0:01
Surgical Neurology International, an Internet Journal with Nancy Epstein as its editor-in-chief, and the new SI Digital, an editorially curated multimedia platform featuring operative videos,
0:19
expert interviews, goal discussions for the next generation of clinicians, interactive discussions of information, not just more information. James Osmond is his editor-in-chief. Those two
0:35
publications are pleased to join with the Latin American neurosurgeons in presenting the third Latin American International Neurosurgery Grand Rounds, held in the last Sunday of each month. That's
0:50
in addition to the meeting with the Sub-Saharan African neurosurgeons. on the Sub-Saharan Africa International Neurosurgery Grand Rounds Program, held in the first Sunday of each month.
1:09
These meetings are dedicated to the topic of global solutions to clinical challenges in neurosurgery.
1:17
This meeting of the Latin American International Neurosurgery Grand Rounds is organized by
1:25
Johann Schokie Veliskes, with a Strata Bernard, or a Lazarus and James Osmond, as an associate host.
1:36
This is presented in front of an international audience.
1:41
This International Neurosurgery Grand Rounds is on the topic of thoracic discs, surgical tips for success by Nancy Epstein.
1:55
Nancy Epstein is the Professor of Clinical Neurosurgery, the School of Medicine at the State University of New York at Stony Brook, and the Editor-in-Chief of Surgical Neurology International.
2:08
Dr. Valisquez is a Peruvian neurosurgeon and researcher who specializes in cerebrovascular skull base, interventional and stereotactic radiosurgery. He's a researcher affiliated with the Department
2:22
of Neurosurgery in Helsinki, Finland, and he's head of the unit of neurosurgery at the Regional Hospital in Cusco, does research in oncology, neurology and neurosurgery in Peru.
2:40
Dr. Valenzquez is from Cuzco in Peru. The name Peru is derived from a catch-all word implying the land of abundance, a reference to the economic wealth produced by the rich and highly organized
2:54
Inca civilization that ruled this region for centuries. The country has vast mineral and agricultural resources, marine resources also, and they've served as an economic foundation for the country,
3:08
but by the late 20th century in addition tourism also became a major element of Peru's economic development. Favorite destinations for international travels include Machu Picchu, a site located
3:23
about 50 miles north west of Cusco, to the site of ancient Inca ruins, also has museums and artifacts from this civilization.
4:33
because on the pudamos móstra.
5:05
Thank you very much. It was very complimentary and I even understood it. So I wanna encourage everybody, you know, if you have a question, just interrupt us. Andor Estrada's gonna keep an eye on
5:17
the chat and try and integrate everything, but it's really to get everybody involved. And what I'm going to, let's see, I wanna start from the very start here. I want to make sure
5:32
if people come away anything from this lecture today, it's do not do a laminectomy for a thoracic disc herniation. We were just chatting about this before everybody was here and basically it's been
5:47
out of vogue for 40 plus years and it's the best way to make a patient paraplegic. So one of the reasons that I write some papers, sometimes it comes out of medical legal experience and I had seen a
6:02
bunch of cases recently where thoracic discs were improperly treated. So I wrote the perspective on the diagnosis and treatment of thoracic discs. We're talking about the large central thoracic
6:13
discs. Lots of these are calcified or ossified, somewhere ossification of the posterior longitudinal ligament, large interlateral disc, where you can hear the chord and the interlateral location
6:24
is apparent and others may just be lateral, really foraminal or almost far lateral in some cases.
6:33
This is a very visual talk. I'm just trying to go over anatomy, as well as some of the literature on how not to do a thoracic disc, which is a laminectomy, just to remind everybody. But here
6:45
we're just going to start with the cross-section anatomy. You've got the annulus and the nucleus pulposus anteriorly. Then you're going to come laterally. This is going to be the head of the rib.
6:55
This is going to be the pedicle itself. You know, look at that pedicle. Here's the spinal canal. Here's the cord. When we talk about trans-particular, you've got to come down this way. Do not
7:06
do olaminectomy. And here, by the way, over this - of this lateral aspect is the transverse process. Again, if you were talking to any of your colleagues, and they're about to do a thoracic disc,
7:18
and they say, oh, I'll just do olaminectomy, please, please. Stop them from what they're doing, because it's not going to work out well for that patient. This is a view from the side, or a
7:28
lateral view, obviously, You have the anterior vertebral body and the disc. And then you have, again, a view of the pedicle here. Here you can have a view of the head of the rib. Here's the
7:39
lamina. And then over there's going to be the Spanish process. And some of the rib articulations, et cetera, are going to be seen. So obviously, you have to be familiar with the anatomy if we're
7:51
choosing to do any operation on the thoracic spine, much less any place else in the spine. Symptoms and signs for thoracic discs Well, a lot of it's going to be myelopathy. Average age, 48 to 56
8:03
pain. Very, very common. Up to 75 of the time, myelopathy, up to 99 of the time, but basically almost 50 to 99. And this is certainly true with the central and anterior lesions,
8:18
myeloidiculopathy for more of your anterior lateral lesions, radiculopathy for your very lateral and foramid lesions. Loss of bladder function about a quarter of the patients. And really, to
8:29
emphasize this, well, it's very nice to be sitting in the grandeur of the United States, where we have access, both to MR and CT, to diagnose thoracic discs. Nevertheless, I can't tell you how
8:41
many times thoracic discs are being operated on, only with the MR. And they don't have the advantage of looking at the CT scan. Is it calcified or ossified? What's the full extent of it? To
8:54
confirm the level, also a good idea How, you know, where it is in the neuraxis, et cetera. But anyway, here's your classical ventral MR. A thoracic disc can appear hypodense. Hypo-intense,
9:07
rather than. You can't differentiate, as I can be calcified or bad here. And here's the CAT scan. And there you can see the CAT scan. Massive anterior thoracic disc that's definitely calcified.
9:20
You know, you read some studies and they say, oh, well, you know, trans-petacle. I can get this all out, trans-petacle.
9:28
You know, that's a long way from here to there to really have direct visualization. They usually get a CSF leak that they can't handle very well from there. And make numbers of these patients
9:38
paraplegic if they're doing it the wrong way, the wrong time, the wrong surgeon. MR is the best study we know to show soft tissues, discs, stenosis.
9:49
MR is going to miss the calcification. And here you can see on the sagittal image, the ventral intrusion, but look what you're seeing on the axial T2-weighted study. All of this mass here actually
10:02
ended up being OPLO and ossification of the post-dural ligament. Also what it signals is, you know, you may have an element of some preserved dura anteriorly, and then the ossification may be
10:15
intradural. So trans-dural ossification of the post-dural ligament, you have to be prepared that you're going to have a CSF leak and how you're going to treat it ahead of time, Be it with Shuntz,
10:25
be it with Shuntz. different kinds of direct repairs. By the way, relying on something like dura-seal, test-seal, and these other things to occlude these leaks, not the way to go. If you have a
10:37
confined space, it's a contraindication to using dura-seal because it will act like a mass. I read something recently where the surgeon thought, Oh, well, but it's just a liquid. And the answer
10:48
is within seconds these things solidify and become active masses. And you don't want overly large mass compressing your cord. So the CT scans are the best for showing thoracic disc, classification
11:02
or ossification, as you can see here. MR is going to miss the calcification
11:18
of a thoracic disc and that's what you're visualizing right there. Let me ask you to interrupt yourself. Sure, please. And we should see if the audience we got a small audience but we'd give them
11:20
a chance to ask questions. Let's say I don't, I may have a CT, I may not have a CT, I may not have any more.
11:31
And it looks to you like there's something going on in the thoracic area from the examination. Right. Would you suggest doing a myelogram? Absolutely. How would you do it? Would you do it from
11:45
below or above? Definitely do it from below, it's safer from below. You want to, by the way, because of counting levels, you're going to probably want to get a chest AP in lateral, and an
11:56
abdominal film AP in lateral, you want to make sure you know how many
12:01
lumbar vertebrae you have, because it's going to help you count levels. And then if you do that myelogram, you should be able to count levels sequentially as you go up, because one of the most
12:11
common mistakes in the thoracic spine with a myelogram alone is going to be missing the levels. In fact, even with myelogram CAT scans and everything else, they're still fairly good. incidents of
12:23
missed levels. But certainly if you're doing a myelogram, you're definitely going to want to be able to count as accurately as possible, and you count from the bottom up. And this is actually what
12:34
you also will do when the patient's prone on the fluoro table. If they're, you know, if you're going trans-petacle or something like that,
12:56
if you're going trans-seracic, then it becomes even more difficult and you've got your access surgeons who can then hopefully count ribs for you and make sure you're operating at the right level.
12:56
You know what, do you agree with that? Yeah, let's say you don't. Images aren't that good and you want to make double sure can you inject some dye at the level above so you know when you open it
13:06
up where you are, can you put a needle in and take, and leave it in the prep and then as you dissect, you follow the needle down, huh? What are other ways of doing this? I would, hopefully, be
13:19
relying on that because then you're looking for other sorts of CSF leaks as you're doing this. You're probably going to get much more bleeding from the epidural venous plexus if you do it that way.
13:29
If on the other hand, let's say you had a total block to contrast from down below, then you're not really quite sure what you have up above that. That might be an instance where you may do a, you
13:42
know, put in some dye intraoperability to get some more information But I would say in general, I think it's pretty rare that you end up having to do that or, you know, trying that out.
13:55
Should we ask at this point, if the audience has any questions, Strada, know what you have?
14:03
Yeah. Do you consider Nancy, if,
14:08
yeah, in those challenges and environments, could Eric's machine be useful for something. Could could the x-ray machine or the floral machine be useful? Yeah, or fluoroscopy. Yeah. Oh,
14:22
absolutely and in fact, I would do these under fluoroscopy. In other words, you want to make sure you're going to end up at the correct level. You want that floral machine because as I said,
14:32
you're going to have to count up. You're going to have to know how many ribs are there. Are there any anomalies here? Are there any anomalies in terms of the lumbar spine? And you're going to want
14:42
to count up ribs until you know where you are or you're going to count from the cervical spine down. You know, placing markers as you go, but absolutely you need fluoro. Just plain x-rays or
14:53
you're going to do a lot of plain x-rays and fluoro is really the way to go. We saw months in eight road. Do you have any questions? Do you, how do you do this? Are Marvin Sandovalo or Ronald?
15:14
Or in one more question, yeah. And when we choose the fluoroscopy for the dorsal spine, always there is some challenges to localize that correct level as you mentioned it, yeah. So how to perfect
15:26
the technique, how to make it easier to localize properly the space without taking so much time in operation? Well, I think, let's say you think that it's a very lateral thoracic disc or very much
15:43
more interlateral. Then what I would do before you go to the OR, bring them down to the radiology suite and under
15:52
fluoro, use methylene blue, just a small amount. If you use too much, it's gonna go all over the place and put that on the interspinous ligament. Hopefully you will inject it on the correct
16:02
interspinous ligament, but that is a way to get better visualization and to sort of know where you're gonna hone down on. And I think that's very helpful in terms of saving you time in the operating
16:14
room. Sometimes you can also put in a little metal clip,
16:20
like any of the vascular clips that we sometimes using, you put that on the interest bonus ligament. Yes. But these are about, definitely, if you can take advantage of that, they have better
16:31
visualization with their fluoroscopy down in the radiology department than you're gonna get in an OR, typically. Yes, yes Because usually, the problem are the ribs, right? The problem are the
16:42
ribs that are covering the images, and then it's quite challenging to localize the living, especially in the lateral view. So maybe it might be better the AP view. You consider the anterior view,
16:56
it could be better. Yes, I think the AP view you're gonna wanna use to count up the ribs to at least give you the best chance of being at the correct level. Bring your radiologist into the OR if
17:07
you're having trouble counting them. I mean, sometimes they're very helpful. And then
17:14
you have to try and make sure that you're gonna go down the correct pedicle to make sure you're at the correct level, 'cause you don't wanna take off pedicle the wrong level if you can avoid it.
17:23
What do you, what do you
17:28
do? Yes. Yeah, usually we do in the same way what the Nancy is commenting that we bring our geologist. But yeah, but for the dorsal spine, always it takes a bit of time to localize. And we,
17:43
after we open, of course, laterally or after we do some kind of procedure, we put some kind of metallic reference and we take again and again and the fluoroscopy until we recognize properly the
17:59
space. Right. And I think also, you know, especially if you just used a monogram to localize these lesions, you know, make sure you have access to doing, to converting that trans-petacle where
18:12
you've not done a laminectomy, you avoid that laminectomy, but ready to do a costar trans-resectomy or even an extra-cavitary exposure on that side so that you really get down to the base of the
18:24
canal and safely take these discs out rather than just trying to sort of get to the side a little bit, and I mean, these are very unforgiving lesions And I'm sure you've had that experience, right?
18:38
Yes, yes. One thing also we do is that pre-operatively, pre-operatively, we bring the patient to the X-ray machine and we localize and we put a reference before. We mark the line so to make some
18:53
kind of
18:55
approximately approach and then intra-operatively we confirm the level. Yes, absolutely.
20:00
The more ossified or calcified the more difficult these are to remove and especially if you have anything that's anterior, interlateral, you do an insufficient exposure or you are doing that patient
20:12
a real disservice and lots of these patients are going to be made paraplegic by mistake. And the CAT scan, how long does the CAT scan take, minute, right? And by the way, if the patient happens
20:24
to have had a CAT scan for any reason in months, years, or whatever ahead of time, there may be previous films for that patient that document where this thoracic disc may be or how calcified it is.
20:37
So there are other CAT scans that abdominal pelvic CTs, chest CTs, et cetera, that may give you some information. So here's your classic CT. So when you're calcified, I'm going to calcify
20:48
thoracic disc herniation. This is probably more like an OPLO mask. Here's an axial view. Here's a sagittal image. And basically, CT and Milo CT scans, how often are these calcified? Fully
21:02
calcified, 65 of the time, partially 27 of the time. Giant thoracic discs. And we encounter some of these. 30 to 40 of the canal is occupied with these. And anything between like 43 to 100 can
21:16
be intra-dural. And if it's intra-dural, it's more likely than not. It's so pretty long, so it's fun to look through the burrow.
21:24
So here, a CAT scan This is that hypo-dancy area. That's your dura. And then here's your ospication, your OPLL inside the dura. And that's the OPLL2 and through the dura. And you really have to
21:38
be ready to deal with the leaks that you're going to get. You can't just, as soon as you get a leak, back out and say, hey, I wasn't prepared for this. I don't know how I'm going to deal with
21:48
this. And how do I get this out from here? Otherwise, you just leave everything behind So here is your MRI scan of that same patient. and it's a big hypo-intense lesion. If you only had this and
22:02
you didn't do that, you're gonna go in thinking you might have a soft disc and you're gonna do the wrong operation for this patient. 'Cause you think, well, maybe I can get it off from the side.
22:12
'Cause everybody's always saying, oh, transphoracic, oh, it's so traumatic, et cetera. Well, if it's the right operation, it's what you have to do. And you just have to be prepared to do the
22:23
correct operation. This was a great summary slide, I thought, of the different approaches. So I'm just giving this a big no-no. Do not do a laminectomy. Why? Because any time you put, you know,
22:39
a kerosene punch underneath that lamina, and, you know, look, the kerosene punches, I'll go over this. The bite for the punch can be one to six millimeters, but more often it's two or three or
22:50
four. You're gonna directly compress that cord and you're gonna damage the cord before you even start. we can talk at some point and people want to talk about, you know, do you monitor these cases?
23:01
And Estrada, what would you say?
23:05
Well, I would say, no.
23:10
I know you probably think contrary, but
23:18
the last time I looked at it, it didn't seem like monitoring affected the outcomes, but.
23:24
I would just do the monitoring because it can tell you, I think, especially if you're doing the wrong approach, it can drop out fast and early and maybe say, hey, this is not the way to go.
23:34
While you're doing the anterior approach, I think you're going for broke, but I think that they can be helpful. Trans-particular approaches, you're going trans-pedicle. Again, you're not doing
23:46
the laminectomy, you're just going straight down the pedicle, you're staying lateral, very important. Stay lateral, and this could be for your foraminal and very lateral disc.
23:57
costar transversectomy, it means that you're basically going down the pedicle, you're taking out the rib, and you're taking out the interlateral segment of that vertebral body lateral
24:07
extra-cavitary. This is for your more central lesions, and here the extra-cavitary look, you're taking out a good portion of the vertebral body as you're going. Again, the advantage is it's a
24:18
posterior approach, and obviously the transceracic, you know, Hey, I would do this with an excess surgeon, but that gives you the best bilateral visualization of the anterior cord. Also, if you
24:32
think you're going to get any kind of dural closure, you're going to have a better chance of getting that andor, you know, you can be shunting either of these into the cartneal cavity or even the
24:44
pleural cavity, but probably more the cartneal cavity is better tolerated, unless anybody else has a different thought about that. So I will ask you a question. So if you, if you have access to
24:54
an access Why would you pick a lateral extra-cavitary over a trans-thoracic approach? I wouldn't, I would take the trans-thoracic approach. I think it's safer, especially if you have a large
25:09
central calcified, ossified lesion, you're directly seeing everything you have to. You extra-cavitary, you're still working from a tremendous disadvantage, and you're gonna have a really hard
25:19
time looking around the corner there. I think, you know, I'm throwing an extra-cavitary, I still think the trans-thorac is a much better and much safer approach to this. You agree? Oh,
25:29
absolutely. That's my preferred approach. I mean, I hardly ever did the extra-cavitary, to be honest, because I think the trans-thoracic is so much better. And the extra-cavitary,
25:42
you're trying to peel that pleura off of the bone, and how many times are you getting, like, massive holes in the pleura, so that you're gonna have to deal with chest tubes and everything else,
25:50
right? Right.
25:53
How about if you have a CSF leak, are you gonna do
25:58
a wound peritoneal shunt, rather than a wound pleural shunt?
26:05
Good question. Well, I think that you might have issues if you're trying to shunt into the pleural. So I think your go-to position is gonna be a
26:19
peritoneal. And I think the peritoneal is better tolerated and I'm not gonna get short of breath and everything else that you can run to. So here's the section that if everybody is falling asleep.
26:28
And that's it, we have a question, we have a question. Oh, okay. When you have a compressive effect of one at this carnation in the dorsal spine or any other kind of compressive effect might be
26:43
extra dural or intra dural. Don't you consider to do the wide laminectomy for reducing this compressive effect?
26:53
If your problem is a thoracic disc, you do not do a laminectomy. If you have a patient, different pathology, thoracic stenosis, hypertrophy of the
27:07
olegment, ossification of the olegment, synovial cystic sturgeon, or you have a lateral intradural extramigillary tumor or posterior lateral extramigillary tumor, those are instances where
27:21
laminectomy is an appropriate operation. But if it is a thoracic disc, it's a long operation.
27:29
Now I'm going to tell you why.
27:32
OK, perfect. Anyway, but yeah, keep asking these questions, but I'm going to show you some pictures of the - this is a typical laminectomy. I'm sort of borrowing from the lumbar literature to
27:43
just show you the typical laminectomy. And I'm just reminding everybody that, you know, The Keras and Punches, the Bite. which is the portion that goes underneath the lamina, is typically three
27:54
to five millimeters. It can be up to one to six millimeters, but most punches are not one to six millimeters. They're usually a right angle or they're like a 45 degree angle. And here, the bite
28:06
on this, this is just an illustration from the literature. Here, the bite, again, one to five millimeters is what I'm just trying to tell people about. This is just an example where this bite
28:16
was five millimeters as it is treated These, if you put this instrument underneath the lamina and you have any anterior interlateral, or lateral leaving cord compression, you are going to create a
28:30
spinal cord injury in a lot of these patients by just introducing that device. So here's the argument for not performing a laminectomy for any of the thoracic discs. Here's obviously a figurative
28:38
diagram of a
28:42
huge central thoracic disc compressing the cord. Here's - this happens to be a monogram CAT scan of a central disc at the T-1011 level.
28:53
And again, this is the large central disc here and figuratively shown here. You don't want to put that byteplate underneath here and further compress your cord. Now, people often ask, what is the
29:07
typical anterior posterior diameter of the thoracic spine? And the literature is going to tell you 16 millimeters, OK? Now, what's the typical anterior posterior dimension of the cord? Well,
29:20
it's typically supposed to be, let's say, 7 to 12 millimeters or 8 to 13 millimeters. Well, here you can see you've got a massively compressed cord. It is dorcely draped over the anterior massive
29:33
thoracic disc. You put any instrument between this lamina and over this cord. You're going to damage that cord. And this is just a figurative diagram of the byteplate again of the Azure, and then
29:45
I was trying to. illustrate this here, how you're gonna damage that cord. By the way, you know, one of the advantages of intraoperative monitoring is as soon as you start doing the wrong
29:55
operation in a patient like this, your somatosensory evokes should drop out almost immediately because your posterior columns are sitting right in the back of the cord. Your motor evokes won't be
30:06
very far behind, but this is something that I think you definitely have to look out for. But there are, there's a literature over 40 years old talking about the wrong operation for thoracic discs,
30:19
which really make doing a laminectomy for these disc herniation below the standard of care. Here is a study from 1985, and whoops, here. He said the evidence began to mount that neurological
30:33
worsening was a laminectomy-related complication. The procedure ceased to be useful for the treatment of thoracic dysgligions. Here's a study by Russell in '89 in the British Journal of Neurosurgery,
30:44
67 cases of thoracic discs, okay? Results of surgical treatment indicate that trans-thoracic and costar trans-resectomy equally effective, laminectomy is not advised, okay? Singunus in 1992, 14
31:00
cases, okay? Costar trans-resectomy in its modifications, equally effective, laminectomy contraindicated Fessler, 1998,
31:09
and surgical neurology. Thoracic discectomy has evolved over 60 years from a section through standard laminectomy to poster lateral procedures to open the dichotomy and finally thoracoscopy. And
31:20
what did he claim? Morbidity seems relatively similar between most procedures other than laminectomy. Laminectomy does not, does not provide adequate access for the safe removal of these lesions
31:35
and some more, chin, 2000, neurosurgical focus. The vast majority of patients with thoracic lesions did not experience worse than status postoperatively, likely cleanly apparent now that
31:46
laminectomies are not being performed. Show it all in
31:53
2022, 2002, the threat of court injury has obviously been reduced, because posterior laminectomy has been abandoned currently as too likely to result in neurological loss, and it
32:06
favors cusptotranseresectomy, transtheracter, transplural, everything else under
32:11
the sun. In World Neurosurgery 2018, consecutive series of patients, the feasibility safety and results of poster lateral approaches for the excision of all types of extradural disc herniations. I
32:23
did a summary article, review article 2023. It's amazing to me, by the way, if you ever do any depositions, that seems like the lawyers don't seem to understand that the purpose of a review is to
32:33
review the literature, not just everything that you agree with, I mean. We won't talk about where they went to school.
32:42
But in SI, you know, it's a perspective, looking at all these approaches, anti-transurassic, post-irilateral, trans-particular, are now utilized. Laminectomy has not been a viable option for
32:53
decades because it has a higher risk of neurological morbidity and paralysis. Well, let's go ahead and just let me interrupt for a second to ask this question. Sure. So, is, is there an element
33:05
of,
33:07
is of destabilization that's affecting, that's having an impact on the outcome in that you're removing your posterior tension band with the naminectomy, is that, you do you think that's a factor?
33:19
Beyond, beyond just putting in a kerosene because I was gonna be provocative and ask you, well, what if one could remove the posterior elements with a high-speed drill and not introduce a kerosene?
33:34
Yeah, well, you're not introducing kerosene, you could use the high-speed drill, you can use your correct. you're still manipulating and causing some motion, some trauma, dorsal to the court
33:46
itself. And I would guarantee you, if you have SCP monitoring the one while you're trying to do that, you're gonna get some loss of potentials because what seems like micro-emotion to you is not
33:56
gonna seem like micro-emotion to the court. This was the question that was repeatedly asked by multiple lawyers. Oh, you're being super careful though, whatever. I don't think you can be careful
34:05
enough when you're doing the wrong operation And in this case, I think that's the wrong operation to do. The other thing is, people when they're trying to do the trans-petacle approach may not be
34:16
staying lateral enough right over the facet, right over the pedicle, staying away from anything over the cord. And they're also gonna create major errors, major mistakes. But, you know, the
34:29
notion, your notion that, you know, okay, you know, you're freed up from behind, but the problem is, You still have that anterior draping of the cord over it, and you have a cord that is so
34:42
tenuous already that your chances of damage, I think, are much, much too high. But hey, I could send you to the malpractice attorneys that work for the defense and see what happens. It'd be an
34:53
interesting discussion. No,
34:57
I'm just bringing that up for discussion. I think it's a great discussion to have, and it's a great discussion to have with colleagues who may be thinking along these same lines, well, it's a lot
35:07
easier to do a laminectomy than it is to do all these other things. Well, you know, at least trans-petical or costo-transversectomy, do something way off to the side. Stay away from the posterior
35:20
court because you're gonna end up with a surprise that's not gonna be good for that patient. And especially if you don't have monitoring, I think, it's even more likely. Let me ask you a question.
35:30
You're just gonna get it right now Okay, let's assume. that I've already, I understand they've got a thoracic disc, and I've
35:40
now developed my lateral approach. But I've got a calcified disc in there and it's already penetrated the durable, or the cord is draped over it.
35:54
I'm in trouble right away. I don't wanna get
35:59
this hard thing out of the soft cord, which is already in trouble, because it's draped over it. I mean, what would you do next? Okay, even if that calcified disc is interlateral and you do a
36:14
cost of transversectomy or
36:16
a more extensive version of that, you have to be prepared for the fact you're gonna have CSF everywhere. But more likely what you're describing, Jim, is those are the huge central discs that are
36:29
this big calcified mass, okay? The answer is if you encounter that.
36:35
And you cannot access that because your approach is basically the wrong approach for that patient. You close, and you backtrack. Before hopefully you've made that patient paraplegic, so that
36:51
you're going to redo and redrape and come back and do a trans-teracic approach to get to that lesion directly. At the same time, you're gonna have to realize you're gonna have to remove that dura to
37:06
remove that disc or you're gonna leave all the pathology behind. Are you gonna get a CSF leak? Of course, you're gonna be in the midst of the CSF pathways. What can you use to repair it? Well,
37:16
you know, sheep periosteomer, one of the bovine periosteomer or something like that, and maybe you can get a stitch or two in here or there, but you're gonna have to be prepared to basically put
37:27
in a shunt, like a wound peritoneal shunt at the same time. But I think the crux of what you're asking is the most important factor. And I think as Trotter would agree with this too much list,
37:38
Johan, if you are there and you can't get from here to there safely, close, back out, and come back and do another operative approach. And that's probably one of the most difficult things to do,
37:52
because you figure, well, I'm here, and I'm sort of married to this operation. Why don't I just keep going? And stopping yourself from continuing down the wrong road is, well, Estrada, isn't
38:03
that one of the most difficult things to do when you're in the midst? Oh, absolutely, because you're there. You want to get it done. But on the other hand, your point is very valid. You don't
38:14
want to get yourself into a deep hole where you can't define the margins.
38:21
That's right. And that's a terrible position to be in. And especially if you get in there, And let's say you're lateral. And you see, what do you see? Well, you see basically cord would appear
38:34
to be massively draped over this anterior rock. Well, you're not going to get from here to there without going through the cord. So you close up, you back out, and start with another approach.
38:47
And that's, I think, is one of the most difficult things to do, is to back off.
38:53
Anyway, here is the going over the trans-petacle approach. I'm just trying to show you here how everything - this is a very, very - this is really like a far lateral
39:03
thoracic disc, because it's impinging on the nerve root, almost at the dorsal root ganglion. You're not really dealing with chord compression. But here's your facet joint, and the pedicle is
39:12
right underneath there. That's where you want your dissection to be. A trans-petacle approach, guess what? Has to be trans-petacle, OK? It just can't be, oh, well, I did a laminectomy, and,
39:23
well, I went down the pedicle a little bit, Well, I didn't. have enough room. Well, I tried my best. Well, that's not good enough. Here, again, it's for the lateral disc only, and you can
39:36
remove the pedicle and, you know, some of the head of the rib and everything else. This gets into somewhat of a posture trans-resectomy as well, but
39:46
stay over the pedicle, stay lateral, okay? This is too much of the lamina here has been removed, so this is like a mistake, you know, okay, you use a diamond drill, but
39:59
you're going to be in there with a curette, you're going to be micromanipulating, stay away from the lamina, you're right over the cord at that point, not a good idea. Again, trans-particular
40:10
approach, stay trans-pedicle, remove the burrow of the set, not over the cord, expose the pedicle and access that disc space, and then here is the disc space that you hopefully access very, very
40:23
laterally, once you've gone through that exposure. And then we want to ask for any questions at this point for me. Yeah, that's the trans-petical approach. Any questions? Interesting. Some of
40:34
the literature claims, oh, I did a trans-petical exposure. And I removed a big central disk because I took out both pedicles, and I did it safely, and the patients did great. And you're thinking,
40:47
I don't know.
40:49
I still think that trans-thoracic is the safest and the best way to go I mean, Strata, did you ever do bilateral pedicle resections to get out of central calcified thoracic disk? No, no, no, not
41:03
a calcified central disk. No, as I said, mine go to approaches of trans-thoracic using an access surgeon to get there.
41:13
And it's interesting, because sometimes people challenge you well, I read this article, and Dr. what do you think about this article, you say, well, I want to see that article. It's like if
41:22
you're in the middle of a deposition, you today. I want to see that article and read that article. before I respond to you, because otherwise, it's a pure speculation and I'm not gonna speculate.
41:33
So anyway, costo-transversectomy. Here's an interlateral disc, and you can see there's port compression as well as compression of the root. The costo-transversectomy is for these larger
41:44
interlateral discs, and again, you're going to want to remove, here's the, it is where the pedicle in theory would be. You're then gonna go over the head of the rib and remove the rib up to about
41:55
a section over here So that, and you remove the transverse process as well, so that you have adequate exposure. Again, these are just images, again, of the interlateral thoracic disc, and again,
42:07
images of exposing and removing the pedicle, the head of the rib, and again, the proximal portion of the rib itself, other than, you know, the head of the rib. So the bony removal, just to
42:19
re-emphasize pedicle,
42:24
and removing the proximal portion of the ribs so that all of this is out, okay? You are not impinging on the canal itself or on the cord itself, and every movement you do has to be lateral,
42:39
nothing going medial. And if you encounter leak, you've got to try and repair it, you know, seven-o-gortek sutures. I wouldn't use silk any longer. Proline sutures, not good because they tend
42:51
to unfurl So gortek's tends to be much better. So here again is what, this is the figurative diagram of your costotransferectomy. They took too much of the lamina here. Lamina should be still
43:04
intact up to here. But, you know, we can't redraw everybody's images. But this is what it looks like in a CAT scan. Not the best CAT scan, perhaps. But here, interlateral disc started over
43:15
here. And here you can see that the pedicle is gone, head of the rib is going, and then the proximal, this is the rib, is also good. been effectively dissected and resected. And
43:28
I think post-operatively, do post-op studies in your patients. See what you did. Estrada, do you have any problem doing that post-operative in your patients to document what you did? No, no, no,
43:42
no, I was trying to put my vision. No, no, I agree. I think it's instructive and it helps guide how you continue with the practice and know that you accomplish what you intended. That's right.
43:55
And if you didn't, then you can figure out what you're going to do about it, right? I mean, that's the thing that's staggering to me. But I think, you know, looking at a lot of medical legal
44:04
cases, and Jim and I have discussed this in some of these cases, what's the first thing they don't do? They don't do a post-op study. What's the next thing they do? They delay it for as long as
44:13
possible. Number three, maybe they don't do the appropriate study ever, or maybe do it a year or two later I mean, really, we all. try and remember that our job is to do the right thing for the
44:26
patient in a timely way, right? And get them the best results. So that patient wakes up paralyzed. Do we wait eight
44:34
before getting a study? How many of us wait, you know, two, three, four days? It's just, and in a patient who is hemodynamically stable could tolerate an MR. You can get the MR, you can get
44:47
the CAT scan, whichever study you think is most appropriate and oftentimes it may be both studies, not just the one. Let me ask you another question. Do you've taken off a large portion of the
44:58
body there? You've taken off the pedicle, you've taken off the rib. Are you using a drill to do this? Are you using a carousel? What instruments do you do to achieve this? With the least amount
45:14
of damage attraction to the core destruction? It's usually a diamond drill. And not a coarse diamond drill, and it's not a cutting burr. A cutting burr can skivvy off and create disaster. But a
45:26
diamond drill would be what you're going to use. And if you've created enough of a knightess, then you can maybe even use a Lexel to bite off a little piece. But most of the time, I'd say,
45:36
diamond drill, irrigate, irrigate, diamond drill, and occasionally use some of the other instruments as you go. A strawberry, any other comments about that? I agree, I mean, honestly, I
45:49
start with the
45:52
cutting burr, and as I get down to the delicate tissues, I transition to the diamond. Yeah, yeah. Johan, what most of the fellows that are women are doing this, were they have access to a drill?
46:09
Sorry, sorry. What most of
46:15
the people that are - Well, here we go We can get the - here, we can get the hard drill. High drill speed, or high speed drill, but we need to rent it from a company. And yeah, when we ask, of
46:30
course, we get it, but not all the centers have it. So you have to rent it on a case-by-case basis, you know? Yes, yes, I think. And well, if it's suitable, then we use carisons.
46:44
Or actually, well, it's not in the case, but in the lumbar spine, what usually the orthopedist do here is to use a mechanic systems, are those correct? Like they're like knives, and then they
46:60
just cut the -
47:02
Oh, osteo-tomes. Oh, osteo-tomes, no, no, no. They just do osteo-tomes. Yeah, I don't think I'd use osteo-tomes here. It's a little too dangerous. Two minutes work, two minutes work So I'm
47:16
gonna stick to delicate for that. But then again, you have the pleuras sitting over here. Anyway, okay. Your argument, Nancy, is you don't have as good control of the osteo too much as you have
47:28
with the drill. Absolutely. And in fact, the same thing for you, I mean, I started saying, you know, you might use a cutting burr superficially, but when you get down to any of the important
47:38
areas, you're gonna use a diamond drill because those cutting burrs can skivvy off and create disaster. So you don't wanna end up with a drill in the middle of the pulmonary parenchymal over here or
47:50
something like that, much less a major vessel anteriorly. I mean, it's all about control. I've seen some medical legal cases where the neurosurgeons are doing a very fancy operation and they have
48:04
no assistant whatsoever. And they say, well, with my left hand, I'm suctioning and I'm using a drill with my right hand. And I think we were all taught that you always use a drill with both hands
48:16
Strotter, comment. Well, as you said, control is the key, and you need both hands to optimize control, absolutely. So,
48:29
you know, it's like cowboys and Indians. I mean, we're dealing with a lot of cowboys, and, you
48:36
know, how do you re-educate? You know, it's like, you know, neurosurgery should not be a macho specialty, right? I mean, it should be one where everything is directed at trying to do
48:48
everything as carefully and compulsively as possible, right? I mean, you're working in an expensive real estate. You can't afford to be cavalier. Yes. And now let's say, let's say you get this
49:01
far, and I can't imagine how you'd stop at this point, but you get this far and things are just getting difficult and so forth. And you talked about this 10 minutes ago and the hardest thing to do
49:13
is stop. Correct. So I think that it's worthwhile pointing out is if this looks beyond what you had planned for, if this is beyond what you had instrumentation-wise, if this is taking too long,
49:30
and it's your marginal in terms of help that you have, is this a problem if you stop and back out? You close. You close, you put your drains in whatever you're going to do, you stop, and then
49:45
you leave them in the recovery room overnight, maybe come back the next day or the next day or two or whatever, re-image them to see how far you got or how far away from the pathology you were. You
49:58
may want to repeat that MR and CT scan, in fact, you should be doing that to see what you have left, but yeah, it really is critical to the back off and say, Hey, this is just not going So Nancy,
50:12
what feature, oh go ahead Jim. No, I'm sorry, go ahead. So, what pre-operatively, what features would lead you to prepare for a long peritoneal shunt? If I - Correct, prospectively. Okay, I
50:30
do an MR, I do
50:33
a CT. If it looks to me like it's ossification of the post-year longitude ligament, or some people are just gonna call it a calcified disc that is going to and through the Dura, okay? I make sure
50:46
that I have number one access to it. I need to have an approach that's going to allow me access to even do a repair. And the question is that going to be, is it a very lateral problem that we have?
50:60
Or if it's gonna be central, then I'm gonna wanna do the anterior transauresic approach. Then what am I gonna use as a Dural substitute? It could be bovine pericardium We're not using cadaver
51:11
grafts in the mover. What sutures am I going to use? Usually seven or four tech sutures, what I've been predominantly using interrupted sutures, you don't want to use running because if anything
51:22
loosens or one suture breaks, the whole thing falls apart. And then you're going to think about, well, what kind of a shunter am I going to use? In the early days, we were using the uni shunts
51:33
from Codman, you know, the low pressure and no pressure shunts with no valves, etc. If you're going to use a shunter, I would say check it out and see what the pressure is going to be or make
51:44
sure that you could put it on the lowest pressure. Some of these you can actually,
51:50
if it's a very, very thin patient, you could actually maybe even bring the dome out so it's subcutaneous, so you could almost tap it if you really had to. And then I would prepare the prep and
52:02
drape of that patient from the get go would be so that you would have direct access to the abdomen to put in that wound peritoneal sons. I mean, some of these patients, You know, people are going
52:14
to go, Well, you could always put in the lumboparadneal drain, you know, lumbar drain post-op. Then, of course, you're stuck doing the lumboparadneal sunt, et cetera. But I would be prepared
52:25
to do womb paradneal sunt, just like with cervical OPLL. I mean, I did a whole slew of, you know, multilevel anterior corepectomy infusions. We
52:34
didn't have that many that were CSF leaks, but some were significant, about five or six of those We were prepping and draping all the time. You'd have your incision like this, but you'd prep all
52:45
the way down to the abdomen, right para umbilical incision to put in your wound parrot in your shunt, or you could put it right over the liver if you chose to, you know, put a para median incision
52:56
there. But prep and drape from the get-go, make sure you're going to have adequate access and visualization to repair that as best you can Don't just leave it and don't
53:08
think that you're going to use any of the duraceals. to seals any of those they form like concrete layers that are gonna be court compressive in many instances and they're going to resort. To seal
53:22
will resort over a course of a week. Duracile usually takes maybe up to a few weeks but it is not, those are not solutions. You really have to prepare to have a wound peritoneal shunt and maybe
53:35
even subsequently a lumbo peritoneal shunt if you really need it. Well, rather than a wound peritoneal shunt, what about a temporary lumbar drain? Well, that's what I say. You could use a
53:49
temporary lumbar drain, but then the problem is the wound pressure, just like in the neck, the wound pressure, okay, is so much lower than having to drain out of your lumbar drain that
54:05
in the cervical region, you would accumulate fluid and patients will start to exphyxiate. And the problem you have in the thoracic spine is what fluid increasingly attenuate to the point where it's
54:17
cord compressive. So I would be worried about that. That's why I would plan to do a wound parettinol sent at the same time. I'm
54:31
just trying to get to what I think are some sensitive issues here. Okay, I'm at this point, I've got this thing done. By error, I've got a CSF
54:43
leak. I penetrated the door of the aeractics leaking. I think I'm over my head.
54:51
Maybe the thing to do is to close it up and refer to somebody out of town. I'm just trying to think of what somebody might think. I don't want to be embarrassed by referring it to my colleague down
55:02
the way.
55:04
What's everybody thinking about, feel him?
55:09
First of all, I think, when we do this course to transfer sex to missing, we approach to the medical, and when we are using the high-speed drill, always we go from lateral to medial part, and we
55:24
live like a very thin-born aspect in the medial part, not to touch the dura, and when we are getting this like thing, we can use some kind of a small dissection to open this medial aspect of our
55:43
drilling, so with that I think you prevent a lot of this dura leaking, we always do like, here we do like that, we always approach to the pedicle and we are drilling drilling, but once we are
55:57
reaching the medial aspect of that drilling, then we don't open all the bond, but we just use small-day sectors to try to break that aspect of that. So with that, we prevent it. You can still try
56:13
and even use your little micro curates at that point, but a certain number of times you're probably going to end up with a duralic, especially if it's densely adherent to the neutral component of
56:24
the calcified disk. For example, yeah, we have operate a couple of schonomas, bigger schonomas that were coming from the foramen. And then when we took them out, of course, you get the leaking,
56:39
the CSF leak. So what we do here is we don't put this glue or this else. We got
56:48
that in the lumbar spine. So it's different, of course, in diameters and inside to the thoraxic spine. But what we use here is that synthetic dura, and we put synthetic dura just other end inside
57:04
the dura. We don't put out that we put inside between the nerves or between the
57:14
spinal cord and the duran. We don't shoot your them, we just make them to attach the duran to cover that space from inside to outside and we put another layer outside. So after that we put some
57:29
kind of fat and we try to close that space. We just use that and because it happened a couple of times that when we put some drainage there, honestly that the hole doesn't close ever. So we can
57:47
keep weeks and weeks and the pressure of the CSF always comes and makes the CSF coming out and we had a couple of cases where we put drainage and unfortunately they didn't work.
58:06
So aren't you worried sometimes that that intra-dural graft is going to migrate?
58:12
Yes, but there is this kind of
58:16
adhesive, dura, synthetic dura. So once you put, they
58:22
adhere
58:24
to the dura and you put also another layer out, so you make like a sandwich, you know, between the inner and outer dura. Of course, also, you can put a couple of
58:37
yeah, shooters there, but they are designing it, attaching each other. So, and even if they, even if they are not well attached, I think the CSF pressure mechanically makes them to attach,
58:55
makes makes the dura that the synthetic dura to attach to the dura. And it doesn't be great. Of course, the patient should go, should rest. for three, four days. And then you don't get that.
59:08
And that was our solution for a couple of bigger Chinoma cases that maybe I can show you at the end of the presentation. And yeah, for us it works. But yeah, we had this couple of cases with
59:24
champions in the operating field and they didn't work, yeah
59:32
Okay. Okay, well, sometimes it works and I'm sure sometimes it doesn't. Yeah. Okay, so let's look at axocavitary approaches.
59:43
The bigger interlateral disc, almost huge, just anterior, central, but not quite. Extra-cavitary surgery, it's a lot of dissection and a lot of disc.
59:55
These are big operations where you're taking out the rib, you're taking out the pedicle, you're trying to take out the vertebral body The biggest thing you're trying to do is see around the corner.
1:00:04
And I think we've discussed with the Strata that it's really hard to see around the corner and get really good visualization with these large central disc herniations. This is just another example.
1:00:15
Large calcified central disc. And here's your large calcified disc now. Could you call that anterolateral? Could you call it central? Well, it's almost a giant calcified disc that's actually
1:00:26
filling the entirety of the spinal canal. But unless you go anteriorly, you're not gonna have direct visualization to really get at all aspects of this and look, your chord is just sitting under
1:00:39
here posteriorly. So I would stay far away from, again, the laminectomy approach that we're talking about avoiding. This is just some figurative diagrams of how this is actually done. You come
1:00:52
down, you expose the ribs and then you come down along the lateral aspect of the vertebral body and the pedicle Obviously there's your plural, you want to try to avoid. multiple holes in that
1:01:06
pleural cavity, and they can definitely occur. And then hopefully at the end of it, you have your nerves and your cord nicely exposed and you've put a graft over that level to stabilize it,
1:01:21
et cetera. If you think you need it, you can use posterior stabilization for these. Obviously you're dealing with the thoracic spines, so sometimes you don't even have to do a fusion at these
1:01:31
levels depending upon how much dissection you've done, I'd say, you know, certainly with removing a single pedicle, you probably don't have to use those patients when you get to the extra
1:01:40
cafeteria and it's more diffused, you might. The trans-thoracic approaches, I trained with Joe Rancoff, and I think he was a good proponent of this. You know, I was a resident starting in '76,
1:01:52
but even before that, in the late '60s, early '70s, he was talking about trans-thoracic approaches to these large thoracic disc herniations.
1:02:03
And here again, CAT scan, you're seeing how calcified that disc is anterior transthearacic approach gives you direct visualization from here, essentially everything that you really need to see.
1:02:16
And here
1:02:19
is your section of the rib is being illustrated here. You've got your retroplural dissection coming down here. You're going to be exposing the lateral aspect of the vertebral body And again, this
1:02:32
is in a transteracic exposure seen here. And obviously look at all the good real estate that you have over here that we want to avoid with that. You don't want that drill to skivvy off to the side
1:02:44
because what do we have here? We've got the aorta, you've got the esophagus, you've got the vena cava. I mean, all kinds of major structures you can get into big trouble with.
1:02:54
Screws for the distraction of the vertebrae you're going to use And then you're going to do a bony resection that's illustrated here. where again, you're going to have a good exposure of that
1:03:06
ventral cord to do what you have to do. And you've got your microscope to help you out. And then you can use a, you know, you're going to do a vertebraectomy sometimes rather than just a partial
1:03:19
corepectomy. And then you can put in your vertebral strut graft and your antrolateral plate. Here's an example of a pre-op and a post-op MR after removal of a large central disc, your hypo-intense
1:03:32
disc after that resection has been completed. And this is, again, an example of the graft and plate system that you can use in these patients. Again, access surgeons, I would use an access
1:03:47
surgeon rather than trying to be a cowboy and saying, Hey, I can do it myself. I don't think that's too smart way to go. But that's the way it might look on your post-op MR. And obviously your
1:03:58
CAT scan is gonna give you kinds of definition. So here, After you've done the resection, you obviously are going to do a corpectomy graft of some sort, and you're going to have your skeletonized
1:04:10
dural sac as well as the individual nerve roots at either end with free. So in short, what we've tried to do is discuss avoiding a laminectomy, the whole purpose of today's discussion, if nobody
1:04:24
remembers anything else, is don't do a laminectomy. Don't do a partial laminectomy Don't do a complete laminectomy. Don't do anything that's going to at all go across this final canal or start
1:04:37
going over the cord itself. Everything has to be away from the cord. And the surgeons who'd be doing these should be the right surgeon performing the right operation for these just, you know,
1:04:48
surgeons who don't know how to do these, who've never done these, they should really transfer to the institution that doesn't know how to do these, no matter what the political ramifications may be,
1:04:58
because that's our job is to do the best for the patients.
1:05:02
And I thank you. Well, thank you. Thank you very much. Very, very complete discussion of that topic. Really good. Well, couldn't do without my friends asking some really good questions.
1:05:18
Your arm, did you have some cases you wanted to present?
1:05:22
Yes, yes. I wanted, maybe you can let me too. Sure. You should go to Shay's screen I was just, I was just organizing those. Okay. I thought, yeah, that's cool. Please just leave me a moment.
1:05:53
So what is that maybe if somebody might have some some question see Alguin Tieni al guna pregunta para la provizor anan sieps de emprofor
1:05:60
Yeah, I'll go over again this no problem. What what city are you in again, Johan? I'm coming. I am living here in Cusco. Oh my god. Yes, yes, you know, I am in Cusco, which I am in the sun.
1:06:19
I am
1:06:20
in Casan Can you see this slide? It's like a meninger. Yes, yes.
1:06:26
Actually, unfortunately, I don't have like a dorsal, my experience is very small. So I couldn't find it. And a dorsal disc herniation. But I wanted to show you this few case. For example, this
1:06:41
was a meninger. Yeah, extra dural mass in I think the one the two. She too, yeah, it looks like them. And yeah, the patient came like in the term. She was with a very,
1:06:56
she had a, she didn't have a paraplegia, but she was with
1:07:03
a severe paparazzis. My look after him. So, in this case, yeah, we made like a, we opened the laminus and then we went laterally from both sides to resect this tumor. And yeah, this was like
1:07:20
the, I am showing, I have only this picture, so I would like to share more, but I have only
1:07:28
these pictures. Was it biased to one side, you know? I went, yeah, we made a laminectomy, and then we went by both sides, yeah, first. So the mass was completely central? It wasn't more on
1:07:42
one side? It was very central, yeah, and yeah. But this, as you could see, the spinal channel was a little bit wide, so it allowed us to
1:07:57
remove the chumon with a small
1:08:04
partial edura. We didn't open the door, of course, and we could do this. So the patient recovered quite well, and she was working after, I think, four weeks, four weeks. So we could do this
1:08:19
under the microscope, and it was a very nice case, but for sure, it was in the upper dorsal spine, so it would allow us to make it to sit here. You could sit here, the laminectomy, and over the
1:08:32
addition of the. Is that a piece of
1:08:40
T1, just the very super aspect of this? but the 2020 one most is going to do. Yes, so this case was good. And also, this was another case. It was like Dorso Jumor, which was operated in other
1:08:60
cities. So they made some kind of fixation. Just they did
1:09:07
a fixation. And the patient came after one or two years here And he came, again, with some kind of
1:09:16
lower limbs. Para-parisidine. Yeah, we
1:09:23
had to operate. And in this case, we did this bilateral costo transversectomy, because before they just did the instrumentation, and we couldn't remove all the
1:09:37
tumor. I was here, I think, one and
1:09:43
a half year I didn't have that. I would say the courage to go and remove all, but we made a very white removal and we could put
1:09:53
this, we made a corpectomy and then we replaced, we put this replacement there. And yeah, in this case, for example,
1:10:03
some technical challenges were that this tumor was barely bleeding So it looks like an aneurysmal bone cyst, was it? Yes, yes, it was like, but in the differential diagnosis, it was like also,
1:10:19
what is giant cell tumor
1:10:22
and this aneurysm bone cyst.
1:10:28
And during the resection, bleeding was so hard that we couldn't stop with that Well, I was about to ask, pre-operatively, did you get a CAT scan with contrast? Thanks in. Believe me that I could
1:10:42
take more pictures, but I have only this and those people before you operated on the patient Yes, we did you do a CAT scan with contrast because that might have warned you that it was an aneurysmal
1:10:54
bone system That the patient had to be embolized before you operated on them We did an MRI we did an MRI and we could we couldn't see some kind of large veins or large vessels. They're inside And we
1:11:11
just thought that no, it was
1:11:15
Music two more Okay, but
1:11:19
you also had access to an MRI scan with contrast you could have given an MRI with contrast Yeah, we didn't we didn't we'd come to stay unfortunately with it. We just did it in T1 and T2 MRI And
1:11:32
cities can yeah, we we couldn't do Sorry
1:11:44
So, and the patient came, actually, with another differential diagnosis,
1:11:51
it was probably a tuberculosis So,
1:12:12
what we did during the
1:12:16
interpretive
1:12:18
removal was to inject or to put some kind of cotons with epinephrine,
1:12:28
and they worked very well there inside the tumor. They worked even better than any other substance that we were using So actually, you know, if you were convinced that is did not drain
1:12:41
significantly into important veins or whatever, sometimes this is an instance where you can use a firing sealant as a coagulant to stop from the bleeding. Yeah, we didn't have on that time, we
1:12:54
didn't have at the moment what do we have injected a bit of peroxet that works sometimes for some many jobs here. We use it also at the height speed, really in for trying to bend the small vessels,
1:13:10
we put this bone replacements for stopping the bleeding, but they didn't work so well. But what worked well was this
1:13:23
topic use epinephrine. And with that, we could remove widely, we couldn't go until the anterior part because as you could see, There is the article.
1:13:39
Basil here and we're very afraid to go in front. But in any case, we could make a decompression and a wide removal of the tumor and we could put the replacement and
1:13:56
find a patient went well, he was standing walking. Now I contacted him, he's like three years from the surgery
1:14:10
and apparently he's doing this. But we did what we could do on that time here. You know the other thing is sometimes if you take, we would use peroxide all the time and if you take peroxide and use
1:14:19
some gel foam and you can put some gel foam and peroxide and then just temporarily put cotton balls on top of that and try and get some human stasis, sometimes that will help. Yes, yes. Take the
1:14:30
cotton balls out though. Yeah later, of course, we could analyze more and I think in our following.
1:14:39
It's an extremely difficult case
1:14:42
and it's really challenging. And this was the case that I was commenting on. This is a genre. Yeah, I think it was indeed. If I remember it was the eight or the nine
1:14:59
in the lowest point. And you could see here The actual
1:15:06
deal that the tumor is going through the phenomenon. So in this case, we have removed all the tumor. And in the last part of the removal, we produced this CSF leak.
1:15:18
Okay, so we went laterally and that since the tumor was going inside the door. When we remove it, when we remove it, then the CSF came out And in this case, we solved that as I mentioned, a
1:15:34
small graph of this. synthetic adhesives, synthetic dura. We put it inside, and another outside, and later we put also some fat grab there. And, yeah, our results were quite good.
1:15:51
And the patient also became, it was a junk patient, 18, 17 or 18 year old patient. And he came here from a very far place, from Avonchai, a Burimak. It took like four hours traveling by car And
1:16:06
we operated and, yeah, he goes for recovery. He's
1:16:13
a mother function after, I think, one month. And, yeah, in this case, for example, we make him to rest for one week. Just not moving a lot, but make some kind of therapy on the bed. But we
1:16:28
didn't get a lucky one CSF issue here, which was totally surely going to happen We're good man as well. And you didn't use CSF drain in that case, did you? No, in this case, not at all. Because
1:16:43
we've had the bad experience in one case before that I told you that it never closed. So here we preferred just to seal it from inside and outside. And you could see here there is some small fat.
1:16:58
Yeah, so we put fat. And then we put some stitches over this And we closed very well the hyponeurosis. Lots of times it's better to use muscle that you can actually pound down rather than fat
1:17:12
because the fat tends to be absorbed and shrink back whereas the muscle doesn't. The muscle scars down a little bit better than fat. Yeah, that's true. But also I think a very important part of
1:17:23
the technique is to close very well the hyponeurosis. Yeah, the hyponeurosis. I mean, the muscle layer - The fascia. The fascia I think that should be very tightly closed. Then the mechanics of
1:17:37
the
1:17:39
CSF liquid, they balance. They balance and long-term they just have equated balance there. So yeah, those were these three small cases that I wanted to show you. And yes, of course, you comment
1:17:53
on this laminectomy about this carnation is very valuable and
1:17:59
we should consider them because really even the movements of the height, the speed drill can produce some kind of neurological damage there. And yeah, but yeah, going laterally, I think it's very
1:18:14
useful for the dorsal spine. And here if we go anteriorly, then we always ask the thoraxic surgeon to approach. We don't have the experience to go by ourselves to do anterior approaches. But
1:18:30
laterally and postural laterally, yeah, we can manage those situations. Okay, well, good. Thank you. Thank you, thank you. She was excellent. That was a very provocative, terrific, you
1:18:40
earned good cases and a good teaching, a good teaching. Yeah, well, thanks for
1:18:53
all. Yes, so I think we closed the session for today. Yeah, I appreciate it. It was very nice to have you here in the team Excellent.
1:19:12
Okay, all right, until next time. Yes. Thanks for trying to do all this. Thank you.
1:19:22
References are given throughout this presentation. Be prepared to take screenshots.
1:19:30
We hope you enjoyed this presentation. Views and opinions expressed in this program are those of the author and interviewee and do not necessarily reflect the official policy or position of SI
1:19:43
digital or its management and the information contained in the program should not be considered to be medical advice. Patients should consult their own physicians as to their specific medical needs.
1:19:56
Please fill out the evaluation of the video at the bottom rating scale on the home page where you'll find this video. Choose from one to five stars so I was the highest to help us improve the
1:20:08
information we bring to you on SNI Digital. These programs are available free on SNIdigitalorg. If you have questions, comments, suggestions, or requests for
1:20:18
CME credit,
1:20:22
press the blue icon at the bottom right of the home page and that communicates directly with us SNI Search going around International. is read in 239 countries and territories, as the third largest
1:20:36
readership of neurosurgical journals has over 200, 000 readers a year, and its web address is SNIglobal. SNI digital is seen at 158 countries in the last 24 months of publication. It's the first
1:20:54
video neurosurgery journal that has 24, 000 viewers, and it's heard on podcasts by 10, 000 additional people a year, and its web address is SNI digitalorg.
1:21:08
These publications are free to everyone in the internet free 24, 7, 365, and the purpose of the foundation supporting them is to help people throughout the world.
1:21:22
This podcast and all of the other podcasts of SNI Dibble are available on Apple, Amazon and Spotify look for us and our digital.
1:21:33
Foundation supporting this program also brings truth through the medical and science news to the world through its medical news network. It's medical news you can depend upon. The program is
1:21:44
comparator by the James I. and Carolyn our Osmond Educational Foundation. All rights are reserved. Contact Dr. Osmond at the email address below. We hope you enjoyed this presentation. Thank you
1:21:55
very much.
