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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
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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.
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Part two of the Lumbar Cotto Aquinas Syndrome series is on avoiding malpractice in lumbar spine surgery. And part two is going to be what the neurological configuration is, the negligent lumbar
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surgery that we're going to be dealing with these entities. Okay, go ahead. Okay. You know, we've got a spot here where you can cut this and we're okay.
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So, negligent lumbar surgery and corticoidis syndrome, they definitely go together and I'm gonna try and tell you about different cases about these. I already have started emphasizing that you're a
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classic patient. They have several emergency room visits. They might start out a week or so ago and they're just having pain all of a sudden going down one leg or the other. They show up in the
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emergency room Lots of times they won't get any labs. In this case, that you could miss an abscess, just with an elevated white count. White counts only gonna be elevated 50 of the time. ESRCRP,
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it's gonna show you a lot more than just the white count, but that's what you're going to wanna do. CT scans, not gonna show you very much. You really have to get the MRs, but typically these
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patients have repeatedly, I would say the average is at least, they've seen patients like three times, is a charm, they finally see the patient and then operate in the patient at that point. But
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lots of VR visits, no labs, MRCT may or may not have been done. They presented with, in some cases, with severe partial-quarter point of syndromes. Some end up even require Foley catheters.
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They need timely MRAs and labs,
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in this case, to diagnose an epidural abscess. This was actually a specific case where the patient had been to two emergency rooms and finally showed up early in the afternoon. The patient was then
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taken to the MR. They had a non-contrast MR. Surgeon was contacted by phone, ordered a contrast MR, confirmed the presence of the abscess, laboratory studies definite for abscess infection The
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patient then was ready. ready to have surgery. Surgeon delayed the consultation, and surgeon evaluated the patient and decided, oh, I'll do the surgery in the morning. Because they're thinking,
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well, you know, the literature tells me I have 48 hours, and what I'm telling you here is that was not very good literature. You look at those studies, they're small case studies, they're poorly
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done. The better studies, less than 24 hours. But if you read carefully, the studies really say that clock starts ticking as soon as you have that neurological deficit onset. If you have a
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patient who's come in and they are already severely paraparetic or plegic, a severe partial corticornic syndrome or total corticornic syndrome, that is not the patient where you wait until the next
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morning to do the operation. In this case, unfortunately, that was the case and the patient did not do well, remained plegic. And certainly, once they have a loss of bladder function that tends
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to be the most permanent deficit and the most difficult to regain.
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I was gonna ask you that, is there recovery, what's the chance of recovery they have, if they're bolus out, or the bladder is out? It's porous, it's probably in the 30, 40 range, 30, 40, 50,
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it depends on the duration, it depends on what the original ideology is, but it's not good, and then there's some studies that show there's no return of function whatsoever And many of them end up
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self-catheterizing for the rest of their lives.
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This is what you said before as a surgical emergency. Yes, and it's interesting because you go to depositions and many of the surgeons will say, oh, full quadrant, the emergency room physicians,
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the hospitalists, infections of these general surgery, everybody, oh yeah, quadrant syndrome is a neurosurgical emergency, but it's only. the plaintiff's experts, the ones who are trying to
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work with the patient who was irrevocably harmed, who are really telling the truth about this, saying, well, yeah, corticointed syndromes in emergency and had this patient had surgery in a timely
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fashion they would have regained or avoided this neurological deficit.
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Other causes of corticointed syndromes, minimally invasive or negligent minimally invasive surgery. It's negligent to do a minimally invasive procedure if you have a maximal problem. If you're
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doing an inadequate exposure to safely decompress the spine, if you're doing an inadequate exposure to avoid a CSF leak, you know, can you, most patients, most physicians are gonna say, oh,
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well, you know, you do a lumbar operation, oh, there's a high risk of getting a spinal fluid leak. Well, that risk goes way down, If you use a microscope, yes. If you use monitoring, hey,
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that helps. But the main thing is, if you have adequate exposure, the risk of getting that CSF leak markedly diminishes. So insufficient exposure is the biggest problem. You're gonna get more CSF
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leaks with inadequate exposure. You're gonna get more neural injuries with inadequate exposure, and you're gonna get more retraction injuries contributing to that, and it could be a different, it
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could be to individual nerves of the entire quarter-quina There also is the other aspect of it with quarter-quina syndromes, negligent or overly extensive surgery. Operations multiple levels for
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black discs. I can't tell you how many patients I see. You go to spine conferences, and all of a sudden, Sadie, who's 82, with some lumbar stenosis, and a little scoliosis is getting a T10
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to S1, decompressive laminectomy with inter-body fusions, 15 lifts at, you know, two, three, three, four, four, five, and five, one. all of which you didn't need, and some of which they
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couldn't get the antibody device in because they were spontaneously fused. So you've got lots of fusions, T-lift, transferaminal lumbar interbody fusions, posterior lumbar interbody fusions,
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anterior lumbar interbody fusions, exelip, which are extreme lumbar, extreme lateral lumbar interbody fusions. All of these can result in significant deficits, screw injuries, traction injuries,
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interbody devices, neural and vascular injuries. In fact, life-threatening vascular injuries we're seeing more and more of these more recently, where they're supposed to know where theiliac
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arteries are, iliac veins,
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and aorta, obviously, inferior vena cava. So here's an example of a large central disk with minimally invasive surgery where there was inadequate exposure, where really you need a - bilateral
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exposure, you can even do a bilateral laminotomy here if you want it to, you're better off doing a laminectomy to get the bilateral exposure so that you're getting enough room to work around that
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fecal sac and under the fecal sac. Here a large central disc,
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you're going to get corticointed syndromes if you're just doing it with your minimally invasive metrics retractors, and the tube length goes to three to nine centimeters in depth and up to really 16
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to 26 millimeters in diameter. 26 millimeters is one millimeter over one inch. That's not a lot of room to work in, and the longer your tube, the less you can maneuver your different instruments.
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So surgical errors can be occurring during these minimally invasive procedures, more clots,
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more recurrent discs and more residual discs with more deficits and more CSF leaks. And here's an example, here's an example of a CSF leak resulting from a decompressor procedure being done
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minimally invasively.
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Here is a case where a medical legal case, younger or patient, where a minimally invasive exposure contributed to an intraoperative CSF leak that could have been, should have been avoided Now, the
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argument is going to be here from the defense saying, well, but that was enough of an exposure. It's an accepted exposure and a risk of a leak. Anybody can get a leak. However, if you don't have
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enough room to adequately repair the leak, what does some people do? They'll just put an onlay graft. In one case, it might be a fat graft or maybe even a piece of muscle, which is the right
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thing to use. But if you're not sewing it in place, It's not gonna stay in place. And if you just throw on dirt, gin, and even fiber and sealant, that fiber and sealant is going to resort over
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the course of five to seven days, unless you're using duraceal, which might take three weeks. But still, you're going to get a current post-op leak. And the problem is, if you don't have enough
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room, you can't get in a suture. The bevel of the needle is going to be too wide, even with your seven-o-gortex sutures, that can be a problem. You need, if you get that leak, because your
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exposure was inadequate, you have to extend that exposure, so you have enough room, and try your best to get a real repair that's watertight with a suture, with a muscle patch graft, don't use
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fat, it will rezorb, and then you're going to use your derogen or fibine sealant, you have different kinds after that. In this case, the patient had recurrent post-doc leak, but they ignored the
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fact that the patient had postural hypotension In other words, every time the patient stood up. severe headaches had to lie down again. And over the course of months, continued numbness, tingling,
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weakness, everything else, they finally ended up doing an MR several months later. They still didn't re-operate on the patient. CSF was still there. And then, you know, a year later, they do
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an MR that shows severe adhesive arachnoiditis. And that is
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a permanent ongoing progressive syndrome where you do not get, that doesn't stop. And you can operate on that because all you do then is create more scar. So anyway, the patient ends up with a
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permanent partial quarter-quarter point of syndrome, motor and sensory dysfunction, bladder dysfunction and sexual dysfunction. And again, you know, not the way to go. And here's just an example
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of, you know, a discectomy and what the CSF leak
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can look like ultimately Thank you very much. Reminds me as I see this of what I used to talk about. Are we treating the patient? Are we treating the doctor?
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Are we protecting the patient? Are we protecting the doctor? How can you let that go for a year? Yes, well, it's just, it's just - And ignoring all those symptoms and signs. It's just
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incredible. Well, what's incredible to me, period, just by doing medical legal work, 'cause you find there are so many instances where patients have immediate post-op complications where people
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do not do immediate MRs or CAT scans, 'cause they don't want to have to, they don't want to deal with it, and they just ignore it. And they discharge the patient, and there it goes. Here I wrote
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a paper years ago about four negligent minimally invasive diskectomies. All four patients, by the way, never needed surgery in the first place. One had a residual disc, one in infection, one in
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CSF, legal and one in post-op clot And let me just tell you, this patient with the infection. had had this minimally invasive discectomy, went back to the doctor again and again and again, had
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successive MRI scans, showing you all the phases of progression to discitis and osteomyelitis. Finally, they showed up on my doorstep and I said, this is a horrendous infection. You've got to go
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back to the original surgeon. I call the original surgeon. He says, Oh no, it's okay if you take care of it. And I said, Oh no, it isn't. And sent them back But this is what's going on out
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there. Different operations that we have, this is a typical laminotomy. As I was saying, if you have, you don't have significant stenosis and you have that younger patient, you may get away with
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having adequate exposure with the unilateral laminotomy. You take a portion of the lamin above, a portion below, okay.
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But if you have a patient with a massive disc herniation, you may need to do a full hemilaminectomy or even we'll talk about a laminate to me. and even take off the facet joint if you have to,
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depending on whether or not that disc goes laterally, foramidally andor for laterally, and the disc indeed can go all the way medial to lateral. You have to have enough room, you have to have that
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exposure. This is called anipsic contra, whatever. You're doing your bayonet and nerve retraction of the dura. You see a portion of the disc, but a huge portion is going foramidally and for
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laterally. So here you're going to have to do an exposure, both medially, an extended laminotomy at least, and then you have to do a far lateral exposure. And that means that you're taking off
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the inter-transverse areas, ligament and fascia to expose the nerve root that's usually angling downward and get the disc out that's underneath it. But again, more exposure, don't just leave it
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there. If you just try and pull that disc out, you may actually be damaging and pulling the nerve root at the same time if their adhesions.
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Coronal hemulaminectomies, a great way to bilaterally decompress. For years, we were trying to preserve some of the spinous processes and interest spinous ligament, then we just decided it didn't
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do anything other than hinder your ability to maneuver and didn't really have any significant impact on preserving stability. So this is a terrific operation to use. The management minimally
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invasive procedures for abscesses
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Again, if you have abscesses and you have breakdown of this kind, you're not going to do a minimally invasive operation to cheat this patient, or you're going to leave tremendous amount of
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infection behind and end up with residual quarter point of syndrome. So minimally invasive surgery and poor exposure, you're going to have inaccurate removal, especially with an abscess, where you
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really have to actively de-breed. You're going to end up with residual paralysis and much higher mortality rates. Never forget that if you have a patient of an abscess and they are neurologically
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progressing or their lab studies, their white count is going up or more importantly, their ESR, their CRP, their pro-costotone and all these other things, you have to go back and re-operate and
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clean it up. And here is a case of just a minimally invasive operation for a post-operative hematoma. And here's the hematoma, poor exposure resulted in, you know, post-op clot, et cetera, that
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recurred and wasn't taken care of, resulting in corticornic syndrome. Extensive disease, again, requires more exposure. Here's a figurative diagram where we're doing a partial Coronal
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Hemulaminectomy of L3 and L5. You see a little bit of the Spanish process left and the lamina. And then we're doing a full laminactomy of L4, preserving the facet joints, by the way. So it's
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better to preserve your facet joints on either side than it is to. you know, knock off the facet joints on either side 'cause that really then produces instability. But here's an L3 to 5
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laminectomy being done. And here you might be your laminectomy and if you're taking out a disc, then you have your nerve root retractor, you have more room to work in. Here's your pituitary,
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taking out a portion of that sequestrated free fragment of disc, but you're still going to look above, below, medial and then go into the disc space itself So make sure your decompression is
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sufficient to do the operation you want to do. Here's an L3 to 5 laminectomy for excision of a disc herniation. And I'm just doing this to just show you L3 to 5. You've got your decompressive
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laminectomy for the stenosis. Here's a portion of the disc that you're removing and more of the disc fragment. Obviously, this is under higher power. And at the very end, okay, this is what
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you're going to see. You may not have seen that nerve root until the very end. All you know is when you're looking for that disc, you're going to look lateral and superior. You're not going to try
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and manipulate significantly inferiorly because you do not want to come right across that nerve root. And again, if you have SCPs and EMGs, you're going to have more information. But you see here
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you may have very little room to work and you have to take off more bone to get that room to work and extend it to a full laminectomy if you need more exposure, because otherwise, the spinous
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process is going to get in your way, especially in the way of a bayonet and nerve root director. So, tailor your operation according to where the pathology is.
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Unnecessary spine surgery is the other thing that we see too much of, you know, here you know, you have, I saw 183 patients over a period of 20 months, and I was the second opinion in these cases.
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The best way to avoid creating a corticornic syndrome is not to do an operation the patient doesn't need. And I found that these patients had gone for a first opinion, almost 61 had absolutely no
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disease on their armoris and CAT scans and no neurological deficits warranting an operation. Another 33 were told that they needed operations but they were typically much too extensive. Major,
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multi-level, fusions, et cetera One actually happened to be a cervical case where the patient looked like jaws and the skull-based surgeon was gonna do an anterior dyscectomy infusion at C34,
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whereas old patient needed was a cervical laminectomy with a posterior fusion and that would have been the right thing to do. Six percent, by the way, got it right. Negliging fusions, multi-level
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T-lifts, lifts, A-lifts, X-lifts.
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Unnecessary surgery has been good to us, Ferguson Well, I'm.
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I was in 2018, I wrote a paper comparing a series of 58 two to three level laminactamies. I did for significant stenosis. A subset had spondylocyst grade one,
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58 patients, no deficits, no infections, no dural tears, no re-operations, and no peri - and post-operative corticuline syndromes resulting from the surgery. If you look at the T-LIFT data,
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just the T-LIFT data alone, the risk of errors, okay, because you're putting in screws above and below, you're putting an inter-body device, you're retracting like crazy the entire cord or coin
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in that dural sac to get these devices in, and even more so in the patients who are supersonotic, 83 risk of infection, dural tears over 6, almost 10 motor deficits, and sensory deficits about 20
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of the time. So you have to stand back and you ask yourself, which of these procedures should you think about doing? By the way, reimbursements for the laminectomy. be a fraction of what the
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T-lifts are. And by the way, also, the hospitals are going to make a lot more money from the instrumented fusions.
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Okay.
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Why did negligent T-lifts cause quadraguina syndromes? Well, neural injuries, neural injuries, vascular injuries. All of these can occur as well as other factors. And here, you know, you have
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the screws that you're going to use. This is the way the screws should be placed through the pedicle into the vertebral body, not extending past the vertebral body, not extending outside the
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vertebral body, not going through the spinal canal. And you look at that and you say, Oh, well, of course, everything goes just according to plan. And here you put then your interbody device in
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just according to plan. Well, it doesn't always go that way because you can then see plots, vascular injuries, CSF leaks, motor deficits, sensory deficits. If you look at the vasculature, this
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happens to be at the sacrum. If you've got youriliac veins, you've got youriliac arteries, internaliliac arteries in particular, and these can get injured, especially if you have screws that go
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through the sacrum. The sacrum can only take screws that are maybe 30, 35 millimeters. There are other kinds of big sacrum screws that you can use that go way out to the side. But this is a screw
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that is very dangerously close to the internaliliacovane and
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not far from the internaliliac artery. Okay, so why do you not get post-operative studies? This is one of the reasons. A lot of surgeons don't want to know this is there. Okay, can screws go
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across the spinal canal? And you say in your mind's eye, Oh no, not going to happen. Very sloppy, can't possibly occur. And then all of a sudden you see the CAT scan where there's your screw
23:25
going directly across the spinal canal. If you're doing AP and lateral floral images, you should be able to see this, especially on those AP images, missed, ignored, sometimes repetitively
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ignored, even in patients with new post-op deficits, new root deficits, CSF leaks, postural hypotension, et cetera, ignored and no studies done. Here is a medical legal case of an L45 minimally
23:53
invasive T-lift, grade one slip and an LED patient And here you can see on the MR, here's L4, and here's L5. Minimal grade one slip. By the way, flexion extension films were done pre-op showed
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no active motion in this case.
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So the surgeon, a week before the surgery, the surgeon said, oh no, no, no, I'm gonna have my partner do the case. Made no arrangements for the patient to see that partner. That partner never
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saw the patient, never examined the patient So there's no informed consent, of course.
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He did the minimally invasive tealip. Now, the last time he'd done a tealip, it was about five years ago when he had just, he'd just gotten out into practice five years ago, but hadn't been done
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doing it recently. And he'd done maybe 30 during his residency training program. And if you look at the data to be prolific or to be competent to do this procedure, you have to do at least 39 to 44
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cases and hopefully more recently than five years So, patient woke up with a total new foot drop after the operation. And actually, that surgeon went to apologize to the patient. The patient then
25:04
sued, they went to court and who knows, you got a court, it's a crapshoot, so to speak, and it ended up being the defense verdict. Who could explain this, but it happened. And the patient, of
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course, is living or the rest of her life with that full foot drop.
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Negligent T-lifts. They sometimes use bone morphogenetic protein that can cause quadratic syndromes in cancer, acute risks of an infection, quadratic syndromes, ceroma, massive, massive drawing
25:39
in a fluid that can cause quadratic syndromes. Long-term risks can be the formation of calcification and bone forming everywhere or bone vascularly disappearing from everywhere and obviously the risk
25:51
of cancer. Negligin exelipse, these are extreme lateral lumbar interbody fusions can also cause quadruss point of syndromes. Here's the exelip approach and that's, you know, the nice diagram of
25:59
where the graft is supposed to be and here's your access route. Notice how in the
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access route
26:10
they're drawing this, by the way, to go around the bowel but there are cases going through the bowel They're going through the psoas muscle and guess what's located in the psoas muscle is of course
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the lumbar plexus. and then a whole slew of other nerves. That's why in the best of hands, basically this can result in at least a 20 to even 40 risk of sensory deficits in the thigh that are
26:35
permanent in a reversible plus 20 motor deficits, et cetera. And this is what it's supposed to look like to get there from here,
26:44
okay? And they have all kinds of different kind of monitoring. You put like a thimble on your finger to make sure that you're not going through nerve tissue Sensory deficits, motor deficits,
26:56
cage overhanging, plexus injuries, life-threatening bowel and vascular injuries. This, by the way, vastly underreported. So these are just coming out in the medical legal suits that we're seeing.
27:08
And again, this is where the device is. This has been implanted laterally and then sometimes you put in pedicle screws posteriorly. But this comes way off from the side
27:23
these patients can be obviously devastated. And the main thing is the vascular injuries. See, you have your arteries and your veins up here. It's not only the internaliliac artery, but also the
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veins. And if you're putting the device in from here, and much less this, you know, you can actually end up extruding that device anteriorly where you're getting multiple vascular injuries. You
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know, I think about this and I think about you go out of the operating room and there may be, depending upon the company, some representative there. You've talked to them beforehand, you need the
27:59
instruments online, or you need the instruments there. Oh yeah, we've helped Dr. X or Dr. Y with this. Yeah, we can do this and the next thing, and you go and do it and you get a complication,
28:11
they sold you the instruments. They don't go to court, you go to court. That's correct, absolutely. if you then try to sue the instrument companies, then they will come up with all kinds of
28:28
experts for the defense saying, Oh, no, no, no, no, no, no. Our instrumentation is great. It was the fault of the surgeon. Or they're just saying, Oh, well, it's just a complication.
28:38
Basically, when you're dealing with medical legal things, you never say complications. It's an error, a mistake,
28:44
and
28:47
they will try and pass the buck and they'll pass it right back to the surgeon. And lots of cases, the problem with the surgeon is they went to a course for a few hours, maybe even one or two, or
28:57
maybe even three. And what do they do? They go home and they start doing it. And they may do it with the reps, but still, they've had no experience doing it. Many of them are in institutions
29:08
where, let's say you're the neurosurgeon and you went to the course, well, you don't ask the orthopedic surgeons who are in the next room to come help you do a few. because they've been doing it
29:17
for, you know, six months, a year, two years, or whatever. That's what's really reprehensible is for the patient's sake, they should be getting mentored in the operating room to learn how to
29:26
actually do the case safely before they actually do it. Okay. So the best timing of surgery for corticwinis syndromes and you can take away the message the sooner the better
29:44
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. The clock starts
29:56
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, they're counting
30:06
from the time that the patient had the onset of the deficit in general and a lot of the other studies are saying, less than six hours, less than 12 hours are basically the sooner the better. This
30:16
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 is big data, obviously. Best
30:29
result, 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, don't let any of your spine surgeons
30:43
get away with just, Oh, well, you know, I had 24 hours So it's within that 24-hour period, wrong. You want to do the best for your patient. You want that patient to have the best outcome. Get
30:54
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 syndromes. Worst outcomes were found at days
31:06
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 studies, the poorly done studies that said you
31:17
have 48 hours, that's not correct. Curist's study, quadratic syndrome is a potentially devastating spinal condition. Timely diagnosis and treatment is imperative for outcomes for avoiding also the
31:31
medical legal ramifications. Emergent spinal surgery is indicated and urgent decompression and enhances your chance of recovery. I'd written an article the sooner the better surgical neurology
31:44
international 2022 after writing just a review article. This was really the sort of the perspective. This is again looking at the nation in patients sample that was over 25, 000 cases. It was from
31:57
one of the other authors. And again, early surgery, the earlier the better. And this is just documenting and reminding surgeons, doctors, patients,
32:08
everybody, especially the emergency room and your physicians and your hospitalists,
32:14
partial quarter coin of syndrome incomplete you don't have to have everything and here's the complete quarter coin of syndrome where you have, you know, the paralysis, the sensory loss, societal
32:24
anesthesia, urine and bladder discontin, etc, incontinence. So the emphasis again on partial versus just complete quarter coin of syndrome, that is the biggest message to get out there,
32:35
especially to our adjunct of personal and friends. You know, do the right operation, the adequately extensive operation might be your laminectomy or your coronal hemilaminectomy, as I had, you
32:47
know, shown people before, adequate exposure decompression. Doing these the sooner the better, the clock starts ticking as soon as that patient started developing that deficit, not just when they
32:58
hit your emergency room. It's not at your convenience. Negligent and delayed surgery likely results in the poorest of outcomes And again, now practice makes perfect or really imperfect. So the
33:13
conclusion is that surgery, the earlier the better or the sooner the better, certainly less than 24 hours, six and 12 hours, the sooner you can decompress these patients, the better they're gonna
33:25
be, choose the right time and the right surgeon and the right operation to get the best results.
33:33
Well, it's an excellent job, Nancy. I just toured a fourth script. Done
33:45
the sooner the better. No. Okay I think as I was thinking as you were going through all this, you know, it gets down to some basics. I'll just take a couple minutes here, but it takes a history.
33:53
You mentioned that so many times. You have to take the history. Don't let somebody else do it. Don't hear it from somebody, even the emergency room. You gotta go down and get the history. When
34:03
did you stop urinating the last time? When did your legs start getting weak? They don't know how to ask these questions. when did you start get tingling and so forth? When did you notice your foot
34:15
was dropping and then you were dragging it? Well, a month ago or so, you got to get a very good history and then you find out I'm uncommitted or I'm on some blood thinners or I've had heart trouble.
34:28
I mean, all of these things are relate to your outcome and do an examination. Do an examination. Obviously,
34:38
you want to do it yourself it's doing examination of telemedicine. You can have somebody do it. I think you mentioned that you can get some pretty good examination if you're there directing them to
34:50
do the things. And then you come near differential diagnosis. What do they got? And if the differential diagnosis contains a threatening disease, you don't wait. I mean, it's like waiting live.
35:03
Could have an aneurysm. I don't know. I'm going to take two weeks to figure it out. No, you can't do that. And so you get a differential diagnosis. You got to do imaging. We've talked to you.
35:12
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 can take a do a mile a grammaging. You can get a very
35:25
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 operation Everybody in the hospital doesn't want to
35:39
think about that. Well, we're off. We've got to call it a special crew or this. And the next thing, there is no reasonable excuse. What you have to decide is what would you want or your family
35:52
needs if they had the same problem. And the other thing is you've got to have enough exposure. Don't be convinced My representative is another people. I can do this minimally invasive. not saying
36:10
that all the minimally invasive is wrong. 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
36:21
report some cases from
36:25
some country where they've done 10, 000 through a 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 it, do the job, do it, do
36:37
it right. And 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
36:53
problem is and then fix it. That's the amazing thing to me is what they, the extent that many surgeons will now go to, to basically ignore, that there's a post-operative deficit or problem, even
37:06
a life-threatening problem and just.
37:09
Yeah, just quite a little bit of the data. 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 then - And
37:25
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
37:36
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
37:47
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
37:56
just show people, if they're - Your letter to them, yeah, I'm sorry So thank you very much and I am seeing it just a spectacular job.
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