0:08 Hello, I'm James Ausman here to address the second of two spine sessions that we have
0:15 the spine session is covers some more complicated issues, degenerative disease of the cervical and lumbar spine, Introduction of new technology to solve similar problems
0:29 such as arthroplasty, answering the question should refuse decompress or do doing arthroplasty.
0:38 We introduce a faculty to you. Menstrual analyse, is professor of neurosurgery at Yes, Rush University Medical School In Chicago, Is the moderator is is is assisted by Nancy Epstein, Jose, Chief of the Neurosurgery Spine in education session, a section at Winthrop University Hospital in New York,
1:03 and long with them are five other. Experts from the North and South America have had a lot of experience in this area, though Venga Astro Ball, Who's professor Neurosurgery, Dean of the medical school at the Universidad de Cactus to Seoul and Texas to solve Brazil, Harold Deutsch, who is an associate professor and co -director This response center, Rush University Medical Center, Chicago, Richard Hinds president. I have the back the A C K center, or he is an orthopedic surgeon, and is in Melbourne, Florida, Todd Landman, neurosurgeon, private practice, and landmines spinal neurosurgery, also on the staff of Cedar Sinai, U, C L, A St. John's Medical Center in Los Angeles, and Rick Sasso, who is an orthopedic surgeon, the head of spine surgery, and founder of Indiana Spine Group.
2:07 Indiana University in Indianapolis, these people have had extensive experience with these kinds of problems, and we'll see what they have to say in regard to how you treat degenerative cervical spine disease.
2:25 They're going to first start with the cervical spine,
2:30 and you'll see the major discussion issues are going to surround arthroplasty.
2:36 What are the criteria for doing an archer? They usually should be done on young people who have degenerative disease normal alignment? You'll find some other criteria they introduce.
2:48 There's a question about whether or not arthroplasty is really work or not, and apparently they'll tell you the tenure data shows at its too, and attacked two times more than two times better than fusion, and there is less adjacent segment disease.
3:06 Is your problem with clashed in different parts of the country and in South America
3:11 there's a demand demand different demands of the community, but the key part of the the arthroplasty is that it preserves motion, so you'll hear the discussion about that. Among all these people, It's very productive.
3:29 The next area of the lumbar spine. It's harder to do. You'll hear what the indications are. They're much much narrower and hard to come to her complications. If you want to go anteriorly and looked like the consensus errors to have a girl, an actual and vascular surgeon with you.
3:48 You need experience in this area to do this, They the questions, and came up about what about revisions in the cervical spine,
3:57 duro replacement arthroplasty with a fusion. The orthopedic surgeons, if they put it in arthroplasty is replace them with different Archie pastiche, so you'll see what their discussion is about that.
4:14 What should you do are in the cervical region.
4:17 Your approach a post, Your approach, Should you do a fusion? Should you do a lamina for 'em anatomy, or should you just do in arthroplasty? Right away. You'll you'll hear what they have to say about it. I think it'll help you decide. Would you want to do in your part of the country and world Question is what's the standard of care. There
4:39 is no standard of care you'll see from these people that are all experienced. They have different approaches to the problem. We've done a lot of cases and you can't distinguish one from the other. It's based on their experience, and it also depends on each individual case, So we hope you learn a lot from this. It's an excellent session. Lots of good discussion should answer many of the questions You have. We appreciate your being here, but my name is now Alice. I'm moderating the session once we go off on her panel. Look at my screen we have. Coins are from Florida to Atlanta, Who is in L A
5:24 for Alto age, Also a rush here in Chicago, Asdrubal Jalapenos from Brazil, and Giuseppe, Barbara Gala was to join us, but he has a family issue that came up yesterday, and it will not be able to join, Not from Europe, and I'm waiting for Rick Sasso to sign on. This is a session. Yeah,
5:49 specifically focused on on options in degenerative cervical and lumbar spine disease, and and with an eye toward the newer technology, it as arthroplasty, and we have some cases that we hopefully can discuss, and they'll show where they were we can disgusted. Should we use, Should we just decompress How should we need the crash, and how do we reconstruct with? If after the decompression is time, and and these cases should be somewhat in an area, equal voice in terms of procedure, chosen, and hopefully, the panel and the audience in their participation can all share their thoughts and ideas and how they would approach these cases. I'm going to primarily present the surgical cases, Todd, who has a tremendous experience him. With lumbar surgery of this nature is going to show us Cup of cases, and will will discuss those, and
6:55 once we get started up, you're free to sending questions or if something seems
7:02 confusing, Let it snow, and also if you have, If you have a particular idea of how you would handle the problem that we're not, We're not addressing, and which ran up and share that with us.
7:17 I think that at this point there are many options for decompressing service was fine, and in the properly selected patients to the newer technology arthroplasty appears to have a number of benefits, but the key modifier is properly selected patient,
7:36 and offer any of the other panel our wing for these cases to, I, O, welcome Rick you're in if anyone has any other comments while we're waiting to see the cases. Please feel free to speak up.
7:49 Then why don't you just take some of the time. Too? How do you choose and what age groups do choose to consider arthroplasty versus enter discectomy and fusion, just as a general topic
8:01 to think that
8:04 if we consider if we consider the Id East studies, they had rigid criteria, virgin disease, one or two level, depending on the study. And if wanted, here's to those criteria, then which would also include stability the normal line, but relatively normal alignment, a good one, and so on, if one adheres to those criteria, you could expect to replicate the results of the styles which were excellent,
8:36 as any device gets out, people begin to expand the boundaries and. Start the treat patients that would not have been in the study primarily, and there are those that have shown good results in doing so, and some that have not shown such such good results and and I think that's where the issue lies now. If we completely follow the rules, I think that we would get good results, but as we expand them and and looked treat more degenerated segments less overstatements. How does that play out? Is it beneficial to the patient? No, I mean some studies have shown that there's almost a two -fold greater reoperation rate for the arthroplasty is, and can you comment on that as well as the difficulty in revising a previous arthroplasty
9:28 showing your data would would refute that the two year data that early data there was a lot of noise. There's lot of similarity to a Cbf. There are no statistically significant. Differences, but around five years as patients are followed, those two groups begin to diverge, and even more so at seven years, and the need for further surgery overall and and adjacent segments is significantly less than arthroplasty patients.
9:57 That's correct, Then the ten year follow up on the produce the prestige, Lp. The movie, See all shows statistical superiority and. At least a twofold decrease in the incidence, and then for adjacent segment surgeries, so probably two and a half times less the chance for those need of operations at adjacent levels and an index level surgeries are also significantly lower with the arthroplasty over fusion, so I think that poses a great point is you know one were confined to the restrictions of.
10:40 Placing patients within trials that are purely adherent to the Id inclusion criteria, it becomes very limiting in fact if we limited fusion to the true Fdr criteria that would be a much greater level of spondylolisthesis. We will not be using for just digits in general, so we do expand and occasions, while there were completely aware of it or not. But certainly useful and craze, because the data so compelling and overwhelming, there are some arthroplasty a statistical superiority, not non -inferiority but statistical superiority in pretty much every outcome measure neurologic outcome. Overall success, neck pain scores aren't pain scores, and so forth so in revision, surgeries are less indeed on at the seven and ten year marks, so I, I think that. We'll see more arthroplasty is an, isn't on the other plas the advocate, anyways, Maybe I'm a bit biased, but I think the data is that the data. What about spontaneous fusion. That's occurring at the level of the arthroplasty And how does that impact your subsequent decision making be that that is an entity, just as we can't get all fusions diffuse. All arthroplasty is done to the outcomes are similar to that of a fusion, which is still a good operation.
12:07 Lemme lemme ask us durable. What is what is happening in Brazil, in terms of arthroplasty circle, and then we will eventually get to lumbar. Thank you, Thank you, Darnell, It in Brazil, Where he will face the same idea. We tried to rule out a facet disease, and or supervising those patients, and tried to select properly the patience, far the the surgical options. One thing that it. Maybe it's different from us in Brazil. The device costs around two times two point five more than diffusion, so we struggled to get insurance approval for for this type of device, so I want to hear for you about Is is the cause similar than one level Fusion If you compare an Mba at the point of surgery?
13:06 We're rare coins. You have any thoughts on that question. Yeah, I think has a great point. Because in community practice, like mine in God's waiting room and Melbourne, Florida, in the arthroplasty is not taken off yet For that. That's the primary reason the costs and the literature is clear, and I know many of you at Burke contributed widely to it and have shown great results, but I will tell you what I see in the community. It is a lot of failures of arthroplasty in the cervical spine, and not the face of the device, and is not because of the theory is because of the lack of training. The average Q certain isn't train well unless they came up through the ranks of the appropriate program, And what happens is they think they can just put them in and they don't understand Center of rotation. They don't understand. Balance. His. Damn what levels are correct. They don't think about ask your process. I don't think about all the contributing factors that may cause failure. And and I think this is what happens when we have literature done by the best technicians, the best surgeons literally in the world, who can probably make any operation work well, but the problem isn't it translates to a community. Will it will it be the same thing, And I think that's only a question of training and the second point that was just made from Brazil, The the costs as the comparable, and I think it's going to get there. I think your training's going to get there. I think the cost is going to get there. As a wonderful option to the fusion events, afraid know that the actual implant itself is certainly more expensive
14:46 than in the actual implant, but not the total number of implants for fusion of your plating screws. You have the implant, Then you have the the graft or Dvm, or you use I factor or whatever. Graft you're usually by the time your total that up at the overall payment in California, and this certainly for those of you, not the United States payments differ state by state, but the reimbursements in California, and the overall payout for arthroplasty is significantly lower than it is for fusion, so we we, we don't see the reimbursement to the facility, nor to the surgeons, and certainly for arthroplasty then. Submitted for fusion
15:31 in Chicago
15:33 and Chicago, the implant costs for arthroplasty infusion is the same. The surgeon. Reimbursement is less for an arthroplasty has an incentive for surgeons not to do arthroplasty. Is if you will, and I think that you see that in in what surgeons choose to do, I think if you look at most community, the surgeons, they would prefer to do effusion. They're more familiar with it and they're going to be reimbursed at a higher rate.
16:00 Oliver record set as Wells as high, you know very critically important that the surgeons are doing doing, and arthroplasty is not the same as doing a fusion, and, and as far as the decompression in the trap of the disk space itself, and opening the foramen, Because when you create an arthroplasty replacement arthroplasty device, you, you're maintaining motion and so if? As we expand indications for a little more degeneration. There there can be
16:35 some degenerate once in a spring. Things like that that we don't tend to clear as widely for fusion. Because were watching the segment, so it's not really necessary, but with arthroplasty Because you're going to create more motion. You will impinge on those for Raymond, and so some people still have a ridicule or pains and symptoms. I am placing the device as also wrecks out at Richard says that, placing that central rotation, the proper position, choosing bone quality. Although things are a tremendous factor which are less so in that profusion so there doesn't need to be more education and training done for surgeons who who want arthroplasty, Certainly here on the west coast of California, we're seeing such a tremendous demand. Promotion preservation surgery is it's it's people come in, and they will not have a fusion anymore or if they do have to have a few really haven't explained well, So
17:39 that's my thought on that, Rick. So what are your thoughts on lumbar arthroplasty Alright then so were changing the subject here that so we ever have, because while awaiting for cases. What do you think about lumbar alrighty?
17:59 Well as their role in Schaeffer? I. I think it's tougher Venza, and I think the main reason is the diagnosis is much easier for cervical classy than lump to be the The indication for surf arthroplasty is ridiculous apathy, and the outcomes are much much better. That is not the case for a lumbar arthroplasty. It's for degenerative disc disease, back pain and boy. That's just tough. That's really really hard. I think. Though that if you look at the F, D A I to Ii trials that have been done, the outcomes of lumbar arthroplasty are actually really good. They're they're very very good, but it does not have the same traction. At least in the U S that cervical arthroplasty as
18:52 the outcomes report as well.
18:55 I haven't are also been some major complications with removal of extruded devices in the lumbar spine, including some life threatening problems
19:05 that I. I think that's another issue that a revision, anterior cervical operation is especially in someone who does cervical spine surgery routinely is is not a big deal. On the other hand a revision, anterior retroperitoneal or transparency of approach is super hard. And you're right, Nancy. It is potentially life threatening. It is suitable, really impossible at L. Five as one after you've gone through the area, at least in my experience with all of it's destructors to go back near the Iliac vessels and the octopus. The plants are very large, and I. I just in my experience with the mod idea to go back and the to the with one I agree in the neck. It's not that hard to take out a failed arthroplasty, or or. Sudo, Apt, Vs and the parrot, but it's treacherous at all. I'll fight as one. Probably maybe it Philadelphia for five, so I've had bad luck in trying to solve that problem where I can't get the archipelago device out a fuse from the back and I get marginal improvement, and I'm stuck. I don't know what else to do for the patient, but I'm not going to go back the terrorists. Five, one,
20:16 Alright, Weird Why they get one. Actually, It's not bad. You need to do a transparent approach, though you need to change everything. Need your transparent, Neil and your vat score guys have to be on it. We put the wires through a both set femoral vessels in in into the Iliac to blow balloons. In case we, we, we need to stop the venous bleeding, and it's it's a big deal. I will tell you. Though the the revisions I have done have all worked out really well, I've only done a handful, but the preparation is is. Immense, and you tell the patient that it is potentially life threatening,
20:58 or we read them alone, Referral Alpha this one revision, and explains whether they're for Sierra news, or failed osseointegration, and enter a stall are exposed, and plants and Nancy that the initial series of data when we were doing the Shar -pei to work that that was about implant. Then the failures are mostly all Father swollen. Forests are exposed, and also her tshirt form locks. That's now changed with the producers to active roles better,
21:31 but I don't buy that one is under the bifurcation of the vessels, and I think the key thing is is people who want to really be lumbar arthroplasty surgeons of kids, getting a fabulous vascular surgeon, Because all of our we abandoned the transparent meals, will we do all retroperitoneal? So, when we do an edge or a retroperitoneal approach back at alpha, Thus one, we just call the contralateral side, so are on an initial alpha. Thus what do we always go on the right? Because L four or five, That's where the bifurcation of the common Iliac vessels is located in that one always needs to be approached from the left retroperitoneal side to move the vessel to the right, so on a revision L. Five, thus one will go then on the left. I have less scarring and then able to stay under the bifurcation of comedy early action. Yeah, we do you reader. All stance, Du. Silly, Know where the orders are located. We have not placed a vascular
22:31 balloons, for. For possible occlusion at our five, S wanted all four or five, We have L four or five as extremely difficult to mobilize the bifurcation. So I turned to revise those almost the older for a direct lateral. It's hard to get produced through with the kiehl's From the outside. You do a partial core packed me there, and and also as Richard said, it's hard to get a good fusion when you have an arthroplasty device in the front that can take several times to get that to fuse that micro motion over that implant, just does not want it to to allow the bone to heal properly and our experience. I mean, given the complications that are quite severe, rest of the arthroplasty is in the lumbar spine. At what point you decide that is just not worth doing them
23:22 with our vascular surgeons. We have no deaths or earned, or any serious or vascular complications. This, the vascular injuries that are the real issues were talking about, I. I.
23:37 But are are vascular surgeon, That does approaches has done over Southern thousand. Of these is all he does all day. So is extremely calm, confident, and that's sort of the
23:51 person you need is someone like cat, or certainly under revision case, and that would minimize the complications there,
24:01 I think indications for the lumbar arthroplasty, or more limited, Vs, I think cervical you, you can. Address a lot more patients, but for lumbar, I think it really is more appropriate for the younger patients, for some on their twenties or thirties, who's going to have a long lifespan, and for those people, I think that gravy that the benefit outweighs the risk my found that once you get in your fifties and sixties and patients don't do as well as the arthroplasty, they've got more for said arthropathy, and they've got more other issues going on, so it's really limited. Patient is really candid, and most of the patients that we see are are going to be the older patients, so, but for that certain patient who is in his thirties and has severe degenerative disc arthroplasty, think has it a significant advantage over effusion?
24:50 Well, Harold. I'm
24:53 in my fifties, I have three lumber protests in my back, so I have zero pain, so so I don't feel that old. When do I think that the fifties upper limit and I? I haven't done them and people in their fifties, and I think that it. It's a special patient. I mean not every patient or fifties is an appropriate candidate, but I mean certainly in your fifties, you're probably still a candidate. I'm glad you practice what you preach, taught.
25:22 What's the role of arthroplasty in Brazil. Lumbar
25:27 lumbar Arthroplasty is less than Sarah go to protest. The main reason is to find the right patient for the lumbar arthroplasty, So patient selection is the key for lumbar spine and I. I see that is not easy to find the right patient for the rights surgery in lumber. I see easy to to define for cervical spine, but not as so is it for longer is fine.
25:59 I saw Cervical arthroplasty is more more in Brazil than lumber is spy.
26:06 Okay now, Since we talk about Ai Revision lumbar. Let's move to Cervical, which I agree is fairly straightforward, but but the questions are
26:17 you know, would you remove and arthroplasty and replace it with another arthroplasty? If so who is that patient, and if you converted to effusion? What are your results? Do you think that it really made a difference? Those of you that have done so any any takers to those questions, Cheryl, all answer of have experience
26:42 with revising arthroplasty and Ashley, too to answer Nancy's question from earlier was or what happens when the arthroplasty goes on to order of fuse, and what we always say is. The worst result of an arthroplasty is the best result of a fusion. After your adult with the same result, so that an H one.
38:56 During an arthroplasty, an older person, maybe someone older than Todd
39:02 is a good idea, like a sixty year old, a seven year olds, that may make a difference between deciding a seat as our pastor Effusion, Azzurri. Will. How about you?
39:14 My opinion is besides city, I like to refer them flexing the in extension X ray to understand the mobility. And if there is a loss of mobility may be indirectly, I can have her face at our property. I like Joe to see if there is air in the face at join, and did the how hype is the space. The disk space is lower than fifty percent Collapse Made me is not an option to have arthroplasty and those patients with Opie A. I prefer fusion and neck pain. It's an extreme for sectionals Is not the only four patients. So to have a patient with connecting acting primarily are secondary to surgery. It. My my first option ends Eco motion is try to find dipping sauce with injections like reexamine and and rehabilitation, and after after I know the patients psychology. Evaluation and everything I tried to do something with surgery, and maybe. My. My. I'm very prepared for fusion. Those patients. Let me let me switch. I'm going to tell you I had a spare case in case we were short on time, and it. It's a lumbar case in it to the forty five year old person with single, just L. Five, S one collapse, axial back pain fails everything, and it's got. Really good,
40:56 favorable sacral. Slope. Everything looks like it's teamed up for an arthroplasty, but on the sea on the M R scan that the sets look okay, but they've got fluid in. What would you guys think about that
41:13 city shows no arthropathy? They're the only assets in the whole spine in the whole lumbar area, but they got that have fluid in.
41:22 I might block them to do facade blocks to see if that's as a generator of their pain. A lot didn't change anything. Then I would arthroplasty that patient Terry Martinez, a huge series of those, and he really believes that when you offload the open, the disk space offloading overstressed facades that you'll see he show some excellent films have resolution of fluid as well as arthropathy improving. Over time, you know, we've seen others do the other go the other way as well, but those are usually improperly placed devices, so I wouldn't move arthroplasty or group. Anyone would views that patient, while fluid on on the amorite, me off the times indicates it's going to be instability, and I mean I would definitely get flexion extension views, and be very vigilant as far as those being done correctly and make sure there is no spondylolisthesis because that would be a bad candidate for an hour for classy. But assuming that there is no spondylolisthesis and it's it's a well -done flexion extension found then I think arthroplasty E. Okay,
42:31 what about Gaudi Uric acid crystals that may be vocally involving those facet joints. There are rare cases of that, but
42:40 I haven't experienced That are so
42:43 rare coins. Would you use that patient or do arthroplasty if you were going to do something, I think it depends a look at the age. The dynamics of the patient their expectations, the inability to really easily cracked a failed arthroplasty, but I'll talk with a patient about what happens if the artifices doesn't work. What happens if the fusion doesn't work out that bringing into the discussion on issues like that, because five one was particularly treacherous, postoperatively less you have, as we talked about, these really are expanse of opportunities, and it sounds like we got a the orders and spent the early acts. In preparation for revision surgery at all, he tells me we're in a place where only revision should be done in In those places are not routinely, so he the community more likely a fusion at this point, and I would do the same thing that was discussed. I would inject Mit, even ask my pain doctor, your radio frequency ablation of that cassette as a secondary
43:47 method, determined that was causing pain or not, for a pretty graphic phenomenon. And I'm becoming you might later part of my career much more inclined to get preoperative cities. Because I have, and I've been let down by property. Enter I alone in several patients were, If I had just at a C. T, I would have found other pay generators that would have changed my surgical decision, As there is a risk of well that I, the service. The whole surgery failed versus the risk of a cat scan in some patients. Okay, that sounds great, Rick sasso fluid in the joint. Everything else looks perfect for arthroplasty.
44:27 Yeah, I'm scratching my head a little bit about that Vance. I. I. I. I liked the the question of what the facade injection that you're telling me that was negative, So I, I, I dunno. I think you know I'd I'd agree with Todd that he just sort of ignore Ignored. Maybe that's just overloading the facades from a primary. At disc pathology and then, if that were the case, if if all the other indications were reasonable for for an arthroplasty, I think that'd be fine.
45:00 Go Who is the patient you would not do in arthroplasty on
45:06 if they had significant for set pathology. I mean more than just fluid, and if you know if they had significant degenerative for set disease, okay? How about the capability of removing the bear sized lumbar disc herniations through the entire approach and then arthroplasty?
45:26 I like that absolutely remove many that were a huge reason behind the body with the right angle hook. You can pull them right out and anteriorly. Have you ever been wondering and the? Very rare color coin a syndrome with the massive herniation if we don't do a disservice going posteriorly because you're trying to retract already incredibly stretched nerve roots to pull out of huge fragment entirely, and it seems
45:58 it might be better to do an anterior approach and withdraw that huge variation immediately the way web came out his back and.
46:09 And then arthroplasty refused that segment in general, but but that's just the bottom and having, Because it seems these kind of climate syndrome patients never do that well with large herniation, but you can also leave room of your targeted fragments are very large, and even behind the body,
46:27 anteriorly done it many times, and even revision herniations that way, so so how would we walk me through the? In the decision -making process of a big disc herniation some collapse of the disk space?
46:42 Am I going to do a micro disc, or am I gonna do have you know anterior decompression and arthroplasty With how you done differentiate between issue? I would always try micro discectomy first and the, even if the person has significant back pain, the micro discectomy If you have a large desk can't get That may help. I mean that's a much less invasive surgery. I mean you're talking about reducing complications. Even though there's Iran. There's really do exist, so I mean I don't think there's much to lose by trying a micro discectomy first. If that doesn't work, you can always do an arthroplasty later and that'll be my recommendation for the patient.
47:22 Yeah, My, my opinion is that if the clinical presentations is sciatica, just nerve the compression, that's Is the is my idea, and and if later you started with back pain is something new If we can have it like a topless your fusion, but a treat just the problem, not not give them more prone to the patients, so if she just sciatica just the compression, and that's it same day, go home and and no pro, how bout will move up the cervical and lateral disc herniation.
48:01 It could be treated your post, your discectomy emotions spirit operation or enter decompression arthroplasty? What what would how do you guys shake through that
48:14 I personally prefer the anterior discectomy in arthroplasty?
48:20 Want to do it, and you have to get laurel an a posteriori priority. Even a micro. You know you're often shaving a little bit of the medial for surgery. Disrupting the capsule, so I've seen some of those later have some bridging bone and get some arthropathy and that facade, which later may not make them a good arthroplasty candidate, when they have a return of neck and arm pain, so I, I tend to to just stay away from the post Earlier Approach is if I can do,
48:56 I, I just remember I had our conversation long time ago with Ralph, our.
49:02 And he said, I just don't remove a real believe in removing the patient from the disease. So when you go in the back, you're removing all this normal anatomy to get to the disease, which is an anterior disease problem, and hence he came up with the venture operation that that he advocated so well, and I always stuck in my mind that discussion, and so I think that that no dust diseases enter or disease. There is though a torment for literature that that which suggests that it validates a post. Your approach is very effective and durable, and in the right patient your answer, I had, I had a micro discectomy on my neck, myself poster micro, by two mountains, and another great, and three months later, I returned, he added, and the fusion to the before arthroplasty. I have Northrop last year about that. When I broke down on the matter adjacent levels. I have a circle or an artificial June. So Yeah, it worked fabulously and painless, preemptively. Yeah, but I think there are many other patients who have benefited from the lemon over and anatomy, and they didn't have to have a fusion, and it was a pretty durable. It depends you know, it has to be a very lateral for animal disk in order for this to be the write operation. I think.
50:25 I have no question that works. I would say, check nine to one in terms of the number of Hpd apps versus post your parameter must be do what I do, and I think that the pressure from monotony is great for certain patients, especially C seventy one. If someone has a true radiculopathy and ramble narrowing, it can be great, but it's just not that common patients we see Mostly has you know a lot of neck pain and other issues in a central discrimination? So I pick it is a great surgery, but it. It's just not that comment about the patient that needs it
50:59 breaks. Also do you use post your breathing on me?
51:05 I I do post your from anatomies, but I do way more anterior operations for cervical disc herniations and I think that one of the fallacies Vance's. I mean so easy, you can certainly decompress the nerve repost dearly but if you think that you're going to decrease the end. Incidents of adjacent level problems. The studies do not do do not support that, and you're gonna have just as many adjacent level problems with a post your non fusion operation. Then you are from A from an Ac. Df. I think one of the big problems. Though is we don't have really good data on post your. From now we have these huge retrospective studies. You're right. Lots of people have done post your framed armies, but the science is not really good. And end this study's small studies that that have looked at anterior versus posterior anterior seems to be better.
52:01 Isn't found myself. Now that very few senior senior surgeons may be doing the past year approaches, and they know how to do it, but a lot of the junior surgeons don't know how to do it. I, I think there are many more people comfortable with the viewer. Approaches. Yes, How about a foray monotony in the cervical arthroplasty patients who have one? Persistent ridiculous pain and nothing else
52:27 reclines, I think I would depend. You know the classic pop places, Islamic mechanical problem with inadequate reflection of a, E O L. And Anthony A post. Your comment makes perfect sense to me.
52:43 How about an interior frame anatomy? The job procedure. Any comments on that? What I do the operation, but not usually this for the arthroplasty patients, That and they have not had enough resection, and I actually do anterior incident resection alongside the arthroplasty without explaining it,
53:07 and Oh,
53:09 there is a role for them. I don't do that primarily. Well.
53:15 I think it's about. Time or session should and I apologize about the slides. Any anyone have anything else You want to say a quick comment or something you think's important to to a to the audience before we move on,
53:32 I think he did a great job, Vince. Under difficult circumstances, the job coming up the great questions without having afford it. The hell or who has continued to try to join his effort to
53:48 any any of you for for donating your time and expertise to discuss these, and hopefully some of our audience will find this a discussion about it so. Thanks again, super fun, then take care of you for.