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SNI, Surgical Neurology International, an internet journal viewed by over 600, 000 people around the world every year, and Nancy Epstein is its editor-in-chief. An SNI digital, a new,
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editorially curated, neurosurgery and medical information resource, with a multimedia platform, operative videos, expert interviews, podcasts, global interactive discussion of information for
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the next generation of clinicians in 13 languages, with James Osmond as its editor-in-chief.
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Are pleased to present
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in cooperation with the sub-Saharan African neurosurgeons representing 50 countries and almost
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a billion people? The sub-Saharan Africa international neurosurgery grain rounds held in the first Sunday of each month.
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In addition, SI and SI digital are sponsoring with the Latin American neurosurgeons, the Latin American international neurosurgery grain rounds held in the last Sunday of every month.
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This is the 21st Sub-Saharan Africa International Grand Rounds in Neurosurgery, and it's dedicated to global solutions to clinical challenges in neurosurgery. Estrada Bernard is the head of SNI
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Digital Grand Rounds Programming and is a co-moderator with James Osmond. This is presented before an international audience
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This international Grand Rounds has a topic which is a seminar on thoracolumbar fractures, the global
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management experience with case presentations and discussion.
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The first speaker is Tiffany Grace Perry, who is the Vice Chair of Spine and Education Associate Professor of Neurosurgery at the Cedar Sinai Medical Center in USA. and she'll talk about
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thoracolumbar fractures and traumatic thoracic spondyloptosis.
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The second speaker is Hugh Dokopono,
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who's a consultant or a surgeon at the Military Teaching Hospital in Benin, Africa. And he'll talk about his experience and the update of management and outcomes of thoracolumbar fractures.
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Just for your information, Benin, Africa is the Republic of
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Benin, formerly Dohome. In Western Africa, you can see on the map here, on the inset, located on the Western, on the Atlantic Ocean coast of Africa, and you see it's next to Nigeria, Togo,
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and it stretches inland. It has covers about 44, 000 square miles, or 114 square kilometers. It has 12 million population. Its capital is located on the sea coast. And its porto novo and culture
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no is its largest city also on the sea coast. The fine people, one of the tribal people there, in related groups constitute about two-fifths of the population, 70 of the people are under 30 years
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of age, has a high growth rate. Its language is because it was occupied by the French, is French, and it has 27 Muslim population, 40 Christian, and still 11 voodoo, which is where voodoo arose,
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coming to the Western Hemisphere. Its main food sources are from its own agriculture and fishing. And it also has oil, which is one of its products. In the southern part of Benin, the fine
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established the Obama kingdom in the early 17th century. And in the 18th century, the kingdom expanded to include areas where the French forts were located as they expanded the kingdom north. By
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1882, the French were firmly established in the area, but had conflict with the French and the African tribes. And it was in 1894 that De Homie became a French protectorate, and that was its
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original name. It was incorporated into the Federation of French-West Africa in 1904, was then achieved its independence in 1960. And De Homie was then renamed Benin in 1975.
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Okay. All right. Well, welcome everyone. For those who log in early, we had the chance to meet Dr. Peterson. She's the Vice Chair of Spine and Education at CELO-Sina Medical Center in Los
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Angeles. And she's going to share with us our experience with the Thurgolumbar fractures and thoracic spondyloptosis. Our other speaker is Dr. Hughes Doc Pano from Benin, and he's going to talk
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about
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his experience with Thurgolumbar fractures. And the third speaker is Dr. Ben Matiso from Kenya, who will be discussing about post-operative epidural hematoma.
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So welcome everyone. We'll get started. Jim, do you have any comments before we get started? I think this will be a very. fascinating discussion and I'm very much looking forward to it. Yeah,
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so I'm not going to say anything. I'm really looking forward to hearing this. All right, Dr. Perry,
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thank you. Did I call you Peterson? Yeah, it's okay.
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I have the UNC connection with Peterson and Perry as soon as I look at it anyway. Eric, excuse me. Yes, yes, no, thank you, Dr. Perry for agreeing to do that. She has a very busy schedule,
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so I'm glad she was able to accommodate us. So please proceed. Of course, thanks so much for giving this opportunity. And it was exciting for me. I'm at the AAAS and actually got to meet a
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neurosurgeon yesterday evening. I was just telling Dr. Bernard, what a small world it is, how he actually was training at the hospital that I go to in Kampala, Uganda.
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memorize this because everything's so accessible. But I just think it's important to remember the underlying thing. So take a moment and go through just type A type B type C just to give you a
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gestalt for what each injury represents in the thoracolumbar injury classification system. So in general type A's you want to think about being that there is some form of bony fracture and it's a
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primary bony fracture. There's not going to be disruption of ligaments per se that are destabilizing in these injuries. So A0 is going to be just like a Tp fracture or maybe like a very, very small
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little shear off of a spinous process, but in general it shouldn't be a ligament is destabilization. Wedge compression is just one end plate with a small little wedge deformity. A2 is going to be
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where you either have a sagittal or coronal split. We're also gonna see a case example of that. A3, you wanna think about one end plate involved. Posture bony elements can be fractured, but again,
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no ligaments and it's gonna be bone. So that's an incomplete burst. A4, complete burst, both end plates are involved. So if both end plates are involved in bony injury, you're gonna be either
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being A4 or you're gonna be a split, A2 So that's sort of how you wanna classify those A. So the A's really in sequence make a lot of sense. Like you look at this diagram and it can be really
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daunting, it's not. So then type B, we wanna think ligaments. It can be ossius disruption, ossius fractures, but you're also gonna have ligaments involved. So this is sort of that classic B1,
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it's gonna be that classic chance type fracture The chance fracture can go through the disc and the posets
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it can go through the bone that the sets in the ligament or the bone, the pedicle and the ligaments. B2 is gonna be essentially anything involving a fracture, whether it's one end plate or two
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implants and a posterior tension band disruption. Type three is gonna be that hyper extension. Usually that's gonna be through a disc where you're gonna have disco ligamentous disruption and that is
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a destabilizing injury Type C are sort of the ones that we really don't wanna see. And type C is the one that typically, and we'll talk about this a little bit later, about a 62 to
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96 incidence of spinal cord injury, of Asia A injuries with a type C injury. So that's gonna involve either some component of translation, dislocation, rotation with dislocation, but these can be
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really incredibly devastating injuries. So I love this algorithm. I'm a very linear thinker. And so I think this is super helpful. If you've got displacement dislocation, you're a type C. Done.
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If you have a tension band injury, you're gonna be some form of B. If you have an isolated vertebral body fracture and either low suspicion on CT or no suspicion on MRI of like a mental injury,
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you're gonna be somewhere in your A's So then we have modifiers onto this classification system, either the neurology or the subsequent modifiers M1 and M2. The neurology, you're graded on zero to
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M4 and tacked down to complete spinal cord injury. You can have an NX, which means that patients have tended, you can't examine them or they're sedated, you can't examine them. And then other M1
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and M2 modifiers, the M1 modifier is where you can't quite determine
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And I really like interactive. So I am gonna actually ask some questions along the way to make sure everybody stays awake on Zoom. So we're gonna, I'll ask some questions as we go along. So let's
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take this first case. So this is an L1 fracture. These first two cases or cases that I did at Cedar Sinai, it was one of those weekends that you're on call and it just so happened to be a
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thoracolumbar weekend. And within four hours, I had four patients that came in with TL injuries and they were all four managed very differently, one of them even being non-surgical. So these are
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just two of those selected four cases and we're gonna talk through them. So this is a 58 year old gentleman, he presented to our ER after crashing his e-bike. I hate e-bikes, I hate e-bikes. I
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don't like anything electronic that people ride on with or without helmets And he landed on his back in buttocks. He was not wearing a helmet, but did not hit his head. He denied loss of
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consciousness. He was GCS 15 when he came to the ER is exam. He was completely intact, but had severe low back pain. So I'm going to take you through his trauma CT that we got in the emergency
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room. So you can see on this coronal view that at L1, you could almost say, well, I'm going to call this a sagittal split fracture,
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right? Which would be an A2. But you've got both end plates involved. It's not just a split injury. And you've got retropulsion in the canal. So this really goes to sort of the two end plate
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involved A4. So let's go through now. We're going to go through some parasagittal views. This is going through that left-sided pedicle, the left-sided facettes. This is going through the
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right-sided pedicle you can see there's a fracture. extending through this TP. So we know this is also involving dorsal elements. So we sent him for an MRI so I could evaluate the posterior
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ligament is complex. You can see here the retropulsion into the canal. He's intact, so I'm not very stressed about the moderate canal stenosis, but a lot of stir signal change through the bone
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here. So now let's look at the parasagital views. So here we are again going through the left and you'll see stir signal going through that left L1 pedicle on the right stir signal going into the
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right L1 pedicle. But again, the PLC looks intact. So I'm gonna call this an A4 burst type fracture, all right? It's a sign of significant compression forces, but the absence of disruption of
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the post your ligament is complex. Now let's take case two, this is a little bit different. It's a T11 oblique type fracture. So this is a very unfortunate 61 year old gentleman, car versus
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pedestrian, he was the pedestrian. He got hit by a car going about 40 miles an hour and flew about 40 feet. He had a head strike and positive loss of consciousness, but he was GCS 15 on arrival to
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the emergency room He had a lot of co-morbidities coming in because he also had some health issues, diabetes, hyperlipidemia, but then he had a lot of concomitant injuries. He had multiple
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left-sided rib fractures with a subsequent pneumothorax that had to be treated in the emergency room with a chest tube, and he had bilateral tip the fractures. So significant amount of distracting
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injuries for this guy His exam for us, proximally, and his legs, we obviously couldn't check well distally. but he was three out of five, approximately in his legs, which made me a little
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concerned because, yes, he's got the tip of fractures, so, and he had a lot of distracting injuries, a lot of pain, so could it be from that? It could be, but this also could potentially be
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neurological. So, let's take a look at his imaging.
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So, here we are looking at it. Hopefully, you can see this relatively well. This is T11, I labeled these for ease of view, and you can see on this sagittal CT, this lucency here, but then
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let's also look. T7 is autofused to T8, which is autofused to nine, which is autofused to 10, and if we scroll to a parasagittal CT, you actually see that T10 and T11 also have these large
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bridging dish type, you know, hyperastatic osteophytes, and
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they're a T10 is fused to T11 You'll see this oblique. coronal cut through the vertebral body of T11, which is concerning. It takes a lot of force to be able to do this, to create this fracture.
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So, well, you know, we can't get a great exam. I need to probably get an MRI, but this guy actually had so many injuries. He was getting in his X fixes from ortho and the ER.
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They were doing the chest tube. So he said, look, we want to get into the ICU. We don't, he had gone into A-thib We can't get the MRI now. OK. So exactly 36 hours later, they finally got the
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MRI for me. His exam was stable. He was still three out of five, approximately. But we see this.
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And so what are you concerned about with this? Does anybody want to venture a guess?
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Anybody in the audience?
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I'll take a bite, but I can't do all - I can't take all the bites, so I'll go first.
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So, well, I'm thinking of hematoma. Yeah, me too. So the biggest thing I was worried about, here you can see your ligament and flavum, which is beautiful, right? Disruption of the ligament
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and flavum, basically a sheer injury with a concomitant epidural hematoma. And that's what
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I was very worried about here, where you can see this hypo intensity on the T2. And then you see this stir signal in the interspinus ligament. But actually, his super spinus ligament was still
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intact. So I agree. I was very worried about that, which made me incredibly - So let me interrupt you. So what are you thinking this was
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a compressive force or a destructive
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force? I think it's a chance type injury. Okay. So I think it's fractured this year. So that's sort of like
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a distraction, right? Potentially? It could be distraction, but it also could be. It also could be compressive because remember, he's supposed to be auto-fused here. Right, it's like
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an ankylosing spondylitis situation, okay. But so since his super spinous ligament was intact, I really can't say this is disruption of the PLC, right? So really, I either can call him a A3,
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which is what I called him, or you could say some version of an A2 with the split, but because of this epidural hematoma disruption back here, I felt like he fell more into the management of the A3.
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But no matter what, I agree with you epidural hematoma guy who's weak.
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I get, he's got a chest tube, I get his X-pixes, but this, I'm concerned, right? So - And what's happening in teary is that - Yes. Is there a process, right? Well, I'm sorry, the anterior
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spinal canal. Oh, anterior spinal canal, right here? Yes, yes, yes, is there any - There's no spinal canal. Okay, okay. Discernation, traumatic discernation. Okay, good, okay Yeah, and
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then you can see all of this, right? So this is a little hematoma as well,
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anteriorly, from this
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injury. So what this tells me, like I look at, you look at this CT and you're like, what are you talking about, Tiffany? This guy could be managed non-surgically. He's probably gonna heal this
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fine. But there are two really important things here. One is the moment arm that's created from the autofusions above, as well as you look this MRI.
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which gives you a host of more information and you say, this is actually really significant injury, right? In spite of the fact that this fracture doesn't look terrible, right? So let's talk
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about management 'cause then you're gonna tell me what you would do. So let's talk about case one. So let's go back to the L1A4 injury. What do you wanna do? Would you brace this guy? Would you
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do surgery? If you do surgery, what type of surgery? What's your timing of surgery in this completely intact guy? You know, do you think you could get away with braid, like get some x-rays and
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bracing? What do you think?
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Okay, this isn't just a dialogue between the two of us, but I'm gonna make, I'm gonna take the easy route and have somebody else take a more difficult route. So when I first saw this case, I was
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thinking, I'm gonna make the argument to Dr the - in especially, that Perry.
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place with limited resources, and you only have this, no neurologic deficit and 50 maybe of the canal, why not make a case for just treating this patient with a brace?
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And so, but I would like somebody in the audience to make a case for surgical intervention. Anybody, any takers?
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Go ahead So,
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there's somebody next to that. Do we agree that it's post to your elements that are also disrupted? Post your
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elements are not disrupted. Here's his stir
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in the bottom right picture.
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How about his ligaments? Nothing. No stir signal change there. It's all in that. All that. It's all in the vertebra. So is this a three column injury? It is, correct? It's a two column injury
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because it's getting your - anterior middle, your posterior is intact, as the sets are intact, yeah. So, I think the issue is not necessarily decompression, although you could, but the issue is
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- You stable. Surgical stabilization. Now, there was somebody in the background talking when Jim was talking with us. Yes, it's Professor Nimbert from Narrow, please. Oh, please, yeah,
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please We do have orthopedic sergeons from Narrowby who do a lot of these cases. And I wonder whether they could give their opinion. Dr. Kimani, Dr. Kimani is one of our orthopedic sergeons at
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the Canadian University Hospital. Dr. Kimani, are you able to comment on this case?
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Can you start the kumani? Can you hear? Are you?
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Dr. Kimani, I know he's on the call. And
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then of course we have Dr. Magoha who also does spine cases. I don't know whether he
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would like to comment on this case. I think I saw him in the call also. So
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there's Dr. Braheem, Dr. Braheem, would you comment? You say you would prefer surgery. Give us your thoughts.
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Braheem?
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Braheem indicated that there's two out of three columns involved so they would prefer surgery. So you have two different opinions. One is medical management to the other surgery So there.
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Thank you. So if you do a phrase, how would you mobilize? I mean, would there be an initial period of bedresting? 'Cause that's one of the arguments about non-surgical
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stabilization. You might be delayed with mobilization and you
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could incur some risks with that. Any comments about that?
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Dr. Maguva.
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No, I do see that, I'm just caught because there's no need to be that aggressive, I could be being naive. I think a few weeks sitting down is better than recurrent operations, so that's what I
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would lean towards. It would be something more conservative, but I'm listening keenly. Okay. So, one of the concerns with non-surgical, just to now counteract both of you, Now choose
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non-surgical is a 58-year-old active guy,
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you know, remember, he's right out riding his e-bike, he's very active, he's very healthy, slender guy, and is that he's going to incur a deformity at the Dorka Lumbar junction, which can be a
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really big deal. And so again, remember, I can't say anything about his alignment, because I have not gotten him up. So you can expect that when he gets up, his x-ray is going to look probably
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look very different, even if you put him in a brace, this whole fragment is going to go out, right, this area is going to compress. And over the course of three months that you brace him, not
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only is this going to compress, this is going to retro pulse, again, I'm less concerned about the retro propulsion, but when he gets up, this is going to look worse right so i think that one of
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the biggest more
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And the fact that, in the long term, a 58-year-old that's going to live another 30 years, this could incur later surgery, later pain, later disability, right, even if they don't have it at the
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outset
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So, let me interrupt you, so is that inevitable, again, this argument's sake to make this interesting, is that inevitable or is
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that, wait and see, based on an if is inevitable, why is it inevitable? So it's because of the instability of the answer to columns, which are completely disrupted, both end plates completely
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disrupted with greater than 50 compression of the vertebral body. We know those are the ones that are more likely to progress.
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for A4 fractures, for A4 injuries. And so with those, you may say, if they were less than 50 compression, both them plates evolved, you may be saying, you know, I think I can brace this guy.
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But once we hit that 50 compression mark, we know they're probably gonna progress. So there's no point in
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trying to see, putting them in a brace, getting them up to see if there's progression. 'Cause it's going to happen, you might as well just plan for surgical stabilization We know that population
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is more likely. They are more likely to progress. It's a higher likelihood in A4 injuries. A3 injuries, less so. A4 injuries, they will. And so it's just important to remember that distinction
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in these two fractures, which seem relatively similar, right? And
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then I'll show you, but then, so then in a moment, and I'm just gonna ask this question, but don't answer it yet, 'cause I'll show you what I did. do we have to fuse this 58 year old? Could you
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say, well, I'm going to argue fusion's terrible for this guy's poor 58 year old. You're going to put in screws. You're going to Arthur and Decim. That's going to be much worse than this 58 year
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old, right? And so I'm just throwing that out for food for thought, and I'll say, do we have to Arthur and Decim, right? So we're going to go to case two, and then we're going to come back to
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case one. So case two, what do you want to do for this one, right? This guy has now, we know, an epidural hematoma, disruption of the ligamentum flavum, but not the postural ligament is
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complex doricily. Again, Dr. Osmond, this is the one where you're right, he's proximally weak, he's three out of five, is that because the epidural hematoma, is it because of his TIB fibs and
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his distracting injuries? Is this an unstable enough fracture to take to the OR? So what would you do here, brace surgery? timing of surgery, if surgery, what surgery?
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Okay, Randy, are there anyone in the audience?
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Braheem, you had been wanting to introduce your commentary earlier. Do you have
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access now? Can you comment?
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Well, Jim, again, I'm going to make this interesting by arguing with you Well, the argument I'll make against bracing him is you have a neurologic deficit and you have canals stenosis. You have
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an epidural hematoma. And you could say,
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well, his early trauma, the examination may not be that reliable. It might be pain and other issues And I would assume that the three over five is significant and is refractive to spinal cord
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compression.
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or at least contusion from the initial impact. And you can, I mean, this is a, I call this severe cord compression. Like this is the hematoma here. So. But he has, and he has anterior cord,
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anterior and posterior cord compromise by the disc and
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the epidural hematoma. And that suggests to me, he's got injury all the way across because now we got a sense that his disc is disrupted.
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His posterior ligaments must be disrupted to have induced that epidural hematoma. So what kind of surgery would you suggest? Well, okay. Dr. Goontai had a recommendation about
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the laminectomy and stabilization. Now, Dr. Goontai, would you like to elaborate? like to elaborate.
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and indicate what type of stabilization you would do.
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Well, we like several people have put messages in the chat, but feel free to speak up. This is the conference for all of
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us. We should all be able to feel free to discuss. I would go for the next to me only with no spinal infusion.
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And the aim of the laminectomy would be to evacuate the hematoma and to decompress the spinal cord So what levels I'm going to ask you like I do in my residence? What levels are you going to do a
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laminectomy at?
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I'm
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not sure if I can count, but I can't go for a single level. It's T11 and T12. Here's T11 and here's T12. So are you going to do T11 and
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T12? I think I can do T11, and maybe just add an add. and maybe just a little bit of T12. And that should be enough for me to get enough space. So I'm gonna argue with you. You're completely
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removing the posterior tension band, right? I mean, I'm assuming it doesn't have good integrity anyway, but with the laminectomy, you're completely removing that and your disc is disrupted. I'd
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be worried that this patient needs stabilization. Yeah
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Yeah, and that was obviously my worry and concern as well. So
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let's go through the evidence-based medicine, which I think is really helpful in trying to figure out how to manage these. So let's first talk about my classification, right? I classified these as
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an A4 and an A3, right? And so
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how reliable is MI as a neurosurgeon, as a spine neurosurgeon and classifying these? Well, let's look at this. So this actually, a systematic review took a look at, they pulled 396 papers which
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were looking very specifically at A3 and A4 fractures for TL, right? And they look to see how good is the inter-observer reliability on diagnosing these fractures. And basically they found the two
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stud and nine total studies looked at that actually inter-observer reliability. Two studies had poor reliability. One had fair, four were moderate, and two were excellent. So basically two out of
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nine studies showed that surgeons and different surgeons and saying this is the type of fracture that is actually we're classifying the fracture appropriately. And we know this, right? All
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fractures are different. They're like snowflakes. They're all completely different. So we know that that also can be something through the management of these fractures, which is really important
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to look at. So considerable variability exists in the classification of these fractures. Let's take a look at radiographic outcomes. This goes back to what you were discussing, Dr. Bernard. So
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this paper took 112 patients with a retrospective review with TL fractures. And again, this is retrospective. So in my epidemiology class in grad school, like we all know, the retrospective's not
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great, but that's what we got And they had fractures at the TL junction from T11 to L2. They were all braced. There were 61 A3 injuries, 51 A4 injuries, two A3s and two A4s required surgery. But
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what they found is that A4s were more likely to develop a segmental kyphosis at a year. So the A4s, they found the ones that were, and they had all this exclusion criteria So patients who even had
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50 or greater compression with A4s, they didn't even include in this study.
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and stabilize him internally close to the IAR, and even maybe try to correct a little of the collapse and surgery, what if we could do that all percutaneously? And can we? And so in this paper,
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they looked at, and sadly, they were looking at lower lumbar NTL, but there were 32 patients at the TL Junction 18 patients in the low lumbar, and they found that they actually could get good
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correction with percutaneous instrumentation in these compression type fractures, A3 and A4 injuries. And again, this is a little bit of a skewed data set, right? 'Cause we've got 43, A4, 7,
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A3s.
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And my suspicion is, is that a lot of the A3s that came into this institution in Korea didn't actually proceed towards surgery. So that's why we have primarily A4s,
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who had fractional kyphosis of greater than 30 degrees or canal stenosis greater than 50 or vertebral body height loss greater than 40. And they found that in these patients, they could instrument
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them percutaneously and even found that they then could subsequently remove the hardware once those fractures were healed. Yeah, down, we've got to be critical, right? Let's look at our data This
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is 10 years of collecting material at a single institution and only 50 patients meeting this criteria. So again, you may argue, well, this is really poor data. But again, this is sort of what
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we've got and what we've got out there to look at. So let's talk about what we did with case one. So case one, I said, I want to instrument this guy, but I'm going to say he needs an internal
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brace. So here's what I did I put him on the OR table prone and look at how well that fracture opened up just by putting him prone. you can see how straight he got, right? Remember that fragment
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that was very collapsed here? Well, look at how already already corrected. So I decided, percutaneously, I put in screws at T12L1 and L2,
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and then I distracted gently, and I use monoaxial screws. That's also important. So not polyaxial screws. If you use polyaxial screws,
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does everybody understand the difference between the monoaxial and the polyaxial? Please tell me if you don't, 'cause this isn't - Well, previously, I mentioned that just 'cause there may be
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people of different experience. So the monoaxial screws are where the shaft of the screw is completely as one with the TULOP head. You get no movement between the TULOP head and the shaft of the
41:35
screw. In the polyaxial screw, you'll get the TULOP head that can wobble around and can go to different angles. So it's really important, and something like this, it use mono axial, because if I
41:46
use mono axial and I distract, my screws are gonna be able to actually distract. The actual shaft of the screw will distract. If I use a polyaxial screw and I try to distract, the tulip heads are
41:57
gonna distract, but the actual shaft of the screw is not going to. So really important, when you do these cases, to know ahead of time and planning what you're gonna do, so that you can make sure
42:08
that you've got the appropriate equipment at hand to do so. So I gently distracted using the monoaxial screws between T12 and L1, and in between L1 and L2. And here is my intraoperative CT scan
42:25
after my screws. So you can see we've restored the height back to really what's anatomical. Here's his first set of upright x-rays, pretty happy with that And I did no fusion. I put no bone. in
42:40
the fissettes, I didn't decorticate because I didn't want him to arthrities. The plan was once he's internally braced with these screws, as long as he heals at six to nine months, I'm gonna remove
42:53
the hardware. So let's see what happened. So here he is. So here was our initial injury CT. Here was our
43:05
CT at our six month follow-up where he is actually healed this fracture. He's bridged bone across the fracture. And on the coronal, you could see as well. I didn't do a video. And then I removed
43:16
the hardware and here's what he looks like. So he no longer has hardware in and he has a healed L1 fracture, but most importantly, he's not kyphotic through his TL junction.
43:31
So case two, I got - What did the post stop MRI look like? Oh, I didn't at Marham Post obvious neurologically intact. But you can see the retro, look at the retropulsion at the injury and here.
43:49
I was just interested in the compromise of the canal. Oh, I mean, on a CT, it looks good. If you have it, if the MRR would tell you what it would be doing.
43:60
Here's our, like I look at the CT from our intra-OP CT, the
44:07
first one prone, but you can see here, here's the pre-OP CT in the trauma bay, and then here's his CT after. And you don't have the retro-pulsion any longer, so. Yeah.
44:26
So then for case two, we're gonna visit the guy with the epidural hematoma. I'll just play this video while I talk. with Dr. Bernard, I agree, and I forgot who mentioned, they really felt like
44:40
Lamenectomy was warranted. I completely agree. And I did exactly what you said. I did a little inferior T11 Lamy, and then superior T12 to get that epidural hematoma out, which is really quite
44:54
compressive. The ligament and flavum was completely shredded,
45:01
and then instrumented him with the just T11 and T12 screws, just a sort of reconstitute. You could argue this guy has dish. Why are you not doing a really long construct? And the reason is because
45:17
before his injury, he was only autofused down to T12. So I didn't feel the need to extend him any further up or any further down I felt like we could get adequate fixation through this. and keep in
45:33
mind, I'm also putting a guy prone in bilateral x-fixes and a left-sided chest to with a pneumothorax. So you want to also think about, this is where those modifiers come in, the M2 modifiers.
45:45
You gotta think, what can I get in and out of the OR safely and do what I need to do, which is decompress the spinal cord and stabilize them and get this guy off the table safely?
45:58
So did you do an orthodecis? I did, this guy absolutely did I absolutely did. I, he had a, you know, essentially this is right, discoligamentous injury along with that fracture. So I did
46:10
arthrodesem. So
46:14
the TL junction I view is very sacred space. You can see all the nuances, not just of thoracic and lumbar fractures as a whole, but the TL junction, which we really view as a T11 to L2 process.
46:29
The ribs and sternum, are very stabilizing down to T10, cross over T-bore articulation as a lot of stabilization for those levels, and that makes the TL junction T11L2 more susceptible to injury.
46:43
The other things, the coronal orientation of the facettes in
46:50
that T1 to T10 to that transition of really sagibly oriented facettes at the TL junction also makes this area more susceptible to injury and disruption of the facettes. The kyphosis of the thoracic
47:05
spine, T1 to T10,
47:08
the lordosis of the, what we call the lumbar spine, right? L3
47:15
to S1 and then the relative straightness of the TL junction, T11L2 adds to any load is really gonna stress that junction. I think the other things to consider are those autofusion processes, right?
47:32
So dish, enclosing, spondylitis, right? Those are the things that create, but that can create a moment arm which add to your consideration of how to manage a patient. You may lean more towards
47:46
surgery in those, you should lean more towards surgery in those patients, which is really important to consider. And again, that's where the modifiers come in So we're gonna shift gears a little
47:59
bit because as I told you at the beginning, I really felt like that was like a weekend of call back in September. And then January hits, I'm in Uganda in January, February. And it was like we had
48:15
an insane amount of TL injuries that came in and with the amount of trauma that we see from motor cycles, bow to bow to his car accidents, Pedestrian action accidents fall from trees that's really
48:29
where those TL injuries can come into play.
48:33
So I'll talk a little bit about, this is my crew that I go to. It's a different manner in rough for a second. Dr. Guantai has his hands raised. Yeah, I'm so sorry. A question, Dr. Guantai.
48:46
Thank you very much. My name is Guantai. I work out of Meru County in Kenya, a few kilometers out of Nairobi I had a question, one thing you didn't capture, you didn't tell us is the timing of
48:46
the surgery, especially for the second patient. Thank you. In view of the multiple other injuries they had, and the risk of the re-heat phenomena that happens when they have polytrauma, when you
48:46
have polytrauma patients. So how do you tell your surgery safely? Yeah. To
49:16
avoid running other problems down the road. Great question. So again, this guy came in through the trauma bay and then they took him up to the ICU because he went into eighth. fib, he didn't have
49:29
a history of the eighth fib, but again, he had the pneumothorax, right, had a chest tube placed bilateral tip fibs, had the spine fracture. So they got him up, I had him on full spine
49:39
precautions. And I said, I want an MRI. I can't tell if he's weak from pain and distracting injuries or if he's weak from a spinal issue, right, like an epidurali and a toma. And it took them 36
49:53
hours to get go down to get and our hospital is very good about getting them. They just felt they could not transport him safely. So 36 hours later that so he came in on a Sunday morning about 36
50:05
hours later. He got his MRI.
50:09
I saw the MRI. I asked the trauma team to clear him for surgery. And so he went to surgery like 30, you know, eight hours, 39 hours, post trauma. And the trauma team did clear him to go. We
50:24
kept the chest tube, obviously, in for surgery. It's the safest time to be able to take him with the chest tube still in.
50:32
And so I think that again, it's a lot of communication between the traumatologists who assess these patients and take care of them. I ultimately tell patients and patients' families and the trauma
50:46
team, I can make a recommendation, but I can't take the patient to surgery until they give me the green light. That is not my job. I consider myself biased because I'm biased to preserving the
51:01
neurological function. I'm biased to stabilization of the spine and of the injury. And so they are objective because their job is to look at the patient as a whole and deem that the patient can make
51:13
it through an hour and a half surgery with me prone in the OR. The other thing that I think is really important is letting them know, here's the length of my surgery, here's the position of the
51:24
patient, and that way they know, okay, here's what we need to make sure we clear the patient for. They may have told me if I would have said the surgery's gonna take me five hours, they may have
51:35
said, no, we aren't clearing him, right? And so again, I think this is really, it's such a great point and a great question that you brought up, which is it's communication, it's discussion
51:46
with the team that state the primary team taking care of the patient to ensure that we get the patient safely to and from the operating room.
51:57
Great, thank you. Yeah, so this is, these are just some photos for our mission trip this year and the crew that we took that we work with. This is actually one of the chief residents, Derek,
52:10
who worked with us quite a bit during our week So let's talk about, we're gonna really transition to some patients that had some devastating spinal cord injuries as we advance in our TL. injury
52:23
process to the type Cs that we're gonna talk about. So spinal cord injury, obviously you can have pretty significant delay in treatment, which is a lot of times what we see where patients have come
52:36
in with an injury and either can't have the surgery, aren't safe to go to surgery, or they actually just flat out, have a delayed presentation to the hospital and families have, you know, tried
52:47
to take care of them at home and then ultimately bring them in for the spine camp. So, you know, this is just one of the patient I just showed you, those are some of his spinal, the cubitist
53:00
ulcers from the spinal cord injury after this T-12 fracture and he was in Asia A. So obviously a significant fracture, common needed, going through all three columns and disrupting T11 and T12 here
53:15
and bilateral pedicles and all of the ligamentous processes. Dorsally, we don't need an MRI to even explain that. So let's go through a couple cases that we dealt with there. So
53:30
Ian is a lovely, lovely, adorable 14-year-old girl. She was picking mangoes for her family to earn money and fell about 15 meters from a mango tree. And she landed supine on either some sort of a
53:47
rock or a log. The family wasn't certain. And she had a cute onset of back pain and had no movement or sensation and her mid abdomen down her lower extremity since the accident. The accident was
54:02
about 10 days prior to her presentation to the hospital. So here is her injury. So you can imagine if you just replay for a moment the fall, right? So a rock, or a log, or something that caused
54:20
a translation type injury, and I labeled this here for you. This top vertebra is C2, and this is T5 and T6. And really, the incredible, impressive thing about this injury This is a true spondyl
54:37
octosis of the thoracic spine. As you'll see here, this little wedge here is actually the anterior superior corner of T6. And then T5 is actually down level with T7 here. So this is an extensive
54:57
injury, high velocity injury, with a lot of translational force
55:03
And of course, she's on bed rest. You can see her x-rays where the vertebral body is actually in front of the T6 vertebral body is actually in front of T7, or T5 is actually in front of the T6,
55:16
down to the T7, which this is T7 right here.
55:22
So here's the C, a few more shots of the CT, which you can see here This is really, these two shots are really what
55:31
concern me on her imaging as a spine surgeon. Of course, neurologically, I recognize the fact I am not going to make this child neurologically better. There is no improvement. She actually
55:43
severed her spinal cord. But what I need to do in the goals of surgery, or to get her to an alignment that's acceptable such that she can be up The other thing is you want to think about subsequent
55:56
neurological injury with this. Patients can develop a traumatic syrinx that can be ascending. So what I don't want, this is T5. right, we know she's gonna have court signal up to here. I don't
56:08
have an MRI on this child. And but an ascending serine, right, could start to get her distal hands, right? She's gonna need her hands to feed herself to roll a wheelchair, right, for functional
56:22
capacity. The last thing I want as a neurosurgeon is an ascending injury to the spinal cord. So I need to get her in good alignment to try to prevent that because we know if CSF can flow Somewhat
56:35
normally we should hopefully be able to prevent that. We're looking here at T5, here's T6, and T5 is completely subluxed here and almost like it wants to
56:49
attach here. So I look at this and I think, how am I ever going to be able to distract this injury, bring her upper thoracic spine back and realign her? Because that's ultimately what needs to
57:03
happen. lift her spine from the front of T6 and T7, distract and then real line, reattach. So how do we do this? So this is a type C injury, again, as I spoke before, 66 to 92 present Asia A.
57:21
It depends on, right, if it's a rotational force, patients can actually, I've seen patients with thoracic rotational injuries like this, that actually remain intact, versus that spondyloptosis,
57:34
which is a complete spinal cord injury. There's about a delayed 25 mortality because of these injuries. And then the reason that we don't see these necessarily very often is because a lot of times
57:48
these patients and high velocity injuries don't survive. So if it's after a car accident or a high speed collision, they may have an abdominal injury, they may have aortic injuries, they may have
58:01
other vascular injuries or injury to the lungs, just aren't compatible with them surviving the actual injury. So here's what we did. So we exposed and then I was able to actually, this is cranial,
58:17
this is
58:19
going
58:21
to be caudal, we were actually able to come in and play screws. Here, this is T5, again this is T6, we're able to play screws at T4,
58:33
T3 and T2, and I put what I call a temporary rod in. On both sides, I placed also screws in
58:46
T6, T7T8, here's T5, which I did not instrument, because it was so incredibly deep within the wound and just completely disrupted And I pulled her back manually using two large rod holders using
59:01
my temporary rods. Once I got
59:05
the T5 bone out of the front of T6, I then used my pre-bent. I had pre-bent two rods, and I cantilevered her into her new alignment. And so I put the temporary rod on one side came out, which was
59:26
just a short rod, and I put in my longer permanent rod, fixating her first at T2, T3, and T4. And I cantilevered this down and locked her in to
59:41
the T6, T78 screws. And then I put my other rod in on the other side and locked her down with that same cantilever force to really ensure it. And then of course, lots of arthrodesis. We packed a
59:53
lot of bone. This is now, you can see spinous processes here, which now are well visualized. I simply removed a lot of the dorsal elements here, simply for the purpose of just correction of the
1:00:07
actual fracture, ensuring that I had adequate space to count to leave or her back and did bilateral vasotectomies here, which as well was helpful.
1:00:18
And so this was her new alignment, which I was very pleased with her ability to be upright. So this is her and her mother here The other part of this, the management of the type C injuries, if
1:00:34
they're Asia A is, of course, the trauma workup. She had no other injuries. Stabilization with de-rotation andor reduction of that fracture, appropriate management of any CSF leaks, because of
1:00:47
course we know the dura mater likely will be shredded or disrupted as in her case, but fortunately we didn't get into any CSF. Early mobilization and infection prevention is really key and then
1:00:59
ensure adequate. family educations. You can see here, when we got her up, you know, her knees obviously fall together. So we taught the family, you know, putting a sheet in between the knees
1:01:08
enables her to keep the knees out. She's going to have better hip alignment, better knee alignment. She won't get any ulcers. But this was her actually within 24 hours of her surgery. She was up
1:01:19
and she was working with our physical therapist and her new wheelchair to get up and move around. So again, this is the best thing for these patients. Early mobilization after stabilization. But
1:01:31
most importantly, you can see how great she was just a little bit getting used to my, you can see my therapist here holding her head. She was trying to get used to the fact that now she actually
1:01:41
could be upright and she was in a normal alignment again. So she, she ultimately went home post-op day four with her family back to her village She lived in a pretty remote village in Uganda.
1:01:57
We're going to go through this case, which a 16-year-old who underwent a Bota Bota accident, interestingly, had the accident, got off, walked away from the accident, complained of some mid-back
1:02:11
pain, but was awake and walking, didn't seek any medical care, but three days post trauma, the back pain seemed to be worsening, so her family brought her into our hospital and she got a CT. She
1:02:25
was completely neurologically intact, okay? So here's the CT, the initial CT from the outside hospital. She was transferred into Malaga, but this is the initial CT.
1:02:38
So let's take a look at this. So they show me the CT and they're like, Yeah, she's neurologically intact and we're rounding. And I'm like, There is no way this child is neurologically intact with
1:02:51
her T6 vertebra beside, this is T6 and T7 with her T6 vertebra beside her T7 vertebra. that's physically impossible. So I look at the axials, right? These are all reconstructed images. So I look
1:03:06
at the axials and I'm thinking, this may just be a rotational injury, a type C injury, but rotational, but the reconstructions are just reconstructed very poorly. So I said, I want a new CT
1:03:23
'cause I don't believe these reconstructions and she does need stabilization, But the 16 year old is completely neurologically intact. I have no room for
1:03:36
error in the OR with this patient, right? That's a lot harder for my standpoint. So we get a new CT, look at the reconstructions. Completely different images, right? So you look at this and you
1:03:47
say, wow. So yes, here's T4, T5,
1:03:53
T6 is shredded, T7 is shredded, T8, shredded. T7 is shredded, T8. has a coronal type fracture, right? This is a A2,
1:04:05
a coronal split fracture, but look at the difference in this canal picture, right? Compared to what we were looking out on for. So either we had a patient who had inadequate reconstructions of her
1:04:15
axial images from the outside CT, which I suspect, or they perhaps sent the wrong patients imaging on disc, right? My suspicion is it's the prior So our repeat CT, so when you, the point to this
1:04:29
one is, if you see an image and it's not making sense with the neurology of the patient, re-scan, get another CT, take a look, because this made my operative plan a lot easier. So then I see T6
1:04:42
is a complete burst, T7 is a complete burst, A4, A4, T8's and A2. The
1:04:49
PLC, believe it or not, didn't look like it was disrupted. You know, there could have been, there were no fractures in the back, so I said I think that we can probably instrument her all
1:04:59
dorsally, right? Let's see what we can do. We can get in screws at T4, T5, maybe T8, T9, maybe T10. We'll see if we need to. So here's what we did. So we did a T4 to T10, post your
1:05:17
instrumentation and arthrodesis, right? We're dealing with three levels of fractures with T8
1:05:24
as an A2, T7 and T6 as
1:05:28
A4s. So I definitely wanted arthrodesis through this for her, but we got her to stabilize and in good alignment. I did no decompression because again, she was completely intact and was intact and
1:05:40
walking post-out day one. So the other thing, some of the other pathology that I know you guys deal with especially in sub-Saharan Africa is obviously POTS disease, infectious pathology,
1:05:53
osteo-disgetis, Metastatic lesions. primary bone tumors. These are all reasons why you may need stabilization andor surgery for diagnosis, right, as well. And so this was the third case, which
1:06:10
we'll go through from this visit. And this is a 52-year-old who had presented three years prior with this pathological fracture concerning for potentially POTS disease. She had gone to a different
1:06:23
hospital and had surgery and for stabilization, decompression, diagnosis. They did a T10 to L2. And she presented, again, this is three years later with horrible thoracolumbar junction pain,
1:06:38
but neurologically intact. So I look at this. Does anybody want to tell me what they think's going on with this one?
1:06:51
Dr. Darkman, would you like to comment? We're going to be hearing from you after Dr. Perry, but we'd love to hear what your thoughts are
1:07:08
Yeah.
1:07:10
In this position, I think the
1:07:14
screws are at the T5, I think. There are 5, 5, and T6,
1:07:19
why? So this is T10,
1:07:22
T11, and this is T12, and
1:07:27
then L1 and
1:07:30
L2. Okay. So the two first, the T10 and T11 are having a fist The school has, first of all, in the physician, they need to go forward to 23 of the vertebral body. That wasn't the case, and
1:07:43
this is why the school has been losing, and that's what we can see on the skin of the patient.
1:07:51
Well, I bet that before all this happened, that the screws were going through most of the vertebral body, but you're absolutely right Now, her vertebral body is. all the way here. Here's the
1:08:06
anterior aspect of the body. That's it. And so what do you think's happened?
1:08:13
The screws have pulled out, right? So she's probably gonna have haloing of the screws or lucency of the screws in the body. But then I'm gonna be critical for a moment because look at these, the
1:08:29
rod is lordotic at the
1:08:34
dorka lumbar junction. So this was sort of destined to fail from the beginning, right? So if we come here, you can see she's probably cathodic through this. So if anything, they might've wanna
1:08:48
put a little opposite curvature to prevent pullout, right?
1:08:53
And so what happened is a pseudoarthrosis. She never fused through here, right?
1:09:04
over the course of three years, pull out or lose, there's lucency and we'll see that on the subsequent CT. But I kind of don't, this was sort of a setup for failure, right? We've got to be very
1:09:18
careful about our rods. So let's take a look at the CT. The CT is
1:09:23
a little scary as a neurosurgeon because we can see her T10 screw on the left is in the canal, right? Which is scary to take out because you don't know if you're going to get a CSF
1:09:39
leak. Look at the haloed screw here. I mean, there is no bone in this pedicle to put a new screw in. The biggest pedicle screws that we have are
1:09:53
95, 95 millimeters. I don't even have a screw that's going to fit in this haloed area So, you can see air. in the T12 body, which looks a lot worse now, you can see retrolysthesis of
1:10:10
T11 on T12 and this lady's neurologically intact and we've got to keep her that way. And somehow we've got to take screws out of her canal, right? And you see here what's happening, the whole top
1:10:26
third of the posterior aspect of the T10 body's just gone, right? Just the screw literally just like haloed out, when she'll wiper it out. So what do we need to try to do? We need to try to get
1:10:41
her to a more acceptable alignment. We've got to find more bone to get purchase in, because I doubt that I'm going to be able to get purchase in T10.
1:10:53
So in a similar sort of concept, but slightly different, We again are using cantilever forces.
1:11:03
to try to get this patient to this alignment without overstressing her bone, right?
1:11:12
T10 was not an option to get screws in. I was able to re-instrument. I removed the old screws, but a nice long screws at T11, but then we of course had to take this up to T9 and T8 to get adequate
1:11:27
purchase, adequate fixation And so at least now, you can see her global alignment here in her upright x-rays compared to right this, which was pretty significantly kyphotic
1:11:46
at T12. So that's what we did. And we did poster column osteotomies at three levels to try to also help get correction, which we did. So summary of all of this. We've seen so many different types
1:11:57
of fractures, primarily focusing in the TL spine. NTL junction, TL fractures are incredibly complex. Each fracture has to be analyzed for exactly what it is. Analyze it on the imaging. If the
1:12:14
imaging doesn't make sense, re-scan the patient. Ensure that adequate long-term follow-up with the patient if you treat the patient non-surgically. It's not that it's wrong, but you just have to
1:12:26
make sure it's a patient that can follow up with you very, very carefully if you're gonna opt to brace If treated surgically, you need to ensure optimal alignment to the best of your ability at that
1:12:37
time and arthritis is when intended. So I'm happy to take any questions
1:12:45
that you guys may have. Thanks for listening. Great, excellent. Please stop sharing your screen, Dr. Perry. This was an educational tour de force. Thank you, thank you so very much This is
1:13:00
very good, and we've asked some very good questions. good discussion. There are questions, but I want to give Dr. Daupmanu the time to do his presentation, and then perhaps, Dr. Perry, I hope
1:13:13
you'll still be able to stay on, and perhaps after Dr. Daupmanu's presentation, we can just bring all of the questions together if that's okay. Absolutely. And Dr. Matisse, I didn't want to
1:13:28
interrupt Dr. Perry
1:13:31
because we were having such a great education experience, but I think we're going to run out of time for the third presentation. So, Ben, if we could set you up with the next Grand Rounds
1:13:44
conference with your presentation, that would be great. You're the next one of the months after. Well, let's go to Dr. Daupmanu from Benin, because since we're both presentations are about
1:13:58
Turkolumba. fractures. After his presentation, we can just have a time where we can just openly discuss and wrap it up. I received his
1:14:12
opinion in
1:14:15
West Africa, and we'll discuss his experience at the Military Teaching Hospital
1:14:23
Okay, thank you so much. Thank you.
1:14:27
The top area has sent many things about this recommendation. I'm going to talk to Paul Erick. I'm at the Military Teaching Hospital of Paraco. This is roughly one year from now. This is Paraco.
1:14:30
This has been in, as you can see on the map. Paraco is at the Hopa part here. We are about 450 miles from from
1:14:58
Botanovore Capital. Okay, we are not far from this area between Benin and Bupina Faso in India where there is actually ongoing conflict.
1:15:11
This is how we handle the plantation meet, my beautiful wife and my four children. And this is where I'm actually working down here
1:15:26
So, I mean, a fracture from T10 to L2, a troponoma junction, some mini literature you can find T9 to T20 to
1:15:39
L2. This is about 30-50
1:15:42
of all these partner structures Primarily is the highest energy trauma, mid-age is about 30-50 years, and 27
1:15:55
of
1:15:57
this patient that we will present with injury to spinal cord and to go back, we now use the bar motor distribution because it's a high inage trauma for in the youth, in the youth, has a torpedo,
1:16:08
I'll show you what now, and the low inage fall at the
1:16:13
end of the three concepts, standard work now that we are using, the torpedo has this hard, the classification, I won't go into it.
1:16:25
I'll just go to the next slide, because he hasn't said it all. From this classification we ended up to with the outspine, because Denise's proposal was not with treatment proposition. So the
1:16:34
outspine is coming with the three, classification has correctly spent and showed. And what I want to
1:16:52
see here is that the vertical body fracture with the positive column, approach of ligament, possibly gamet. We'll be doing all of that for one and that B will be when there's this disruption. And
1:17:06
that's the of course when there's a rotation. The
1:17:11
tracholumba and gyricospications, you see all those things, so
1:17:15
let's get to
1:17:19
the management. So when do we manage the patient? We need to find out
1:17:25
We need first of all kind of seditious here, they are to assess the patient's mechanism of the injury. No one is able to prepare examination, imaging, all that. And then we decide if the surgery
1:17:37
or not surgery, are we going to address the patient or not in either the activity recession? So we decide according to the steps, stability of the
1:17:51
injury
1:17:53
The goal is to mechanical, to mechanical.
1:17:57
stabilize the patient, prevent second neurological injury and decompress if needed. The first case I want, I have only two cases to present to you and it will be very quick. The first case is a
1:18:12
young lady, 28 years old,
1:18:15
four from a mango. Just as Adri has the
1:18:21
top pick, just so you show it for a WS. good girl. So this lady, she is 28 years old, she fell from a mango tree. Adri had a mission, she came with Jesus of 15, no made no past medical history,
1:18:34
but there was no motor function diminished with a retal tone. Sunscree was a dimensional sensation to light torch below hip. No refices at knee and the patilla, no plonus. And when we calculated
1:18:51
the tilacolumba, engine classification of all of the.
1:18:57
score score, it was 10. So this
1:19:02
was not stable, we need to go on this one's way, it's as yeah, be classified.
1:19:11
So we did a short segment, and trapezicular,
1:19:18
posterior spanum, phystation as you can see. I used to take this
1:19:25
OAP, these pictures, these pictures in the OAP, because most of the pictures we don't have,
1:19:31
but we don't have money to go.
1:19:37
As I'm s-ray or cities come from the post-operative period. So, I take
1:19:44
these pictures, while we are with the images from the CM that we
1:19:55
use to operate this patient.
1:19:57
There in the post-operative period the patients she did
1:20:02
were there we did this
1:20:06
T12 L2 segmental instrumentation as you can see the motor function she there was again to 4 plus 5 she was able to work with this material that this this worker this answer was intact at 8 week
1:20:25
checkup that we follow up and from here has the
1:20:34
teacher also said the early post-operative ambulation are treated at the
1:20:43
day three have helped her help us a lot because this patient
1:20:49
spend we we operated her 10 days after the injury because the opportunity to buy the material from their own pocket and all that. So it's 10 days after the injury that she was able to be operated.
1:21:06
This is very important to mention, even that she was able to recover.
1:21:12
The second case is a young soldier 28 years old that has joined the army for years
1:21:23
ago.
1:21:26
She came with ballistic wounds and
1:21:32
the motor function was zero, annal, incontinence, sensory loss, sensation, below hip, neurofecis was found. As your injury, but the injury was stable And we, as you can see on the
1:21:51
picture here, the A2, the L2,
1:21:56
the posterior column or the L2 was completely destroyed here and from and you can find some bone fragment into the vertebral canal and
1:22:16
this is the the entry of the bullet and the as it. Usually the entry is more
1:22:22
and the as it is more larger as you can see. So, you know, I want surgery to find out what is in there. We are not able to MRI depression if we don't have MRI and
1:22:41
we are taking to the wall and then when we are doing the surgery one of that the bullet has done the
1:22:52
laminectomy of the L2. The blood has the spray completely, the span of the spenus process and the laminar,
1:23:04
and all the postural column was gone at the L2 level. We are taking it out,
1:23:20
and you can see here you have the span of process of the L1, and then the span of process of the tree, and here is the place where we are taking out the L2. We always just already destroyed, but
1:23:32
the most important thing is that the bullet has worked out all
1:23:38
the Java and its content. We sit here,
1:23:44
I can take that while you're shooting a
1:23:48
short video of it. So that the span of code was transacted by the bullet. Yeah, I am saying, but for me, this is a tropical app. Which recorded is a - So the
1:24:06
best of the work out, all the
1:24:10
dry
1:24:16
and heat content. So you can see over here, you can see my mouth Here are the spallings of the spallings of the spallings of the level. So the possumings are going to teach where the L1, T12, and
1:24:21
so on But you can see
1:24:23
the
1:24:25
spallings of
1:24:41
the
1:24:43
spallings of the
1:24:53
spallings of the spallings.
1:24:59
And then the other section I can see that OK, here we go. Because it's here, this is the
1:25:06
installment of the report here. And the posterior axis, the
1:25:17
posterior of the the device is there And then
1:25:23
the postman came to see it is
1:25:30
the G, the N1, and the G12, so when I opened it, the device said this way I don't know what to do. But I also said about today, the needs of the summer. And since I speak after, I'm so willing
1:25:46
to end up because there's no smoke to be done at this level So
1:25:51
we both end the. The imposuperative period, there was no CSF leak, the room,
1:26:00
he spent six weeks in hospital, before we were going back home If we move right now in wheelchair, you can see, and
1:26:15
no sensation, no motor function later on, he still is out of touch. So we've gone through the literature, has promised about the update you wanted to do. We've seen different papers, seven
1:26:30
papers, caps, our attention And from these papers,
1:26:35
we found out that the surgery of our
1:26:38
first initial pain relief and return to activity,
1:26:43
about two to five years, not significant Oh, I.
1:26:50
or in hospital disability and death between surgery and embracing for neurosurgical intervention patient. And the average rate of 85 return to work is influenced more by psychological factors than
1:27:06
radical correlation. And the use of the use of the out spine and the trachronoma injury, classification, severity score is
1:27:17
more objective for decision making
1:27:23
and at the end, what is very important, even though we've been trained on the material for minimally invasive surgery, for this woman in very spine surgery, where I am, where I am right now, we
1:27:36
do not have such those material, but in the literature right now, about the update of the
1:27:46
trachronoma, a fracture surgery. is the minimally invasive spallosology that is replacing open surgery for most stabilization needs. So we have to focus on subject-soluble alignment and early
1:27:58
mobilization rather than perfect radiological reduction. And gunshot or ballistic trachloma fracture is very important. It has, we said before starting this presentation, if we plan it another
1:28:16
time, we can come over and talk about it more largely. Thank you so much. Sorry, we're very pleased that we're here. Thank you. Excellent, excellent. Thank you so much. We've been fortunate
1:28:28
to have excellent presentations on
1:28:43
the Thurgolumba region. And as I, you could stop sharing your stream, Dr. Doukprano, thank you. But as I mentioned to you earlier, with your experience with the conflict in Northern Benin,
1:28:47
very interested in you coming back and discussing your experience with penetrating injuries. But along those lines, when I
1:28:55
saw that case where the penetration went through the Dura and we're looking at the dorsal aspect of the Dura, what came to mind was I
1:29:07
would be wondering about reconstituting the Dura, but it sounds like you didn't do that. Can you elaborate? How did you close? Because I would be very concerned about prospects for CSF still.
1:29:24
Yeah, exactly. That was a great concern and what I did is I used Sijisel, this emostatic gel with the material we used for the emostasis of both the bone I'm calling to see your house.
1:29:46
Is it like gel?
1:29:48
Is it like gel foam? Is it like a. No, it's not gel foam. It's like a stick that we use for the mosets. It's of the bone. So I miss both both together to manage with the the plasma and so that
1:30:04
we don't have the the CSF back, CSF flowing, falling back after the closure. So these are, we use
1:30:15
the some piece of muscles with this
1:30:19
emusatic gel that we mix together and use it to to to seal, to seal the inferior, the inferior and the
1:30:29
spinal canal When the bow had gone through, you seal that area of that was communicating more approximately. Even though we are not able to see the the the doer, but we can see it's posterior,
1:30:43
it's anterior layer. So we We just close it that way at that level of the possible end.
1:30:51
And after, because also we finished our expecting my own, my own fear was mostly the sceph leak after that, that way of closing, because I've not seen it anywhere in the literature either. So I
1:31:05
was like, okay, how to handle this? And then I was okay, let's make sure there's no sceph throwing back Since there's no, there's no, there's no, there's no, but
1:31:14
you are continuing to the end. So we did that way and you work out. There was no sceph leak at the end. They won't have here had been healed safely, but there was no component of headache. There
1:31:26
was nothing else at the end. And the possibility was
1:31:31
without any Well, that's impressive. I haven't heard of that before. And if you accumulate in more cases, you must report it. I mean, I think that's. That can pick some of the lives of a whole
1:31:43
lot. He said, Dr. Perry, you have a comment? I have a question for you. So why decompress this? So you've got a patient who's Asia A, you know if you take off those dorsal elements, right? I
1:31:58
mean, you could just argue, why not leave all the scar tissue, the fibrous tissue, the bone intact, and not decompress at all? Because with a bullet,
1:32:10
the injuries actually, the velocity, right? It's the heat, the velocity. So I would argue, why not just, I probably would have left all that bone and shied far, far, far away from the dura
1:32:22
mater. Because why, if the reason was, is that there's one part of the art issue,
1:32:30
we took out two bullets,
1:32:34
during surgery on the highway, there were traces of bullets. in the on the images, and one bullet was at the
1:32:47
between the L1 and the L2 at the the internet, what about this level, and another bullet was more anterior. Oh, so this was not a single, those are the single shot, there were multiple. Yeah,
1:33:05
multiple. Yeah, multiple And the, the blood also has been, been broken into multiple pieces. I don't know how it went that way, but, uh, and the, when this patient came at the, in the
1:33:17
emergency department, uh, the, the, as it, as it of the bullet, they use, um, they do the big, this wound dressing to that, that, that, that place. They make a wound dressing to that, to,
1:33:28
to the place of the as it. So in the, when I opened it up, there was more, a kind of, uh, 50 ml of, uh, of
1:33:38
blood spills. It's spreading out with some pieces of blood also. So, before going to the OR, we asked a dark question. I would say, why not leave it that way? Why not go ahead and do an MRI and
1:33:49
see more of it? But we need to take out those blood and see if something comes to this patient. We know we do
1:33:57
not have any idea of the disability wiping out all
1:34:03
the contents of the doa. So it sounds like you felt like you needed to do an exploration to get a better definition of what was going on, because you're going to be On the middle, yeah. Inadequate,
1:34:15
mm-hmm. Yeah. 'Cause there was another comment in the chat asking about why we moved the bullet in the first place and not leave it in sight too.
1:34:29
Any other, well, we'll open it up now for questions
1:34:38
and comments for both Dr. Perry open to about their presentations or any issues one might have regarding cervical lumbar fractures.
1:34:55
I think we've got 70 people here and two wonderful presentations.
1:35:05
I'm sure there are different approaches to all of these because I'm looking at the chats. There are questions we didn't even get to answers to those questions, so I think we have to repeat do this
1:35:16
again
1:35:19
But
1:35:21
several things, Tiffany, I think your original outline of the various categories and scores is very helpful. I'd like to see that repeatedly through the presentation, it's very helpful and I was
1:35:35
just that when we showed that I was thinking that she must be filling this in with examples from the literature, which is a very sensible thing to do with a very good job And Dr. Dokopona, another
1:35:49
excellent job, and there's a question from Nicholas.
1:35:56
Thank you very much for the presenters. Two questions for the patient with the POTS disease, the TB at T12.
1:36:06
Is there a role for an anterior fusion, or when an anterior inputting in a cage, or a rib graft, or something? Because these are repeat surgery. It's always risk that it can collapse again, or
1:36:18
it can fail to fuse again. Because I think the main issue here is that lack of support in the anterior column is what makes the first posteriorly more significant and leads to the screw cutout. I
1:36:28
will believe I did my training in Egypt, where they have way more cases of what's disease. And I noticed when they have these kinds of surgeries, repeat surgeries, they always end up doing both an
1:36:44
anterior and a posterior, a fusion either using a rib graft or they use a - this professor there was primarily using rib grafts because we need not to put in hardware in an infected site.
1:37:55
If they're not causing any continuing injury, I think it's always safer to just leave it where it does not have any much
1:38:04
issues because the risk of digging for them, always potential risk of causing more injury surrounding tissues, vascular injury, just leave the bullets there or what does other team think.
1:38:19
So, two questions, if I may distill it,
1:38:25
the one question was, what are the criteria for the length of your segments, rostral and caudal, for these thoracolumba fracture dislocations? How short or how long should you go? And then the
1:38:47
second question was, what are the indications for exploring these penetrating injuries? And both Dr. Dr. Nuhan Perik and Kamen,
1:39:01
if they'd like. Thank you so much. Thank you for this, for
1:39:09
the questions Shot,
1:39:11
panel,
1:39:15
at the track on the budget. So,
1:39:18
long to one, there have been a debate, there have been a discussion between both of them and their, their, their, their, their reasons. Some studies that I've been shown that
1:39:29
the outcome is the same, either you,
1:39:33
you've done the, you've done a, a shot or we don't, a shot segment, a particular school, a posterior spinal physician, or we don't need a
1:39:45
long one Usually, you can do
1:39:48
two up and two down. So that's what we call it if we say it's long, but short one is one up and one down. Both of them give the same result. And what I would have loved to do is to have the school,
1:40:02
the school to face the end one in the middle That was a good one. I'll tell you
1:40:14
Please mute, if you're not speaking, we're getting some chatter
1:40:20
white, so any whiteness will come out.
1:40:26
Yeah, we are pressing that on the left. Okay, so as I said, we've gone over that discussion of short segment and long segment. Both of them have been shown in studies to give the same results
1:40:29
from the patient. This is lived for the patient for its surgeon discretion About the second case, actually, the patient is area A, what is going
1:40:58
on there? What we can see on the CT scan is that the procedure column of the spinal have been fractured with the
1:41:10
presence of bone fragment in the vertebral canal So,
1:41:18
the indication of surgery is there
1:41:21
What, um.
1:41:25
would have been better is to
1:41:29
have to MRI the patient and have the result of the MRI before going into this surgery. But we don't have the MRI on the arm, so we just go ahead and do a pair of the patient to see what's happening
1:41:41
there. Why he's having this area? We've been easier, eh, while
1:41:46
on the CT scan, we can go see that the postural column, that is that the fracture is concerned about. So that's how we go, we went for the surgery And at the same time, we'll be able to take out
1:41:56
these two, let that way easy too. So yeah, so as I said earlier, it sounds like the primary indication was you needed to do an explanation to determine what the anatomical features were. Okay,
1:42:13
any comments, Dr. Perry? I was just gonna go back to your first of the three questions, which I think was directed to me with the revision So you're absolutely right. And I will tell you that in
1:42:27
my residency, and in my first few years of practice, like 10 years ago, I would have said, oh, I need to put a cage in this patient. I need to reconstitute the anterior column. But when I
1:42:42
looked at the suboptimal alignment of the patient, the suboptimal bending of the rod, I felt like this was actually, in fact, more of a failure of what I'm gonna call surgeon failure, which I
1:42:54
have surgeon failures all the time, a failure of the surgeon instead of a failure of the construct. So I felt like I didn't need to do a core-pactomy. And three years after this deformity, three
1:43:08
years after this pathological fracture with collapse, the likelihood of me doing a great job restoring things is very low, very, very low. I think three years before in the acuity at the surgery
1:43:20
one would have been reasonable I felt like if I didn't know. So for instance, I did three levels of posterior column osteotomies to get the patient to the alignment that we got her to and laid a ton
1:43:34
of bone down, right? And if I do a corpectomy, whether it's lateral or posteriorly, I'm going to
1:43:40
be taking away a lot of bone, right? So I felt like I could get her to an optimal alignment by doing less boney work, less blood loss, less length of surgery without putting in a cage. So now for
1:43:56
a lot of our trauma literature, we're actually shying away from corpectomies. Even in our tumor literature, we're shying away from doing aggressive corpectomies and things like that. We're really
1:44:08
focusing on reconstituting alignment or optimal alignment from posterior approaches
1:44:15
And so that's a corollary to that, then when given what you just said, when is it. When is it optimal in these trauma situations with anterior, anterior column, disease, disruption, can they
1:44:34
all compromise?
1:44:38
No posterior element disruption. During an anterior approach
1:44:45
with copectomy
1:44:48
and anterior stabilization, without
1:44:55
posterior stabilization. So I would say that if I'm gonna go long and strong, I don't need the corepectomy per se. If I'm gonna go short segment and like percutaneously, so for instance, I did do
1:45:09
a corepectomy just two months ago and I was putting an expandable cage in with one level above one level below, that was it. From a posterior approach? So I did a lateral core peck. to me. And
1:45:23
then okay, okay, and then and then percutaneous yeah. So and that I had to restore, I had to restore the inter column because I was trying to go short on this patient. But again, I could have
1:45:36
opted and said, well, I'm going to go three above and three below or two above and two below and not restore the anterior column. But I was she was a young patient. So I was trying to go short.
1:45:49
Well, let me just push you a little bit more. Well, why not preferentially go for short as opposed to long? I do. In general, in general.
1:46:02
So like, let's take this lady here where, you know, he was wondering, the doctor was wondering, well, why not just like put a cage in and maybe, well, I knew T10 was gone. There were no
1:46:15
screws that were going in T10. So that I knew I had to go, at least up to T8, no matter what. there was no converting her to a small fusion at this point. There was no conversion of saying, well,
1:46:29
let me see if I can go short on her because T10 was gone. So her hardware, the complication with the non-union and the haloing of the screws, had already declared itself. So I knew I had to go
1:46:42
long. I was committed to T8 no matter what. And if I'm going to T8 and I did PCOs, post or call my Siotomies, I felt like I could just do everything from the back. You've been in a cute trauma
1:46:56
situation. T10 disrupted. It's just going in anteriorly, intra-lateral, taking out T10 and do nine to 11 rods and screws, anteriorly.
1:47:10
I think you absolutely can do that. I think that's, but I would argue that probably if it's T10, got a lot of stabilization there, right? got the ribs that are attached since you probably could
1:47:22
just. I would say probably L2, L1. I would be, that's where I'm way more inclined to say L1, L2. I want to go short segment and put a cage in. Okay.
1:47:37
Other questions? We're on the N52. You know, we should, I think Ben and Ben left us a note to say that we could post on him till next time We appreciate that, Ben.
1:47:53
Ever did everybody find this for a while? It looks like it because there's still 62 people here, so. Yeah, no, I think we've had an excellent discussion. Thank you so much, Dr. Perry and Dr.
1:48:07
Duchman, for
1:48:10
your words, your education. This has been superb. And we want to give Dr. Duchman with too soon enough time for his presentation. So I'll be in communication with him about getting that
1:48:25
rescheduled. Michael, Michael, Michael, you had a question. Michael, do you want to answer that question or what's your thoughts? No, no, I think it was, it's been superseded by time. I was
1:48:39
asking about proximal junction typhosis in long constructs in the thoracic region. If anybody has experience with that,
1:48:48
yeah, and it's interesting to hear about the short versus the long segment discussion. I think it's everywhere in different schools lean to different things, but I was just curious about that.
1:49:03
Tiffany, you wanna answer that? Sure, it's 100 as you know, the vein of our existence as spine surgeons. It's like the patients that you with fear and trembling see their x-rays when they come
1:49:17
back. And yes, I think that I was answering somebody actually individually on a question. I think there are a lot of things that you have to consider, but bone quality is something that you have
1:49:29
to take in mind. You have to take in mind what your optimal alignment is for the patient based on their bone quality, their age, the deformity that they have. One of the most important lessons
1:49:43
that I've learned is as a spine surgeon, I have to, when I'm trying to correct somebody, I have to do enough bony removal to get them to the contour that I want them to be at, that would be
1:49:55
optimal for them, but not take away so much bone that I'm not going to be able to arthritis them, right? So it's this balance. And that's why, you know, we say, this is the practice of spine
1:50:08
surgery, right? We are practicing every day to try to get better and better. There is really no perfection that you're ever going to achieve. And our job is really, I think, just to do the best
1:50:20
that we can and with our hands and make our hands the best and do the best practice of medicine that we can for our patients. Well, one last question that I've had is on my mind that the case, the
1:50:33
spondyloptosis.
1:50:36
How did you use distraction to reduce? And did you say you manually reduced it?
1:50:43
Or how did you do it? The three, so the three screws that were at the top on either side, I attached, I have really heavy rod holders that are specifically designed. And I look small, but I'm
1:50:54
actually really strong. And really big rod holders, and they're my heavy hitter rod holders, and I actually took her and I had my resident hold onto her torso in the OR, and then I physically
1:51:09
pulled her up, and we actually, her head came like off the table essentially, as we were doing this.
1:51:17
the spine from this alignment, back to this alignment. So you must have had a destructive and extensive extension. Translation, it's a dorsal translation. It's a distraction first to get the body
1:51:33
on the other side. And then the dorsal translation forced to bring it back together. So it was actually a lot of problems. I'm impressed by your strength, but you did that. I was intimidated by
1:51:45
the image. I'm very impressed.
1:51:52
All the fighting.
1:51:55
Professor Nimrod and
1:52:00
Sam Bohekobam, or Sam, do you want to make any comments before we close up?
1:52:08
Thanks, thanks, Jim. I just want to congratulate the presenters.
1:52:14
Professor Perry and I was very impressed by the work she's doing in Moolago. I went to Moolago, wonderful hospital with wonderful, wonderful doctors and very, very good environment, working
1:52:25
environment there. I think I saw one of the doctors, neurosurgeons in Moolago in the chat. A great team and we really would like to get them to present in this forum and since Dr. Perry is
1:52:46
connected with them, maybe you can convince them to give some guesses, please. It would be wonderful to have them on the team and also I was very impressed by our colleague from
1:53:01
MELO, Dr. Guntai. I'm not aware of Quentin with Dr. Guntai and that he seems to be doing a wonderful job there. We have some very good neurosurgeons in in Meriwet, Dr. Gontai is.
1:53:13
and I think it's a wonderful, really wonderful presentations and I was also very impressed by the turnout. It shows really the immense interest this case
1:53:27
has attracted, and I think we must keep it up. Thank you. Sam, are you still there, Sam? Oh, you're welcome. Thank you very much. I enjoyed the presentations.
1:53:40
Maybe one day we discussed the cost implications of these interventions. A part of patients who can't afford them. What do they do? Does it influence decisions? The type of implants being used?
1:53:55
And are there options? Cheap implants and expensive implants? That is a discussion for another occasion, not today. Thank you. Okay, thank you, Sam. Well, both for Sam and Nim. Oh, I've
1:54:10
interviewed both of you now. I interviewed Sam today.
1:54:14
who have incredible achievements in your life, coming back to Africa and trying to reestablish neurosurgery. Looking at this conference today where 70 people showed up, should be a real
1:54:27
satisfaction to you as just tremendous, tremendous strides you're making with outstanding people. Yes. Well, thank you, Jim, for being the author of all of this And I think it's a testament to
1:54:44
your investment of time, energy, resources to make this an excellent international forum. But I - Well, you're the major person in charge of it. So I think we're at 959, which is two hours, a
1:55:02
terrific job, Astrade, and thank you, Tiffany. And thank you, Dr. Dovaporno, terrific job, on comments or outstanding. there's a whole bunch of things in the chats we never got to, good
1:55:16
questions, really good. Thank you so much. Okay, well, we'll let everybody get on with us Sunday, but thank you all very much again, and we look forward to recompaining in a month.
1:55:31
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