that
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down by an incurret safely in and out of the opening that you've made in that annulus to remove more disk.
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Can I ask you another technical question? I'm sorry about it, but it just comes between me I hope I begin to open it up and
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you probably thin out the bone on the lamina beforehand because you could stick a ronjour in there and this space as tight as can be and you know to just take bite some more bone off. How do you deal
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with that? Because usually with a big disk in this region, it's tight
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Well, first of all, you're going to extend your, if it's super tight.
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you use your drill is gonna be a diamond drill.
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Make no mistake, it is a terrific mistake to use a cutting burr because the cutting burrs can skive off and actually cause massive spinal fluid leaks and nerve damage and everything else. So you're
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gonna use a diamond drill and then you're gonna use your one or two millimeter kerosene punches or even an upbiting correct to remove that very thin lamina.
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And if you try and put a pinfield in laterally and try to start sweeping the quarter coiner medially or the drill sack medially. And if you can't maneuver, you just keep taking off more bone. In
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other words, go ahead, do that medial fascatectomy for amenotomy. Do a more extended decompression above or below. If you need to do a hemilemonectomy If you really need it, do a laminectomy.
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The other alternative, of course, is if there's a mass of discrimination on one side, and you are having trouble getting in, you can always, you do your laminectomy and start from the other side.
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That's good. Make your end, you're opening, start taking out disc, decompressing, and once you decompress to some degree, then you can start working on the other side. But you're absolutely
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right. You have to think when you're feet. You have to also anticipate, I mean, I trained with Jo Ransop, you always said, do the operation, you know, hundreds of times in your head before you
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get to the OR. Don't waste the patient's time because time is infection. And
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you have to have all of these avenues of alternative modalities to deal with the pathology at hand. You can't just say, this is the way I'm gonna do it and keep going that way and then damaging
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nerve tissue while you're doing that. And or what some have ended up doing is they go right through the Dura And, uh. then they can, you know, end up getting to the disc, but then they have this,
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this, these final fluid and they have the quarter coin in their left. Yeah. So what I was getting to, I would assume most people have drills, if not all. If they don't, the goal is to thin the
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bone, thin the bone, thin the bone, thin the bone, because you don't want to have to put an instrument in there in a very tight space. Yes, absolutely. And this is, this is important in the
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lumber spine, but it is totally critical in the cervical thoracic spine where underneath there you have the cord. You know, here you have the quarter point of much more forgiving, even with a big
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mass of discrimination, still more forgiving. But if you have the spinal cord underneath there, that's not forgiving at all. And you must use that diamond drill and your up-biting caret. And if
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you're going to use a kerosene punch, you should be using the 1 millimeter kerosene punch. The more lateral you are, the safer you are. So the goal is don't compress, don't compress this act.
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Don't just take the pressure off this act. Don't compress it. Is that right? That's right. That's absolutely true. I'm sorry for the difference. No, this is critical. No, this is really
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important, especially, I think we were talking about thoracic discs on one of our discussion and thoracic dyscronations. It's one of the reasons why you don't take out a central thoracic disc by
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doing a laminectomy. Because the last thing you wanna do there is put the end plate of your kerosene punch between the lamina and that compressed cord. Okay, terrific. So we got the signs of an L5
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and an S1 lesion and you did the L233404 and okay, I'm sorry for the diversion, but I thought it was helpful that people would wanna know Absolutely, that's why we're here. Defining quarter coin
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of syndromes, I found it fascinating. I mean, as I was telling you before, you know, tremendous number of malpractice suits are about quarter coin of syndromes. And what's the failure? They
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failure to diagnose a partial quarter coin of syndrome because the vast majority of patients present with partial quarter coin of syndromes. They don't have to have everything on the list. And I can
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tell you, not only the spine surgeons, but you have the emergency room positions, the hospitalists, your other specialists. They think that everybody just comes in and they have all the full
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blown symptoms of a quarter coin of syndrome. So they don't recognize that it's an impending or partial quarter coin of syndrome. So most quarter coin of syndromes are partial, not a total loss of
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motor function, sensory function. It can be in the lower extremities, numbness. It can be loss of saddle sensation, perineal sensation, sphincter function, urinary retention, bowel dysfunction,
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and also sexual function, which obviously is hard to test on first evaluation. But here is just a figurative diagram of your large central disc herniation, resulting in, look at that, thegal sac.
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Your thegal sac should be right around here. And here, your nerve roots are compressed posteriorly, markedly, markedly compressed by a central disc herniation. And here on a lateral image,
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you're seeing the same sort of thing, lateral compression of the quarter of a coinum.
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Partial quarter coinus syndromes, partial leg weakness. It might be weakness of one leg. It might be weakness of the foot. It might be just the upper part of the leg. Partial sensory loss might
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be any part of the lower extremity or it can be the saddle region, the perineal region. It can be speech or dysfunction. The patient can come in and they've got urinary retention If anybody
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bothered to ask them if the, you know, when was the last time you urinated? You know, I haven't had anything to drink. Well, that's not the answer, you know, and they end up doing studies
25:28
where you can see the bladder's distended and the sexual dysfunction, et cetera. So here is an example of a partial quarter-quincentrum that you might see with a disc herniation. And here you can
25:39
just see figuratively, I'm just trying to illustrate that again.
25:46
Okay, so that is as opposed to the full-blown quarter-coinage syndrome where I've already shown you this image. The patient comes in, they have urinary incontinence, they're numb from the type of
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the thighs down. They have loss of sensation in the saddle region, loss of bowel and bladder function, and loss of sexual function, which is, again, harder to test for So I'm going to tell you a
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story
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of, actually it was him as a friend, and it
26:24
was, she called me one day, and she said, you know, I just went to a medical facility because I had back pain today, and it was going down my right leg, and I was really having trouble walking
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So I went to the facility and she said, I went to the facility.
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And I said, they do an exam? No, no, not really. Did they do any studies? Yeah, they did a CAT scan, and I said, what? A CAT scan, okay? Somebody comes into an ED emergency room. You
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don't do a CAT scan if you're looking for a neurological problem, really, unless you've got somebody who's got a pacemaker, et cetera, whatever. But here, you
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do an MRI scan, 'cause that's gonna show you where the pathology is So they did a non-contrast CAT scan, okay? And they sent her back to her house, okay? And I said, well, give me permission to
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go see it. I took a look at the CAT scan, okay? And this is a, this is failure to timely diagnose and treat a partial-porter-coin syndrome, okay? Well, what did they have? Loss of bladder
27:35
function. She had a distended bladder. Loss of motor function in the right lower extremity. and a quarter point of syndrome. So anyway, they typically present multiple emergency room visits again
27:48
and again. That's the greatest of the times. There's something. So this line was just - You told us, you told about the woman who called you on the phone and went to the hospital. Well, I didn't
28:03
get there. They sent her home. What was the diagnosis? What did they tell her? They sent her home. They said, We have no diagnosis And what did they say? Okay. They sent her neurologic
28:13
deficits and they did. They said, If you get worse, go to an emergency room. That was it. And they
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didn't check the bladders, all right? They didn't check anything. They didn't do a neurological exam because nobody knew how to do one. It was a nurse practitioner who was seeing her. They had
28:33
the CAT scan, the STAT read, missed the synovial cyst filling the spinal canal I actually. hold her because I said, Give me permission to go see the CTI. So all of this is, you know, you don't
28:47
always see this. I know if you're just feeling spinal canal and non-contrast CT. That's why you need an MR, but I saw that. And we got an MR, and there it was. And she came in and she had
28:57
weakness of the entire right leg. She had not urinated all day. The CAT scan, by the way, did show that she had a very dilated bladder. And we sent her for emergency surgery. And the MRI scan,
29:09
obviously, had confirmed the massive quarter-point syndrome associated with the synovial cyst filling the canal at the L3-4 level. The reason I ask you to do this is because that's probably not an
29:20
uncommon presentation. Well, that's the problem here, is that so many patients are going to an emergency room or urgent care. The first visit, especially if they're women, they just say, Oh,
29:34
you're just hysterical you're just histrionic and they don't really even believe them. But it happens to men too, 'cause I
29:42
have another case where it was a male, and the first visit, lots of times they don't even do any labs, and lots of times they don't do any diagnostic studies. And they return maybe the next day,
29:53
maybe even 12 hours later. They still don't do any, they start doing some studies. Lots of times they'll do a CAT scan, 'cause it's fast and quick, but it's not gonna show you the pathology.
30:02
Ultimately, they do an MR, but only usually when the patient presents with a full-blown quota coin syndrome by that time Now they've lost bladder function, now they're completely paraplegic, and
30:14
now you have something that may look like this, a full quota coin syndrome due to a massive disc herniation. In other cases, it might be because they have a spinal abscess or some other etiology
30:25
for their presentation, but this is the story we hear and see again and again and again. So the answer is partial quota coin syndromes, be aware of it, recognize it, know how to read your own
30:39
studies, make sure you order an MRI scan. Cat scan is not going to do the trick. It's not going to show you the pathology that you need to see.
30:48
Very good point.
30:52
Here's that. Okay. So this is the patient that I was telling you about. She went to the emergency room, urgent, dull care. They missed the diagnosis of the acute cis-filling the canal. They did
31:05
a non-contrast CT. They did note that her bladder was full, but they didn't think anything of it. On exam, I found that she had diffuse right lower extremity weakness at like the three out of five
31:16
level. She walked into the emergency rooms. Her husband was a really big guy, was almost carrying her. She wasn't urinary retention, had not urinated since the morning. On the
31:28
MR, she also had a massively dilated bladder. She ended up with emergency surgery. And fortunately, She ended up having no residual deficit. So here is an image of the synovial cyst just
31:38
figuratively shown. Here is an actual MR. Here is a cyst filling canal. This doesn't happen to be her particular image, but you see this hypo-intense region around, that's the synovial cyst in
31:49
the center. This is calcification around that synovial cyst. And notice your theclosac is compressed completely contralaborably. So this is on the left. Here is the facet joint, facet joint here
31:50
So it's coming right out of the facet joint. And that is a classic presentation here. On a sagittal MR, you're looking at the same thing with, sorry, you've got, this is some hyperintense
31:50
material. And then here is your synovial cyst.
32:16
People think mistakenly that you can treat, by the way, a synovial cyst that is just like a bubbled. And you have neuro radiologists or radiologists who are saying, oh, I'll just pop that cyst.
32:30
by putting a needle into it, and you're sticking your thumb, you pull out a plumb. The problem is, just like you see here, that synovial cyst is usually a huge, tough, fibrinous capsule that
32:44
may or may not be calcified, and only a small section of it may contain a liquid material. It's often a very thick crankcase material that you can't even aspirate with the needles that they put in
32:57
So, you know, a completely separate discussion, and I've written some papers about that that you can look up on surgical neurology international. Synovial cysts in the lumbar spine, don't attempt
33:09
to aspirate them. You're actually gonna create a lot of dural holes for no reason whatsoever. You're not gonna sufficiently decompress or aspirate that cyst in most cases. And then when you go in
33:19
surgically, you've got all these CSF leaks that you have to then repair. And you have been - So look at the dorsal lateral compression here. You have a video that you made on basically synovial
33:30
cystis in two parts on SNI digital So they can find it there too Okay I forgot about it
33:40
This is what a synovial cyst can look like I've actually have the the bite plate of your kerosene punch underneath the
33:47
cyst because I've got cottonoids now under the cyst These cysts originate from the facet joint and that means that it's very lateral and very foraminal And you have to make sure you are completely
33:59
around that cyst before you put in a kerosene punch to take this out Or you're going to create a huge CSF leak very laterally for amelie That can be very very difficult to repair and actually in one
34:10
of the papers that I wrote about Taking care of uh, you know multi-level laminactamies If you have synovial cyst the incidence of CSF leaks with these synovial cysts Can be up to you know 10 15
34:24
actually 16 of the time So you have to be super careful when you're trying to excise these. But this is what that can look like. The cyst here is filling the spinal canal. And then here's just the
34:35
anatomical specimen that you may have after you've done your decompression. So these are tricky. They can cause the same kind of problems that lumbar discs can cause. And you just have to take care
34:49
of them in a timely fashion, just like you would in acute or massive disc herniation Just getting slightly off on the topic of epidural injections and massive disc herniation. This happened to be a
35:03
middle-aged fellow who came in. For three months,
35:09
he had an MRI scan that looked just like this. He had an L34 disc on a lateral image here, it's seen here. Here's the axial image. This is all disc. This is your spinal canal Let your thickled
35:24
sac compress contralarily. So all this is disc and all of this is disc. The MRI scan that was obtained originally and three months later when he presented, basically paraparetic with a full-blown
35:37
court of coin syndrome,
35:40
this should never have been treated with three months of epidural injections one being performed every three to four weeks. And again, this is a good example where the people, the pain management
35:52
people be it, sometimes it's radiology, sometimes it's pain management, sometimes it's the rehab guys, very rarely is it neurosurgeons or neurologists, but
36:04
this is not the appropriate treatment and actually what they're doing is they're doing a wallectomy, taking money from your wallet and putting it into theirs. And basically, terrifically
36:16
mistreating these patients. Okay, so anyway, these are neurosurgical emergencies, not something that just should be left alone.
36:25
So we're now going to move on to a subsection. Looking at the MRs and the CAT scans as causes of corticorna syndromes. Again, I can't emphasize enough how important it is. Learn how to read your
36:37
own MRs and CAT scans. Learn from
36:40
your radiologists. You have a case, go to your radiologists or neuro radiologists, sit down with them, let them teach you what they know. And by the end, I mean, I've been working with the same
36:50
radiologists for about 40 years. It's a back and forth, but I would always go and learn something before I did the surgery from it.
37:03
Okay. All you have to do, this is when I'm talking especially to lawyers, or if you're a resident or maybe a medical student, if you don't remember the difference between an MR and a CAT scan,
37:16
think about an
37:19
MM. Okay. An MM, the center is chocolate. That's the soft part of the MM. Just like an MRI scan shows you the soft tissues. It may be the nerve tissue. It may be fat. It may be ligament. And
37:34
hard candy shell, that's going to be your bone. So this is a good way to explain it to patients, a good way to explain it to colleagues,
37:45
and certainly your lawyer friends will appreciate it. But here's an example where you have different factors contributing to a quarter point of syndrome and a patient with lumbar stenosis. So here's
37:56
a sagittal MR, here's a four and five, there's a bit of a slip here. Nice big disc herniation scene here. So there's an anterior spur. In this case, probably a soft disc plus a grade one slip.
38:10
But posterior, laterally, there's gonna be some compression from ossification or hypertrophy of the L ligament in a younger person, ossification in your older person. And you may have very, very
38:21
large facet joints, especially in the patients with congenital or acquired stenosis. Okay, and here in your axial MR, you're seeing the same thing, you're maybe an anterior spur or a disc, and
38:34
here are your facettes that are hypertrophy. And here is your posterior ossified yellow ligament. In many cases, the ossification of the ligament on an MR is gonna appear black, very much like the
38:48
black that or the hypo intensity that you're gonna see of the lamina themselves. But you can see here, it's called the trefoil configuration. So it's like, you know, all of a sudden, This is
38:57
down to like a tiny triangle. And that's all that you see left of the fecal sac here and a little tiny bit of epidural fat. So again, MRs can show you all of this kind of detail, which is really
39:12
important. Here's your CAT scan. It shows you bone information. Certainly on the CAT scan, you can really measure your lumbar stenosis, mid-aspect of the vertebral body to the posterior
39:23
interlaminal line. You can measure it at the different levels. Obviously, this is a patient with some scoliotic deformity because it's getting narrower and narrower. Myelogram CAT scans. That's
39:33
like the Cadillac. That's like the gold standard. It's going to show you everything and better. And here might be an anterior pseudo disc with a slip that you're seeing at the four or five level,
39:44
let's say. And here, that hypo intensity could be your posterior longitudinal ligament. Very rarely do you get calcification of that ligament in the lumbar spine. You see it in the cervical
39:55
thoracic region. But look at your teproil configuration. This fecal sac containing your nerve roots all squashed together is like a triangle, okay? And here, look at these enormously
40:07
hypertrophyed facettes. This is your inferior reticular facet. This is your superior reticular facet, okay? I'll actually grab that. This is superior, this is the inferior. Infer reticular
40:18
facet coming from the level above, superior reticular facet from below, and it's called superior facet hypertrophy resulting in this compression.
40:32
So, more findings, here, this ventral compression, it could be a spur, or in this case, it's an extruded disc because of its bigger and more regular configuration. Look at your fecal sac on
40:46
your myelocyt, you
40:48
have marked deformation, it's almost like a washboard. And here, drosolaterally, you've got ossification of the oligomite that's compressive And here on the axial image, you can see your anterior
40:60
disc herniation is markedly compressing here. This image shows your ligament, hypertrophyid, maybe here. But I'm trying to show you that your compressed dural sac is sitting right there and your
41:15
compressed dural sac. You see that little dot? That's what's left of it. So marked compression can be present There are findings, you patients with scoliosis, and I'm just trying to show you
41:28
x-rays are going to show you the bony scoliosis.
41:31
Your MRI scan is going to show you the soft tissue associated with that scoliosis, okay? Going a different way here, obviously different patients. And then here is a CAT scan showing you the
41:43
scoliosis. And any of these patients with scoliosis can have a tangent, lumbar, compression, five, four, three, two. There's tremendous rotatory deformity here. So at the two, three level,
41:57
you can have neural obliteration of your theclosac and a quarter point syndrome associated with that. Other things that you're going to see on m-lores and CAT scans. Here's an MR L5L4
42:09
burst fracture resulting in quarter-coinic compression ventrally. Here's an MR of infection, and this is both with without gadolinium. And you can see that you're getting enhancement of
42:20
the disc space consistent with discitis and the findings in the vertebral bodies. That's consistent with osteomyelitis By the way, you're
42:28
going to see more changes. With the way I've gadolinium up to two weeks, after the onset of infection, CAT scan at least six weeks. So you're gonna see changes on them more earlier. And here's
42:40
just an example of when in more, you may see metastatic disease, resulting in involvement in multiple vertebra, as well as here, you know, the Theco-SAC resulting in chloro-coiner compression.
42:55
Here's a fracture associated with this that you may see on the non-contrast CAT scan Another example of infection that's just sort of completely eaten away the disc and the vertebral plana. Here's L5,
43:06
four, three, and two.
43:09
Vertuberplana here from massive infection here. You can see it's extending into L3. This is just an osteoporotic compression fracture of L5.
43:20
And here tumor, you may see it in multiple locations can also impact your quarter-coiner. And you can see the multiple holes It might be in the vertebral body. It might be in your
43:33
lamina or your transverse processes. So different locations may be seen. MR scans are gonna better show you quarter-quina syndromes. Here, I'm just repeating for you from Hogan at all. 65 of
43:47
quarter-quina syndromes are due to disc
43:53
herniations and the other causes are gonna be stenosis followed by clots, followed by tumors, trauma, and infection. So we're gonna see all of these, but in their large series, that was the
44:06
frequency that they found. And here is an example of a disc herniation, filling the spinal canal in your MRI scan. Here, next to it is the stenosis that's seen under here and below it, you're
44:21
gonna see an epidural clot.
44:25
And to the right of this, we're gonna see tumor. and tumor beef, L5, 4, 3, 2, 1, 12, 1, that's actually probably an appendomoma coming out of the conus. And then here down in the sacrum,
44:38
you have more tumor. So metastatic tumor, drop tumors, et cetera. All of these can cause corticointed syndromes. Can you go back to it? Okay, go ahead. Let's say we've talked to some people in
44:53
the last months who have hospitals in a country where they're not in the main city or these are people without money. They have to go to the general hospital. They don't have all the, they don't
45:07
even have a CT scan. They don't have the general facilities. So what do we do? And if they're distant, they can't refer them any way. They've got somebody or they've got to go on the basis of
45:22
their clinical exam and the presentation I think they can get spine films. But what about doing, you mentioned that, to see the Mytheogram? Yes. The old way to do it, but if you don't have any
45:34
other choice. That's what you do, that's what you do. I mean, I had mentioned in the very beginning, my uncle Bernie, who actually was an expert in myelography, and so was Joe, and you
45:46
actually used these. Everybody forgets that only in 1976 did the CAT scan start showing up, and the MR showed up about a decade later. But basically, yes, you put in dye into the lumbarthical sac,
45:58
and you do a myelogram, and you do your best to put the patient up and down, and this and that to try and maneuver, and that's how you make a diagnosis. It was interesting, I was once talking to
46:09
a colleague who was going to other countries, and he was saying that the newer trained neurosurgeons just could not get over the fact that, I mean, and they were stymied and paralyzed by the fact
46:20
that if they didn't have an MR, they couldn't do anything. Right, that's the problem. you know, this is where you do your myelogram, you know, run it up as high as you have to go to try and
46:31
make the diagnosis. And you can just do, you know, playing films. What do you, I'm going to go one step one step further. Uh, where do I put the needle? Because if it's five s one and I stick
46:44
a needle in there, I'm stuck it right in the middle of the pathology. Uh, so how do you deal with that? You go high or most people you go above that I mean, typically the widest interspace to get
46:55
into was typically, you know, five, one, uh, and then you may try four or five, but somebody asked by us to notice is that and if huge disfilling the canal, then you do it. You can do it all
47:06
the way up to really L two, three, you know, you're not going to want to do a C one C few puncture, especially if you haven't done those before. Uh, I can remember visiting, uh, San Paulo,
47:16
Brazil, and they had a, I guess a radiologist and. He would just run around on the floor and he would without any floor or anything else. He would do C1, C2 punctures, but he'd done thousands of
47:27
these. And I was saying, well, you're gonna get a lot of morbidity mortality otherwise. But the answer is yes. You try the lower levels because they tend to be less stenotic, you get more
47:38
stenotic as you go more saveline. But you can go all the way up to L2, three if you really had to. Okay. Okay.
47:47
So the MR scans are better at showing you you're free or sequestrated disc. These are the disc hernations that are surgical. By the way, you're degenerative disc, you're prolapse disc, you're
47:57
black discs on the MRs and CAT scans, those are not surgical lesions. I mean, I see patients, I see papers that are submitted all the time. And back when I was just yesterday, where they're
48:08
saying, well, I'm operating on a black disc and I'm doing a T-lift fusion. And these procedures are going very well and the patients are doing okay. And I'm thinking, well, That was an
48:19
unnecessary operation. You've done like 40 or 50 of these, why don't you see some desist? But the extruded disk, the disk here is the one that's still in continuity with the disk space. And here
48:31
is what you're seeing is the extruded disk, ventrally impinging on the dural sac, okay? The next is your secret straighter fragment. That means the fragments have broken off and they're free and
48:42
they've moved up or down. And here's an example where it originated a four or five moving downward to L5 And this is like the surgeon in Japan where he's going after the free fragment alone and not
48:55
going into the disc space itself, which is
48:60
not the way to go. But these are the surgical disc that you're looking at. So I deliberately turned this image upside down so that I could show you the large disc herniation here on both of these
49:12
images. Here is a large lateral disc.
49:16
And here's an even larger lateral disc. So this one might give you a partial quadricorna syndrome. This might give you the full quadricorna syndrome. You just have to make sure that you examine,
49:27
listen to the history for that patient. I mean, the history can be everything. And without a decent history, you're never going to suspect anything. And by the way, if you're an emergency
49:39
department over there, or in fact, seeing your physician in the office and they have you in a 15-minute slot for that first visit, that is not adequate. You just cannot practice medicine
49:51
adequately with that 15-minute visit. You're going to miss almost everything. You're lucky if you get their name. I can't tell you how many times that patient has their hand on the door, they're
50:00
leaving. And they say, oh, by the way, I'm on an eloquence because I had a stroke, you know? It's like, oh, thank you very much, okay? So here's your lateral disc that might cause your
50:11
partial cordicoid syndrome. an MR scan of that lateral disc. And here is the sagittal view of that same lateral disc herniation. Again, I'm emphasizing how important it is to recognize and to be
50:25
able to see these, you have to go in your head from the cartoon to the actual images. Here's a larger disc nearly filling the spinal canal. And here on the sagittal image, again, it's nearly
50:36
filling the spinal canal. And that's what is going to correlate with either your large central disc or your lateral disc. So the different locations, the different sizes of the disc herniation are
50:48
going to give you different syndromes. And again, just emphasizing there is something called the partial codercoinis syndrome. It is much more frequently encountered than the full codercoinis
50:58
syndrome. And if you recognize this, you're going to help and treat a lot more patients before it's too late. And here is actually an anatomical specimen of what the, that's what the codercoin
51:08
actually looks like. you know, from your pathology. And here is your figurative diagram of a disc filling with spinal canal. And again, here is a large lateral disc filling the canal here on your
51:22
two MRI scans over there, okay. Spinal stenosis can contribute to compression of your quarter corner, compression of the lumbar nerve roots. You need to realize that you've got the normal spinal
51:39
canal that was defined by a canal that's about 17 millimeters from the mid aspect of the vertebral body to the interlaminar line. Two types of stenosis, one is called absolute or congenital 10
51:51
millimeters and then acquired or what you develop over time, maybe 13 millimeters, okay. But this is a setting that's going to increase the difficulty of your surgical procedure, increase the
52:02
necessity to expand
52:07
your decompression 'cause a good part of your job is to make sure that there's enough room for the patient's nerve tissue and also to do what you wanna do underneath that, which may be to remove
52:19
hypertrophy ligament, remove a disc, remove a synovial cyst. This is Joe Epstein, my dad's illustration of a large hypertrophy facetinolumbar spine. Here's your hypertrophy of the olegament,
52:33
contributing to lateral recess stenosis on one side If it's on both sides, then you have bilateral lateral recess stenosis. But notice on the other side, this would be the left, because that's
52:45
just how we read these. This is a normal facet. There's no fluid in the facet. Here's your nerve ring on that side. So normal facet, no focus stenosis on this side. But you have to be able to
52:57
read your MRs. I can't stress enough how important it is. Really, if you're going to do an operation, especially on an older patient, get a non-contrast CAT scan It shows you so much. important
53:08
bony information and stenosis information, it may correct for you the level that you're operating at because you may have missed a lumbar sacral anomaly that occurs 5 of the time. So here's your
53:21
figurative diagram of the normal spinal canal, yellow ligament, not hypertrophyid. Here you may have a ventral bulging disc and your hypertrophyid ligament or ossified yellow ligament posteriorly,
53:36
producing that triflural or triangular configuration of the fecal sac that we spoke about.
53:42
Ossification of the yellow ligament, again a figurative diagram. That's what it may look like. And again, here happens to be in blue in this illustration.
53:54
And here's an operative image. It is in fact, it's really orange. It's really not so yellow. And sometimes it is so thick and tough and tenacious and stuck to that dura that you have to actually
54:09
just work your way around it circumferentially. Take off your bone laterally and for amole. If
54:17
you can't make any headway on one side, go to the other side. If you can't make any headway below, then go above. So many times, you may start your lumbar stenosis surgery by going cordad to
54:29
cephalad Well, if you encounter this, skip over it, do whatever levels you have to do above it, and then under your microscope, if you have a microscope, your loops, if you have loops, but
54:41
definitely if you have a microscope, take it out of that dusty corner and bring it into the operative field, even if you didn't start with it, to try and avoid getting a CSF leak and resecting this.
54:51
If it is stuck to the dura, you can actually just shrink it
54:56
down leave the least amount still stuck to the Dura, but you do have to decompress it.
55:04
but that's how you're going to avoid creating a CSF leak while decompressing the quadricorna. Here is just another example of multi-level anterior spurs and your multi-level posterior lateral,
55:18
ossifiedial ligament, and also probably hypertrophythic sets. This is resulting in L2 to 5 stenosis, L5, L4, L3, and L2. So probably a
55:28
decompressive laminectomy here is what's going to be necessitated, again, contributing to a quarter point of syndrome. Here, you can see another example where you may have a grade one
55:40
spondylolysus, or grade one slip. If you have underlying
55:44
stenosis, it makes you, if you have a grade one slip here, it makes the stenosis even worse. So if you don't start out with stenosis, but you develop that grade one slip, you develop stenosis.
55:55
But you can also develop a disc herniation ventrally, that's compressing things And when you have that grade one slipped. It's not only compressing the nerve root exiting below, but it's the
56:07
foraminally exiting nerve root above that slip. So here's your slip. This is the L-45 level. This is gonna be your L-4 root. This is gonna be your L-5 root down here. So you have to just make
56:18
sure that you keep track of which roots you're decompressing and don't forget the foramal root. Do you do the, a routine flexion and extension? Somebody comes in with caught a coin of syndrome. Do
56:30
you do any motion films? To see if they have motion, you obviously do the AP and lateral spine, but do you do more or do you satisfy with what you got? No, I try to do flexion and extension films.
56:43
You wanna know if they're in so much pain or spasm, you may actually not see motion. So in those cases, flexion extension films might not be reliable, but it's a great idea to get, you know,
56:55
you're getting your CAT scan, and do those flexion extension x-rays, because it tells you if you really need to do a fusion at the same time that you do in the decompression. Okay.
57:07
Okay, so basically that's the end of part one, and we can go on and talk about part two. And okay, so the best timing of surgery for corticwinis syndromes, and you can take away the message the
57:25
sooner the better, and then forget everything else. Certainly less than zero to one days, but you don't have those 24 hours, especially if you already have a patient with a significant deficit.
57:37
The clock starts ticking as soon as that patient gets that deficit. The studies that say you have 48 hours, they're wrong and they're poorly done. The studies that say you have 24 hours, well
57:48
they're counting from the time that the patient had the onset of the deficit in general, and a lot of the other studies are saying, you know, less than six hours, less than 12 hours, or basically
57:57
the sooner or the better. This was a very good study by Hogan et al. He looked at less than six, less than 12, less than 24 hours, nearly 21, 000 cases of corticoidis syndromes. I mean, this
58:10
is big data, obviously. Best results, surgery day zero to one. From the initial onset, better at less than six to less than 12 hours. So don't let your colleagues, don't let your friends,
58:22
don't let any of your spine surgeons, get away with just, oh, well, you know, I had 24 hours. So it's within that 24 hour period. Wrong. You wanna do the best for your patient. You want that
58:34
patient to have the best outcome. Get out of bed, stay out of bed. Do the operation that night. Don't wait till the next morning. And this applies to both partial and full-quarter coin of
58:45
syndromes. Worst outcomes were found at days two or greater. And again, this is a huge national inpatient sample database. So 21, 000 cases. So these are the big studies, forget the small
58:58
studies, the poorly done studies that said, you have 48 hours, that's not correct. Carissa study, corticitis syndrome is a potentially devastating spinal condition. Timely diagnosis and
59:10
treatment is imperative for outcomes, for avoiding also the medical legal ramifications Emergence spinal surgery is indicated and urgent decompression and enhances your chance of recovery. I'd
59:23
written an article the sooner the better surgical morality international 2022. After writing just a review article, this was really the sort of the perspective. This is again looking at the nation
59:35
in patients sample that was over 25, 000 cases. It was from one of the other authors. And again, early surgery, the earlier the better And this is just documenting and reminding patients.
59:48
Surgeons, doctors, patients, everybody's, especially the emergency room and your physician's in your hospitalists, there's something called the partial cordicoidness syndrome incomplete, you
59:60
don't have to have everything. And here's the complete cordicoidness syndrome where you have the paralysis, the sensory loss, societal anesthesia, urine and bladder discontin, et cetera,
1:00:09
incontinence. So the emphasis again on partial versus just complete cordicoidness syndrome, that is the biggest message to get out there, especially to our adjunct of personal and friends. Do the
1:00:21
right operation, the adequately extensive operation might be your laminectomy, or your coronal hemilaminectomy, as I had shown people before, adequate exposure, decompression. Doing these the
1:00:34
sooner the better, the clock starts ticking as soon as that patient started developing that deficit. Not just when they hit your emergency room, it's not at your convenience negligent and delayed
1:00:46
surgery likely results in the - poorest of outcomes. And again, malpractice makes perfect or really imperfect. So the conclusion is that surgery, the earlier the better or the sooner the better,
1:00:59
certainly less than 24 hours, six and 12 hours, the sooner you can decompress these patients, the better they're gonna be. Choose the right time and the right surgeon and the right operation to
1:01:11
get the best ones ads
1:01:15
Well, it's an excellent job, Nancy. I just toured a fourth script. Don't make sure any better. No, I think, as I was thinking as you were going through all this, you know, it gets down to
1:01:29
some basics. I'll just take a couple minutes here, but it takes a history. You mentioned that so many times, you have to take the history. Don't let somebody else do it. Don't hear it from
1:01:41
somebody, even the emergency room. You gotta go down and get the history When did you stop urinating the last time? When did your legs start getting weak? They don't know how to ask these
1:01:52
questions. When did you just start getting tingling and so forth? When did you notice your foot was dropping and then you were dragging it? Well, a month ago or so, you got to get a very good
1:02:04
history and then you find out I'm uncommitted or I'm on some blood thinners or I've had heart trouble. I mean, all of these things are relate to your outcome and do an examination, and do an
1:02:17
examination. Obviously, you want to do it yourself. It's doing examination, you have telemedicine, you can have somebody do it. I think you mentioned that you can get some pretty good
1:02:29
examination if you're there directing them to do the things. And then you come near differential diagnosis. What do they got? And if the differential diagnosis contains a threatening disease, you
1:02:42
don't wait I mean, it's. It's like waiting live, it could have an aneurysm, I don't know, I'm gonna take two weeks to figure it out. No, you can't do that. And so you get a differential
1:02:51
diagnosis, you got to do imaging, we've talked to you. If you don't have the finest imaging in the world, you can still do basic imaging. We all did this years ago, you can put in some dye, you
1:03:03
can take a do a myelic damage, you can get a very nice image of what's going on. Obviously, if you have a CT and an MR that's only better and it's quicker, and it's surgery, it's an emergent
1:03:18
operation. Everybody in the hospital doesn't want to think about that. Well, we're off, we've got to call it a special crew or this, the next thing, there is no reasonable excuse. What you have
1:03:31
to decide is what would you want or your family needs if they had the same problem And
1:03:41
the other thing is you're going to have enough exposure. Don't be convinced by representatives and other people I can do this minimally invasive, not saying that all the minimally invasive is wrong.
1:03:54
I'm saying that what Nancy said, you've got to find the right operation for the right circumstance and the right environment. And just because they may report some cases from
1:04:07
some country where they've done 10, 000 through minimally invasive exposure, doesn't mean you can do it. And it doesn't mean you're inadequate if you don't do that. Do the job, do it right. And
1:04:21
complication, admit it immediately and fix it. I mean, that's - And if there is a complication, recognize it and do a diagnostic study that can allow you to diagnose what the problem is and then
1:04:36
fix it. That's the amazing thing to me is what they, The extent that the. Many surgeons will now go to basically ignore that there's a post-operative deficit or problem, even a life-threatening
1:04:49
problem, and just.
1:04:52
Yeah, I just like to think that that's done. Let it make your diagnostic studies, if that's what it means, look, well, we all make mistakes, fix it. That's what surgeons do, fix it, and.
1:05:06
And don't hand everything off to your adjunctive personnel Not everything should be the PA, the nurse practitioner, or whoever else you happen to have in your office. I mean, so many of these
1:05:18
patients go back and forth and back and forth post-operatively to the office, never seeing the surgeon. And it's supposed to be transmitted or discussed with the surgeon. And they have, some have
1:05:29
no knowledge of it, some refuse to admit that they had knowledge of it and they don't do anything about it. Let me just show people if they're looking close You're a letter to me. Yeah, I'm sorry.
1:05:41
So thank you very much, Nancy, just a spectacular job.
1:05:48
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Surgical Neurology International has been published for 14 years and is read in 239 countries and territories. It's the third most widely read 2D journal in neurosurgery And SNI Digital Innovations
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in Learning is a new 3D video journal. the only video journal I've been in surgery. And it's now seen in 111 countries in seven months. The goal of the foundation supporting these programs is to
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help people throughout the world.
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A medical news network is a network, television network, designed to bring truthful medical and science news to the world.
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