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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,
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imaging, clinical presentations, and surgical lessons
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in treating this syndrome. This is Nancy Epstein, who's gonna 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 MRs and CAT scans and everything else. Here's a figurative diagram on the left of a normal disk spinal canal. This is a lumbar canal. And
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here's a patient with a quarter coin syndrome with a large central disk creation. Can I ask you a question before you even start? Yeah. How common is this disease of all the spine diseases, you
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see 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 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 know, 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 virtual body anteriorly to the posterior lamina line. And if you look at my hands for a minute and you pretend that
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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 six
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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 A. Sacred roots are gonna be S1 to S5, seen down here. Quarter of coin A 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 four, what are
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those nerve roots gonna show you? Well, I'm just gonna show you here. Here's an extruded, sequestrated disc on the sagittal image, whereas that disc herniation has extruded superiorly. And here
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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 to read your own MR and
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CAT scans. I would say your radiologists, your neuro radiologists are going to miss the pathology at least five to even 10 of the time. And I'll show you one case shortly in which they miss the
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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 cotenoids here that happened to be a patient who also had significant stenosis. So here
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you're taking out fragments of disc with a 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
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doing a 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
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into the 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
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walk 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
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drop. 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
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toes. 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
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of pin 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 do. Because.
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I don't know if we're gonna come back to this, but you show the large disk there and you show how you're removing the disk. And the question then comes up, how much is this debate? How much of the
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disk do you remove? Sometimes, you know, you look 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
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some more? You said you're using a pituitary ringer so it obviously suggests you're just not shaving off the top of it. You're evacuating with the loose fragments in the disk space. Do you want to
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spend some time now or later on that? No, no, no, 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
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just go in and take out the extruded or the 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. So
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you have to have an angry vision patient. One more next data. One more question on that. Are you used the pituitary ronchurors, which I think everybody understands? And sometimes they're correct.
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So how aggressively do you empty out the disk space? Well, I think you use a downbiting curette. You are protecting the nerve root with a bayonet and nerve root retractor, as well as cotenoids
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above and below. And with the curette, you're certainly going underneath the posterior longitudinal ligament. And everything is dissected downward into the disk space itself. And you're also going
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to shave off the cartilaginous end plate, as well as disk from the superior and inferior
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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 pituitary. You don't
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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 already freed up with that
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down biting curette And these discs which often are large, the quadroquinic syndromes. Do you go to the other side and take the disc out there? If you've emptied one side, what you're thinking of
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there? 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. So you have to wind up
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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 patient, you can get
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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 bigger disc, then the
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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 tissue while trying to
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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 the coat of coin it too
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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 gotta be very careful in any of these. One last question, I'm
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sorry for the diversion to wants looking know everybody 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,
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and I
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can't have monitoring. Was there,
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just persons unavailable, we don't have them there or so forth. What do you 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 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. 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 CAT
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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 that is, 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
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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. Can I ask you another technical question? I'm sorry about it, but it just comes between
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here. 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 and you know to just take bite some more bone off. How do you
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deal 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 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 of lamina. And if you try and put a pinfield in
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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 other words, go ahead, do that medial
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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. The other alternative, of course, is
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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. That's good. Make your end, your
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opening, start taking out this decompressing and once you decompress to some degree, then you can start working on the other side. But you're absolutely right. You have to think when you're feet,
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you have to also anticipate, I mean, I trained with Jo Ransop, who always said, do the operation, you know, hundreds of times in your head before you get to the OR. Don't waste the patient's
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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 going to do it and keep going that way and then damaging
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nerve tissue while you're doing that Or what some have ended up doing is they go right through the Dura and.
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then they can, you know, end up getting to the disc, but then they have this, this, these spinal fluid and they have the quarter coin in their left. Yeah. So what I was getting to, I would
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assume most people have drills, if not all. If they don't, the goal is to thin the bones, thin the bones in the bones in the bone, because you don't want to have to put an instrument in there in
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a very tight space. Yes, absolutely. And this is, this is important in the lumbar spine, but it is totally critical in the cervical thoracic spine, where underneath there you have the cord. You
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know, here you have the quarter point of much more forgiving, even with a big mass of disc herniation, still more forgiving. But if you have the spinal cord underneath there, that's not forgiving
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at all. And you must use that diamond drill and your up-biting caret. And if you're going to use a kerosene punch, you should be using the 1 millimeter kerosene punch The more lateral you are, the
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safer you are. So the goal is don't compress, don't compress this act, 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
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sorry for the - That's absolutely true. Sorry for the - No, this is critical. No, this is really important. Especially, you know, I think we were talking about thoracic discs on one of our
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discussion and thoracic dyscroniations. It's one of the reasons why you don't take out a central thoracic disc by doing a laminectomy. Right. Because the last thing you wanna do there is put the
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end plate of your kerosene punch between the lamina and that compressed cord. Okay, terrific. So we got the signs of an L5 and an S1 lesion and you did the L2, 3, 3, 4, or 4, and okay, I'm
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sorry for the diversion, but I thought it was helpful. People would wanna know Absolutely, that's why we're here. Defining quarter coin of syndromes, I found it fascinating. I mean, as I was
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telling you before, you know, tremendous number of malpractice suits are about quarter coin of syndromes. And what's the failure? They failure to diagnose a partial quarter coin of syndrome
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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 tell you, not only the spine surgeons, but you have
23:54
the emergency room positions, the hospitalists, your other specialists, they think that everybody just comes in and they have all the full blown symptoms of a quarter coin of syndrome so they don't
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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 motor function, sensory function, it can be in the lower
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extremities, numbness, it can be loss of saddle sensation, perineal sensation, sphincter function, urinary retention, bowel dysfunction, and also sexual function, which obviously is hard to
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test on a first evaluation. But here is just a figurative diagram of your large central disc herniation, resulting in, look at that, thechosac. Your thechosac should be right around here. And
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here, your nerve roots are compressed posteriorly markedly, markedly compressed by a central disc herniation. And here on a lateral image, you're seeing the same sort of thing, lateral
24:51
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
25:18
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 coin syndrome that you might see with a disc herniation. And here you can
25:38
just see figuratively, I'm just trying to illustrate that again.
25:45
Okay, so that is as opposed to the full-blown corticorna syndrome where I've already shown you this image. The patient comes in. They have urinary incontinence. They're numb from the type of the
26:00
thighs down. They have a loss of sensation in the saddle region, loss of bowel and bladder function, and loss of sexual function, which is, again, part of the test for So I'm going to tell you a
26:15
story
26:18
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
26:39
So I went to the facility and she said, I went to the facility. 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
26:53
scan, okay? Somebody comes into an ED emergency room. You 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,
27:04
whatever. But here, you
27:08
do an MRI scan, 'cause that's going to 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
27:21
to 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.
27:53
That's the way this is home. There's something. So this line is just - You told us, you told about the woman who called you on the phone and went to the hospital. When I didn't get there, they
28:04
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 find? Okay. Neurologic deficits, and they did. They said,
28:16
If you get worse, go to an emergency room. That was it. And they
28:22
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. told her because I said, give me permission to go see the
28:46
CTI. So you don't always see this. I know it's 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
28:54
she had weakness of the
28:57
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, obviously, had
29:10
confirmed the massive quarter-point syndrome associated with the synovial cyst filling the canal at the L3-4 level. The reason I asked you to do this is because that's probably not an uncommon
29:21
presentation. And - 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. Or, oh, you're just histrionic, and they don't really 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 a 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.
30:51
Oh, 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
31:05
did 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
31:15
five 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 contralaterally. So this is on the left. Here is the facet joint, facet joint here
32:01
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
32:13
material. And then here is your synovial cyst. People think mistakenly that you can treat, by the way, a synovial cyst that it's just like a bubble. And you have neuro radiologists or
32:26
radiologists who are saying, oh, I'll just pop that cyst 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
32:38
cyst is usually a huge, tough, fibranous capsule that 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
32:53
can't even aspirate with the needles that they put in. So, a completely separate discussion, and I've written some papers about that that you can look up on surgical neurology international.
33:05
Sinovel cysts in the lumbar spine, don't attempt 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
33:16
that cyst in most cases. And then when you go in 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
33:27
have a video that you made on basically synovial cystis in two parts on SNI digital so they can find it there too. Okay. Good. I forgot about it.
33:40
This is what a synovial cyst can look like. I've actually have the bite plate of your kerosene punch underneath the
33:47
cyst because I've got cottenoids now under the cyst. These cyst 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 amylate, it can be very, very difficult to repair and actually in
34:10
one of the papers that I wrote about taking care of, you know, multilevel laminactomies, if you have synovial cyst, the incidence of CSF leaks with these synovial cysts can be up to, you know,
34:23
10, 15, 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
34:34
here's just the anatomical specimen
34:41
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 of them in a timely
34:50
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 middle-aged fellow
35:04
who came in. For three months,
35:09
he had an MRI scan that looked just like this. He had an L34 disc on the 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 contralaterally. 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
35:37
full-blown 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 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
36:49
mean, I've been working with the same radiologists for about 40 years. It's
36:55
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, and certainly your lawyer friends will appreciate it. But
37:48
here's an example where you have different factors contributing to a quarter-point syndrome in a patient with lumbar stenosis. So here's a satchel and more. Here's a 4 in 5. There's a bit of a slip
37:56
here.
38:01
nice big disc herniation scene here. So there's an anterior spur, in this case, probably a soft disc plus a grade one slip. But posterior laterally, there's gonna be some compression from
38:14
ossification or hypertrophy of the L ligament in the younger person, ossification in your older person. And you may have very, very large facet joints, especially in the patients with congenital
38:26
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 here are your facettes that are hypertrophy. And here is your
38:37
posterior ossified yellow ligament. In many cases, the ossification of the ligament on an MR is gonna appear black, very much like the black or the hypo intensity that you're gonna see of the
38:50
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 down to like a tiny triangle. And that's all that you see left
39:01
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 important. Here's your CAT scan. It shows you bone information.
39:16
Certainly on the CAT scan, you can really measure your lumbar stenosis, mid-aspect of the vertebral body to the posterior interlaminal line. You can measure it at the different levels. Obviously,
39:26
this is a patient with some scoliotic deformity because it's getting narrower and narrower. Myelogram CAT scans. That's like the Cadillac. That's like the gold standard. It's going to show you
39:36
everything and better. And here might be an anterior pseudo disc with a slip that you're seeing at the four or five level, let's say. And here, that hypo intensity could be your posterior
39:48
longitudinal ligament. Very rarely do you get calcification of that ligament in the lumbar spine. You see it in the cervical thoracic region. But look at your teproil configuration. This fecal sac
39:60
containing your nerve roots all squashed together is like a triangle, okay? And here, look at these enormously hypertrophyed facettes. This is your inferior reticular facet. This is your superior
40:12
reticular facet, okay? I'm actually glad that this is superior. This is the inferior. Infer reticular facet coming from the level above, superior reticular facet from below, and it's called
40:23
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
40:45
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 this is your compressed dural sac is sitting right there
41:15
and your compressed dural sac, you see that little dot, that's what's left of it. So marked compression can be present Your findings, you patient patients with scoliosis and I'm just trying to
41:27
show you 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,
41:56
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-larsen CAT scans. Here's an MR L5L4
42:09
burst fracture resulting in quarter-coinate 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, caskin at least six weeks. So you're gonna see changes on them more earlier. And here's just
42:40
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.
42:54
Here's a fracture associated with this that you may see on the non-contrast caskin 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 vertebral plana 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,
43:34
you
43:37
know, in your lamina or your transverse processes. So different locations may be seen. MR scans are going to better show you quarter-coina syndromes. Here, I'm just repeating for you from Hogan
43:46
et al. 65 of quarter-coina syndromes are due to disc
43:53
herniations and the other causes are going to be stenosis followed by clots, followed by tumors, trauma, and infection. So we're going to see all of these, but in their large series, that was
44:06
the 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
going to see an epidural clot.
44:25
And to the right of this, we're going to 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 gonna go one step, one step further. Where do I put the needle? Because if it's, five S, one, and I stick
46:43
a needle in there, I'm stuck it right in the middle of the pathology. So how do you deal with that? Do you go high or most people are? You go above that I mean, typically the widest interspace to
46:55
get into was typically, you know, five, one. Okay. And then you may try four or five, but somebody has spinal stenosis that, and if you're disfilling the canal, then you do it. You can do it
47:05
all the way up to really L2, three. You know, you're not going to want to do a C1, C2 puncture, especially if you haven't done those before. I can remember visiting San Paulo, Brazil, and they
47:17
had a, I guess, a radiologist, 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 these, and I was
47:28
saying, Well, you're going to 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 stenotic as you go
47:39
more saveline. But you can go all the way up to L2, 3 if you really had to Okay,
47:47
so the MR scans are better at showing you your free or sequestrated disc. These are the discrenations that are surgical. By the way, your degenerative disc, your prolapse disc, your black discs
47:59
on 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 saying, Well, I'm
48:08
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.
48:19
That was an unnecessary operation, and you've done like 40 or 50 of these while you see some desist. But the extruded disk, the disk here is the one that's still in continuity with the disk space.
48:30
And here 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
48:41
free and 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
48:55
and not 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
49:11
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
49:50
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,
51:11
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 two MRI scans over there. Okay. Spinal
51:27
stenosis can contribute to compression of your quarter-quarter compression of the lumbar nerve roots. You need to realize that you've got the normal spinal canal as defined by a canal that's about 17
51:42
millimeters from the mid aspect of the vertebral body to the interlaminar line. Two types of stenosis, one is called absolute or congenital 10 millimeters and then acquired or what you've developed
51:54
over time, maybe 13 millimeters. Okay, but this is a setting that's going to increase the difficulty of your surgical procedure, increase the necessity to expand your decompression 'cause a good
52:09
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 hypertrophy ligament, remove a disc,
52:21
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, contributing to lateral recess stenosis on
52:36
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 just how we read these. This is a normal
52:47
facet. There's no fluid in the facet. Here's your nerve root seen on that side. So normal facet, no focus stenosis on this side. But you have to be able to read your MRs. I can't stress enough
52:59
how important it is. Really, if you're going to do an operation, especially on an older patient, getting non-contrast CAT scan It shows you so much. important bony information and stenosis
53:10
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 figurative diagram of the normal
53:23
spinal canal, yellow ligament, not hypertrophyid. Here you may have a ventral bulging disc and your hypertrophyid ligament or ossified yellow ligament posteriorly, producing that triflural or
53:37
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 only 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 more 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 stenosis, it makes
55:45
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. But you can also
55:56
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 foraminally exiting
56:08
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 sure that you keep
56:19
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 you do any motion
56:31
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 extension films. You wanna know if
56:44
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, you're getting your
56:55
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 part. Part two of the Lumbar Cotto Aquinas Syndrome series is on avoiding malpractice in Lumbar spine
57:24
surgery And part two is going to be what the neurological configuration is, the negligent Lumbar surgery that we're going to be dealing with, with these entities. Okay, go ahead. Okay. You know,
57:40
we've got a spot here where you can cut this, so we're okay. Okay. So negligent Lumbar surgery and Cotto Aquinas Syndrome, they definitely go together. And I'm going to try and tell you about
57:54
different cases about these. I don't need to. and has started emphasizing that you're a classic patient, they have several emergency room visits. They might start out a week or so ago and they're
58:07
just having pain all of a sudden going down one leg or the other. They show up in the emergency room. Lots of times they won't get any labs, in this case that you could miss an abscess, just with
58:19
an elevated white count. White counts only gonna be elevated 50 of the time. ESRCRP, it's gonna show you a lot more than just the white count, but that's what you're going to want to do. CT scans,
58:31
not gonna show you very much. You really have to get the MRs, but typically these patients have repeatedly, I would say the average is at
58:39
least they've, they've seen patients like three times. The third time is a charm. They finally see the patient and then operate in the patient at that point. But lots of ER visits, no labs, MR,
58:51
CT, may or may not have been done They presented with us. In some cases with severe partial-quarter point of syndromes, some end up even require Foley catheters. They need timely amores and labs,
59:05
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
59:21
taken to the amore 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
59:38
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
59:52
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
59:60
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
1:00:14
patient who's come in and they are already severely paraparetic or pliigic, severe partial corticorna syndrome or total corticorna syndrome, that is
1:00:22
not the patient where you wait until the next morning to do the operation. In this case, unfortunately, that was the case and the patient did not do well, remained pliigic. And certainly, once
1:00:34
they have a loss of bladder function, that tends to be the most permanent deficit and the most difficult to regain I was going to ask you that, is the recovery, what's the chance of recovery, they
1:00:47
have, if their bowel is out, or their bladder is out. It's porous, it's probably in the 30, 40 range, 30, 40, 50, it depends on the duration, it depends on what the original ideology is,
1:01:03
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 self-cathidizing for the rest of their lives.
1:01:18
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, you know, full quadratic, the emergency room
1:01:31
physicians, the hospitalists, infectious disease, general surgery, everybody. Oh yeah, quadratic syndrome is a neurosurgical emergency. But it's only the plaintiffs' experts, the ones who are
1:01:43
trying to work with the patient who was irrevocably harmed, who are really telling the truth about this,
1:01:50
Well, yeah, corticoidin syndrome is an emergency and had this patient had surgery in a timely fashion they would have regained or avoided this neurological deficit.
1:02:03
Other causes of corticoidin syndromes, minimally invasive or negligent minimally invasive surgery is negligent to do a minimally invasive procedure if you have a maximal problem. If you're doing an
1:02:17
inadequate exposure to safely decompress the spine, if you're doing an inadequate exposure to avoid a CSF leak,
1:02:27
can most physicians are gonna say, Oh, 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
1:02:37
microscope, yes. If you use monitoring, hey, that helps. But the main thing is, if you have adequate exposure, the risk of getting that CSF leak markedly diminishes. So insufficient exposure
1:02:50
is the biggest problem. You're gonna get more CSF leaks with inadequate exposure. You're gonna get more neural injuries with inadequate exposure. And you're gonna get more retraction injuries
1:02:60
contributing to that. And it could be a different to individual nerves of the entire quarter-quina. There also is the other aspect of it with quarter-quina syndromes, negligent or overly extensive
1:03:11
surgery. You know, operations, multiple levels for black discs I can't tell you how many patients I see. You know, you go to spine conferences and all of a sudden, you know, Sadie who's 82 with
1:03:24
some lumbar stenosis and a little scoliosis is getting a T10
1:03:31
to S1 decompressive laminectomy with inter-body fusions, T-lifts at, you know, two, three, four, four, five and five, one, all of which you didn't need. And some of which they couldn't get
1:03:39
the inter-body device in because they were spontaneously fused.
1:03:44
Lots of fusions, T-lip, transferaminal lumbar antibody fusions, posterior lumbar antibody fusions, anterior lumbar antibody fusions, X-lip, which are extreme lumbar, extreme lateral lumbar
1:03:54
antibody fusions, all of these can result in significant deficits, screw injuries, traction injuries, interbody devices, neural and vascular injuries. In fact, life-threatening vascular
1:04:06
injuries, we're seeing more and more of these more recently, where they're supposed to know where theiliac arteries are, iliac veins,
1:04:18
and aorta, obviously, inferior vena cava. So here's an example of a large central disc with minimally invasive surgery where there was inadequate exposure, where really you need a bilateral
1:04:34
exposure. You could even do a bilateral laminotomy here if you wanted to, you're better off doing a laminectomy to get the bilateral exposure so that you're - getting enough room to work around that
1:04:45
fecal sack and under the fecal sack. Here, you know, a large central disk, you know, you're going to get quarter coin of syndromes if you're just doing it with your minimally invasive metrics
1:04:56
retractors. And the tube length goes to three to nine centimeters in depth and up to really 16 to 26 millimeters in diameter. 26 millimeters is one millimeter over one inch That's not a lot of room
1:05:12
to work in. And the longer your tube, the less you can maneuver your different instruments. So surgical errors can be occurring during these minimally invasive procedures, more clots, more
1:05:25
infections, more recurrent discs, and more residual discs with more deficits and more CSF leaks. And here's an example of a CSF leak resulting from a decompressor procedure being done minimally
1:05:39
invasively Thank you.
1:05:42
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,
1:05:57
the 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
1:06:08
have enough room to adequately repair the leak, what does some people do? They'll just put an onlay graft in one case, you know, it might be a fat graft or maybe even a piece of muscle, which is
1:06:21
the right thing to use. But if you're not sewing it in place, it's not going to stay in place. And if you just throw on dirt, gin, and even fiber and sealant, that fiber and sealant is going to
1:06:30
resort over the course of five to seven days unless you're using dirt seal, which might take three weeks. But still, you're going to get a current post-op leak The problem is, if you don't have
1:06:40
enough room. you can't get in a suture. The bevel of the needle is gonna be too wide, even with your seven-o-gortex sutures, that can be a problem. You need, if you get that leak, because your
1:06:55
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 fat,
1:07:09
it will resorb, and then you're going to use your derogen or fibrosilent, you have different kinds after that. In this case, the patient had recurrent post-doc leak, but they ignored the fact
1:07:21
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,
1:07:34
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
1:07:47
an M1 that shows severe adhesive arachnoiditis. And that is a
1:07:53
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
1:08:06
permanent partial quarter-quarter coin 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
1:08:16
example of, you CSF the what and discectomy a, know
1:08:22
leak can look like, ultimately.
1:08:25
Reminds me as I see this, I used to talk about are we treating the patient or are we treating the doctor?
1:08:34
Are we protecting the patient or are we protecting the doctor? How can you let that go for a year? Yes. Well, it's just an ignoring all those symptoms and signs. It's just incredible. Well,
1:08:46
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 do not do immediate
1:08:58
MRs or CAT scans, 'cause they don't wanna have to, they don't wanna deal with it, and they just ignore it. And they discharge the patient, and there it goes. Here I wrote a paper years ago about
1:09:10
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 CSF, legal and one in
1:09:21
post-op clot. And let me just tell you, this patient with the infection had had this minimally invasive diskectomy, went back to the doctor again and again and again, had successive MRI scans,
1:09:33
showing you all the phases of progression to discitis
1:09:39
and osteomyelitis. on my doorstep, and I said, this is a horrendous infection. You've got to go back to the original surgeon. I call the original surgeon. He says, Oh no, it's okay if you take
1:09:49
care of it. And I said, Oh no, it isn't. And sent them back. But this is what's going on out there. Different operations that we have, this is a typical laminotomy. As I was saying, if you
1:10:01
have, you don't have significant stenosis and you have that younger patient, you may get away with having adequate exposure with the unilateral laminotomy. You take a portion of the lamin above, a
1:10:11
portion below, okay?
1:10:15
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 laminectomy, and even take off the facet joint if you have to,
1:10:27
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
1:10:39
exposure. This is called anipsic contro, whatever. You have, you know, you're doing your bayonet and nerve retraction of the dura. You see a portion of the disc, but a huge portion is going
1:10:52
foramnally and far laterally. So here you're
1:11:02
going to have to do an exposure, both medially and extended laminotomy at least. And then you have to do a far lateral exposure. And that means that you're taking off the inter-transfer series
1:11:07
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 there. If you just try and
1:11:18
pull that disc out, you may actually be damaging and pulling the nerve root out at the same time if there are adhesions.
1:11:26
Coronal hemulaminectomies, great way to bilaterally decompress. For years, we were trying to preserve some of the spinous processes and interspinous ligament and we just decided it didn't really.
1:11:38
It didn't 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
1:11:49
minimally invasive procedures for abscesses. Again, if you have abscesses and
1:11:55
you have breakdown of this kind, you're not gonna do a minimally invasive operation to cheat this patient, or you're gonna leave tremendous amount of infection behind and end up with residual
1:12:07
quarter point of syndrome. So minimally invasive surgery and poor exposure, you're gonna have inaccurate removal, especially with an abscess where you really have to actively de-breed, you're
1:12:17
gonna end up with residual paralysis and much higher mortality rates. So never forget that if you have a patient of an abscess and they are neurologically progressing or they're lab studies, their
1:12:27
white count is going up, but more importantly, their ESR, their CRP, their pro-costotone and all these other things, you have to go back and re-operate
1:12:37
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
1:12:48
post-op clot, et cetera, that 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
1:13:01
a partial Coronal Heavy Laminectomy of L3 and L5
1:13:07
You see a little bit of the Spanish process left in the lamina, and then we're doing a full laminectomy of L4, preserving the facet joints, by the way. So it's better to preserve your facet joints
1:13:17
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 laminectomy being done. And here you might
1:13:31
be your laminectomy, and if you're taking out a disc, then you have your nerve root retractor, We have more room to work in. Here's your pituitary taking out a portion of that sequestrated free
1:13:41
fragment of disk, but you're still going to look above, below, medial, and then go into the disk space itself. So make sure your decompression is sufficient to do the operation you wanna do.
1:13:53
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 laminectomy for the stenosis. Here's a portion of
1:14:06
the disk That you're removing. And more of the disc fragment. Obviously, this is under higher power. And at the very end, OK, this is what you're going to see. Now, you may not have seen that
1:14:19
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 and manipulate significantly inferiorly because
1:14:34
you do not want 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, you may have very little room to work, and you
1:14:44
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 process is going to get in your way, especially in
1:14:56
the way of a bayonet and nerve re-director. So tailor your operation according to where the pathology is.
1:15:05
Unnecessary spine surgery is the other thing that we see too much of here. You have, I saw 183 patients over a period of 20 months, and I was the second opinion in these cases. The best way to
1:15:18
avoid creating a corticorna syndrome is not to do an operation the patient doesn't need. And I found that these patients had gone for a first opinion, 60, almost 61 had absolutely no disease on
1:15:32
their amorous and CAT scans and no neurological deficits and working in operation. Another 33 were told that they needed operations, but they were typically much too extensive. Major, multi-level,
1:15:43
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 discectomy infusion at C34, whereas old
1:15:57
patient needed was a cervical laminectomy with a posterior fusion, and that would have been the right thing to do. 6, by the way, got it right Negligent fusions, multilevel, T-lifts, lifts,
1:16:08
A-lifts, X-lifts. A
1:16:11
necessary surgery has been good to us, Ferguson. Well,
1:16:16
I was, in 2018, I wrote a paper comparing a series of 58 two to three level laminectomies. I did for significant stenosis. Subset had spondylocyst grade one, 58 patients, No infections, no
1:16:34
dural tears, no re-operations, and no periampostoperative corticornic syndromes resulting from the surgery. If you look at the T-lift data, just the T-lift data alone, the risk of errors, okay,
1:16:45
because you're putting in screws above and below, you're putting an inter-body device, you're retracting like crazy the entire corticorna in that dural sac to get these devices in, and even more so
1:16:56
in the patients who are supersonotic,
1:16:59
83 risk of infection, dural tears over 6, almost 10 motor deficits, and sensory deficits about 20 of the time. So you have to stand back and you ask yourself, which of these procedures should you
1:17:13
think about doing? By the way, reimbursements for the laminectomy, gonna be a fraction of what the T-lifts are. And by the way, also the hospitals are gonna make a lot more money from the
1:17:22
instrumented fusions.
1:17:25
Okay
1:17:27
Why did negligent T-lifts cause corticorna syndromes? Neural injuries. Dural injuries, vascular injuries. All of these can occur as well as other factors. And here, you have the screws that
1:17:41
you're going to use. This is the way the screw should be placed through the pedicle into the vertebral body, not extending past the vertebral body, not extending outside the vertebral body, not
1:17:52
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 inter-body device and just according to
1:18:02
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 happens to be at
1:18:14
the sacrum. If you're, you know, 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
1:18:28
go through the sacrum.
1:18:32
The sacrum can only take screws that are maybe 30, 35 millimeters. There are other kinds of big sacral screws that you can use that go way out to the side. But this is a screw that is very
1:18:41
dangerously close to the internaliliac vein and 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
1:18:56
to know this is there, okay? Can screws go across the spinal canal and you say in your mind's eye, oh no, not gonna happen. Very sloppy, can't possibly occur. And then all of a sudden you see
1:19:09
the CAT scan where there's your screw going directly across the spinal canal. And by the way, if you're doing AP and lateral floral images, you should be able to see this, especially on those AP
1:19:19
images. Missed, ignored, sometimes repetitively ignored, even in patients with new post-op deficits, New root deficits. CSF leaks, postural hypotension, et cetera, ignored and no studies done.
1:19:35
Here is a medical legal case of an L-4-5 minimally invasive T-LIF, grade one slip, and an LED patient. And here you can see on the MR, here's L-4, and here's L-5,
1:19:46
minimal grade one slip. By the way, flexion extension films were done pre-option of no active motion in this case.
1:19:55
So the surgeon, a week before the surgery, the surgeon said, oh, no, no, I'm going to have you, my partner do the case, made no arrangements for the patient to see that partner. That partner
1:20:08
never saw the patient, never examined the patient. So there's no informed consent, of course.
1:20:14
He did the minimally invasive T-lift. Now, the last time he'd done a T-lift was about five years ago when he had just, he'd just gotten out into practice five years ago, but hadn't been done doing
1:20:24
it recently.
1:20:26
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 cases and hopefully more recently
1:20:40
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 sued, they went to court and who
1:20:54
knows, you got a court It's a crapshoot, so to speak, and it ended up being the defense rotor. Who could explain this, but it happened. And the patient, of course, is living or the rest of her
1:21:06
life with that full foot drop.
1:21:12
Negligent T-lifts. They sometimes use bone morphogenetic protein that can cause corticoidic syndromes in cancer. The acute risks of an infection, corticoidic syndrome, seroma, massive, massive
1:21:24
drawing in a fluid that can cause corticoidic syndromes. Long-term risks can be the formation of calcification and bone forming everywhere or bone vascular disappearing from everywhere and obviously
1:21:37
the risk of cancer. Negligin exelipse, these are extreme lateral lumbar interbody fusions can also cause corticoidic syndromes. Here's the exelip approach and that's you know the nice diagram of
1:21:45
where the graft is supposed to be and here's your access root. Notice how in the
1:21:52
access root
1:21:56
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
1:22:08
the lumbar 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 permanent in a
1:22:22
reversible plus 20 motor deficits, et cetera. And this is what it's supposed to look like to get there from here,
1:22:30
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,
1:22:42
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.
1:22:54
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
1:23:09
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
1:23:19
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
1:23:33
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
1:23:45
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,
1:23:57
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
1:24:14
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.
1:24:24
Basically, when you're dealing with medical legal things, you never say complications. It's an error, a mistake,
1:24:30
and
1:24:33
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
1:24:43
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
1:24:54
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
1:25:03
for 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 actually do the
1:25:16
case safely before they actually do it.
1:25:20
Part three of the Lumbarcota Aquinas Syndrome talk is on avoiding malpractice in the treatment of CSF's leaks.
1:25:31
So, part 3, the failure to diagnose and treat corticornic syndrome is negligence CSF weeks and their treatment. And then we're going to go through this and then the best timing of surgery for
1:25:41
corticornic syndromes.
1:25:45
The anatomy of the meninges, probably people are very familiar with this. You have the dura.
1:25:51
And then you have the arachnoid and below the arachnoid, you have the spinal fluid And then pia is just on the surface of the nerve tissue itself.
1:26:01
Dural tears, everybody will say, especially lumbar spine, corticointed syndromes, it just comes with the territory. It's a complication. However, if you've done the wrong operation or you're
1:26:14
doing an inadequate exposure or technically poorly performing that operation, then it is negligence and it is not just a complication is the technical error of your ways. And here's just an
1:26:30
illustration of, you know, identifying the Dural Chair that may be present, obviously doing valsalvin maneuvers. We'll tell you if it's there. If you're just using loops, get out your microscope.
1:26:39
If you didn't even put on your loops, get out your loops. But it is best to use a microscope if that microscope, again, has been the corner, take it out. If you do not have a assistant helping
1:26:50
you in that case, this is a great time to ask for an assistant. It's really difficult to repair these adequately if you don't have an assistant Running sutures, you do not use a running suture.
1:27:00
You do interrupted sutures, even if there are papers out there saying, Oh, they're just comparable, whether or not, because if you get one suture loosening, the whole thing is going to fall
1:27:10
apart, and that's not gonna be the way to repair this. The repair, gorteck sutures. I was using 70 gorteck suture. The needle is very, very small
1:27:23
The size of your. exposure has to be enough to allow the curve of that needle to get in so that you can actually do the repair. And you can see as you go up the different sizes, how wider and wider
1:27:36
the bevels get, this is a non-resorbable suture. And what's great about the suture is that the suture itself is bigger than the needle. So that means every time you go through the dura, you are
1:27:50
obliterating that hole with the suture itself. If you're using neural line and some of these others, the needle is bigger than the suture and you're going to have constant leak still coming from
1:28:01
that. But the gortek sutures, they're non-resorbable and they have higher risks of resistance to pressure. Neural lines and basically the single sutures, they leak at lower pressures. And again,
1:28:15
they start to unfurl. They can't, you don't get as tight a knot with those and they loosen. So that's not the suture to use. The best neural repair, is to use your interrupted sutures. If you
1:28:27
need it, you can add a muscle graft, or actually you can get fascia as well. I would not use, could have a graft any longer. It's got too many problems with it. I would not use fat. Fat is
1:28:41
gonna shrink up and disappear and resort. You do a primary 70 suture repair, and you then want to do your valsales to make sure it's as watertight as possible So here's your dural repair with your
1:28:56
sutures. Again, you can add a muscle patch graft to that if you need it. You can test the quality of your closure with a valsale maneuver. If it's still leaking, you can put in another suture.
1:29:10
You can also add what are called micro-dural staples to facilitate that repair. So here's just an example. This happened to be a tumor case. Here you can see your dural edges above and below, and
1:29:22
here's your quarter point of sitting here. And then
1:29:27
in this instance, we've got seven-o-gortex sutures, we were taking out a neurofibroma in this case, but you've got your retraction sutures. So once you've taken out the tumor, what you can do,
1:29:37
each of these sutures, retraction sutures is on a clamp. So you can flip the clamp one side to the other, one side to the other to bring the leaves of that dura together. And then what you do is
1:29:49
if these your dura, you try and evert the dura to then with a pen field, forceps, and you then bring your suture around and through the dura on each side, and you do suture by suture by suture,
1:30:03
et cetera, as you go up to repair that. And then in between that, you're going to put your micro dural staples. Micro dural staples are like 14 millimeters. So you then get a valsave at this
1:30:17
point. You really wanna make sure it's as watertight as possible If it's not watertight, this is when you put in your muscle patch graft. If you put an onlay graft over an open CSF leak, it's
1:30:30
going to float away. It's not going to work. It's going to get worse. And you can put in the dirgent you want. You can put in the, you know, as I said, dirseal, which is big and blue and
1:30:42
glommie, and it takes about three weeks to resort. But when it resorts, you're going to have a massive CSF leak underneath this And if you don't have the microclubs, you just put more sutures in,
1:30:53
right? That's right. That's right. And if you, if it still doesn't work, take a, take a piece of muscle. Muscle is great for occluding the leaks. It doesn't have to be a live muscle graft. We
1:31:05
were doing that for a while where you, you know, make it a pedicle graft and we didn't really bother with that anymore. But just a, you really have to keep going. The other thing you can do, you
1:31:14
put your, you know, you do this, you do your muscle graft, et cetera. And then, you know, you, you can put in your first layer of five concealant over that. And that's what that is, but and
1:31:27
by the way, don't leave gel foam behind or flow seal because that can actually swell and cause a quarter coin syndrome, but over that, the microfibular collagen, there are two kinds, one is for
1:31:38
just onlay application, okay, that's it. There's no leakage. If there's leakage, you put in a little fiber and sealant, you may put in what's called the non suitable derogen And then above that,
1:31:54
okay, that's what it looks like when you put it in, it usually deforms to the shape of the dura, et cetera. But don't be fooled, you're going to put another thin layer of fiber and sealant over
1:32:05
that microfibular collagen or derogen
1:32:09
You're going to want to take suitable derogen where you get out your 7-0 Grotech sutures and you just, on a perimeter around it, you're going to directly repair
1:32:21
that leak. And this is what it actually looks like. So here's your suitable derogen. And I put a final layer of fiber and sealant on the outside and see all these little sutures here, here, here,
1:32:33
here. There's some under there as well. This way it's not gonna float away. It's not gonna disappear. I can't remember the last time that a sutured derogen repair failed. So it takes throwing in
1:32:47
the kitchen sink. It takes much longer, but this is the way to do it because as soon as you're coming back again, then you're really ending up with trouble much less possibly an infection.
1:32:59
Here's a case of negligent minimally invasive surgery that can lead to an avoidable leak and
1:33:07
recurrent post-op leaks because you didn't repair it the first time, you didn't enhance or enlarge your exposure and it might take a lot of enlarging of your exposure to get it, but it can lead to a
1:33:19
quarter-point syndrome if you have a lot of compression from it. And here, a negligent minimally invasive discectomy, poorly repaired, recurrent post-op leak. This is your post-op leak caused a
1:33:34
quarter-point of syndrome. And then in this case, you know, led to that patient's continued deficit. Okay. So the best timing of surgery for quarter-point of syndromes and you can take away the
1:33:50
message the 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
1:34:02
deficit. 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,
1:34:14
well, 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
1:34:23
basically 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
1:34:35
mean, this 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
1:34:47
friends, 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
1:34:60
want that 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
1:35:11
of 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
1:35:24
studies, the poorly done studies that said you have 48 hours, that's not correct. Carissa study, quadratic syndrome is a potentially devastating spinal condition. Timely diagnosis and treatment
1:35:36
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 written an
1:35:49
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 in patients
1:36:02
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. Surgeons, doctors,
1:36:16
patients, everybody's, especially the emergency room in your hot, physicians in your hospitalists, there's something called the partial quarter coin syndrome incomplete, you don't have to have
1:36:26
everything. And here's the complete quarter coin syndrome where you have, you know, the paralysis, the sensory loss, societal anesthesia, urine and bladder discontin, et cetera, incontinence.
1:36:36
So the emphasis again on partial versus just complete quarter coin syndrome, that is the biggest message to get out there, especially to our adjunct of personal and friends. You know, do the right
1:36:48
operation, the adequately extensive operation might be your laminectomy or your coronal hemilaminectomy, as I had, you know, shown people before, adequate exposure, decompression. Doing these
1:37:00
the 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
1:37:12
delayed 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
1:37:25
better, 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
1:37:37
operation to get the best ones ads
1:37:41
Well, it's an excellent job, Nancy. I just toured a fourth script.
1:37:51
Don't make sure you're the better. No, 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
1:37:60
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 somebody, even the emergency room. You gotta go down and get the
1:38:10
history When 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
1:38:23
notice your foot 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
1:38:35
had heart trouble. I mean, all of these things are relate to your outcome and do an examination And do an examination, obviously you want to do it yourself.
1:38:49
Do an examination, you have 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 do the things. And then
1:38:60
you come near differential diagnosis. What do they got? And if the differential diagnosis contains a threatening disease, you don't wait. It's like waiting live, it could have an aneurysm, I
1:39:12
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 diagnosis, you got to do imaging, we've talked to you. If you don't have the finest
1:39:21
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 myelic damage, you can get a very nice image of what's going on.
1:39:35
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 think about that. Well, we're
1:39:49
off, we've got to call it a special crew or this, the next thing, there is no reasonable excuse, but you have to decide is what would you want or your family needs if they had the same problem And
1:40:07
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.
1:40:20
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
1:40:33
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 the job, do it right.
1:40:46
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 problem is and
1:41:02
then fix it. That's the amazing thing to me is what they, The extent that the. many surgeons will now go to to basically ignore that there's a post-operative deficit or problem, even a
1:41:15
life-threatening problem, and just,
1:41:18
I mean, it's like, let it make your diagnostic studies, if that's what it means, look, we all make mistakes, fix it. That's what surgeons do, fix it.
1:41:32
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
1:41:44
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 no
1:41:55
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 at it. Yeah, I'm sorry. So thank you very
1:42:09
much and I am seeing it just this spectacular job.
1:42:14
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