0:08 Hello, I'm Jim Ausman. I am here to introduce the first of two sessions. We have dealing with problems of the spine as they affect the spinal cord and nerve roots. This comprises a large percentage of our practices all over the world, and I think it's important that we know where we stand, we understand what we're doing and one of the ways to do that is to compare what the experts do. Where the people with a lot of experience to people in practice can have a lot of experience, so we want to know what they're doing and compared to what we do,
0:46 so the way we are doing this is to run a session, Sir discussion sessions. We assemble experts from around the world. We present them a case. It's the same case that you may see every day or are commonly in your practice, and we asked them how they approach it. You can find out what they do
1:05 what considerations they have. What are the things are worried about and you can compare what you're doing with what they were doing?
1:14 So we think this is an excellent way to learn. I want to know what other people are doing. Want to learn from them. Maybe they can learn from us. So I've asked to Langston Holly to moderate this session. He's done an excellent job for us in SNI Digital in many sessions He's professor of Neurosurgery and Orthopedic surgery at U C L A medical center.
1:41 He'll be assisted by Nancy Epstein, who's the editor -chief -in of S N I, and also heads the Spine education section of Winthrop Hospital in New York,
1:54 along with these two people there for other people who are widely regarded around the world,
2:01 Michael Failings from Toronto, Canada, Professor Neurosurgery at the University of Toronto.
2:07 Silver go Guava professor and chair of Neurosurgery Italy, clinic and Boston, and also a Touchy University Medical Center In Boston, Praveen, Most luminary
2:19 was in San Francisco, at University Of California At San Francisco, you Csf professor of neurosurgery there, and we have Jeffrey Wang, who's an orthopedic surgeon, Head of a professor of orthopedic surgery and neurosurgery at U S C Medical Center in Los Angeles.
2:37 Thanks then has assembled
2:41 a number of cases. Two of which we'll get to today.
2:45 The first is lumbar involving the lumbar spine. The sections of cervical spine lumbar spine problem is a problem you see all the time
2:54 it spondylolisthesis, It's about a grade one doesn't appear to be much motion, but she'll tell that from the images
3:04 in an addition. Or spinal stenosis at that level
3:09 and the patient presents with symptoms of spinal stenosis has failed all medical therapy. It's I think he needs surgical therapy,
3:19 and we will see from the experts what their approaches or
3:23 should you just to decompress of laminectomy, Do you do a wise decompress of laminectomy?
3:30 Do do in about a fusion to do a lateral fusion refuse of hiset. If you need any fusion?
3:40 So these are questions we face are Rea, What do you do? In an older people for older people, how extensive a surgery do want to do?
3:50 What are the complications you have
3:53 If you don't fuse it, You going to fuse it later
3:58 so they'll answer all these questions
4:02 and I think this will be helpful.
4:04 A second area. Langston going to present is going to be a cervical spinal stenosis with Mile apathy. Multiple levels of cervical spinal stenosis patient has a mile apathy with spasticity beginning to get symptoms in the arms.
4:23 In addition, there's a.
4:28 Well, gorgeous below this the last level of stenosis? What's that? From what do you do about it? How do you work it up? How does that change what you do?
4:38 Should you approach is anteriorly
4:43 to a graph to fusions.
4:46 Should you do a? As of cervical laminectomy, How wide you go? You go out and do for him Anatomies
4:55 is a patient going to be stables. You need to be fused.
5:00 Do you do mile a plasti?
5:04 How does age influence search? How does medical health influences?
5:08 So these are common problems we see every day
5:12 We want to see how other people do it may seem if they do it the same way, daughter. I have differences and how those differences things that are significant
5:21 is what they do things that I can do in my country,
5:25 so I'm sure you'll enjoy it. That's why we have these sessions or discussion sessions.
5:32 It's time to learn where other people are doing ask him questions, so we have a panel of people are being asked questions,
5:41 and we think this is an excellent way to learn, so we hope you enjoy it. Thank you for coming. I,
5:49 we will then not have a second session later on more common problems in the spine, and we will see what's being done. Thank you, well, Welcome to the spine roundtable case, discussion at and Holly, the moderator, and I'll be joined at which up by Nancy Epstein was going to be our assistant moderator in our faculty panel of Michael failings, Zoega, Gowalla, Praveen, Romany and Jeffrey Wall.
6:20 Suitcase one. Sixty five year old male with severe bilateral lower extremity pain.
6:27 I said was standing and walking. The painters. Really was sitting
6:32 there. A guy. Percent of the painters isn't a legs and twenty five per cent in the back. The patients neurologically intact.
6:39 He did P T for several months, which didn't help, and you can see on his M R. I hear
6:45 that severe lumbar stenosis at the Alpha five level with a grade one spotless thesis.
6:55 Langston, What about the additional stenotic findings above that level that your sale will happen tomorrow?
7:04 And then at then you can see on the actual view at L. Four or five, We've got severe stenosis most. A hypertrophied leg amount of flavor them, as well as Africans to set joints and levels above fifth, relatively mild stenosis on Yasha, So really, it's a symptomatic of four or five, and then flexion extension views demonstrate a grade one spondylolisthesis at about seven millimeters that does not have any sort of instability on flexion and extension,
7:36 So now we come to the treatment room and I'd like to begin with Dr. Zo mobile wallet. The article was published extensively on this and had a landmark article in the New England Journal of medicine, A regarding this pathology.
7:51 Thank you. I think he likes dinner, and thanks to the organizing group for A are making this conference possible. This is a. This is a a great case to start for us by a discussion, and I think the fundamental question is diffused or not diffuse when you're doing a decompression for degenerative red wine spondylolisthesis. And I'll say at the outset that I think most of us would agree that both options, a decompression alone and a decompression with fusion are very reasonable options for this patient, and as I saw the flexion extension, images with no motion, and as I see that this is a single level of stenosis that the set joints did not have much fluid in them. I, they were hypertrophied as you say,
8:43 but there is a disguise here that's greater than seven millimeters and I would go with the results of a randomized controlled trial for a single level grade one spondylolisthesis and degenerative spondylolisthesis, and say that the optimal treatment for the sixty five year old. What a a single level interbody fusion with pedicle screw fixation and decompression. I wouldn't personally do that, says a minimally invasive case. A minimally invasive, A T lived in the L. Four and L. Five level. I say this, though recognizing that if a patient desired a decompression alone, I think it's reasonable I would
9:32 counsel the patient that the. Likelihood for a subsequent need for a fusion would be about thirty percent over a four to five year period, and that's an acceptable option for many patients, but for me and my hands, I would say minimally invasive, L. Four o five at eleven decompression for this patient and do you feel the need that it has to be an inner body fusion a patient at this age with this presentation? More of a neurogenic claudication versus let's say an isolated L for ridicule apathy with a was thesis. Is it isn't mandatory. There's an interbody fusion. Know Lex's. I would say it's not mandatory. That would be my preference based on experience, but I think that a pedicle screw fixation with poster lot of fusion would also be very acceptable option in this station. I mean, along the lines of a license talking about, I mean, aren't these patients when you do the interbody fusion. They're subject to traction injuries, and the rate of neurological deficits when you do that, especially since the canal in this case is so narrow, I think Nancy what they have to live. That that risk is very very low. There's not much nerve attraction at all and most of those cases, I think as you look at this case, probably there would be minimal to none.
10:56 So I think that there's good data that has come out of the equality outcomes database on the complications associated with the interbody fusion, which is very very low, and so I, I, I recognize that it's an extra step and I think that we need more long -term data to understand
11:19 which patients fuse to successfully, but, but I think that the placement of an inner body. I have fusion. This type of patient would be appropriate. Net. Now Michael. Up there is a group Id in Canada. Rochman research group published on a multi center study in Canada, where they look at decompression alone versus fusion for spondylolisthesis, great wine, and they found for their study that it was really roughly equivalent in terms of the results at any thoughts on that Canadian study that makes them your colleagues may participate in, Yeah, so those from the sea, sorry.
11:55 Nadiad the registry 'em are the kind of him. In general. I, If you look at the short term outcomes at about a year, probably in most situations, it's roughly equate. You know it's roughly equivalent, and then I think the challenges here though are to try to that to really figure out the predictive classifications of these grade one spawn me, so just calling something. Grade one once found he doesn't necessarily differentiate between those that can be treated successfully with decompression or those at my require a fusion in zero alluded to the disc height might be one. This one is a bit. You know kind of collapse on the presence of the eucharist. Significant mechanical pain. I think if there is movement, I'm deformity on the dynamic film that I think would certainly cut up of push you toward. And the fusion, my accreditation pigment, so I would say yes, In general A Canadian, see some results resemble those of the Scandinavian study that was published back -back -to was Zoe's trial in the New England in the New England journal, but again those are short term results, and not everybody with a grade one spawn the the same Yeah, Yeah, and just to amplify that point. The the results and the and the and a slip study a single level raid once Bondi for decompression and decompression with fusion. What are the same at one year, and it was at two years that there was a superiority associated with those patients who are treated with fusion, and the superior result was seen it two years, three years and four years, so as durable. Right, you are one of the factors it's been looked at, in addition to the railroad graphical ones that that you both mentioned is the relative ratio of back pain versus leg pain in terms of what the patient has a nancy. Any thoughts about how that impacts what you would do well. I think that you know here you and seventy five percent like paying twenty five per cent back pain If you have somebody who's you know more fifty fifty, if a different range, and. I think that you know one of the things that you're an expert on certainly lacks in is minimally invasive approaches, and even with open approach is here if you're using microscope visualization, and you're adequately undercutting the facet joints on either side. I still think the pros of a decompress of laminectomy alone have to be carefully considered, especially in patients with other major comorbidities, those on aspirin plavix, eloquence, whatever with the requirement to go on. Anti platelet medications that that's a different population that you may be dealing with, and also we should have a discussion of poster, lateral fusion pie, as well as postal, lateral insight to versus instrument infusion. Yeah, Yeah, and I agree with you about your point about 'em I, It
15:01 this to be losing stability is probably the biggest reason why these patients will fail, as as others have surmised that the. The possibilities of maintaining some of the structures, the super spinal ligament, interspinous ligament, Some of the ligaments capsule ligaments, the contralateral, for. Set a joint by doing an Ama as approach. You are able to save some of these important structures, and that in some patients, you may be able to prevent slip that would have occurred if you did a traditional midline approach, as I think that that's something that has been looked at Jeff. What are your thoughts and as an orthopedic spine surgeon? We've kind of got you outnumbered here. What you spend so much time with us that you're kind of one of us. Anyway. What what what what are your thoughts? Yeah, so, first of all you know, I agree with everything that has been said, and and I do think that I would probably tend to lean towards effusion here, but I, I would say that if you're trying to figure out the ideal candidate for doing a decompression alone. This case comes pretty close to that, because on the flexion extension views, you don't see a great deal of motion. There. There are a couple of things on this case. Though that I think would maybe push me one way versus the other. I think number one is. I'd want to look closely at their symptoms and I agree with Nancy when she says at your portion, Most of the paint being the leg pain for me were deemed. He compressions only Fail is when they have really bad for animals to gnosis, so so if this patient has. The not so much back pain, it's mostly neurogenic claudication. Which I would add atomic least is the central canal. Then I think doing the decompression decompressing the central canal without effusion is something that can easily be accomplished in this ancient, but as we all know, when when there's that spidey, you get that for animals to gnosis, and so, if this patient as elf, word, nerve root symptoms, or any elf or weakness, I think that the disadvantage of doing a decompression alone is that I, I can't clear the foramen as well. If you're doing it, Amyas approach, you get the contralateral side better, but the ipsilateral side is a little bit worse. The other issue. If you look at the the cross -sectional view. When you look at the face at joints, they're very sagely oriented, except when you get towards the top where you get that transverse part and so here is where I think the approach makes a difference. Because if I'm doing it am I asked Approach I can clear the central canal without taking that that part. That's the transverse part. But here, if you're going to do an open approach, and as you said, likes and taking the interspinous ligament, or maybe undercutting that for set joint, and if you're cutting half that and off, you're left with those sagittal assets, I think his patients more likely to fail in the long term, and I think the last thing is when you look at the x rays. There's almost a bridging osteophytes Alpha five, s one, right, and so so it's not a complete fusion at one five us one, but it's a. I think it's pretty stiff at all five as one. And so you're starting to get some adjacent segment forces that might tend to cause failure down the line, and so for me, it's more about the symptoms. If there's frameless stenosis or nerve root issues versus neurogenic claudication have to set joint, So for me, it's how you do the approach to the decompression and then I just kind of would have to warn this patient that if I don't do a fusion, there's all right. This is this could be a product of some adjacent segment disease from the all five us one sorta out of here yet. And I think what I'm hearing is the same thing that that so sad Michael said earlier. Which is it's not all about grade. Once Fridays. We do this great. Too. We do this. It's there's a lot of individual characteristics for each case, both Raina graphical and clinical that you need to look at for each individual patient before you make a decision, and so prevent I know that you've published some the National Neurosurgery database on this and and I, I remember when your presentations. Where you looked at, I think was octogenarians. I. I can't remember what the age cut off was where it seemed as though the rest of benefit ratio room shifted towards decompression. Alone were ready to congrats find that age, and and once again it's all comers, but I do think it gives us a little bit of have kind of a an overview and something to look at. When we think about this. I think that's a great point Langston. You know. What I can say is Nancy brought this up earlier is that not all patients are treated equal, Because not all patients at the same comorbidities, So if you have a young healthy person who has a tremendous amount of back pain, that's a different individual with the same x ray than someone who's eighty who has primarily nearly neurogenic claudication symptoms, and has you know cardiac comorbidity pulmonary comorbidity, or whatever the other comorbidities that they have. And so and you also have to judge and difficult to do this in any study, But you have to judge how active is your patient is your patient? Someone who bicycles and does triathlons on and really stresses their spine. Hers your patient primarily a sitter walk around the house, kind of person who really doesn't stress their spine, so there's going to be a lot of individual nuance. Here. It is true that if you do an interbody fusion, you know as your age goes up, risk goes up, and so perhaps with those people we don't want to do at the age. Eighty, you know a big extensive fusion operation. May we just get them off the table and in, Resp?
21:11 Yeah, the app, absolutely, and the question I asked earlier was do in terms of you know inner body versus, not, because. As as as I recall, so your study, The one that was published in New England journal, That was that was was a parameter. The poster. Lateral fusion was not necessary to do interbody correct. That is that is correct. Yeah, All the cases in that trial were pushed. Allow fusion only her body these. Yeah. And so in in my practice, you know older patients. You know that I deem necessary for a fusion effort at first from the local, like this are frequently still do. Post your lateral in terms of concerns about their own quality, putting something in the interspace with the endplates, possibly subsidence cages. Because the you know the task you true, poster Lateral still works well in certain people. And so I'm not shy about doing that in older patients, and I feel really new to fusion, and and and also we have to be wary of cost in today's environment as well and so if if the cost is is cheaper, but the procedure is equally efficacious than we do have to take that into consideration Langston within, can we interject one question that I just saw on that I think would be irrelevant, Clean the audience question, Nancy, Yes, Yes, please. What is the experience of patients who were initially decompressed with no interbody fusion, returning with Lake pain meaning? Would they developed pyramidal now offering, later on,
22:47 so I can speak to that a little bit from the data that was generated in the slip study and the patients were treated with decompression allowing who did well did did great. And in fact, their outcomes were equivalent to the patients who were treated refuge, However, the three three per cent of patients who returned for further surgery, the majority of them had mechanical back pain and development of greater spotted, lowest thesis, as opposed to developing pyramidal symptoms at the at the nerve root above. And so, while I can't say that that was something that we looked at, in particular, the incidents of the development of delayed for animals to noses in patients were treated with decompression now was small, thanks Junior. It also been studied, I know Harry her coates in the early early early days, you know had looked at and and correlated the fact that the level of progressive post operative slipped did not correlate with recurrence or recruit essence of symptoms so. Sometimes the radiographic studies have very little to do with the clinical presentation. You going to comment about that. Yeah, That's a great great point. There. There were patients in such study that had progression of all thesis without any symptoms, and without any change in their overall health related quality of life scores. I think that's absolutely correct, but those patients who did develop mechanical back pain and symptoms. Almost universally had a change in their spondylolisthesis and also incidentally a change in their angulation on flexion and extension, strongly, suggesting the development of Adelaide instability, and further those patients, when fused, and all of those patients who underwent re operation in the slip study had interbody fusion, done. All of them saw improvement in their health related quality of life.
24:57 The thing can I just interject a question that might be of interest, and that is what do you do when the patient has a pseudo arthrosis from one of these procedures? Especially after a T live? What's your approach?
25:11 Anybody want to take that up? Jeff? Do you want to go for that shirt? So you know if this patient has a pseudo arthrosis, you've done it in her body and you put in pedicle screws. Yeah, I would. First take a look and see sort of what has failed, right If it hasn't failed, and if failed, the interbody space in the screws are loose. A lot of times. I'll just go anteriorly and take the cage out. I'll get a big structural graft, and even the screws are a little loose in the back. You still get that tension band. If you jack them up and and distract the deceased, and then I'll typically use you know on lable B, M P used for the anterior interbody fusion, which typically gives them a pretty good healing ray, and that's provided. It's really back pain. It's you arthrosis with mechanical back pain without any like a recurrent neurological stenosis or neurological symptoms. I, I think if they get a pseudo, and they start having neurologic symptoms, and they were incompletely decompress then you probably would have to do some type of poster decompression, but also for like in these older patients, where they failed on the on the initial case, when it was urgent case without a scar tissue going back in there and just doing the same surgery post your laterally probably has a lower rate of healing. And I don't feel comfortable taking the cage out from the back, so so typically I'll do some at least in anterior, an immediate nature poster. If
26:29 I find that I find lightweight, or for me, and since Maddox Tudor roses is extraordinarily rare in a situation like this, but I think the issues here then I'd be more worried about it wood or something you alluded to dance at the outset. Is the adjacent levels and there's a lot of spondylosis the day level? So we have one area of vertical snows of work by, but you know there is a record of seasons, The Greek three quarters some early for set to end changes, and and I just am interested to see you know what the faculty would would advise the spatial, the likelihood of requiring further surgery with or without huge in in end or have any other tricks at a mite. Are you a lover? When I you? In this pic? I would do a single level decompression Antigua for pedicle screws. I do this remedy open approach in a combined glyph with a postal route fusion that I would undercut the
27:34 I I Michael. That's a great point. I pretty much do exactly what he had ally. I do have minimally invasive, four or five, T live. I would also undercut at the El Rio for level two. I get that level decompressed and and generally have had pretty good results with that, and I typically on the contralateral side, too, Where it placed the cage. I'll do a mini open and of the sub fusion to get the most reliable fusion. As well, Yeah, Yeah, that sounds great, well, I bet you the audience is chomping at the fed. You tell us what they with you. So Mike can we pull that up? These are our audience response and give them a kind of a pretty simple set of options here now Langston. While that's coming up, I would do a little bit of a different approach. Here. I would actually do an open T Levon this case, and undercut the level above. I think it's just quicker faster easier to decompress it That way, get the pyramidal distraction with the interbody cage and then prevent having to come back immediately from the adjacent segments. Faster on and off the table. I like to do. Am I S T live, but not any case. When the stenosis is this bad, The adjacent levels already started. Have some troubles, Sure, yeah, and and and I think that that's also a great approach, and and the the nice thing about this type are cases. I think that everything that everyone talked about ranging from even a simple, am I as decompression to an open fusion could potentially work in this in the case, so somebody to be have our audience response it. If we don't that's okay. Just let let me know. Yeah,
29:13 Okay,
29:15 Yeah, I'm sorry that I. I. I didn't click the right button and and I stepped away for one second, so if you want to
29:23 well while we're winding roads, so one on what sexual make do we have it, just just so we know if not we don't currently it, so maybe we'll move on and we'll get the moment, but let's let's move on, so we'll move on to the I to the next case here, which will be case, too. And so this is a forty six year old gentleman with spastic gait and he's really getting worse over two months. He now needs a cane, and he is on his way to a walker. He's got some mild hand in coordination problems, and he's got problems with his bladder, control his urine and sexual dysfunction and his amorous over there on the left, T two sagittal, and you can see, he's got a pretty severe stenosis at sea six seven, as last five six. He's got a pretty profound spinal cord edema to the point where the neuro radiologist who read the film's said that he could not rule out intermarriage Larry lesion, With this An examination. He's got five out of five strength at all four extremities, except for or five right intrinsic hand muscles. He has little hand numbness has got brisk reflexes, and all four trimmings, He's got a positive Hoffman sign. He's got Province skippy. And he's got Claudius as well
30:42 and the axial views are what you see here on the left To see five. Six were at the disc herniation as a centric to the right and causing pretty significant flattening of the cord, and then at six seven, it's much more broad -based wet, but very severe compression, and you start to see some of that signal change which is located behind the vertebral body of C Seven
31:07 so. That he had plain x -rays flexion extension, or you can see that an extension. He's got a very nice lordosis. He straightens out a little bit in a neutral, and there's no been no evidence of any instability on the dynamic films, so I'd like to get into the management now and we'll start with Dr. Movement. You need to tell us kind of how he sees this case or Langston. I think it's interesting that the court as a good expanded to three four. At C seven, the court has been expanded so I might start off getting a contrast, enhanced amirite, serve a goal just to make sure that we don't have an intermediary lesion there that I got to worry about, so if there is a great point on screenplays where people and still they did that, and it has this very patchy enhancement. There is not any confluence solid lesion.
32:01 The other thing you have to worry about it. Sometimes it's an atypical presentation of a mess as well, so that's another differential. Yeah? So so keep gone Prevent tells tells how you keep things. So let's let's let's presume then that you know that's basically is to gnosis my lap at the picture, and the patient doesn't have any brain lesions consistent with their mass, and doesn't have any enhancement consistent with intramedullary tumor. Then you know we basically at us to gnosis case, and you have a stenosis case. Then the patient is myopathy. Can already losing some neurological function, were headed for decompression here, while your options for decompression in broad categories is their anterior. Or post airier Xo has a nice study looking at anterior and posterior Csm study of randomizing. You know some of these patients to different kinds of approaches, and then post area. Your other options are laminectomy, alone, a laminectomy with fusion or a laminate plasti. Are the broad aspects of doing. You know the post your options, Just looking at this one. You know. I think if you were going to do a interior, I'm not sure and Ac, the app would be enough. The diameter of the canal looks pretty narrow. So I think if you come and Jerry, you may have to end up doing a back to me, which tends to be a little bit bloody, so I would tend to do this, excuse me post eerily either with a laminate plastic, or with a laminectomy infusion, considering that we're getting close to see Seventy one is, hadn't issued to two with a lot of Puerto de Uma, You know the C seven level, and then if you think about you know laminate plastic or laminate new fusion, what really drives me is the Fram analyst analysis and the neck pain, so if a patient has a lot of. I tend to go with fusion. The patient doesn't have a lot of neck pain. I consider laminate plastic. And if I do those approaches the other thing that I think about it. Do they have unilateral or bilateral for animals to doses. If they have unilateral for animals to gnosis. And that's really the main symptom than eleven of past. He is nice, because I can easily do from anatomies with an open door laminate plasti on the side that they have the more symptoms, and their bilateral, ridiculous path, ridiculous symptoms, or bilateral hand dysfunction due to severe nerve compression. I tend to use it by lammy fusion because I can do wipe rim ottomans bilaterally. Whereas an open door laminate plastic. I'm really limited on the side of the hinge, so I think those are the broad spectrums of things that I think about. I think about neck pain, I think about for ammo stenosis. There's enough Lord doses here that I think it would be fine to do a plasti. I think the Corbin floodway and you could certainly do eliminate the infusion, do a bilateral decompression, but I would tend to prize your posterior on this. It was either and to your lammy fusion, I would tend not to do a simple laminectomy on someone who's only in their forties and we're getting to a pathology that's near the junction. Nc. Seven Is. I think there's going to be potential person delay junctional problem. You know some years down the road, not immediately, but some years down the road, so I steered away from doing simple laminectomy in this age group. I might change my mind, the patients eighty six, rather than forty six. I might just do simple avenue to get off the table, but this is a forty six year old. With pretty bad for eminem bilateral stenosis near the junction with a fat cord from a demon, so I think you know, come and dorsally or decompressing, and potentially they're fixating with fusion, Orlando, plus you'd probably be where I would add Devil, Great
35:16 Chapter Chancellor, Would you like to do,
35:19 So, I, I think Ravine just gave us a mini lecture on that and I, I agree with everything you just said. I think he hit all the high points. When I first saw this case, you know my knee jerk reaction was to level a Cpf better again with the amount of compression. I just feel like I want to get more of a decompression. So I was thinking also post yearly young person. I would probably lean towards the lamina plastic, and I would completely agree with Praveen that my only concern would be you know. Where is he having problems for Amelie because I'm not gonna be able to clear that as well going coast dearly as as opposed to going anteriorly. If he's really just sort of on my lap of the hand with some intrinsic, so there's really no se, six or C seven root involvement, then then I think the lamina class. He would be fine, and maybe doing some bram oddities on the right side, Because that's where some of his weaknesses and M G might be somewhat helpful just to rule out any C six thirty seven nerve root issues, and if that's you know normal, then and I think it would be more more impetus to consider going post yearly, and just based on him being young, I would I would agree with the laminate plastic. Yeah, how about Michael. What how about you young? So I just used to cook this a couple of points. I would also reiterate I mentioned the circuit color or prior to this. At the outset. That to me, the I. I am concerned about the intrinsic chord changes, so I would work this out the ornate. It's assumed this was related to cervical myelopathy, and you notice its or contrast scan vasculitis work of other issues, and then also to. War invitation that you know, sometimes you're dealing with two pathologies, and you've brought this and I've had a very rare case where you deal with with with this thought with the general pathology, but the intermezzo Larry, the issues or worse have been mentioned, but I think that needs to be emphasized on Mrs. At sea Seven, You know that the main issues here at C seventy one, and so on I'm not a big fan of Latin classes and cervical thoracic, John can be interested to see what. The needle, the thoughts are accredited, The faculty renovate your C seven, so I would I would go post your me here. If if you were to go anteriorly at the work back to me down at seven tonight looking at a multi level kind of a hybrid approach, so I would do this post you really, and I would combine this with a with a with a posterior fixation boil down to the T, one self note that that brings up a great point. Do you routinely crossed the junction on your post? Your cervical fusions? Or is it unique to this case with the edema and everything,
37:58 so I think here Because this is up like on the the the edema in the intrinsic, changing the quarter right at the sea seven level, so I would want to ross served with rice and gumption, and for early. An earlier may experience, I never crossed the river with Roger Johnson, Routinely Mercer is a governance of a slip, and then sure enough, I had a few failures at sea ones. Who now I I usually use will will will will go down to the T will go down without a T one, although I recognize that that may be kind of overkill in a in a minimum a lot of people. Yeah, I, I see you nodding your head, Nancy. What what are your thoughts? I think. In this case, you know you do your laminectomy of five, six and seven, and I would probably go into two levels above to lovers glow. I go down to tea to to make sure you cross the cervical thoracic, The, Because, just like Mike is saying, you know when you've done enough of these and you've seen people come back with the Ccp to one discs and recurrent mile apathy. If you start saying well, maybe not the best way to go, The other concern here is I'd also get a non contrast cat scan to see whether or not there's more Opi ll hear that you're actually not adequately visualizing, Because some of these axial studies are actually not just at the displaced level, but again you know one of the questions that we're getting from the side here which I think you might want to address here now is the question of you know how does how what's the role of the K line in terms of? Is all of these patients deciding whether or not to go into earlier post yearly?
39:40 Yeah, I think that's that's a great point. Nasty want to delve into the caroline. A little bit more for. Right, Okay, so let's just look. I mean, and in this case I just look at the picture. I'll look at the sagittal, and more, basically the K line is defined groups to go back to the other one, okay, if you, if you at sea, too. You make a dot in the middle of the Spinal canal at sea to the middle of the spot Spinal Canal at C seven, and you draw a line satellite caught, and that is the case line Okay now. Oh,
40:17 yes,
40:19 If you are Legion. Goal. How steerer to that came line, it's called a negative K sign and that indicates that you're going to have to do a direct anterior decompression. Because otherwise doing a post your procedure, you're not going to relieve the cord compression, If on the other hand, your pathology stops before that K line, it's called a positive case sign. Then you actually have the option to do.
43:09 Im saying would be one of the main concerns here or some other nerve deficit with the your migration of the court. I know Michael. You were doing some research with that with a prevention.
43:20 While I. I am. I am now actually using really resolve all of my patients. Even you're the primary outcome was negative, but on recent strong signal toward reduced pain in, we're now analyzing result my own of my own experience. Is that real years all producers of the late C five ballsy both in frequency and severity and I would also? I also use kind of peri operative decks methods One to try to deal with some big plan for a issues, but if he uses his outline leggings, start the steroids, and how you taper them or in them cause, I think that's an important point, I. I start in this patient would likely start the steroids at the time the surgery, and then I would do. I give them about a forty five day taper post post operatively, and they usually start. There really is all a few days prior to surgery, and then I would get continuous support. The surgery
44:24 interest sell. So this is an interesting case up, so I saw the sky and I agree with everything you guys said, and to me this was a dorsal approach. Because of the the Jima the team us, this next patient
44:39 to me would have been really risky to be drawn out the ventral cord on somebody that's already swollen and tight like this, and that you're not really expanding the canal the way in which this patient me needed to be expanded, and so interestingly he had seen to other people you know which is classic for for Los Angeles where I am, and they both recommended a C D F's for him. And it took it took me a lot of effort to convince him that I thought a post your approach was better because he'd already had in his mind and it was told twice, and and and and I also brought up the tumor thing. I said. You know if it is a tumor and we go back. You know it's going to be a lot easier if we've already done a decompression air to go back if we have to, and so I chose to do a laminectomy and fusion on him just because they were founded, Jima, I found and published on this that he did get a little better core drift. With a laminectomy been a landfill plastic. I get. I get post up memorized from studies I do on a high percentage of these patients, and that really analyze a lot of this, and you tend to get a little better drift and decompression with a plain lammy, the lamina plastic in most pavements, Although I Lord Laming, requesting, I think it's a fantastic a surgery, so and I stopped at seven, which I think we we talked a little bit about, so I got named Mri as part of one of my reach the studies. Three months later and the cord was completely normal after a while. When I say completely normal. I mean I didn't completely normal Alright, so I thought that was pretty profound. Because normally we see a lot of mile Malaysia in these patients. What was actually atrophy of the cord At the level We not see Frank a demon like this very often in a non -traumatic degenerative cervical myelopathy, so, but it, but it completely resolved. And the patient it up very well. I did want to throw out something else for you guys, harm or plastic. Not necessarily in this case, but for Mile apathy was the feeling of one or two level arthroplasty in a case where you would possibly do in Ac Ds, and a patient, that's clearly mile empathic with signal change, not not a demon like this, but more of a classic look that prevent you've got a lot of experience. And publications in his field. Where do you see arthroplasty in my lap? As he? Yeah. I think that's a really interesting question. Langston. I think there's a couple of issues to just consider one. It is you know as Nancy mentioned, I get a C T scan in cases where there is a cord contusion with ventral disc osteophytes because I want to see how much osteophytes There is. There's a lot of osteo fight. Then what happens is that tinsley the deep or arthroplasty tend to autofill years? And so I tend to lean towards Ac. Df. I have heard people say in the past that patients who have really bad my lap, The preferred to have you know fusion in terms of the cord getting better, because the court is not continuously being pulled and pushed after the decompression. However, you know, if you, if you think about that laminate plastic patients actually do really well Enzo's Csm study, so you know there is some argument to say that may be some motion is not. Terrible for these patients, so I think what really drives me is to get the pre -op C T scan and the preamp C T scan shows it's truly soft disc, a relatively young patient. As a little bit of court signaled James and I discuss with them is an option to do North of Plaza The versus an Ac Df at two levels, and I, you know, Let the patient tell me if they're really interested in how much motion they want to preserve the older. The patient gets, the less likely I am to do not the plastic, so in the sixties age group, I'm doing infusion. In the forty's age group, I might think of an arthroplasty that the patient truly has a large discrimination with a little bit of court signal change, and that's kind of you know where I've ended up over the years, and we didn't look so much at big signal change and doing arthroplasty in the in the in the arthroplasty trials. When I did them, You know about ten years ago, You know Arthur, plus Se D at both do really well, but really it's It's more for ridiculous that we were doing those trials rather than for a severe mile off.
48:52 Langston, there are some questions or comments You want me to,
48:58 George Joseph has been on the line and he said I just had to make this decision, and an older patients. The symptoms were multi. Ridiculous. I recommended a decompression in that prob patient did well doctor going to in Salt Lake City, said I counsel patients that have decompression so long. At the degenerative changes will progress, and if they live long enough to redevelop stenosis that may require reoperation.
49:23 Anyway, some some some reason it and standing presentations, etc, some also said they would stop the post. He refuses, as he seven one other comment I would make when you're looking at an em where I liked this with a swollen court like that, and you're thinking of doing an anterior discectomy and fusion, and I think we see this with appeal all patients all the time. We know too typically those interior district being over distracted, and these patients are ending up with major new neurological deficits because of the over distraction by placing an anti graft in place, Which is again. I think an argument for going post yearly when the court decide compromised.
50:02 Yeah, Yeah, No, I totally agree, and at the end of the day for somebody like this with us at the Dm. What they need a cortex. They need a canal expanding procedure. Well, for the most part adversities he was going to just kind of give you a little bit cent at all eye opening, so some might do we have a pool available for this or or do we not have it?
50:26 Ah, Yes, we do okay, great recipe for case two, so can you can I just make one one stall comment before we get to the pole. Yeah again, Please do it finally woken up. You can go go for it, Ok? Just one consideration that wretched, I think, in this case, I would do Atlanta plasti, and one of the things that I I've found is that when doing the Atlanta last year, I do it see five, fifty six at C. Seven, I just do lemon out of me
50:54 or decompress and leave the the interspinous ligaments attack, and The, these have done very very well, so I think that you know one option. With the Atlanta blast as to not do the latter us, he actually at the junction a level, and just do Atlanta ought to be there, and that provides a nice core decompression and less of a risk I think for junctional, and can lead in the cases that you're describing, but certainly in this case with this amount of court, a daemon directly going to Mitzi, seven, and even an almost empty seventy one. Maybe that would not be the best
51:31 girl would be my concern here. You know as well, I. I. I think that it'll usually. You can kind of do kind of like what the Japanese call a dome or classy and seven when it says he, when you undercut it right down and I am, but I at least like in my hands, I'd be worried about the amount of intrinsic cord edema at sea Sabbath, So why was was your favouring actually doing the laminectomy alone and then because of everything, all say? I that would sway me toward your Ford Fusion. Sure, Sure, Yeah, at night, I agree, Michael, and and at much as I love lamb in a plasma, and the last point that I'd like to make about lamp fusion as the other mechanism that you get for the decompression, not only you get the drift, but you get the regression of the anterior or disgust. You have like complexes weight when you when you stabilize me, fuse, and so those disappear over time, actually, and so it just gives you a secondary way. To act to get some cord decompression as well, so Mike can we get that done? Then polar. It's up and rent. It's up and running. Now we. We have a few people responding to it to urge everybody to. If you see it pop up on your screen, make your selection, and yet so far we've got four or five, but have responded Green, waiting for that Linkedin. Why don't we have people comment about their use and interpret Monitoring that these cases in their concerns and their bass lines and things like that?
53:00 Yeah, listless guilt for that.
53:02 Like the monitor, so yes, I'm the fan, so I used multimodality electric, physiological Monitoring these cases, motors and medicines, reason rerunning rerunning Mg makes me feel makes me feel better. Makes me careful of, gives me. I do you know a readout in terms of you know the appropriate and proper blood pressures to maintain to maintain kind of court profusion. So my bias is to use it. So you're treating Doctor Michael
53:34 look very very good, but I, I also, I think that it does, and it it it it I, I think it provides you credit with a quality check to make sure you're not hurting the patient as he gives you a physiologic sense, in terms of the court refused, and, and you know that that that that that that sort of that sort of thing, so I guess my my practice is to use it. Yeah, What anyone not monitor this case? So I, I feel slightly different approach, and even in cases where there is a substantial quarter of the and my lot with the, if there's no motion and flexion and extension, I, I, I just don't think there's data and I just don't think that it adds much to to have monitoring their. Although, I recognize that a large number of people the cervical spine like to have monitoring, and I think in many of these situations were treating the surgeon as opposed to the patient. I that, but I don't routinely used monitoring how these types of cases, and I'll even argue that some people who don't use monitoring or treating the surgeon to, because they don't want to know they don't want to their treatment might not do, yeah, but you have to think about it. If you have an adjunct that it potentially makes an operation safer. That is warning you of an impending problem, Because any peace don't just drop out. They typically go slowly down the same thing with with the. As the peace, and if you can have access to that information, why is the surgeon? Would you not want to do something that's safer.
55:06 I guess. The other of the question is that there are multiple studies that show that people who use larger and have complications that are the same as people who don't use monitoring, and whether that is because there are changes that. You know you can't explain by what you're seeing in surgery, and so you don't really change what you do or whether there's no true false positives and false negatives. I'm not sure, but I think that to say that monitoring you know has a level of reliability that can really direct assertion to change what they're doing. Absent. You know, gross change and and
55:50 grow change in alignment. I think it's probably overstating the case for monitoring. As a personal view, of course, monitoring is only going to be as useful as the surgeons. Knowledge, adherence and reaction to the monitoring, those who completely ignore it. It's useless. Those who don't understand it. It's useless. I think for those who do understand it and know something about it. I think that in those patients. It's useful. I mean. Jeff. What do you think
56:20 so? Although I agree with the comments I use it, I think it's gotten so much better over the years I would say fifteen years ago when it was kind of in the earlier stages. You'd get some things you like God doesn't mean anything. You didn't know what to make of it, but nowadays I get some very practical information from it and I can think of of countless cases where it just makes me reassured. You know, I can think of doing some very difficult cases post yearly around the C eight nerve root, and, and as I'm working around it and trying to get more aggressive, they're they're telling me they're seeing some changes, and I see that also in the lumbar spine with with some nerve changes and and with bigger complicated cases. And so I do think it gives me some very practical information that is definitely changed my practice, and sometimes you're you're leaning over to anesthesia and say what's the blood pressure. You know what's the amount of crit. We get it so involved in the surgeries, and sometimes, especially for these mile off with the cases. I worry about court profusion, keeping the the profusion to the core and keeping the blood level up, and sometimes you get behind and anesthesiologist doesn't doesn't keep up and nowadays when we're getting, you know scrutinize for any blood transfusion, and things like that, I can, he gives us some valuable information. So it's I'm a big fan of it. I think took the Zoe's point about instability. For me. The main thing. I use it for his positioning. You know to make sure that I've got the patient in a position where you know. Especially when they're prone. That is not going to induce any problems before I even really get started. I'm not really worried about what's happened during the surgery. To be honest, I I rarely don't don't even shoot another motor till I'm done on most of these cases, so for me, it's more for. In my position that patient correctly as the court happy with the way in which I've done that, I. I think it's critical links than if you're just doing one after positioning. I think it's critical. Every you know ten minutes. Whatever it is. You're monitoring persons. She said. Hey, Can I shoot the motor to stop what you're doing for a sec. I think you need successive motors during the procedure. Because you're monitoring might be smarter than you are.
58:28 Yeah, I I dunno about that for me. That's not. I don't find it necessary. I. You know. I generally. I feel pretty good about what we're doing. You got a pretty good handle the pathology. If I'm doing the instrumental core tumor where I'm getting into the court in. As much as I'm getting ventral. Lot. You know. Then that's it then Then I shoot them a little more often, but for Atlanta plasti an uncomplicated decompression. I, I don't. I don't feel the need to. Keep asking them what's going been as long as I've got the the chronic information that intramedullary spinal cord tumors, You've got the most frequent loss of potentials, but the other instances, Michael. What do you do? I acknowledge? Relax and saying, I do think it's incredibly helpful for positioning, but I use Are you shoot motors through a periodically throughout, so I do like to kind of get at a readout say after placement of the implants, and that you know. I kind of wondering decompression one you've for the answer. I will kind of gutted. You know he will not monitor it so and and that's that's kind of my. That's kind of my my practice. I guess. One comment I'll I'll just make is that. The more you use it, the more fluid it becomes so if you only use a once in a while, it's a real hassle, and I think there is kind of a learning curve to using it in terms of the flow of of things, and so. We we just use it so routinely now that I. I find that it doesn't really kind of you didn't really disrupt anything that I'm that I'm doing Alright. Yeah, thanks to Michael. So might do we have the results of our poll. Can you put it up, so he can actually see.
1:00:09 Let me see if I can put it up. I can tell you that the results for it, We had twelve votes and fifty percent for posterior cervical fusion and fifty per cent for the Ulama Plasti. An alright, so I think we we have were pretty persuasive group here.
1:00:28 Alright, Well, I'll tell you where we're at time. Believe it or not. That was fifty five minutes. Didn't feel like it to me, but I think that's because we're having a good time, so I'd I'd like to really just wrap up by thanking Jim Ousmane for really inviting us here, and I'd like to thank all of our faculty and our assistant moderator as well for joining us on this case, resin which beggar, Thank you, modify. Great, certain things are alright. Thank you, rewind very very good, very good, thank you, and you're away. Bye.
