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SNI, Surgical Neurology International, a 2D Internet Journal, and SNI Digital Innovations and Learning, a 3D video journal
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in association with the Sub-Saharan African Neurosurgeons are pleased to present the Sub-Saharan Africa International Neurosurgery Grand Rounds, held the first Sunday of each month.
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This Grand Rounds is devoted to global solutions, to clinical challenges in neurosurgery, the moderator is a Strata Bernard, there's an international audience.
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The topic of the first lecture by Nancy Epstein is failure to diagnose and treat. Kota Aquinas syndromes.
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Nancy Hepstein is a professor of clinical neurosurgery, the School of Medicine, the State University of New York at Stony Brook, and she's the Editor-in-Chief of Surgical Neurology International.
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Welcome, this is, I think this is our seventh edition of the SI Digital Neurosurgery Grand Rounds for Sub-Saharan Africa Dr. Osman is the leader of this,
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and he's not able to be here today, and so we have Dr. Epstein with us, who is the Editor-in-Chief of SI, the Surgical Neurology International Journal. And she has great expertise in spine care,
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and will be offering us her perspective on called Aquinas Syndrome Oh Welcome to everybody and after Dr. Epstein's presentation and further discussion, we'll go with the Kenya group to discuss
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spinal cord tumors and management and sub-Saharan Africa. So Dr. Epstein, welcome again. You've been actively involved with us and we love having your participation. Please go ahead and get
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started, thank you Okay, as I've said to Estrada as well as Michael and welcome everybody else. If people have questions, by all means, interrupt, discuss, that's the whole point of today's
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discussion. My topic is going to be the failure to diagnose and treat corticornia syndromes. It's a very common thing that's actually seen and it's one of the most common mistakes that's made in
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spine surgery is the failure to recognize it and to do something about it. Here is an example of a large central disc herniation. I'm going to be showing you images. I'm going to show you CT scans,
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MR scans. If nothing else, I think it's important for us to emphasize that spine surgeons need to know how to read their own diagnostic studies. And by the way, I've not completely eliminated the
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fact that in some places you might only have access to putting a needle into the spinal canal and getting a one-shot myelogram So I have not included that in this discussion, but obviously we're
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thinking about that as well. So here to the right, you can see an image of a large disc herniation in combination with obviously a laminectomy having been completed. So for the organization today,
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I'm gonna start with the neuroanatomy and defining quarter point of syndromes. I'm gonna look at MR and CT causes of these syndromes. We're gonna discuss various cases of negligent lumbar spine
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surgery. What went wrong? What were the mistakes and what we can learn from that. Part three, the best timing of surgery. And here, you're gonna see the literature, the good literature says
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zero to 24 hours. The best literature really says, as soon as possible, six hours, 12 hours, however quickly you can get these patients to surgery the sooner, the better. The anatomy that we're
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dealing with, we've got five lumbar discs, sometimes six, sometimes four, about 5 of the time. And you can see that we've got posteriorly, you've got the spinous processes, you've got the
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supraspinus,
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as well as the intraspinus ligaments as well. And then finally, you're gonna look at the dimensions of the spinal canal being measured really from the mid aspect of the vertebral body, anteriorly
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to the posterior laminar line. Normal lumbar is really about 17 millimeters. Oftentimes it's much narrower than that than the patients who are symptomatic with stenosis. Neuro anatomically, I
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think probably everybody knows, the spinal cord typically ends at T12L1, And you've got the quarter coin, which really means horses tail, the nerve roots going down to the s1 level with the
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sacral roots l1 s1 to s5 down there. And atomically, we're talking in the lumbar spine about the l2 to 4, the femoral nerve and the sciatic nerve l5 to s1. So a strata first question, am I
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talking too fast? No, I think the rate is good. Okay, Michael. Okay. It's fantastic. Okay. So femoral nerves. Okay. Here's an example, sagittal view in your MR. 514534.
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You've got a secret straight extruded disc extending superiorly. This is a classic example where if you look at the axial study, you can see that the disc is parapadicular in location at the 34
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level. That's going to be impinging on the l3 root Not the l4 root that's extending inferiorly. So you have to read the studies, know what your neurological dysfunction should be. and then go on
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from there, okay? And then here's an example where your femoral nerve, you're looking for the femoral nerve deficit. You're asking the patient to lift the knee, it'll be a SOS function or
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dysfunction may be present. Quadriceps dysfunction may also be present. Obviously the quad, longest, biggest muscle in the body, that deficit may be somewhat more subtle. Always repeat, I
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always repeat, go back and forth, back and forth. And by the way, if you're gonna examine anybody's lumbar spine, make sure you start from the top, examine the cervical spine every patient,
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every time. You may have cervical disease, about 10 of the time, if you have significant lumbar stenosis. Reflex loss could be the patellar response that's absent or diminished, and the sensory
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deficit, the loss of pin over the thigh, and the inner aspect of the calf. And this is sort of an image of where the sensory deficits, L2 and 3, might be in the thigh. Media aspect of the calf
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is gonna be L4. Lateral aspect of the calf, by the way, And then you can see posteriorly at the bottom of the foot and going upward, maybe S1. It's amazing to me how many neurosurgeons have
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forgotten their basic neuroanatomy and neurological exam, how many
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patients come in in the states. They've got their 5 or 10 minutes and their RV use brewing in the universities in particular, and they're not even doing a neurological exam. So anyway, it's
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important to emphasize do your own neurological exam, get your own information, don't just get it from your quote, mid-level caretakers. Yeah, Nancy, I would add that the importance of the
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during the sensory examination, so many times I've seen people who've had a thoracic sensory level that were misinterpreted as having a lumbar spine process. Yeah. And of course, checking the
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reflexes to assure that there isn't myelopathy. Yes, yes So here's your axial MR showing a big disc herniation on the left at L5S1.
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Here's the root on the other side in tact. The sac is partially compressed with that. And here is an operative image where multi-level M in ECME was done for stenosis. And sometimes you're working
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over the dural sac to get that very foraminal portion of disc herniation that may be present, obviously taken under the operating microscope. But the sciatic nerve, remember, if you ask anybody
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about back pain, I don't know where you are in Kenya or you are in Nevada, but I know New York and Florida, anything that's low back is sciatica. Well, we just showed everybody that there's
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something called femoral latica as well. But sciatica, obviously, the L5 root, ask the patient, lots of times you can watch the patient walk into your office. And if they're dragging your foot
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and giving you that, slap, slap, slap, slap, you know that you have the foot drop and that's the way to pick it up more subtly. A loss of the ankle response or diminished because usually it's
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that's one that results in the total loss. and the loss of pin on the outside of the foot or the lateral calf. S1, you ask them to stand on their toes, walk across the room. I think that's the
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easiest way to do it or they're sitting there and then they'll push down and give you 90 miles an hour. A loss of the Achilles response and then loss of pin on the outer side of the foot. So, this
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neurological exam doesn't take very long, doesn't take very long to go through the upper extremities as well. But a thorough exam, and I think one that's done by the surgeon is really important,
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and as everybody's pointing out here, I think Estrada is saying it, Michael's nodding his head, so do the exam, don't just hit the button on the computer that says I looked at everything, right?
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Right, so on the same thing, I see lots of my residents are joining now. Could you tell them about sensory levels and myotomo levels and why it's important for you to distinguish them? Does they
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think they don't even like to look? Ah, well, I think that when you're looking In the lumbar spine you're going L1 to S1. I think what Estrada was talking about is if they have anything going on
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in the thoracic spine and myelopathy or chord compression, then you have to
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start with
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the T1 distribution all the way down to T12, and T10 is about the level of the umbilicus, so you can always use your pin to go down the chest and the belly to see if there's anything else going on.
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Did I miss anything, Estrada? No, I think that's good, and usually the nipple line is about what T4. Yeah,
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and the other thing too is when you're looking at the reflexes, if you've got hyperreflexia, lumbar disease should be giving you hypo-reflexia, not active reflexes, not clonus, not up-going toes,
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so all of this stuff can be picked up pretty quickly So I think if your residents are here as well, the next portion of this, and my husband taught at Columbia University for over 50 years, he's
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still actually teaching and doing everything This is a good time to wake up. We're gonna talk about quarter-coinest syndromes, partial-quarter-coinest syndromes. Partial means only part of not the
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full syndrome, and partial syndromes are gonna be much more often encountered than total-quarter-coinest syndromes. Quarter-quarter syndromes, partial or total loss of motor function could be
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proximal, could be distal, could be total pledge of both lower extremities, sensory loss, could be proximal distal, or any of those L1 to S1 distributions, could be saddle loss of function, or
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it could be complete anesthesia, sphincter function and sexual function, obviously we can't test, but here is a figurative diagram of a disc herniation that's huge and central, that's gonna be
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causing most likely a full quarter-quarter coin of syndrome, and here on a sagittal view, you can see that you may be getting a partial quarter-quarter coin of syndrome secondary to the degree of
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thick and sac compression. So it's interesting if you sort of fix in your mind what things should look like. in a textbook, then it's easier once you get to the OR to at least have a baseline sort
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of to refer to. So these figurative diagrams, I think, are always somewhat helpful. But here's your partial quadricornia syndrome. Patient may have partial leg weakness, partial sensory loss,
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particularly in the saddle region, partial loss of bladder function. But remember, some patients may just purely appear with bladder dysfunction. So many quadricornia syndromes have been missed
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because, oh, well, they're walking They don't have any weakness in their legs. So nobody's thinking about this. Nobody's getting a bladder scan or something like that. So again, partial
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quadricornia syndrome, a lateral disc with partial compression of the quadricornia may be responsible for that as opposed to a huge central disc. And I'm just going to keep repeating this for the
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next few slides. Here's a massive central disc that may be giving you the full quadricornia syndrome And again, recently I saw a patient where it was a massive disc presented. only bladder
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dysfunction, and they completely missed the diagnosis for days before finally getting the MR scan showing where the problem was and that resulted in the permanent loss of bladder function. So again,
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rare to have the total corticointed syndrome, bilateral leg paralysis, loss of sensation, saddle anesthesia, loss of bowel and bladder function incontinence or urinary retention, et cetera And
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again, this is the constellation of patients that I've seen over many, many different medical legal cases. They come initially to the emergency room. No workup is done. No labs are done. And by
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the way, they typically look at the women and just say, oh, you know, you're hysterical. That's not a good thing to do in this day and age. They have repeated ER visits. They still fail to
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diagnose. They fail to get lab studies. They fail to get the correct studies This is a throw in a CAT scan because it's quick and easy. But that's not going to show you where most of these diseases
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are. It's not going to show you the soft tissues. It's not going to show you the disc or the abscess and everything else. Unless on a CAT scan, you may see an abscess, but it's already been there
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now for six weeks. They may even - So Nancy, what's been your observation about what symptoms tend to be overlooked? Or is it more, is there some partial weakness, difficulty walking, the
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bladder dysfunction? What's been your observation about what tends to be overlooked and not worked up for it? I think the biggest thing is pain, because these patients typically present with severe
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pain. And I think it's the part of the physicians, as well as the ancillary personnel, nurses, everybody else, they're not listening to the patient with the severity of the pain. And especially
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if the pain has progressed and they've been there before, and they've already been given a medral dose pack or anti-inflammatories, and that's not helping.
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I'm having some trouble, you know, I had one episode of urinary incontinence or something like that, and they're just totally ignoring that. I'm having some weakness in my leg, but if it's
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proximal and they're testing distal only, oh, how many times have I seen in a chart? Well, they could pull their feet up and down. Everybody looked for proximal weakness. I'm gonna show you a
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case where they completely missed a patient's weakness 'cause it was more proximal But I think it's the biggest thing, not listening to the patient's complaints. And how is all this? I think
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another thing is in the context of chronic pain because sometimes people have chronic pain and they're ignored because they think they're just complaining as usual that when they've evolved a deficit
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and in that context sometimes they may not get appropriately examined. Yes, especially if they've been there before and they think they're a histrionic or a hysterically. and they've had multiple
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visits, and yeah, it's not fair to the patients, obviously. And here's just another example on an MR, big quarter coin of syndrome, huge disc herniation shouldn't be able to miss that. And
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here's a figure to diagram of epidural abscess with vertebral osteomyelitis, et cetera, just shown figuratively. And I'm gonna show you some, a lot of real pictures of all of these cases.
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So, this is an example of a few things that we've discussed already. A colleague, a friend, locally. I got a text late in the day. It said, you know, I showed up at a medical center. My
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sudden onset this morning of leg weakness and terrific pain. I just couldn't walk. I walked into this facility. They did a non-contrast CAT scan. And guess what they did at that point? They sent
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her home.
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So, I looked at the text. Give me permission to go look at your MR, at your non-contrast CT. I looked at the CT. I saw a large extruded synovial cyst filling the spinal canal at the L-34 level.
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Now, we all know, lots of times you're not going to get that kind of definition on the CAT scan line. Right, right. I called her right back, I examined her. She had terrific weakness
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approximately in the right lower extremity. Okay, this was at the three, four level. So, Ilya saw us in quadriceps weakness. She couldn't put any pressure on that leg, terrific pain And I said,
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When was the last time you urinated? She said, Oh, well, I didn't drink very much, but it was early in the morning. So, she was in urinary retention. We got the statin more. The disc was
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filling the spinal canal. I sent her to the emergency room. The emergency room, I got a bunch of phone calls, you know, 'cause she was trying to put me through. I talked to the nurses. The
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nurses said, Oh, no, she can move her feet up and down. I said, But she can't move her leg up and down. She's got a quadriceps syndrome. Paul, Paul, the PA, and the surgeon's stat.
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I mean, these are hours going by. PA comes. Oh, but she's got no weakness in her feet. I suppose you failed to examine higher up. And by the way, she's got, you know, urinary retention. And
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finally, I spoke to the surgeon who was, she's got coder coin syndrome. We're going to operate on her. We're not going to futz around with T-lifts and screws and nuts and bolts. We're just going
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to do a decompression. And she ended up neurologically intact because we got her in at least, you know, within 24 hours, like 12 hours since the onset So here's just an example, a figurative
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diagram of what a synovial cyst looks like, coming from the facet joint and the lumbar spinal canal. And here's an actual image. This did not happen to be hers. But you can see there's a
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hyper-intense area in this cyst. Too many interventional radiologists are trying to tap these cysts, wrongly thinking that it's like you stick in your thumb and you pull out a plumb, whether it's
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just going to pop like a balloon. But this is thick crankcase fluid. Oftentimes you can't aspirate it and the capsule is tough. firm, thick and rubbery, and it doesn't collapse. Is that your
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experience? Michael,
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Mustrada. Well, I would say, yeah, sometimes they talk about rupturing it, putting pressure in to make it ruptured, but that can lead to quite an inflammatory response. I mean, as we, when
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you take these things out, sometimes they can be quite a bit of adhesion So, yeah, I don't think that putting a needle into it to rupture it or to ask rate it is a good way to go. Yeah, Michael,
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your experience. Yeah, agreed, agreed. Just as you said, we have few spine surgeons and many generalists, so most of the people might not even realize it's assist the first time. They might
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think it's an arachnoid cyst, so no, say no, we'll say they think it's an arachnoid cyst, et cetera. So it's almost utilizing it to the states Some people will stick the needle in and forget the
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patient. Yes, we do see that, but like, as been said by Professor Strada, I don't, I don't agree with that. Yeah, but actually, yeah, the other thing that we've seen is a lot of holes that
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the intervention was made trying to do these procedures so that you get there surgically and you're trying to repair all these holes as you as you go along that they made. Right? No, no. Yes. We
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don't have that. Yes. Anyway, this is the side of limits of the same thing. And this is your tough perm robbery capsule, a tiny area, may actually be, you know, just fluid that's sitting in
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there. In this case, again, you know, this is not from her image, but that's what a sineadosis can look like at surgery. You can, if you're lucky, you get underneath it. About 16 of the time
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has been my experience. You cannot differentiate the capsule from the Dura. Don't try to do that and get an unnecessary leak if you can't. Dissect a plane. Just decompress it. You know,
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marsupialize it as best you can, empty the guts of the cyst, and make sure you have enough of a decompression to accommodate the rest of the capsule. And that's just what, you know, some of these
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cysts can look like.
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So we're gonna go on some of the MRs and the CAT scan findings in patients with the quarter coin of syndromes. My father actually was a nurse surgeon,
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but also he was a medical illustrator at the same time. So this is his illustration of a huge unilateral facet that can be, with the stenosis can be contributing or causing quarter coin of syndrome,
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ossification of the o ligament that's also here, and then you may have not only the compressed nerve root, but also the compressed unilateral quarter coin. But if you transfer this to the other
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side, then it's gonna be bilateral. In this figurative diagram, there's no facet arthritis. The ligament is not hypertrophyid and the nerve root happens to be intact and okay. But it's obviously
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gonna dictate the extent of operative decompression that you may need in some of these cases. central stenosis and lateral recess stenosis can certainly be combined and it can be combined with
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ossification of the olegment to the right. You see that you've got the lateral recess stenosis, the central stenosis and hypertrophy or ossification of the olegment with the hypertrophy facettes
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contributing to the posterior lateral disease. So you get the trifoil or triangular configuration of a thick o sac and the compressed nerve roots in that dural sac.
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And again, ossification of the olegment here, it's obviously in blue. Here is a CAT scan of that ossifiedial olegment and here operatively is your ligament surgery. So for both Estrada and Michael,
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when you have a patient and you're doing multi-level stenosis and you encounter really awful severe ossifiedial ligament at one of the levels typically it's at four or five could be three four as well.
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What do you do? Because I would then try and go above and below and then work my way towards the worst part. Is that how you guys would work? I agree, yes, I would do the same. Yeah, yeah. And
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you have good anatomy, clear planes, proximal and distal, and then work your way to the portion that's more challenging. And nitty-gritty, yeah. Exactly, always from noon to unknown, always.
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Yes, yes So this is what I tell patients and medical students and residents and other ancillary personnel. If they can't remember the difference between an MR and a CAT scan, at least in the United
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States, we have MM's. And Kenya,
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do you have any MM's in Kenya? Okay, so there you go. So I say the soft tissue, that's the center chocolate of the MM, the calcium, the bone, the outside of the MM. So if you remember an MM,
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you know how to remember the difference between the MR, soft tissue in the center, Candy Shell on the outside. that's your calcification, that's your CT findings. So MR scans best show the soft
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tissues, the CT, the bony changes of quarter-coinic compression and quarter-coinic syndromes. This was an article by Hogan et al. in world neurosurgery over 20, 000 quarter-coinic syndromes, 65
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of which were due to disc herniations. It's usually gonna be your central or your lateral disc. It's not gonna be really your foraminal or far lateral discs because that's too far away from the
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central dura But here are the major causes that they define of codercoinis syndrome, 65 disc herniations, 22
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stenosis, 6 clot, 3, tumor, 3 trauma, and 1 infection. So this is just something, I think it's good for people to try and remember this. This is a huge sample and to just give you a very good
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idea. But the most common, again, disc and stenosis, and hematoma happens to be in there along with tumor trauma and infection And here are just some examples, L45, massive disc. filling the
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canal, lumbar stenosis. Here you have your yellow ligament in red being clearly documented for you. This is not the way typically images will come. Here is your post-operative epidural hematoma.
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And here a patient with a tumor of the, it's an appendomoma of the corticuina with drop myths down below. So again, as we go along here, let's hope that everybody's trying to learn how to read the
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MRI scans that we're showing So here's an MRI best showing surgical discs, surgical discs. They're not the degenerative prolapse discs. We should not be operating on, quote, black discs or where
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there's no, no fecal sacronurricular compression, no symptoms, no signs, unnecessary surgery. Shouldn't be part of what we're doing. We have too little time to do the necessary surgery. We're
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looking for extruded discs where the disc is still in continuity with the disc space or sequestrated disc. That's mean disc fragments have broken off So here's your typical extruded disk at the disk
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space. And here's your classical, free disfragment, migrating below the disk space, sometimes to the point where you can't remember where it came from. I mean, both of you have probably
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encountered that. Here's the fragment, where did it come from? I remember visiting Japan, and they were doing minimally invasive procedure. And he was going after just a sequestrated, extruded
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fragment. And I said, well, why not go after, you know, the interlateral, the central disk at four, five, or whatever, he says, we don't have time for that. That's got to be done today.
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And I said, well, how do you patients do? He said, not very well, they complain a lot.
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And the answer is, make sure you do enough exposure to treat this adequately. You know, the size of the insertion is not as important as doing the right operation underneath it. And that's both
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patients and everybody else who have to be prepared for that.
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I once had a patient who said, but can I do this without any scar.
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MR is, again, it's going to show you the lumbar disc, the central disc, it's going to show you the lateral disc, the pherominal and far lateral, not in this group. But here's your interlateral
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disc, L5S1, giving you a fecal sac, as well as individual nerve reconstruction, causing perhaps the partial quarter-coiner syndrome. And here is, again, a massive disc, killing the canal at 51,
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causing the full quarter-coiner syndrome. Again, MRs are going to show you the large central discs, and here's what your quarter point looks like on an anatomical specimen, and if a disc fills the
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canal, this is what can look like on that MRI scan, sagittal image, or here, sagittal image. And you're going to get MR scans that are very different in terms of quality, non-contrast CAT scans.
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Oftentimes, they're going to miss these disc herniations. I remember being at a conference where they presented the MR on the screen, and they said this patient came in with and I took my little
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pointer and I said It looks like there's a massive discoverer here at L12, and everybody took a deep breath because they completely missed this. The patient ended up with a full-quarter coin of
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syndrome and pleases. So anyway, give them a pointer to challenge you at the different conferences. That always keeps us on our toes, right? So here's your CAT scan. It's wonderful for showing
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you the AP diameter of the spinal canal. Not good for showing you exactly what's in the canal, but here's a myelogram CAT scan, and I was just reviewing this the other day. I mean, we do these
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extremely rarely. Are you doing any of these, Michael? You're just doing MRs and CAT scans.
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Only, only, can you hear me now? Only MRIs and CAT scans. Yes. Interestingly, we're getting more and more MRIs and people are just skipping CAT scans entirely. Lots of times, yes. You can do
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that in younger patients, but I think in older patients, it's good to have the bone information. Sometimes some people are still doing cervical punctures, which basically are unheard of in this
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day and age. But in any case, on the Myelus CT scan, here you have the luxury. You can see, you know, ventral osteophilic changes. You can see the trep oil configuration of the thiepal sac.
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You can see the huge hypertrophy facets back here, some yellow ligament hypertrophy, seeing right here, all contributing to stenosis in this patient. So there's so much information that you can
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get on your non-contrast images. There's no reason to do the Myelus CT plus. You then don't have the risk of the CSF leak and everything else, allergy, et cetera,
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MR scans can also show you grade one slips, spondylolistasis, dynamic films may show you if there's an emotion, lots too many of these patients end up with fusions that they don't need. But here's
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just a figurative diagram of a grade one slip. And then here, just to remind everybody, spondylolistasis, four
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different grades really, 25, 50, 75 and then spondyloptosis, 100. Grade one degenerative spondylolistasis, just like you see in this image, very common finding, especially at the four or five
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level, particularly females in the older age groups. And again, they attribute it to, instead of a coronal configuration of the facet joints, it's a oblique angle of the facet joints at that
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level that predispose to that. But again, they don't all have to be fused. Here's the axial MRI
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scan without contrast You may see some ventral disc or spur. cluster lateral, you can see some ossification of the olegment, and then again, you have your hypertrophyte facettes, you know,
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bilaterally. So yes, the MR is going to give you a huge amount of information, and you don't always have to get a CT scan. Sometimes it's going to give you some additional information. But here's
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a CT scan, I'll show you in a sec. And here on your spondylolisthesis, here is a figurative diagram where, foraminally exiting, let's say it's the L4-5 level, it's going to be the
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foraminally-superly exiting L4 root. And you're going to, on the midsection, you're going to be compressing the dural-theical sac and the intralee exiting L5 nerve root. So it's important to
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remember that the superly exiting nerve roots are also being affected here. So L4 and five root syndromes may be present. And again, this is just to show you again the different grades, grade one,
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grade two,
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and then spondyloptosis being present Oh, I'm sorry. Here, the lumbar MR scan also shows you soft tissue changes with a fracture. Here you have vertebral plana. And you can see how it's producing
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a corticornia syndrome here, impinging on the spinal canal, vertebral discitis, osteomyelitis. And here, again, you can see corticornia syndrome. It's affecting what's going on in the canal.
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And then finally, for tumor, you can see on the contrast MR, you're going to see the multilevel tumor involvement and, again, involvement of the corticornia also appearing on these studies. So
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these studies are fantastic for looking at all of these different entities, sometimes with and without contrast, especially if you're looking for infection and tumor. Lumbar CT scans show you the
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bony changes. Here's a patient with dish in a fractured dislocation. That's a fantastic diagram I mean, MR would scan and show you something like that. Infection with and without GAD. you're
32:07
going to see the osteomyelitis discitis vertebra plana, the compressive findings that you're going to want to see, and the contrast study may show you the primary tumors,
32:19
the metastatic tumors that you're going to see here.
32:24
Negligent lumbar surgery, and here I'm going to go over some of the cases that we've seen. Major mistakes leading the failure to diagnose and treat a corticorna syndrome, minimally invasive surgery.
32:37
Not seeing what you're doing, not having enough adequate room to expose what you're doing leads to tremendous errors contributing or causing nerve damage, spinal fluid leaks, other errors, and
32:48
certainly corticorna syndrome. So minimally invasive metrics discectomy, I'm showing you that here. Yes, you have the cosmetic small incision, but it's what's underneath that really counts. That
32:59
tiny laminotomy may not be enough.
33:03
The bony exposure, if it's You don't have enough room to maneuver. You can't avoid getting some of these other major complications. Okay, so here's a classic case of a minimally invasive
33:16
discectomy that was wrongly done in this patient. The poor exposure helped the surgeon cause a significant CSF leak. Now how of description detailed very, very, very a had he, note operative his
33:24
in, the
33:30
repair was done. I believe none of it was done because we later got a CAT scan that showed he had such a tiny laminotomy he could not have gotten that needle into the wound.
33:40
Claims he repaired it, but guess what? Recurred post-op. Post-op for months, he ignored the postural headaches. He ignored the swollen wound. Just said, Oh, we see this all the time. And a
33:51
lot of mid-level personnel were involved here too, but the surgeon was also, 'cause lots of times the surgeons are gonna hide behind the mid-level personnel, the PAs, the nurse practitioners,
34:00
whomever Finally, yes and no more. It shows a big CSF leak, doesn't do anything about it. Patient ended up with severe arachnoiditis. So this is not the patient study, but it's similar. You can
34:13
see here, significant leak, significant leak, okay? And that's where the site of the leak is, fistula was still there, could have easily gone in, primarily repaired it. And there's something
34:27
called the empty sac sign that you can see with adhesive arachnoiditis. I mean, my uncle who was the neuro radiologist as a teenager, I'd go there over vacations and he put me on the spot and he
34:37
said, Okay, Epstein, you know, what's this? You know, and I'm sitting there saying, Oh, I don't like that, the spine. I mean,
34:44
in any case, the nerve roots are just plastered over the edge here. And so the sac sign, adhesive arachnoiditis, and we all know it's a progressive syndrome that's just totally miserable. Motor,
34:54
sensory, reflex, every deficit that you can think of, including sexual dysfunction. Multiple failures in this case. I'm just drawing everybody's attention to, you know, this is what a needle
35:05
looks like. Here's the swedge over here. Here's the tip of the needle. The cord length is the length from the swedge to the point of the needle. So the point in this case was he was using a needle.
35:16
There's no way that needle size could have fit into the laminotomy that I saw on the CAT scan. If you try to measure one for the other, there's no way that this could have fit. So certainly it
35:28
helped me figure it out. He never did the repair that was described And this just goes for everybody. Do not create a 19th century novel in your operative report. Whatever you put in there, put in
35:39
the truth, it will help the next surgeon come in and figure out what was really done. And you're really doing that patient a disservice otherwise. Ignoring the leak, ignoring the patient for
35:50
months, that's a terrible thing to do. And again, in this case, you ended up with adhesive retinitis, now that's a normal mmor, but here are other examples of clump nerve roots here or clump
36:01
nerve, which is along the perimeter, or the empty canal sign that I just showed you. So we should all be able to read these findings, especially, and consult your neuro radiologist or your
36:13
general radiologist before doing surgery. I mean, they may know something else or see something else that you're missing. Okay.
36:22
People will ask, especially in a court of law, well, as a durable chair within the standard of care, and you actually have to qualify it It's not, it is within the standard of care if you're
36:33
doing the right operation for the right patient under the right circumstances, you're doing it well right,? But if you're doing the wrong operation in that patient and you're doing it negligently,
36:44
that is below the standard of care. So, as I say, doing the middle knee invasive operation in a patient who needed a multi-level decompression, that's a mistake, that's an error and that's
36:55
negligence. Here, you need room to do a durable repair. Even if somebody starts out doing a minimally invasive operation, if you get that leak, extend your exposure, get yourself enough room to
37:08
repair that, because you're going to need that, and you don't want that patient coming back. Use a microscope if you have it, loops if you have those, interrupted sutures. Don't do a running
37:18
suture, because guess what? The running sutures, one part of it, lacerates, you have the whole thing staring you in the face. So Michael, I see you shaking your head, yes, you're agreeing
37:28
with that. Yeah, I agree with that. I think, especially for the younger ones, they think that just using something that's expensive, like duracil, instead of opening and doing a clear
37:38
functional repair. So I think, I just wanted to lodge you on that point. There's no shortcut. You don't just make a cut and just put duracil and pray everything is okay. Yeah, always open up and
37:49
just do a primary repair. That's all I wanted to say. Astronaut, any comments? You've probably seen this too many times. Well, same a few times. I wouldn't throw minimal invasive out completely
38:05
out the window. I mean, I've done a fair amount of that and it is, and I would just say it is feasible to do a dual repair through a tube, but you gotta have the skill set. I mean, use a small
38:18
enough needle and I'd use a bayoneted pituitary rhondure to hold the needle and that works out well
38:27
But yes, but the principle you would use a minimal invasive surgery is the principle you would use with open, you have to have adequate exposure and you've got to get the job done. Right, right.
38:39
So just to remind everybody about the layers of the meninges, spinal fluid leaks with dural tears, basically you've got the dura, the arachnoid, subarachnoid space, where the CSF is, and the
38:51
last layer obviously is the pia, which was on the surface of the nerve tissue itself. This is the picture of the needle that I just showed you. But basically, you guys can tell me, I mean, I
39:01
find that the Gore-Tex needles are the best because the needle is smaller than the suture. So if you make a puncture, the needle, the hole is gonna be obliterated by the suture itself. Obviously
39:13
here are different size sutures. This was a study done by Gobrel et al. 2017. Gore-Tex sutures, repairs, resisted higher pressures Neuralon, they tend to unfurl, just like proline will unfurl,
39:26
and it's gonna resist lower pressures. So if you have, it's gotta be a non-resorbable suture, and hopefully one that's not going to unfurl.
39:37
Here's your typical suture repair, muscle patch graft. Muscle is what you need, do not use fat. Fat reserves, it shrinks, it disappears, it goes away. It's gonna result in a failure You can
39:52
just take a piece of fascia. uh, from the surrounding tissues. Uh, Michael, uh, Estrada, what do you, what do you think about that? No, I, I agree. I think the, the GORE-TEX, the
40:04
GORE-TEX SUTURE is superior for the reasons you've already mentioned. And if you can get a, if you can use a 7-0, that's, that's great. Yeah. Yeah. Well, there's difference to interior and
40:18
practice. We don't really have GORE-TEX SUTURE is available here. Okay. The second thing is anything below, uh, 5-0, most places don't have microscopes. So men's region was using groups. So
40:29
that brings the second issue. Yeah. So good fashion, Muralon and nylon 4 is what we use here. Like you say, interrupted SUTURE is most of the time. But like you said, the patch and the
40:41
principle stays the same. Okay. But it's good to know. It's good to know. All we have to do is ask for it and it shall appear. Okay
40:50
So you wanna place your sutures every few millimeters. And then if you have access to them, microdural staples can be very helpful. In order to do the microdural staples, you actually have to
41:02
avert the edges of the dura and then put the staple over that. If you can't avert the edges, you can't use staples. And just then use your interrupted sutures or your muscle patch graft is gonna,
41:15
muscle is gonna be your friend and there should be plenty of muscle around You said Durgin, same thing, microfibular collagen, non-suturable Durgin, or just putting just Durgin over a CSF leak,
41:28
not gonna solve the problem. You're absolutely right about that. Even if you add fibrin sealant. Fibrin sealant, most of these are gonna dissolve or disappear, to seal would disappear in like
41:37
seven days. And if you use Duroseal, that'll disappear in three weeks, but either of those not gonna solve your problem. The other thing too, is if you have a really hard repair You've done your
41:48
muscle patch graft and everything else. There is a sutureable derogen that you can do your derogen, your fiber and sealant, then the sutureable derogen on top of
41:57
that, and you can sew that in with whichever of the sutures you may have. And actually, you can use suture anchors if there's no dura on the side. The suture anchors, I wrote a paper with,
42:08
actually one of the orthopedists I worked with, Marco Golnick, and you can actually put the suture anchors into the surrounding bone to have something to suture to if you've lost all your dura But
42:19
then the sutureable durgeon and edge of fiber and sealant, I don't like the, you know, the wound parent, Neil Schuntz. What do you guys think about those? I think you're just creating a bigger
42:29
hole and a bigger problem. Yeah, no, I've never used that. Dr. Mago, you have any experience with that? 'Cause I think it would just encourage the
42:40
CSF to continue. Yeah, and if they're putting in a lumbar drain, guess what happens when you take the drain out? You have a huge hole that's by sitting there So anyway, this is just a picture of
42:48
what the suture is. and microfibular collagen may look like, and this is operatively actually what it looks like. You can see the sutureable dergine underneath your final layer of fiber and sealant
42:58
in here. The arrows are just going to where the sutures are holding in the sutureable dergine. Many patients want more extensive surgery than minimally invasive operations. I think as Stratus Point,
43:09
there are cases where minimally invasive procedures are the appropriate operation in the right hands with the right surgeons doing it who have experience with it. I think it's a bad operation for
43:21
those who are inexperienced and just trying it out for the first or second time or whatever. Also, if you have significant stenosis, let's say at the four or five levels, especially bilateral
43:32
decompression, the coronal hemileminectomy, you take off the laminar on both sides, the spinous process in the middle, we went through a phase decades ago where you try and save the intraspinus
43:42
ligament and supraspinus ligament waste of time, doesn't do anything different Just have the adequate exposure in this way. Under the microscope, you can actually angle well into the lateral recess
43:53
with your operative microscope and do a better decompression. The multi-level laminectomy, good thing to do. You can do a coronal laminectomy, coronal hemilaminectomy above and below, full
44:04
laminectomy in between, medial facetectomy for aminotomy at the different levels and do your adequate decompression. The basic thing that I think we'll agree on is you have to see what you're doing
44:14
before you're gonna do it. And then hopefully you're gonna do it well
44:19
Okay, so here's just some images of it. We've done a multi-level laminectomy. This was like L3 to S1 disc herniation at the four or five level. When you start with a huge disc, you often can't
44:32
see that inferiorly exiting nerve root. Am I right? So you actually, you have to start your dissection with your pen field and you're really going very superior and you're going lateral. And then
44:44
you're dissecting, you're dissecting, you're dissecting, you're getting more and more disc here. sort of teasing that out, okay? And then at the end of that, oftentimes is the first time you're
44:54
actually gonna see your nerve root. Now, if you have the benefit of having intraoperative SCP and EMG monitoring, it may also give you the benefit of that to prevent you from going right through
45:05
the nerve root while you're trying to take out a disc at this level. And I think we've all seen instances where that was inadvertently done.
45:13
Spinal abscesses causing permanent deficits Some of these patients, prior emergency room visits, discharge, no labs, no studies done. The same thing that we were describing for the disc
45:25
herniation. Presented to the ED, weakness, saddle anesthesia, urinary retention, labs, heart-dressed MR, diagnosed the lumbar abscess. This was actually a specific case where it was a young
45:37
person, and this was the story. Unfortunately, the surgery was delayed because of this Why was the surgery delayed? because the surgeon decided, I'm gonna just schedule it in the morning. This
45:52
was after the surgeon already delayed coming in for several hours. And just for those in the United States on her depositions, she actually admitted that it was several hours before she was on
46:05
her. Benedict, what are you saying? Good morning, device.
46:13
We didn't hear you.
46:19
Go ahead Nancy, I don't, you may have been directed to. Anyways, didn't do the surgery. It was delayed patient health permanent sphincter loss. And this is not the patient specific MR findings,
46:30
but this is how clear that MR was. One of the excuses was, well, but I couldn't explain her deficit based on that Mumbar stuff. I thought the patient might have transverse myelitis. And it was an
46:44
interesting instance because I turned to this person at some point and I said, did you forget about the femoral nerve, OK? You had very significant compromise at 3, 4 going up towards L2, 3.
46:58
You're getting the femoral nerve. That's going to give you the proximal weakness that this patient showed. So I suggested that this person go back and relearn some neuroanatomy and also take their
47:09
alarm off snooze.
47:12
OK, other failures to diagnose Lumbar abscesses. Just like in a quarter coin syndrome, you may not have all the features present, diagnosing spinal abscesses, same thing. You might not have the
47:23
triad, pain, fever, and a neurological deficit. You may have one or the other, it may be of different severities, but the message here too is the same. Diagnose it early, get that MR. A CAT
47:35
scan is not gonna show you these findings. CAT scan can take six weeks to show you anything abnormal. Osteomyelitis, discitis, et cetera, where the MR is gonna show you with certainly a week or
47:46
two or earlier. Do the stat operation. The earlier the better, don't come out with the literature. It's spouting and saying, Well, I've got up to 48 hours. Or, Oh, I have up to 24 hours. The
47:57
answer is the sooner the better, you're going to do that patient a great service by doing the right operation in a timely fashion. Again, an example of discitis going into an epidural abscess here.
48:08
And then here are MR images. This is the non-contrast MR. You can see tremendous vertebral osteomyelitis, discitis, just obliterated in here on the MR with contrast. You can see how enormous that
48:22
abscess has become. So lots of times these patients come in and they've had stuttering symptoms, but they shouldn't be ignored once it gets to you to get it treated.
48:35
Here is a case of a negligently performed procedure The patient was in her mid-60s. It was an L4-5 minimally invasive T-lip that was done. She had mild grade ones stenosis and flexion extension
48:51
films, by the way, showed no motion. Now, in a patient like that, Estrada, would you necessarily do a T-lip fusion in that patient? Well, I would not do a T-lip fusion in a patient like that.
49:02
Yeah, Michael, how about you? Okay. The first surgeon actually planned to do the right operation, was just a decompressive laminectomy, she actually went for more opinions and they agreed with
49:12
that. The week before surgery, the surgeon said, Well, I've got a new guy in my group. He knows how to do minimally invasive.
49:21
He then scheduled her to have surgery with the second surgeon. The second surgeon, by the way, never saw or examined the person, ever. He waved to her from the OR, waved. No hands on, no words,
49:35
nothing. He did the minimally invasive. Teal have had not done one for probably several years. He caused a permanent foot drop and a partial quarter coin of syndrome. Now, again, these are not
49:45
her exact films, but here's the typical grade one slip. Here's a typical image of a T-lift that was never needed. So a surgeon wrongly did the T-lift with an interbody device and likely caused a
49:58
traction injury resulting in a severe foot drop and the partial quarter coin of syndrome in this patient who needed none of the above. And she had to live with this permanent foot drop forever And
50:10
she was actually a lovely person who didn't deserve that. The literature actually shows very clearly that decompressive procedures are still very much feasible. You don't need to do a T-LIF on
50:21
everybody. For stenosis and even with different degrees of spondylolysicis. So here's your laminectomy above, your classical T-LIF below. This is a study that I did in 2018. I looked at 58
50:34
multi-level laminectomies, two to three levels, many of whom had spondylolysicis as well, grade one Most operative, what was my morbidity? There were no new deficits, no infections, no CSF, no
50:47
clots, no re-operations. And look at the contrasting literature or the percentage of errors seen with T-LIFs. Infection, 8, dural tears, 6, motor deficits, at least nine to 10 sensory deficits.
51:01
And we all have to remember that these complications or adverse events, actually, they're not complex, don't say complications because they should not have occurred their errors, mistakes, and
51:11
negligence. and these deficits should not have occurred in these patients. So we look at different injuries, screw and traction injuries, vascular, bladder, bowel, CSF leaks, neural deficits,
51:23
clots, traction injuries, neural injuries, more CSF leaks, et cetera, okay. So here, obviously you've got the screws and you've got your T-lift fusion.
51:34
CT of T-lift screws causing vascular and neural injuries. So here's your anatomy showing the vessels that are in front of your sacrum and here's a CAT scan showing how your screws, it's amazing to
51:47
me that, you know, you can read an operative note that said in the sacrum, I put a screw that was 45 to 55 millimeters, 45 on one side, 55 on another. So bam, you're right past the sacrum right
51:58
into the internaliliac artery in vain. If it goes more centrally, you might get the inferior vena cava, okay. And then here, you also have the opportunity
52:11
If you haven't had experience putting in the screws to put them right across the Dural SAC, you get the CSF leak, you get the quarter coin injury, et cetera. So now we're down to the timing of
52:22
surgery. So the best timing, best studies, you know, less than 24 hours, but actually the best, best study, so six hours, 12 hours, and they will conclude really the sooner, the better. And
52:34
this is the world neurosurgery study, where you almost have 21, 000, less than six, less than 12 is better, even in less than 24 hours, starting the clock from the first onset of the deficit.
52:45
And that's what, lots of times they come into an ED, you don't even know when that time was. So the best results of the early surgery, the earlier the better, and the, it's true whether or not
52:56
the patient has a partial or complete quarter coin, a syndrome, the worst outcomes date two or later, if you have a patient, you have an OR that's ready to go, You have the studies that you need,
53:08
don't hesitate, do the surgery then. there should be nothing in your way impeding you. Again, timely diagnosis and treatment is imperative for the optimal outcome. I like this study because
53:19
instead of avoiding medical legal ramifications, really what it should be is an urgency compression is really important because you wanna get the better chances of neurological recovery. And that's
53:30
what we should all be about. We're all about the patient, we're not about ourselves. And here, when I wrote this, this was more like an editorial, the sooner, the better, recommended bigger
53:41
studies that should be shortened in less than zero to 24 hours, partial or complete syndromes. And here, the definition of a partial syndrome, again, varying motor weakness, sensory deficits,
53:52
perineal numbness, urinary dysfunction. You don't have to have the complete quadacorna syndrome present to tell you that the best results are going to be done if you diagnose and treat quadacorna
54:03
syndromes as early as possible, and then that will give you the best results.
54:09
Well, thank you. Thank you, Nancy. Excellent, excellent presentation. And as Dr. McGohoo, Michael, you put in the chat that that's almost impossible. I know that their nuances involve their
54:22
issues about timely imaging studies and in order to be able to intervene within a short period of time. So any comments?
54:36
Yeah, I think I just need to give a picture of the situation. First, there's almost no pre-hospital care as of now. It's private pre-hospital care for most of the patients. That's number one.
54:46
The second thing is you said about recognition of from the primary healthcare workers. So that seems to be an issue. The other thing is the healthcare workforce. So we're still quite few and we're
54:57
growing. We're in availability and time. So it's not, I'm not complaining. I'm just highlighting the issue. Right, right. Now this is the problem. We're looking for weeks at present.
55:09
If I say it as it's the same joke that I keep saying, just imagine the Spartans at the battle of the Mopoli. We have so many patients that just keep coming and they just a few of us who are trying
55:20
to sift them through. So that's where we are right now and the main aim is trying to get multiple different centers. So locally, government centers are about three or four, but they keep growing.
55:32
That's a more better than before. About 10 years ago, it was only two centers and the service was split between orthopedic surgeons and neurosurgeons. So if you think of it that way, it's a more
55:44
of a systems issue. But in a private facility, it's possible. And with that, I'd say there are about two or three known facilities in Nairobi that can do that as of now. But with the residents
55:56
here, who most of them are going to be in that hospital, which is the largest teaching and referral hospital, it sounds almost impossible, getting it in hours. Or to put it simply, Price, what
56:09
house Koopas did,
56:12
what's the word that I look for? They checked how many people
56:17
we had, we had 100 unique visitors in the hospital a day. And from that, what 12 of them converted in a hospital that only has two operating rooms, one is elective, one is emergency. So just to
56:33
have a picture in your head, but we are getting better The more people need to hear about this, the more we get better. Yeah. And I'm sure the experience will vary across Sub-Saharan Africa. But
56:45
I guess the question is, how quickly can you get an MRI scan in the face of an emergency like a corticoid syndrome? And the other part of that is,
56:60
are there circumstances in which, in an emergency situation, with a clinical examination correlating
57:10
Is there a role for operating without the imaging studies?
57:16
That's a fantastic point. I'll answer and I'll defer to some of my colleagues who are here as well. They can give their inputs. The main issue number one is reaching the hospital. But once you
57:26
reach the hospital, if you're identified by the correct service, getting the MRI is fast and possible. However, there's a caveat. It's if they can afford the MRI. So we tend to get lots of
57:37
delays just because of affording the MRI. Because according to the Kennedomogafkin Health Survey 2017, the average daily wage for a Kenyan was about 15, 000 shillings. A cheap, that's per month.
57:53
A cheap MRI is about 24, 000 shillings. So this is someone in the back pain and you're asking for almost twice their salary. You can see we get lots of strange delays. So even though you identify
58:05
-
58:09
somebody wants to comment.
58:13
I can see some of my teachers. Some of my teachers are here. I don't know if any of them wants to comment as well. Are there some instances, Michael, where you might just do a quick and dirty
58:25
myelogram, just do a spinal tap, put in your die, get a few glitches, and then just use that. Not myelogram, that we left with Professor Samu-Nombe in his time, but you can get really dirty
58:39
MRIs. You can get 05 Tesla MRIs that we use, especially in some places like before in one of the cities, they used to only have a 05 Tesla, so many of the people here are used to using them. So
58:52
it's not availability of the MRI, it's cost of the MRI. It's healthcare financing is the issue
59:01
So there's a question in the chat regarding the indication for non-operative management of partial coricorna syndrome.
59:11
Well, there is a literature on that, and the literature shows 40 of those patients substantially deteriorate with 20 becoming paraplegic. So if you choose to use conservative care, number MRI your,
59:27
one scan should not be showing very significant fecal sac or nerve root compression That's a contraindication to conservative management. If you have a patient and they're clearly septic, that's a
59:43
contraindication to conservative management, especially in the face of infection or abscess. So if they have bladder or sphincter dysfunction, that's a contraindication to conservative management.
59:57
So yes, indeed, there is a place for conservative management. It's a very small group of patients that have to be followed very quickly The problem is, is. By the time they show neurological
1:00:08
deterioration, oftentimes at that point, they've already got a permanent and irreversible deficit.
1:00:15
So in situations where you don't have that kind of access to supervision, follow-up studies, et cetera, you should go with the operative alternative early.
1:00:29
And certainly it's important to differentiate the presence of an infection or not as you sort through that process. And the other question might be, in the
1:00:43
context of early as possible surgery, what is the cut off with someone who may be coming from a referring hospital in which there may have been a delay of diagnosis or the syndrome may have been
1:01:03
evolving for an extended period of time. Yeah. Well, actually, I reviewed some of the literature recently. And even with delayed intervention, you can recoup some function because you're dealing
1:01:15
with the quarter coin or rather than the spinal cord. So even in those instances where they may be peering relatively late in the course and it's even days later or like in Michael's case, maybe
1:01:25
even days or weeks beyond that, you can recoup some function some of the time because you're dealing with the quarter coin and it's definitely worth doing Obviously, if you're dealing with infection,
1:01:37
the sooner the better and what's interesting is like at least half the time, if you have a spinal abscess, half the time, that white counts normal, you know, Michael, do you have access to CRPs
1:01:47
and ESRs and all
1:01:48
those other procalcitonins and all these other labs that he's, you know, that all that is there Yeah, I mean, those are the patients where, you know, you're really starting to, you're worried
1:01:60
that they're going to become septic. And in one of the cases I actually presented here, the patient where the surgeon decided not to operate that night, delaying the consult for at least three
1:02:11
hours. The patient had a white count of over 20, 000 CRP in the hundreds, you know, ESR off the wall, an MR scan that was so positive. And by refusing to operate that night, the next day the
1:02:26
patient was so septic that they developed, I guess, a Iliitis or whatever you would wanna call it, they ended up doing a colostomy
1:02:38
in retrospect. They said, well, maybe they didn't really need it. They could have then operated on the spine that day because the patient was still septic from the back and still delayed it for
1:02:46
another 24 hours. So the answer is, especially if you're dealing with infection dash abscess, you really can't afford to sit and wait on those patients. Hoping your antibiotics are going to treat
1:02:58
it because either that or you tell the patient, two in the morning by the time, you know, somebody gets to this and does something about it, you could be a lot worse than you are now, much less
1:03:07
dead because the mortality also goes way up. Well, two more questions before we move on. There's another question from Professor Jimma in the chat regarding, commenting on extra-ferraminal
1:03:21
far-lateral disc prolapse. Okay.
1:03:27
Far-lateral discs, lots of these patients present with absolutely exquisite pain syndromes.
1:03:34
If you have the extra-ferraminal disc, you have different options as to how you surgically treat them. You could use a,
1:03:43
the Wilsey approach, which you jump the facet and everything is between the interspinus, the inter-transfer series ligament and fascia, and then you go right after that fragment of disc, that's
1:03:55
gotta be a purely extra-ferraminal disc A lot of them are lateral forameral. and then far lateral discs. And some are intra-feraminal, lateral-feraminal, and far lateral discs, in which case,
1:04:07
you're better off doing a full-facetectomy starting medial or going lateral. Sometimes if you start lateral going medial, you're gonna destroy the nerve root as you're trying to find disc, and
1:04:17
you're not gonna be able to differentiate nerve tissue from disc tissue. So the safest thing there is to do the full-facetectomy in order to do the operation correctly.
1:04:30
And then the final thing from Dr. Ben Muteeso is the prognosis of corticwinis syndrome and some of the poor prognostic factors for recovery. Yeah,
1:04:45
prognosis, the recovery from the earlier, the better, you can end up with no deficit. If done within six, 12 or 24 hours, depending upon what the patient's status is going into the surgery,
1:04:56
bladder dysfunction, tends to be one of the worst prognostic factors. The more permanent and irreversible really depends on did they have a full loss of bladder dysfunction prior to your surgery.
1:05:09
That tends to be the biggest factor. Motor function tends to improve fairly nicely in many instances. Sensory dysfunction with saddle anesthesia, if that was really significantly there pre-op
1:05:22
because delays, et cetera, that tends to be also one of the lesser findings in terms of permanency. It's going to be actually more prevalent in terms of a permanent
1:05:32
deficit rather than transient.
1:05:35
Yeah, thank you. I would make a comment on the question about extra-ferraminal disc. What I've found helpful is for a far lateral disc, truly far lateral, is to use fluoroscopy and put a needle
1:05:50
directly into the disc and then just extra-ferraminal approach, follow that needle straight down to the disc. But Nancy, thank you very much. This was excellent. It was very thorough and
1:06:03
comprehensive. Treaties of Cori coin syndrome and everything that goes along with it and the ancillary. So thank you, thank you so much. Oh, as always, you do an excellent job and we've
1:06:19
maintained everybody's interest. So thank you again. Okay, good, thank you Well, Michael, I think your group is up to talk about spinal cord tumors. I think you set us up. We should have gone
1:06:35
before. But at least you can tell me. Can you see my presentation? Yes, we see a screen. We don't see the presentation yet. Yeah. And now? No Oh, my days, give me one second. That's right.
1:07:03
Let me just open it directly first, then,
1:07:09
and now,
1:07:11
no, we see the screen with different windows.
1:07:17
Sorry about that.
1:07:23
Who is that? That's not me. Okay, let me see. That may have been me trying to get you
1:07:37
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