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SNI Digital, Innovations in Learning, in association with SNI, Surgical Neurology International, are pleased to present another in the SNI Digital series on controversies in spine surgery with
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Nancy Epstein, who is the presenter It will be a 75-minute lecture in four parts with interactive discussion.
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Nancy Epstein is a professor of clinical neurosurgery at the School of Medicine at the State University of New York at Stony Brook and is the editor-in-chief of Surgical Neurology International.
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Nancy has been in the practice of spine surgery for over 40 years and has one of the largest bibliographies. of papers in the literature on all aspects of spine surgery and neurologic disease in the
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world.
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This lecture and divided in parts is will be on posterior cervical approaches for neurologic diseases involving the cervical spine.
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Part one is on the anatomy imaging and clinical presentation A posterior surgical approaches for neurologic diseases involving the cervical spine.
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We're back for
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another outstanding lecture from Nancy Epstein, and this is on a subject that she's talked about previously, and it's in the videos that you have on SNI Digital, but this is more detail and more
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background on posterior cervical surgery. Now, you may find, if you go back and look at her videos, that she's done anterior approaches, complicated anterior approaches, some posterior
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approaches, at least we're just talking about the cervical spine. She just did one on the caudal quinus syndrome, thoracic discs, and a whole bunch of other subjects, you'll see them on the menu
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of SNI digital At this talk, she's obviously completing a series of these, which is and plans to have a series of talks, basically, on all of spine surgery. And this one is on a challenging topic.
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It's on better patient selection and performance of posterior cervical surgery. And you know she's clinical professor of neurological surgery at the School of Medicine at Stony Brook,
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editor-in-chief of surgical neurology international, been in practice for 40 years and. probably is more publications than most or if not all people and who are working on spine. But one thing you
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know is Nancy's gone through the literature. We're getting facts. We're getting facts so we can make reasonable decisions. This is not related to any manufacturer. Nobody sponsors this. We're not
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promoting anything. You need to be able to have the facts so you can make a decision yourself So an answer to that, I summarize that right? I think that's great. Yes, thanks Jim, that's perfect.
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Okay, so I think, why don't you go ahead and I'll go for me. I mean, the whole purpose of, you know, creating these lectures is to help people really sort of
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start rethinking about the procedures they're going to do. The mistakes happen when you choose the wrong operation or the wrong patients So we're going to be backtracking and going through this in a
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very. elemental level. We're going to look at cervical anatomy briefly. We're going to go over MRNCT studies because I can't emphasize enough how critical it is that every surgeon knows how to read
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their own diagnostic studies. You can't just rely on radiology. You then have to be able to do your own neurological exams as a patient never ridiculous but they are myelopathy. Choosing to do a
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laminectomy and typically you'll do many of these laminectomies with posterior fusions is very important because if you don't listen to anything else in the lecture today it's to emphasize if you have
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the option to do a posterior cervical approach a cervical laminectomy is approached as opposed to an anterior cervical discectomy infusion or anterior
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corepectomy your posterior operations are going to have much less morbidity and mortality. This is a classic image of a patient who's prone and a three pin head holder. Again you want the three pin
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head holder, you want the eyes free, you don't want pressure on the eyes, you don't want a patient to wake up blind, you want to keep their neck as neutral as possible. The bony anatomy,
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anteriorly, you have the seven vertebral bodies. Obviously, you have the ring of the arch of C1 and C2 to seven posteriorly. You have the spanish processes in lamina. And if you're teaching
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medical students, I always say, ask them to put their arms in front of them, tell them that their body is the vertebral body, the spinal cord is in front of them, from the elbows to the wrist.
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That's the lamina and their hands with the spanish processes And if they're going to do a laminactomy, all they have to do is bend their arms up and they freed the spinal cord.
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Can I ask you a question here? Are you going to finish what you're saying? I was going to go back to the previous slide because for some of the people watching on the previous slide, there's
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someone that's showing the person prone. Right. You mentioned they are not going to get injury to their eyes. And I'm sure you're talking about a horseshoe, a horseshoe head holder. Horseshoe
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head holders also, if
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they're putting plastic over the eyes, those can be very dangerous and compressive, obviously, intraoperative hypotension can also lead to cortical blindness. But the most important thing is use
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the three-pin head holder. It takes minutes to place. You have to put a staple or two maybe when you're taking it off, but you can stop worrying about any direct pressure to the eyes if you use
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that three-pin head holder A lot of our orthopedic colleagues won't do that, but this is really important to use whether you're neuro or ortho to protect the patient. I'd say I'm in a country and
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I've got a horseshoe head holder. I may be wrong, but that's all I've got. What do you do to secure the head? Well, then you're probably gonna use some tape at the same time. Tape them in.
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You're gonna use tape. And actually here you can see the tape
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Yeah. You know, I'm not really gonna spend much time talking about intraoperative monitoring, but very, very carefully, don't over tape the shoulders down because you can cause a brachial plexus
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injury by doing that. And that's why if you have access to it, you want your somatosensory vote responses along with everything else to make sure you're not getting a traction injury to the plexus
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as you're positioning patients in this position. Okay, we can go ahead. I just wanted to make that one point. Go ahead Absolutely. So we went over some of the anterior and posterior anatomy.
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This is just to reinforce anteriorly. You have the anterior vertebral bodies. You've got the anterior longitudinal ligament, the posterior longitudinal ligament going actually from the occiput down
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to the sacrum. You're going to want to remember that for the sake of this lecture. Centrally, you obviously have the spinal cord and posteriorly, the lamina and the spinous processes. Just in
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terms of reminder, The spinal epidural space is circumferential. So anteriorly, you have the vertebral body. Then comes your epidural space. You've got blood vessels, you've got fat. Those are
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the predominant things. And obviously, you've got the posterior ligaments sitting right in front and ventral to the enterepidural space. Then you're going to have the dura. The dura is going to
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hold your spinal cord and the nerve roots and the CSF is going to be subarachnoid, et cetera. But here, again, your epidural space goes circumferentially, and then posteriorly, you've got the
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lamina and the spinous processes. So always keep track of anatomically where you are, what you're doing, and what the structures are that you may end up injuring. Here, you have a coronal view of
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the vertebral bodies, sitting one on top of the next. Vertebral arteries coming out of the transverse foramina. And here on an axial image, your vertebral body, your spinal cord, then you've got
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the lamina on both sides, whatever you want to call it, then you have the spinous processes back here. This is your spinal cord and the space here, your facet joints on either side. Okay, and
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then again, your vertebral arteries. Again, in your transverse neural foramina. I can't emphasize enough, you know, if you have a patient, looks like a cervical disc. If it looks a little
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aberrant, get that MRA to make sure that you don't have a vertebral that is actually impinging on the subarachnoid space and the spinal cord And, you know, you don't want to go take out a disc.
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That's not going to be a disc, but rather the vertebral.
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Anatomically speaking, let's just look at this again. The anterior cord is the motor. Motor evoke responses are going to monitor the anterior cord largely. Posterially, you've got somatosensory.
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You've got the posterior column. So somatosensory evoke potential. And then you've got your roots on both sides. Take out the way of the whole of the bone. Motor evoke potentials are going to
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monitor enter your records. some out of sensory vote potentials, the posterior cord, and then you're going to have your EMGs are gonna monitor the anterior motor root and then the posterior sensory
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root. So if you have access to some out of sensory vote potentials, intraoperative monitoring of any kind, I would say, please use it, and don't forget, don't paralyze the patient because
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otherwise you're not gonna have anything to monitor. CAT scans, MRI scans, I use this actually very much to teach the residents as well as the patients. I say, Have you ever eaten an MM? In the
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United States, almost everybody has. And the chocolate is the soft stuff in the middle and the hard candy shell is what's called a calcium. So if you're forgetting the difference between an MR, MR,
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soft center, chocolate CAT scan is the perimeter. A very good teaching tool for those who might not be as sophisticated. The normal canal diameter. This is the normal canal you're measuring from
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the mid-retie roll. mid vertebral line, you're going to see on the lateral to the posterior interlaminar line. That's where those spinous processes come together, where the laminar come together
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and form the base of the spinous process. And here is your lateral radiograph image essentially. You've got the normal canal is 17 millimeters. 13 millimeters is called relative stenosis. In other
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words, you've developed that over time or arthritic changes. Let's say you start with a relatively small house, but you put in a lot of extra furniture versus congenital stenosis. That's when
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you've been born basically with a very, very small house and you have very little room, if any, to put anything into. Would you just go back to that one slide a minute because you can come to it
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later? I think it's a great view for people to see the difference between a trans-pidicular screw and the lateral mask you and how close it is to the vertebral artery. Yes, in other words,
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obviously, it's C1 very much so. But here, your lateral mass screw is going to go in this way, and your trans-particular screw is going to essentially go this way, and this way. And watch out
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for any of those vermin of transverse area. It can be very, very tricky. Also, the particulus pusticus, where the actual vertebral exits overcoming over the arch of C1
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These are not without morbidity and mortality. So you have to study your pre-operative studies on these patients very carefully. But that's definitely a point worth making. Here, again, a
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figurative diagram of measuring all the different levels. Here is the lateral six-foot film. Again, I've said in multiple lectures, my uncle was a neuroadiologist. And he would test me on this at
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the age of 15 in this conferences. Of course, we did not have MRI scans back then. But very importantly, you're looking at an MRI scan. You're actually not looking at bone. And that's why I'm
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gonna bring up a CAT scan. Anything that is bone is hypo-intense. You're not going to get a really great accurate measurement on that sagittal view of the MR. But look what you see shortly on the
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CAT scan. I'm gonna show you. But here's your canal on an axial study, vertebral body. Look at the definition you have on the MR of your cord Around it, you have your bath of spinal fluid. You
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may be also integrating with that some of the fat in the epidural space that may have the same signal. But this is the kind of detail you're gonna get with your MRI scan. Now, you're gonna look at
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the CAT scan instead. And again, you're gonna get on the X-ray you can measure, but here in the CAT scan, you can directly measure off your computer based on the actual bone, the actual front to
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back, whatever dimension it is you're looking for, the CAT scan is gonna be much, much more accurate when you're doing this. So when you're doing instrumentation, it really behooves you to obtain
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the CAT scan to have those direct measurements and have absolutely all the information you really need. Neurological exams, everybody should examine your patients from the neck down. I don't care
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if they come in with the diagnosis of low back pain, examine them from the top down. Sometimes patients may have cervical myelopathy and then their walk-in funny is what they're saying. And they
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feel like their legs are heavy. Well, the problem may be cervical stenosis. 10 of those patients with lumbar stenosis are gonna have cervical disease. And you're going to wanna look, see five
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root, deltoid. If they put their arm out to the side, can you push the arm down? See six root, really look at the wrist and ask, actually the patient can use one hand to examine the other and
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push that hand down. Does that come down easily? hold your finger through that. Though I'm in pinking now, we're getting to the C7 nerve distribution. These are the kinds of things actually on a
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telemedicine exam that you can get better and better at. And if you're doing telemedicine, see if you can have a surrogate also present, some other person in the room who can help you examine that
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patient as well, but you can get some very, very valuable information very quickly.
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Myelopathy, cord compression, obviously this is an anatomical specimen, a disc herniation, compressing the cord And here on a myelogram CAT scan, you have aiohexyl dye in the subarachnoid space.
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You can see the cord is compressed and that's a direct extension from the disc herniation anteriorly. Okay, so you're looking at these images very carefully and you wanna know do they have motor
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weakness? The motor weakness with myelopathy, it might be an entire arm or part of the arm, the top, the bottom, proximal distal. Same thing in the lower extremities. Might be bilateral upper
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extremities or bilateral lower extremities.
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should be hyperactive. Patient who has thyroid disease or diabetes, they might not be hyperactive at all. Hoffman signs in the hands, you may see that, but Binski's in the lower extremities and
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obviously sensory loss that may be very, very variable. Loss of urinary and bowel dysfunction, that tends to be very late with most cases of myelopathy. But these are all of the things that you're
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gonna look for and you're gonna try and screen your patients Do not just rely on other surrogates evaluating your patient. You wanna know yourself, what criteria do they meet? What disease do they
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seem to have? Because you're gonna have to try and figure out, if you're gonna design an operation, does it really do anything for that patient? Is it appropriate? Is it the right problem? Does
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that patient have MS? Do they have ALS? Do they have some other disease entirely? So I wanted to make it clear how we choose to do posterior operations in patients here you can see again the
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classic three pin head holder we've marked where the incision is going to be taped on the shoulders. Again, with somatosensory vote potentials going, so you're not over-retracting. Obviously, big
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shoulders, you're gonna have trouble seeing down at the lower cervical thoracic junction in patients like this.
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And this is just a summary I wrote a few years back, anterior cervical surgery. This is just an anterior dyspectomy infusion. It's a review article, swallowing difficulty. 9, almost 10 dysphagia
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Lots of studies show that that's even up to 20, 30, at least in the first few weeks and even first few months. Postoperative hematomas. All hematomas are not epidural hematomas. They can be
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retroferringial or wound hematomas. That patient in the recovery room, you're not gonna wait to schlep them downstairs to get a CAT scan, et cetera. If they're having respiratory difficulty,
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you're gonna whip them back to the OR or actually open the wound at the bedside in these individuals. Court injuries, you know, 3. recurrent laryngeal nerve palsies. That patient, you know, may
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wake up in their horse. I mean, I see this all the time where you have a medical legal case. The patient had previously anterior cervical surgery, maybe multiple levels, prior to another
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operation at another level anteriorly, which is better to choose posteriorly if you can, and then they go in and they operate from the other side and they give the patient a bilateral recurrent
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palsy and their respirator dependent and trait. Spinal fluid leak, infections, hornus syndrome, that's injury to the sympathetic chain. Sympathetic chain becomes more exposed as you go more
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digitally, so by the time you get to 5, 6, 6, 7, it can be really hanging out in the breeze. Watch out for your retractors, especially like the Casper retractors with the big teeth. I would
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never use those. You've got to be very careful. Use your smooth blades or your very small serrated blades, and here esophageal perforation. That can go along with dysphasia. Rare, but it can
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definitely occur. I threw this in because I can't resist it. failure to fuse, and anterior discectomy and fusion, you pull together multiple studies. One level, it may fail to fuse about 4 of
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the time, but look how it climbs up every successive level, two levels, and how many people just very flip say, Oh, I'm doing a two-level ACD, or three-level ACD. The failure rates for these
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fusions is astronomical.
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And obviously mortality, anterior cervical surgery is going to have trouble, and some of those major risks are going to be vascular andor neural. But here you have, I've just illustrated for you a
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major risk with anterior cervical surgery. You've got the interlungent religment, you've got the trachea here, the esophagus sitting right here. You're going to be retracting those structures, by
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the way. And you're going to be using your drill. You don't want to piston into the canal. I've seen cases like that as well. And actually, one was a trial graph to that piston, It was the
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surgeon who pissed in the trial graph back into the spinal canal. So these things can occur. And if you go posteriorly, you're gonna have many fewer risks. And we're gonna go over what those risks
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can be. And here is a list. So with posterior cervical surgery, what are the risks? It's very rare to get a vascular injury. Now, can you get a vertebral artery injury by going too far into the
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foramen? Yes, very unlikely you're going to get a carotid injury because a carotid is going to be anteriorly. You can get jugular vein injuries by going anteriorly. These are, by the way, very
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underreported. But you're not going to get a jugular vein injury by going posteriorly, okay? No dysphagia. Well, your only dysphagia may be because of the surgery posteriorly may have taken you a
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long time, but it's not because of direct esophageal retraction. You're not going to get an esophageal perforation from a posterior procedure.
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We're current laryngeal nerve injury, hoarseness, you're not going to get that with a posterior approach because the recurrent laryngeal nerve is located anteriorly. You're not going to injure the
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sympathetic chain and get a Horner syndrome because again, that's an anterior structure. You're not going to get paralysis of the diaphragm or a phrenic nerve injury by posterior surgery and you're
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gonna have a lower risk of spinal fluid leak. So perhaps maybe this is the most important slide of this entire talk. Think about this before you just say, Oh, well, I was trying to do the
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anterior approach, et cetera. I was speaking to a young surgeon the other day and he was saying, I'm gonna do a two-level ACDF. This is at the lower C6-7, C7-T1. And I said, Well, what about a
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posterior operation, laminoframanotomy and then a laminectomy, and then boom, you're doneand you don't have all the risks of an anterior operation? And he said, Well, I've never done those. The
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laminoframanotomies. I said, Well, find a
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surgeon who hasand I pointed out who it would be and it's a much safer thing to do. So again, posterior cervical surgery, you can address stenosis, discs and spurs, spondylosis and OPLL, but you
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have to have a lordosis of some sort. It can be a straightened lordosis. And here I've chosen a diagram to show you that it can be a straightened lordosis. Also, when you fuse, you can actually
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change the three pin head holder to put that patient into somewhat slightly more lordosis so that you confuse them with a lordata curvature. Here, the patient may just have a normal lordosis, the
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normal dorsal curvature, and
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in other cases, it might be a hyper lordosis. And here you can see illustrated, look at all the ventral disease on multiple levels, four, five, five, six, six, seven. And look at this, this
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is C2, C3, four, five, six, and seven. Look at all the posterior pathology, that's ossification of the olegment, and the laminar can shingle underneath each other as well. But look at the
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curvature here.
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Choose to do a posterior operation, and you take off the bones back here, just like a rubber band, that spinal cord is going to push back into your decompression. So here's just another
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opportunity to emphasize the pathology that you're dueling with. On this diagram, here, you may have ossification of yellow ligament sitting right back over here. Next, you may see the shingled
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lamina, again, just like a Venetian blind, where one lamina comes up underneath the other, and that's actually impinging on the cord, and then following down here, you're gonna decompress
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stenosis. So if you
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take the bone out from back here, your spinal cord can move back, like a rubber band, into the space that you created, and then you confuse the patient to make sure that you maintain that
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alignment. So here's just an X-ray, AP lateral X-ray, you can just see stenosis. Why do I know it's stenotic? because look, this is the measurement of the front to back dimension of your spinal
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canal. It is less than the width of your vertebral body. So again, if you don't have any access to a direct measuring tool, et cetera, just look at this, your spinal canal is going to be less
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than the front to back measurement of that vertebral body. That's going to be spinal stenosis. And here is your MR scene to your right. This is the washboard. And the washboard means it goes like
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this and that And what that means is you have ventral compression from a disc or a spur. You've got dorsolateral compression from the ossified yellow ligament or the shingled laminate, et cetera.
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And it's going on for multiple levels. This is a straightened lower data curvature. But this is something still that you can do posteriorly rather than doing something multi-level anteriorly. And
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here on a CAT scan here, you've got your x-ray measuring your front to back dimension. You know that you've got stenosis because here that red arrow is shorter than your green arrow. Again, if
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you're going to remember anything from this lecture, remember this image because you can apply this to any time you're looking at an MR or a CAT scan. This is your three-dimensional CAT scan, by
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the way, over here to the right. And here you can see, look at this final canal. It's a mere fraction of the green arrow and it's seen at all the different levels here. So here is your stenotic
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canal. This is your CT. I just showed you the MR Again, you're going to be reading your own diagnostic studies. By all means, speak to your radiologists, your neuro radiologists. They may teach
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you something or you may teach them something and they'll be of greater use to you and vice versa in the future. One of the biggest questions people ask is, well, how do you choose to do a post
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your cervical approach? Years ago, a K-line was described It goes from the mid-aspect of the C2 canal, front to back, mid-aspect of C7.
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then you draw a line.
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If your pathology, your ventral anterior pathology is in front of that line, you can choose to do an anterior, a posterior, or a 360 approach, okay? On the other hand, if you have what's called
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a negative K line, that means that if you draw this line and your pathology from the front crosses that line, like here is classical PLL, then you are really pretty much stuck in many cases doing
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an operation from the front. Sometimes people will go in and they'll actually put a lordotic graft in at the level above and below to throw the patient into lordosis
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so that they could switch and do a posterior operation.
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But this is basically what you're looking for. The positive K line, pathology is anterior to that line. You have an adequate, you could have a straight and a normal lordosis or a hyper lordosis.
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you can have anterior posterior 360 surgery. Again, if you have a negative K-line and your pathology goes posterior to that line, reverse lordosis, this is not just straight, but it's gonna be
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reverse. It's likely that you're gonna have to do an anterior operation in those cases. Okay, and I'm just gonna keep hammering this home. Here's your positive K-line. Here's C2, here's C7.
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There's your mid-aspect of the canal, and here's your pathology anterior to that line And you can have disc, spur, spondylosis. You can do anterior posterior 360 surgery. But again, if you have
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the option to do a posterior operation and it has less morbidity, you have fewer adverse events, you have fewer problems, choose the posterior operation.
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And here is another example, again, figurative diagram, made it very simple, but here is your K-line and your pathology of. anterior to it, and your normal lordosis, again, could be straight,
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normal, or hyper lordosis. So I'm gonna give you multiple examples of this in just a bit. But here's your classic cervical laminectomy. Here's C2,
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maybe you see seven down here, medial facetectomy, for amenotomy, and all those levels. If you have a disc or a spur, you can use a downbiting curret in order to try and get rid of those and
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decompress those. But here is the premise You've got a good lordosis here. You've done your decompressive laminectomy. Your spinal cord has moved backward into the space that you've created, okay?
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Not kyphosis, but good lordosis or adequate lordosis.
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Here's an MR, anteriorly. What do we see? Here's C2, C3,
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C3, 4, C4, 5, 5, 6, et cetera. And there's also dorsal lateral shingling here
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You can see C2, C3, C4.
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5 is under 4, the laminar 6 is under 5, the laminar 7 is under 6, hyper lordosis, shingle laminar. You remove these, the spinal cord is going to spring back again like that rubber band that I've
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been saying, and that's your MR, but here's a CT showing you direct evidence. And here, C2,
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C3, C4, 5, 6, and 7, all shingled, you remove those, that will allow your cord to move back into the decompression that you're providing
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Let's look at this CAT scan, I included it because look at your shingled lamina, here's C2, here look at C3, C4, C5, these can be so shingled and become so calcified, especially in your older
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patients, and become calcified to
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the yellow ligament as well, that you really need to remove these to decompress the cord in those cases And here, again, this is a two-dimensional image I'm showing you here. you may have a
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superior
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kyphosis and inferior compensatory lordosis. But again, you remove the bones down here. See two, see three, four, five, six, and seven. And again, that cord will straighten out and you'll
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decompress the cord very nicely. On your axial views of your CAT scan you, may actually see two lamina. So here you have the anterior, here's your anterior vertebral body. Here's one lamina And
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then here's your other lamina. And then this image is going to show you the same thing. So look at your CAT scan, look at them yourself. Look at, as many, you know, all the images just scroll
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through these to make sure you have a good understanding of how many levels do you have to include? The last thing you want to do is come back the next year. The last thing you want to do is end up
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with patient with a deficit because you didn't adequately decompress them.
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Another example, this happens to be ossification of the posterior londitude ligament.
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C2, C3, C4. It goes all the way behind the body of C5, going all the way from
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C4, 5 down to C5, 6, okay? And then down the body of 6, to some degree, but maybe, locally, it's 6, 7. And there are different forms of OPLO that can do this. You remove the laminate back
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here, and here's some yellow ligament hypertrophy as well. That cord is going to move back into the dorsal decompression that you've created. Same thing here You've got multilevel anterior disease,
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but your posterior decompressions are going to afford that spinal cord the opportunity to move back away from your anterior disease. So always think in terms of what can a posterior operation offer
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me? You're not going to have to deal with the carotid. You're not going to have to deal with a soft-geal retraction. You're not going to have to deal with tracheal retraction. You're not going to
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deal with all those nerves that can get you into trouble.
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If it can be done more straightforward and more quote simply, I'm never going to call this simple, but this is the better way to do it. Again, a normal lordosis here, two, three, four, C5,
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six, six, seven. Now you might have the alternative to go in front, and then secondarily you might have to go from behind or not. But if you go from behind, and that word can move back away from
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the anterior disease, you may save that patient an anterior operation. Some of these cases, you might have to do a circumferential procedure But again, think about the posterior first. And here's
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a patient with dish. Everything is calcified and ossified. This is a
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myelogram CAT scan. Not the best quality study, but you can see how you do that posterior decompression. That cord's going to migrate posteriorly.
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On case examples and surgical tips for these diseases, of the neurologic diseases of the cervical spine using the posterior surgical approaches. Surgery, well, the one level aminectomy, this is
32:21
what it looks like. And boy, sometimes you get in there, you're doing a one level, a two level, however many levels, the older the patient, the more ossified or calcified things may be, that
32:31
yellow ligament is not just gonna be that nice soft rubbery structure that you've seen in the cadaver lab or imagined, but it can be stuck to everything in sight So you have to be very careful the
32:41
way you're going to perform these. Take out your microscope. Use your interpretive monitoring. Again, you're going to do this in the patient with at least some lordosis. Here's your good lordosis
32:53
shown here and here how your cord is going to move back into this, not an operation for that cation, because that cord is gonna stay tethered over the anterior disease. So always keep in mind, are
33:06
you doing the right operation for the right patient? you're gonna remove that posterior lamina. Typically, you'll accompany it with a medial facitectomy for aminotomy. So you take the medial
33:17
aspect of the facet, there've been lots of biodynamic studies showing you can really preserve pretty much the stability if you do that. If you go in and you knock off the facet completely and say
33:27
you just wanna do a unilateral approach, you're probably better off with a bilateral approach giving you more visualization. You can deal with a bilateral disease that way and preserve your facet
33:36
joints And again, here's the patient prone, three pin head holder. This happened not to be a three pin head holder, this was a halo. And because we'd already done a multi-level anterior operation
33:47
on this patient, now we're doing a posterior fusion with a decompression. Nasotracheal fiber optic intubation, the bigger the problem and the more cord compression you have, the better off you're
33:59
going to be to do a nasotracheal fiber optic intubation. You're working closely with anesthesia with this. and you're using your intraoperative neural monitoring that starts before you position the
34:09
patient for surgery. You wanna do it before you position the patient. The patient's supine, you give them a bolus a propofol, you can get your motor of a baseline then, as well as your SCPs, et
34:19
cetera. This is just an illustration. Again, my father was a neurosurgeon and this is one of his diagrams, C233445. You may just have more unilateral, rather than bilateral, for aminal disease
34:33
Okay, here is your extended decompression that you may have. You're doing your laminectomy on the other side to decompress it. By the way, at the end of the lecture today, I just spend one slide
34:44
discussing laminoplasty. I really don't do laminoplasties. And the problem with laminoplasties, you can decompress one side, but you can't decompress the other and you can end up with a closed
34:54
door where nothing's adequately decompressed. So just for the purposes of today's discussion, I'm really not going to cover laminoplasty You perform your multilevel laminectomy.
35:05
Your medial facetectomy for amenotomy, downbiting curates, these are the curates. You can get underneath that nerve root and take off some of the bone. You're not going to want to do this with a
35:15
huge amount of anterior bone. You're not going to want to do this if the patient has severe OPLL because then you're going to injure that nerve root by over-retracting, et cetera. Also, you don't
35:25
want to go out too for aminole-blindly and end up taking your vertebral. But here's your decompressive laminectomy. This is what OPLL can look like After you've done a laminectomy, so here you've
35:36
removed the bone, but that patient had a good enough lordosis that you've actually adequately decompressed the canal. So here, this is a three-dimensional image. You see two down to seven. Here
35:49
is three, four, five, six, et cetera, and that's your laminectomy defect that you're seeing on your three-dimensional CT scan. Again, here you
36:00
have your K-line that showed you diseases and bacteria to that. a bit of a straightened lordosis. But look in your post-op, the CAT scan is good. You know, here you're seeing some air in your
36:12
wound, but you're not directly seeing the cord. You wanna see the cord in your post-op scan. You have to do that MRI, okay? So here is your pre-op MR. Here is your post-op CT scan, okay? You
36:25
can't directly see the cord decompressed and here is your post-operative MR where you can see the line of spinal fluid post-hear to the cord showing that you've got adequate decompression. And here's
36:39
another example. We're, here you have a patient with a very high signal, see two, three, four, five, six, seven. Right here,
36:50
patient has had a laminectomy in a post-hear fusion, okay? Here are the x-rays, your lateral mass and your pedicle screws. C7 you're gonna wanna put in pedicle screws because it's not good for
37:02
lateral mass screws, Hold. And then here is your MR, your posterior decompression. Look how I keep talking about it. If this is your rubber band, this is your spinal cord, it's moved back into
37:14
your decompression. And look at the path of spinal fluid you have, not only anteriorly, but now posteriorly, because that cord is free. By the way, if you still had more stenosis up above,
37:27
because you didn't study your images, well, that post up MR is gonna show that to you And I would just encourage people to get a post up MR before that patient leaves the hospital. It's good to
37:38
have as a baseline. And it can save you, especially in some cases. If patients migrate posteriorly quickly, they can end up with a C5 palsy occurring within a few days of the operation. You're
37:50
gonna have to do an MR at that point anyway. So you're gonna wanna use that as a baseline. So here's your typical laminectomy. Here's your medial facetectomy for aminotomy. Here we've done a
38:00
multilevel laminectomy, And you can see the nerve root. By the way, the nerve root is - look like it's coming down. In some instances, you know, if the arms were upward, it looked like the
38:12
nerve root was going up. But we used to see that when we were doing patients in a seated position, but here you have your arms right down by the side. And this is where you're working in the armpit,
38:23
really the axilla of the root. You're gonna use your pen field elevator and your suction, you're going to identify that root, watch out, the motor root anteriorly can look very white and it can
38:34
look like disc You don't want to mistake it for disc. And you're gonna use your SCPs, your motor evoked response, et cetera, to make sure the cord's okay and your EMGs here to try and keep you out
38:45
of trouble. So here is your decompression being done where the nerve root is now freed.
38:53
Here's an MR after your C5-6 laminectomy, two, three, four, five and six. Here, spinal cord is freed, bath a spinal fluid, Okay, and you've done a fusion to maintain that lower doses because
39:07
otherwise they can slip into a carthesis, which you don't want to happen. Fusion techniques. This is one of the older fusion techniques. You use wires in
39:19
the spinous processes and this happened to be a laminectomy of C3 and IV. Here, wiring and a fusion above and below. This was C2 to C5-6. You put in your rods and then you can wire it in at the
39:34
levels above and below and manage to decompress. And here is an example of other screws that are being used. These are your lateral mass screws. C3, IV, V, and VI. And the pedicle screws, they
39:51
can be C1 also, but C2, C7, and T1. And you know this, that everything we're throwing in bone autographed as well But this is the screw entry you'll look at. Camille or Marguerl technique as to
40:05
how to place your screws for the lateral masses and here they diagram the lateral mass and for quadrants and it's just the superior quadrant very inferior medially on that quadrant all of these
40:20
directions but it's got to match whatever the CAT scan and the anatomy shows for that individual patient so you're putting in your screws I can't tell you how many times these screws are going right
40:30
into the vertebral foramen so you really have to be very careful and that's why you're going to want to use alarm monitoring or intraoperative CAT scan monitoring if you have access to it. If you
40:44
don't then you have to base it on doing your preoperative CAT scan measurements and hopefully you have that. What are the injuries that you can get from lateral mass groups, nerve root injuries,
40:54
vertebral artery injuries, those top the list but look at this other list now positioning or loose screws, device
41:03
going apart, malfunction, bone fractures, graft settling and displacement, loss of correction, and obviously, pseudothorosis are a failure to fuse. So the list goes on.
41:15
Complications, vascular injury. I told you that, you know, you're at C1 and there's a screw that's going right into the frame and screw right into the frame and, ah, screw is just missing the
41:24
frame. And
41:27
obviously, if, you know, if you're doing an intraoperative image here and you've got a screw that looks like it's in the frame, and you've got to be very careful about deciding whether or not
41:36
you're going to pull that screw out because you may want to get your angiogram right then and there because if you pull that screw out, you may have massive bleeding and you're certainly not going to
41:47
put a screw in the other side if you have a question about that. So all of these are factors you have to think about when choosing to do, you know, these posterior fusions and especially if you're
41:58
fusing to the occiput Lots of times the occipital screws. are gonna be going right into the cerebellum unless you're focusing around the inion. Back in 1994, a boomy at all came up with pedicle
42:11
screws and pedicle screws can be even trickier. This is at C1 where, as Jim pointed out on the image earlier, you have your vertebral arteries here and the transverse foramina. You have to make
42:25
sure you go medial to those. You don't wanna go through the nerve roots on your way to doing that. And again, they're all kinds of explicit entry and degrees, et cetera, that you have to use in
42:39
terms of placing any of these screws. And this is just, again, to show you that what the risk can be with these pedicle breach, vertebral artery, cord injuries, screws loosening, et cetera. So
42:52
it's something to just think about and keep track of. If you have surgeons in your institutions who've been doing these, grab them. Don't just go to a course and start doing these by yourself.
43:06
Make sure you have a mentor. And here your lateral mass screws seen here and your pedicle screws down below. And here is an actual intraoperative lateral image. Here's C2, here three, four, and
43:19
five. Those are your lateral mass screws. And then here down at seven, you may have your pedicle screws. So you're gonna use often a combination of these different devices. Again, your O-arms,
43:31
your
43:40
CT scan I just threw in some articles about using spinal navigation, especially at C-1-2, CAT scan versus the cone beam CT scan. And both methods can be very effective these days and markedly
43:48
increase your accuracy. So use these devices if you have access to them. This happens to be a pediatrics article using the O-arm Again, much more information. non-contained screws with four
44:04
patients, but none of these ended up critical and actually injuring the patient.
44:10
The other advantage, of course, is if you can document with that intraoperative CT that the screws are malpositioned, you can correct it right then and there rather than bringing the patient back
44:20
for a second operation. And you avoid the need for the post-op scan.
44:26
So here, pre-operative Mars stenosis and OPLL, post-op MR, the cord is decompressed. Here is a laminoplasty. Laminoplasty means that they leave one side attached and they hinge it and then they
44:40
open up the other side. There are lots of discussion about laminoplasty. One of the main problems is you come down the lateral gutter on one side, but you don't decompress the other side. You're
44:52
actually hinging the laminar on that side. The laminar can become unhinged and go directly into the cord or the nerve roots. there's a lot you know they used to say well but this preserves stability
45:03
well it really doesn't most people I think would just go for the laminectomy and fusion at this point rather than the laminoplasty so again another discussion for another day spinal fluid leaks
45:15
there's just no comparison ACDFs the risk is low you get to OPLL the risk is high I read a study the other day that said risk of multi-level OPLL was like 58 so it can get very high and certainly if
45:30
you're not using a microscope it's even higher than that look at your pre-operative caskins if it has any one of these signs don't do an anterior operation if you can avoid it here's your c-sign I
45:41
described this years ago where you have anteriorly you have a chunk of OPLL and it's a little off to the side you may have the single layer one big piece or the double layer sign where actually it
45:53
looks almost like an Oreo cookie you see the chocolate and then you see the vanilla and then the chocolate again it means two and through the Dura. Alaminectomy here is OPLL,
46:04
C2, C3, C4. This is segmental OPLL. This is continuous OPLL. This is your double layer sign that you're seeing on this image of your OPLL. Again,
46:17
you've got a good lordosis, go posteriorly. So OPLL, but a positive K-line and a good lordosis, laminectomy infusion, it's gonna decompress your core and you're gonna avoid that anterior CSF leak
46:28
in the, and you're gonna avoid the anterior wound parrot, the lumbal parrot, the lumbar drains. You know, the positive K-line, again, you know, here C2 down to seven, you've got this OPLL
46:41
here, but still, look at your lordosis, you've got a good lordosis. Despite that CAT scan and the MR findings, these are the same patient, by the way, look at the CAT scan shows you the bone,
46:53
the MR just shows you the continuous hypo-intense signal Again, learn to read this. but you go posteriorly, you decompress, it depends, it's gonna be fine. So in short, and in conclusion,
47:04
cervical aminecumine fusion with a positive K-line, and either straightening or a normal lordosis or a hyper lordosis, it's gonna be safer. You're gonna have fewer risks and complications versus
47:16
anterior cervical surgery. And here you have a cartoon that says, Nerus, get on the internet, go to surgerycom, scroll down and click on the Are You Totally Lost icon? And this, you know, we
47:28
all laugh at this. And I can remember years ago an associate working on a case that happened to be a far lateral lumbar disc, he broke scrub, this
47:40
was not his specialty, he broke scrub, ran back to the locker to look it up, and then went back to try and do it again. Thank God the physician assistant on that case had done many of them. But
47:52
in short, your patients will enjoy better outcomes If you do the right operation. And it's saying, Hey, wait, this one's a lawyer. We'd better wash our hands. I just wanna show you some of the
48:02
articles that you can reference if you want to. Part three, our posterior surgical approaches to the neurologic diseases involving the cervical spine. And these are the key references I mentioned.
48:17
I'll make sure you're ready to take screenshots of
48:20
these references for your own records
48:25
This is talking about, you know, posterior surgery, no neurovascular injuries, no re-operations, no residual ventral disease because the cord migrated. So low morbidity, anterior core pectomies,
48:36
increase the risk of CSF leaks, vascular injuries, and vertebral artery injuries, et cetera. So I'm not just making it up, it's based on what the literature shows. You know, look it up, look
48:47
up PubMed. You know, write some papers on this. Alternatively, with an adequate lordosis, posterior procedures may provide adequate, multi-level decompression. while minimizing the risk of
48:57
anterior cervical operations. Here's another one. Open cervical lamina for aminotomy. We know that this avoids both the fusion as well as the risks of an ACDF, lower incidence of dural tears,
49:09
infections and neural injuries. Another one, posterior surgery, relatively safer, lower surgical trauma and incidence of complications. And this is one with OPLL, epidemiology and
49:21
pathophysiology and all the clinical features of it So familiarize yourself with what OPLL looks like on your MRs and CAT scans. This operation actually talked about doing posterior operations, very
49:33
safe and an outpatient surgery center. Watch out for articles like this, okay? Not so fast. Any patient with any significant morbidity do those as an inpatient. This can be fast, slick and
49:49
especially if the surgeon owns any portion of that poster of that facility. Watch out, watch out for outpatient surgery, especially in the cervical spine. Circumferential approaches have
50:01
comparable rear operation, readmission, et cetera, whatever, but they can be high. If you can try it, the posterior operation first, try it. If there is any residual anterior disease, that
50:11
can be done secondarily, but you'll make it safer because the cord will have more room. And here posterior surgery was associated with lower costs and is more cast effective than anterior procedures
50:23
The overall incidence of vertebral artery injuries, notice how low the percentages are that you're given, a 012, this is 11, but remember, the frequency of these injuries is vastly underreported,
50:30
especially with anterior operations, and
50:42
it's the lowest with posterior fusions, 001. Okay, so I think that that concludes what we, what I have to say about this and Jim and I will entertain any questions, right? Part four is an
51:00
interactive discussion with Dr. Osman on all aspects of the talk, discussing practical aspects of this, which you can use
51:13
immediately after this lecture in there. You'll find them very useful.
51:19
We
51:22
can leave the slides up, I guess, son Okay, and
51:28
let me ask you some questions. I think it was a very complete talk. The problem I had is that the viewers don't always, Nancy prepares these, we go ahead and we review them before a number of
51:44
times, before you really see them. So
51:47
in the end, the more we do, the less questions I ask and that can be a negative. Here's my question. I'm the neurosurgeon and I've got the patient who comes in. He's got the symptoms that you
52:02
have. I've got, I can do a CT scan. I've got that. I can see that. I may not have, we've been through this on previous studies, on previous videos. I may not have an MR, but you've said
52:16
before, you can do a myelogram CT, myelogram, which will give you the information you want, correct? Yes. So now we're covering all parts of the world. And then,
52:28
By the way, in that myelogram CAT scan, do with the non-contrast CAT scan first, or that cervical spine, if you have access to the CAT scan, if you just can do a myelogram, then you can just do
52:38
that. But the reason to do a CAT scan, or some cervical study, or even just look at that x-ray carefully, you have to be very careful about doing a myelogram in a patient with really super severe
52:49
cervical cord compression, because sometimes they will deteriorate. Oh, okay, good point, I really appreciate it. That's just a good proposal to think about, yeah. Okay, so now I'm trying to
52:58
cover all parts of the world, so then we've got that. If I've got an MR, fine, I can use the MR, I can use a CT. But the Mylegram's good, yeah. Pardon me? But the Mylegram is useful, yes.
53:11
Mylegram's useful, right. So you're not, I'm trying to get to people who hear all these things from their representatives of the companies who wanna sell the instruments and the people are writing
53:22
papers. And in the end, they say, well, if you don't have what I have or they imply this, you just are
53:30
not can't do adequate surgery and it's inferior. And that's just not true. And you got it wrong. It's not true. And actually what's interesting there, Jim, and one of the reasons that I included
53:42
the slide about putting the wires to the Spanish processes, that costs you almost nothing. Yeah So the reason is the most important to Bob. The most important part is between your ears and it's
53:57
just your brain. So I mean, you can use that. So I'm here. I'm thinking about it. I've defined the lesion and I've decided, okay, I hadn't read about it much. I know about it. You convinced
54:11
me to use a K-line. I look at the K-line
54:15
and I see that the pathology is from what you're saying is anterior to the K-line So I know that I can
54:25
go from behind. Well, okay, now
54:31
I know a lot of people don't use the K-line and I kept asking them all the time, Why are you doing it this way? Well, that's the way I'm doing it. And at least this gives you an objective measure
54:41
of what you can do because I never could get a street answer to this. I could never get a street answer to the question of, Why are you fusing this patient? you're decompressing from behind.
54:52
What's the reason for where we're gonna come to that? And so, okay, I've done that. I bring 'em to the operating room and I'm ready to do it.
55:03
If I have all the facilities there and they're monitoring and everything, that's fine. If I don't, we've talked about I don't have a head holder. Okay, what we can do, it's not ideal. 'Cause as
55:13
you press on the neck, you're gonna create more of a hyper extension that's gonna distort everything And it couldn't make it worse. So you put 'em in there, at least you secure that. You've got
55:25
the shoulders taped down. You put some kind of recording in for neural monitoring. If you have it, if you don't have it, then you gotta go without it, but then you gotta be very careful about
55:36
extremely careful because you're losing a guide, right? Yes, and the biggest thing is avoid any hyper tension. Okay I'm sure you have an arterial line in. Now, the other thing, I asked you this
55:51
when we were working on it, I've got the patient, I put him in the head holder. Yeah. If we were doing a patient prone and we're doing posterior foster surgery, we flex the neck. Yes. So you
56:04
accentuate the midline, you can separate the muscle. Right. Well, in the picture you showed, it looked like it was natural position. Is that right? Well, you try and keep them neutral,
56:15
especially if they have significant neck pathology because if you flex them, sometimes you may be tethering their spinal cord over the anterior pathology. Okay, that's what I wanted you to say. So
56:27
the temptation is, it makes easier surgery, but there is a risk. That's correct, that's correct. So especially those patients, you know you have shingled lamina, you'd love to be able to flex
56:37
them and separate that out and whatever, but the answer is you can't do that because you may incur a deficit in that patient by the time you get to doing the laminectomy.
56:50
Okay, so now I've done that and okay, I'm doing, I'm ready for the surgery, I do the things I should do. We're talking to people who should know how to do a posterior laminectomy by now and I
57:04
think you've outlined the details of the procedure. They're down, they've taken the lamin off, you've told them that they should, at least they could take a lateral, the medial third of
57:18
the facet at least, right? I think you said that. Right But also, Jim, just at that point, they should be using, people are gonna be using drills. If you're using a drill, diamond drills, no
57:28
cutting burrs. A cutting burr can ratchet off. You have to diamond shave it down until maybe you have a tiny little thin rim or bone left over the yellow ligament and then use your one millimeter
57:44
kerosene punch. But very laterally, you're not going to, You want to use that parison punch immediately damage the court. Okay, the key thing is again, particularly if you don't have monitoring,
57:55
very, very, very careful not to do anything that will damage the court. But obviously, we're talking about a wide and range of environment here. Okay, we've done that, we've done the pathology.
58:08
Now, I come to a key question. I never got that answer from this question. And that is, okay, I've done my lemonectomy Should I fuse the patient or not? And I can tell you, I've heard
58:23
everything from, everybody gets fused to, well,
58:28
it doesn't look like, I was overextended by a lemonectomy. Why don't we see how he does? And follow him in the clinic. If he comes back with symptoms, I can go back and fuse him. What's the
58:39
right answer? Well, I think first of all, you get that preoperative MOR, and very importantly, you get that preoperative CAT scan. Too often, especially in your older patients, they are
58:52
getting fusions that they do not need because you could see on their preoperative CAT scans that they're already spontaneously fused. Now, that group is typically forgotten. And actually in the old
59:05
days, obviously, my father was neurosurgeon, and we do a tremendous number of laminectomy without fusions. But the younger the patient, the more the need for the fusion, because they are not
59:18
spontaneously fused. And if they're not fused, oftentimes they will go on to develop progressive kyphosis. And if you have any significant anterior disease, that's going to get worse. And if you
59:28
have OPLL, the OPLL will progress more rapidly if they are not fused. Well, okay, let's take the average person, let's say he's a 40 years old, he comes in, he's got some arthritis, he was
59:43
doing, exercises or carrying things on his head or whatever it was. And she's got some circle arthritis. And you do it, you get a nice decompression. Everything is anterior. And you can do it.
59:57
The procedure, do I fuse that guy or not? And what is it that flips the switch? More
1:00:05
likely than not, that guy's ligaments are not calcified or ossified. His facet joints are mobile and open And that is a patient you're more likely than not. You've got to fuse that patient. So
1:00:19
would you say 100 if you had a, I shouldn't say that, and highly likely if a patient's younger, you're going to fuse them if they're older, you
1:00:29
probably wouldn't. That's more or less yes. I mean, the other thing too is you know, what we're also talking on the border of, and we're not really discussing is, you know, the group of the
1:00:39
laminophuraminotomy group
1:00:42
is a different group. Right, I understand. Let's say you have a two level laminoframanotomy, same side, those are the patients you don't necessarily have to fuse because you've got the
1:00:51
contralateral side holding them together. But I would say overall, yes, the younger the patient, the more likely you're gonna have to fuse that patient, the older, older, older, the oldest
1:01:02
group you're not gonna have to fuse or not necessarily gonna have to fuse, but you've gotta look at your studies. I mean, some of them are, you're gonna do flexion extension studies. If they're
1:01:10
moving, then you have no choice So the question now is,
1:01:17
I mean, do I have a rule as a surgeon, or what is gonna tip my decision to do the fusion or not a fusion, or if the patient's younger, he gets a fusion automatically, boom, that's it. You have
1:01:31
to do your MR, your CAT scan, and you should do your preoperative flexion extension films. See what the motion is for that patient, but still a vast majority of the time, patient having a
1:01:43
laminectomy as a younger individual is going to have to have a fusion. Okay. And the older post-year group, you may get away without a fusion, especially if there's no clear-cut subluxation on the
1:01:55
films and certainly on the Cascan if there's evidence of a tremendous amount of stability. Let's say you choose to just do the decompression, you don't do the fusion. I know in the most surgeon
1:02:07
would do the fusion because I get extra compensation or something for me, there's another motivation. So let's say I don't do the fusion, but I'm going to follow the patient closely in clinic. It
1:02:19
comes every three months or six months. I get some spine films and I'm looking for some of the subluxation or something that might happen. Is that
1:02:31
a reasonable choice? It could be a choice in select cases, especially if you're - Let's say you're just doing a medial facetectomy for aminotomy on one side, and you're not really touching the sets
1:02:45
on the contralateral side. The other question I would raise here, which is very apropos, is let's say I've seen these patients recently, a patient has an epidural hematoma as a result of an
1:02:55
epidural injection Our patient acutely with a
1:03:02
cord
1:03:04
injury,
1:03:09
you're going to want to do laminectomy, get that patient off the OR table. There it is. True. That is a patient where you can do your decompressive laminectomy, follow the patient afterwards. So
1:03:21
would you have the patient where you don't have to take much off the medial facet so that you may preserve stability? So now what you're telling me, I'm getting from this mostly, is that most of
1:03:30
the time you're going to be fusing the younger patient, that's 20, 30, 40, 50 years old. It's starting at age 50 or 60, or you may be a little more conservative, is that right? More or less,
1:03:44
yeah, yeah. Okay. Okay, and is it gonna matter? And this now, okay, so now I've made my decision, this is a younger patient, I'm gonna fuse them. Now, I don't have one of these fancy
1:03:57
machines that's gonna tell me which way I eat breakfast and all the other kinds of things It's a, and so, and I know a lot of older people, I wrote you this, that are able to do this with a high
1:04:12
degree of accuracy, that's obviously experience. Right, right. So the question there are now in a country, I can't get the x-ray technician to the operating room, that's gonna be common, okay.
1:04:24
So there are some guidelines you can use to do this. You do that, you wanna check the patient if you can before he leaves the operating room and so forth. Ah, but it doesn't mean you shouldn't do
1:04:36
it. I mean, you can't - Oh, well, if you have a, let's say you're in a location where you do not have access to X-ray. Yeah. Well, you still, if you're gonna do a posterior procedure, then
1:04:51
you have to identify C2, and you have to do enough of an exposure to count down from C2, to make sure you're at the correct level. Yeah Okay, number two, you're going to do your decompressive
1:05:07
laminectomy as we've described. Number three, if you need to do a fusion, the old procedures that they would just, you know, if you have any stainless steel wire, you can put a stainless steel
1:05:20
wire through the base of the spanish process. You know, using a, you know, you put a clamp, yeah, actually you can have a drill plus a clamp, but you go through the base of the spanish process,
1:05:31
You put the wire through the base of the Spanish process. And then you can get various types of rods that can be relatively cheap. And you can place your rods on both sides. Oh, so now we have -
1:05:43
This is a very cheap way of doing a cervical fusion if this is what you need to do. What about just putting some bone chips in there and watching them and putting them in a collar? You can do that
1:05:56
as well. But if you have access to some of the wires in the rods, you're going to facilitate that fusion. In other words, let's say you have a patient with a fracture subluxation. You're gonna
1:06:10
wanna try and get a rod and a wire in there rather than just relying on the inside too. The inside too, just putting the bone chips down, that's classical for like using, used for little children.
1:06:23
So people have to stay up to you like crazy. If you're really, I mean, if you're, again, we're talking about people who don't have all these things and it costs money for the patient.
1:06:33
Take off the laminate, you take off the spinous process, you could make bone chips out of that, you could put them in there. And
1:06:41
what's the likelihood that patient would get the kind of fusion you're looking for, 60. Oh, probably, yeah, and I would say probably at least the other thing too is, remember, you also have
1:06:52
access to takingiliac crest autographed because the bone marrow you're gonna get from that is going to be excellent to facilitate your fusion. So forget all this, you know, don't use your infuse,
1:07:05
it's not legal anyway, it's not have to approve of this use, but don't use your, you know, your DBM de-mineralized bone matrix. You don't need the cadaver products, you don't need all this other
1:07:17
stuff coming from the different companies. You use autographed and you're gonna facilitate, you can also use some of theiliac crest cortical bone to be some of your bone graft that you may be wiring
1:07:30
into place. So we've actually, this has been helpful too. If I'm from a place where I don't have these things, I'm now able to do it. I'm able to put to do a fusion. I can either put some bone
1:07:41
chips in there. I can put a rod that's easy to get. And I can wire it to the spinous processes that are existing. And obviously if you have more, you can do more, you can put the pedicle screws
1:07:54
in or the lateral mass screws and so forth and so on. But you're not stuck in handicap because you don't have the latest fusion to use on your patient. No, you always have access to these other
1:08:07
options. You just have to think about the options. Yeah, okay, that's pre-operative thinking. Okay, so we took care of that. I'm gonna ask you a question from 50 years ago. I can't remember
1:08:20
the fellow who was at the LA clinic. You would talk about this. Oh, I think, I know you were talking about
1:08:28
You haven't said this, but it's going to come up. So I want to answer it. That we know the dentate ligaments cause the core, cause the, or, or attack the core and then they, the anchor, the
1:08:41
anchor, the core. Right, forget that. I want to advocate cutting the dentate ligaments. Ignore them completely. Don't even bother. That's been disproven for years. Okay. So, so hear about
1:08:52
that. The answer, no, don't open the door. That's only going to add complication. And you're not going to, if somebody told you about it, it's not going to make any difference, don't do it.
1:09:01
Absolutely. And then of course you've opened the door over multiple levels and you've got all the other problems. So you've got all of a sudden problems. Okay, let me see if you did that. I
1:09:12
learned to end with one thing, I mean. Oh, by the way, before we say anything else, if you have a patient prone on a horseshoe or prone for any of these operations, your anesthesiologist every
1:09:26
10, 15, 20 minutes should be lifting up that head and head. Right, right. Check the eyes, et cetera. Check the face, otherwise you may end up with skin from the face sloughing off, much less
1:09:40
problems with the eyes. Okay. And eye injury, that's exactly right. Yes. One last thing, and I - Was Charlie Fagan you were talking about, I think? Yeah, Charlie Fagan, and he did a really
1:09:50
good job, and it's before we had all this stuff. And he was
1:09:55
at the time when people were beginning to think about an interior, and so he was saying, wait a minute, let's understand what we're doing here. I mean, Joe was the president of the Historical
1:10:06
Spine Research Society in 1981, so I knew all these guys. Yeah. I gave my first paper there, but that was great. Now, one thing, just for the people who are watching, is
1:10:20
unfortunately surgeons get in a position where they advocate, well, if I can't do this, surgically. I can do that surgically. And I don't think I think that's not the proper reasoning. What you
1:10:33
have to do, and you've said that here, basically you have any disease. And the question is, you've gone through the disease, you've found out now, there are multiple ways I can treat this
1:10:45
disease. I can treat this disease with treatment A, which turns out to be putting them in a collar and giving them physical therapy. I can do treatment B, which is an epidural I could do treatment
1:10:58
C, which
1:11:02
is what you said today, I can know where the K line is, I do a posterior approach and so forth and so on. I could do a posterior approach with or without fusion. I could do a 360 and so forth.
1:11:15
What you have to do is, and you did this, what you have to do is sit down and say, what are the risk benefit ratios? In other words, your goal is to get the highest success and the lowest
1:11:26
complications.
1:11:29
If I look at physical therapy, it's obviously I'm going down the wrong road. That's doing nothing, and that's why the patient's being considered for surgery. And lots of times it's exacerbating
1:11:39
the symptoms because they'll hyperextend them, et cetera. So what I'm trying to get the people to understand is what you do is instead of asking them out of procedure, you put them down and label
1:11:51
them as A, B, C, or D, or whatever. And what you want to do is choose the one logically that has the highest benefit and the lowest risk. And so you approach the surgical choices after you've
1:12:07
come into that the same way. Do I do it centierially? Do I do it posteriorly? Do I go and do a fusum anteriorly, so
1:12:17
forth and so on? And you've got to measure what my outcome is going to be in terms of what's the chance the patient is going to have an excellent outcome versus the risk. As the risks go up,
1:12:31
then you really gotta think about it. Yes, and I'd say even before that, here's a patient, are you gonna do an epidural on these patients and I would say do not. I just reviewed the literature on
1:12:44
this once again. Some patients may have short-term, the Actually. benefit
1:12:49
ones who have short-term benefit are typically the ones with no disease at all and shouldn't have the epidurals anyway in the first place. There's no long-term benefit I could not come across any
1:12:58
study discussing any long-term benefit. And that could be up to two to three weeks or six weeks. But beyond that, not. And think about it. You don't want to do epidural injections and your
1:13:10
patients on aspirin. You can end up post-ophemotomas, intramagilary hematomas, vascular, injury, stroke, et cetera. The risks go up and up and up and up without the benefits being there And
1:13:23
unfortunately, a lot of insurance carriers require that patients go for epidurals before they go for surgery. Now that may be totally inappropriate, especially if the patient has significant
1:13:34
disease. Don't do it, is your answer? My answer would be don't do it, yes. And you have to tell them, no, I'm not going to do it, it was too risky. Yeah. Because people then comply with what
1:13:45
the insurance or Medicare wants. Absolutely. So they don't want to hassle. Yep. And if you look at, they're almost the first slide you show, if you go in the cervical spay, the cervical, if
1:13:57
you go in the cervical foramen, your shot at getting into the subrachnoid space or into the epidural
1:14:07
space is really limited. That's right. I mean, what is your, I looked at the picture there and says, what is my chance of getting into that space? Right. And when I had, rather than getting
1:14:18
into the cord or something else, I mean, that just isn't. Well, that's also the, the transfer seminal injections usually done at C-71, but they have a much higher. morbidity, complication rate,
1:14:29
et cetera, than the routine epidurals that are interlaminar between the laminar. Well, there was no reason to do that. Even if you went to
1:14:39
interlaminar. That's a lot of good idea. You've got to get into that small space. I'm not, that's not easy. And just think about your patient with very severe chord compression. There is no
1:14:48
space. Right.
1:14:51
So again, it's a risk benefit ratio, and that's what you got to look at
1:14:57
So, do we miss, do we miss anything? I don't think so. I think we pretty much covered it. Naze a tracheal for our robotic intubations. Oh, yeah. Don't let your anesthesia out. This is the job
1:15:09
of the surgeon. You don't just sit in the corner reading your newspaper or on the doctor's lounge. You should be there from the get-go. You should be helping to set up the room. You should be
1:15:19
talking to anesthesia. You should be talking to your monitoring people every step of the way you want them to know what you're looking for. I used to go in and also show the nurses on the OR field,
1:15:31
the circulating nurses, the PAs, et cetera, exactly what the pathology was and what the operative plan was going to be. I talked to anesthesia, no hypotension. If this is significant cervical
1:15:43
disease, the best way to stroke out the cord is to have a hypotensive event. You're gonna lose your monitoring plus everything else. So again, it's compulsive commitment from the get-go and you're
1:15:55
responsible for every step of the way. I used to make up a list that I'd post on the wall and hand out to the nurses and an anesthesiologist, which was the list that you said, Joe is saying, when
1:16:10
he would drive into work, he'd go through the operation in his mind. And I mean, it's like you're gonna take a test. What am I gonna do here? One, two, three, four, five, six, seven, eight.
1:16:21
Why not let everybody know about it? So, okay, let's just start terrific. We pretty much completed the standard anterior and posterior approaches for the cervical spine. We didn't talk about 360
1:16:36
too much when we leave that for later, but I think we pretty much covered that, okay? Sounds good to me, yes. Okay Nancy, another terrific job. Thank you so much, really appreciate it. Okay,
1:16:48
thank you Jim. Okay, take care. Okay, bye bye.
1:16:54
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