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SNI, Surgical Neurology International, an Internet Journal with Nancy Epstein as its editor-in-chief, and SNI Digital, an editorially curated neurosurgery and
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medical information multimedia platform with operative videos, expert interviews, podcasts, and global interactive discussion of information for the next generation of clinicians in 13 languages,
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with James Ioswin as editor-in-chief, are pleased to present another in the SNI
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SNI digital series on controversies in spine surgery.
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And the title of this talk, as presentation, is the most common mistake surgeons make in spine surgery and malpractice cases.
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regarding the timing of surgery
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and cantoacorna syndrome. Nancy Epstein is the presenter and the editor-in-chief of SNI.
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She's also the professor of conical neurosurgery at the School of Medicine, State University of New York at Stony Brook. Okay, well, this afternoon, you know, Jim and I were discussing a recent
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article that just came out on surgical neurology international just a few weeks ago, but it's just a reminder that stat surgery is a standard of care for dealing with codercoinis syndromes. So I'm
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gonna go over the fact that we're looking at emergency MRs and emergency surgery in patients with codercoinis syndromes will go over partial as well as total codercoinis syndromes. And this is a
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lecture that I think medical students, physician assistants, nurses, nurse practitioners, OTs, PTs,
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as well as some orthopedic and spine surgeons should really be familiar with. I've dealt with a lot of medical legal cases, and this is a very, very common topic that comes up. And the biggest
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failures we see is failure to treat in this time, or failure to diagnose and treat in a timely fashion. Most codercoinis syndromes, everybody's familiar with probably or due to disc herniations.
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You can see on the left, there's the AP view, and on the right, here's the lateral view, and here is the codercoin, a figuratively drawn in. Lumbar discs, it'd be central discs in combinations
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with a foraminal
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lateral, as well as far lateral disc herniations, but here is just a listing of other reasons for codercoinis syndromes. First, 65 of the time, it could be discs. 22 of the time, it may be
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stenosis exacerbated by something else going on, and I'll bring up a case in which an acute synovial cyst extrusion was responsible for the patient's deficit.
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hematomas could be, many of them are post-op hematomas, not just spontaneous epidurals. 3 tumors, trauma, and obviously infection is going to be, you know, also on our list.
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Terms of pathology, just just an anatomical reminder, we're supposed to have five lumbar vertebra, remember 5 of the time you may have four lumbar vertebra, versus six lumbarization versus the
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lack thereof You've got the vertebral bodies and the discs themselves. Posteriorly, you have the spanish processes and the supraspinus, as well as the interspinus ligaments. And in the middle,
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you have the spinal canal. The average width is about 20 millimeters. So in patients who are stenotic, you're gonna have more symptomatic patients earlier on. Anatomically cervical and thoracic
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cord gives weight to the quarter of quina. That starts at T1201, goes down to S1, And then below that you have these sacral nerve roots. So when you're talking about deficits associated with
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corticorna syndromes, it can be a femoral nerve deficit to start with before you have a total deficit or sciatic. And we'll go over what some of those deficits happen to be. There are two types of
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corticorna syndromes. I can't tell you how many depositions I've sat through where it could be surgeons, it could be residents, it could be physician assistants, it could be OTs, PTs, physicians
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in other fields. Very few seem to realize that there are things called partial corticorna syndromes, including the spine surgeons themselves, but it makes sense. It's called partial or incomplete
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corticorna syndrome, and it means they may have partial weakness, weakness on one side, not both legs. Partial sensory loss, especially in the saddle region, could be one side, not both.
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Partial loss of bowel bladder function and partial sexual dysfunction, more difficult to prove.
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But incomplete corticoyne syndromes may be mild to moderate compression of the corticoyne seen here on an APVU and to the left, you see the lateral view where you may have compression of the
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corticoyne. Then you have the total corticoyne syndrome. That people recognize that there's a total loss of motor function, the patient's paraplegic, total sensory loss in the lower extremities,
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total groin or saddle or perineal anesthesia, and loss of sphincter function Now, if you look at a Gardner's article on European Spine Journal 2011, he actually quantitated that, well, incomplete
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syndromes, you may see 30 to 50 of the time. Complete syndromes, maybe 50 to 70 of the time. I think based on a lot of the medical legal cases I've looked at, by far and away, the largest number
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happened to be the total correction, the partial corticoyne syndromes. And again, we're going to look at some of the things that we're going to see here. You look at that massive disk filling the
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spinal canal in this figurative diagram. On this actual MR image, you can see the L45 extruded, sequestrated disk with the fragment going and fairly nearly filling the canal. And then on the image
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to the left here, you have a massive disc herniation at 51. Again, complete effacement or compression of the
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court appointment. And it's interesting. You really have to look at the pictures, especially in these medical legal cases. Plus, any of us who are doing any the at look to have you, work
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clinical of kind
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images. Oftentimes, the radiologist, especially in the medical legal cases, they're from the same institution. They don't want to look accusatory. So their statements may say effacement of. And
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when you look at the image and it shows complete obliteration, complete filling the canal. So, sometimes these are underreported in those studies, so be on the lookout for that. As you would
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surmise, patients who have a partial corticorna syndrome, they're going to be the patients who do better because they have less of a deficit going into surgery. Those who have a complete deficit,
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they do worse because they have a more significant deficit to start with and they come out with more severe neurological dysfunction Very important what's emphasized in so many of the papers is to
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intervene as soon as possible, not just waiting why you want to prevent those patients from evolving from the incomplete to the complete corticorna syndromes. So here it may be the partial
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corticorna, the lesion that you're looking at, you want to get it before this becomes a total obliteration of the corticorna and you see an MRI scan that looks like this
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Now, the main treatment. And the treatment for over a decade, I'll show you some articles going back at least in 2014, or talking about the fact that corticorna syndromes should be operated on the
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sooner the better, immediately, without delay, promptly, stat. And this has been one of the things, if you look at so many of these depositions, I can't tell you how many spine surgeons, or at
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the fetus as well as neurosurgeons, you know, they're saying, Oh, well, I have up to 48 hours. I mean, they're relying on, you know, really ancient literature. Others are gonna say, Oh,
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I've got up to 24 to 48 hours. But again, they're pretty much relying on the 48 hours, less than 24, some will admit to. Zero to less than 24, very few are going to acknowledge that. And not
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enough are saying, Hey, it's got to be done stat, or promptly,
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or ASAP. And really, the sooner, the better is when you're going to get the best results. A stat surgery is what you have to do and time is of the essence. You don't have the time to wait for
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these deficits to worsen because once they, it's like going out of staircase. Once you get worse, you may never go back up that staircase and start getting better or retrieve the function that
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you've lost.
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So here is a case when Jen, this is one we were discussing just before. This is a patient, middle-aged, multiple emergency room visits Typically, what happens at these visits? Oh, especially if
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it's a woman, it's oh, sweetheart, you're just being hysterical, you just have some back pain. Oh, let's give you a little muscle relaxant, maybe we'll give you some steroids. And we'll just
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send you on your way. Multiple visits, finally the patient, and in this instance, the patient finally came back with marked weakness in both legs, saddle anesthesia and progressing within hours
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corticointed syndrome with complete loss of bowel and bladder function. The emergency room physicians really did their homework care more or less. They got a stat lumbar MR and they also had all the
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labs. The labs here were showing, you know, white counts in the over 20, 000 range, CBRP, ESR, Procalcitonin, all the lab studies that are consistent with really bad infections, consistent
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with an epidural abscess. The MR scans, by the way, that I'm showing you are sort of de-identified It's not that particular patient, just to protect their privacy. But essentially it showed,
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from L3 down, marked involvement of the quarter-coiner, okay? And here you can see on an axial image, marked involvement of the quarter-coiner, obviously the quarter-coiner is sitting here and
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you've got the epidural flagbone, infection, abscess, etc. that you're seeing Here, the patient I said over just a few hours, completely pliegic, they ended up putting a They called the surgeon
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to see the patient. Surgeon, me entered in several hours later, although at some of the depositions and discussions, they stipulated, oh, I was there immediately and just sort of saying hello to
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everybody and working things over, not true. Surgeon then inexplicably scheduled the surgery for the next morning. And why, when she specifically asked, Oh, there are more complicationsif you
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operate in the middle of the nightI'll show you a paper, two papers actually, coming from Britain, let's say that's not true. It's an emergency, you do it in the middle of the night, the results
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are comparable. So there was no emergency surgery in this case. The patient remained paraplegic and this case settled for big bucks. Actually, it's settled and I don't know if people are aware of
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the fact, but it's settled against the hospital because the surgeon was a full-time employee of the hospital There's a doctrine called respondiat superior. which means that the hospital takes on the
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entire liability of the surgeon, pays whatever the settlement is, whatever the verdict, et cetera, it allows the surgeon not to report this case to their respective state or to the National
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Practitioner Data Bank. I was not aware of this, but this is something that's commonly done. I think it's wrong, but that's what the story is. And here, what's the biggest failure? No emergency
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surgery being done in this patient's case. So she lives now with a complete corticorna syndrome and no bladder function.
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One of the biggest lessons from today's discussion is do an MRI scan in these patients, okay? If you're gonna diagnose a spinal epidural abscess or a corticorna syndrome, please get that MRI scan.
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do not do just a non-contrast CAT scan. You can start with a non-contrast CT if you're going right to MR. But the non-contrast CT, overwhelmingly, is going to miss the diagnosis. MR scans, we
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know, are best at looking at nerve root or quarter-coiner compression. Discs, stenosis, ligaments, tumors, infection, abscesses, and add contrast because that's going to give you more
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information. Only use a myelogram CAT scan If there's absolutely no MR available, there's no way of transferring that patient to get that Sted MR. If you have an adjacent hospital and you can
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transfer, transfer that patient to get the MRI. Or if there's a direct contraindication, patient has a pacemaker or some other implant, maybe a defibrillator, and does not allow you to get the
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myelogram CT. But again, it is wrong, wrong, wrong, wrong, and an error. To just get that non-contrast CT, you're going to miss the diagnosis and you're gonna fail to treat that patient. And
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here are some MR scans of
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sagittal and axial image of disc herniation seen on the T2 MRI studies here. You have a myelocyt here showing you an interlateral disc and notice how it's coming past the center of the spinal canal
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almost all the way to the other side. There may be a limbous fracture here along with that. And here is a myelocyt where you have a complete or near complete block to contrast associated with a
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combination of stenosis and a disc herniation So here's the next case, and I'm going to preface this with, I'm going to tell you that in this case actually the surgeon that this patient ended up
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privately contacting was me. And I'll tell you about this. In a complex that I live in some of the time, the patient acutely that morning developed severe left leg weakness, so much so that she
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went to this medical center.
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They evaluated her, but they did a non-contrast CT scan. And the official reading on that CAT scan was that it was normal, okay? They sent her home. They sent her home in a wheelchair. That's a
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mistake. Patient called a neurosurgeon. That happened actually to be me, because I know this person pretty well. I immediately evaluated her, found that she had severe leg weakness, and she
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hadn't urinated since the morning. Her explanation is so typical of what you get. Well, I didn't drink anything since the morning, so that's why that's the case. A stat MR was done. It showed a
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synovial cyst filling the spinal canal at the L34 level. And actually, in this case before I even looked at the MR, I look back at the non-contrast CT. And interestingly, you could see the
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calcification of the synovial cyst that was actually filling the spinal canal. But again, emphasizing that CT is not the study of choice. You need to do the MR.
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We sent her to a major medical center. When she first got there as so typical in the emergency room, the nurse evaluated her, said, I don't find any weakness. She can dorsey and plant reflects
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the foot. And I said, Well, congratulations, but that's not where the weakness is. The weakness is higher up. Remember, we talked about, you know, involving the lumbar or the femoral nerve.
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So she said, Iliasos and quadriceps weakness. Higher up, she couldn't lift up her leg, but of course she could dorsine plant reflex the foot. So I said, Get the neurosurgeons in here stat. They
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got the nerve, they got the neurosurgery resident, got a call an hour later. Oh, well, I just see the patient's dorsine plant reflection. Strong, normal, motor function, normal. I said, No,
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no, no, no, the deficit's higher up. It's most likely at the L3-4 or even 2-3 level. I said, You need a stat neurosurgeon. Finally, the neurosurgeon saw the patient, looked at the study
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through an thoracic study. I'm just for fun, and emergently operate on that patient, and that patient is absolutely fine. There's no suit. She's got no residual deficit. Her bladder function
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completely returned, as did her motor function. And I must say, I know that I've never met the spine surgeon, but I actually talked to her in a center like three or four other patients, you know,
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to this day. I think that, you know, my discussion with her was very short. I said, I don't want to take your time. I want you to operate on her ASAP. Yes, the decompression sounds right.
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Don't waste your time doing a fusion, and patients should do very well, and she did. So here the real failure was CAT scan is the wrong study, and they miss the diagnosis, and don't discharge
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patients in a wheelchair. So much of the time these days, any of us going to ERs or number, knowing patients going to ERs or relative going to the emergency room, their aim is to get that patient
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out of there The first person who evaluates the patient, they do their exam. They put it into the electronic medical record. Nobody else bothers doing their own exam, and God help you if they do
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one exam and time passes, they don't repeat the exam, they just hit Ditto, and they don't bother repeating the exam to determine or find out that these patients are getting worse right under their
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nose. But in this case, in any case, that's the synovial cyst that you're seeing on both of these studies, and this is the non-contrast, and that's the contrast study Again, de-identified is not
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the patient's pictures.
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There's a literature out there, especially in Britain where they got together and they said, you know, hey, we're missing a lot of these patients. They're getting operated on in a really delayed
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fashion. What's the problem here? Well, they found the biggest problem was they were not getting MRI scans of the lumbar spine and coda-acornis suspects in a timely fashion, 87 of the delays they
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found failure to get essentially the outpatient MRIs or the inpatient MRIs done. So that's classical, massive disc herniation. Patients needed stat surgery. So these are the two studies from
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England, British Medical Journal, British Journal of Neurosurgery. 87 of the MRIs were delayed in terms of diagnosing quadacorna syndromes. Why? The emergency room physicians were not allowed to
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order these studies on their own behest They had to wait for the spine consultants. So they finally reversed that, that the ER guys can order these. And certainly in the states, the ER guys may be
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your emergency room physician. They could be internists. They could be family medicine physicians. Sometimes their emergency room trained physicians with their boards and emergency room medicine.
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Either way, they need to get those MRI scans Don't wait for the spine consultants to order that, and then get the statimores, then get
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consults and go to staff surgery. By the way, the case for the spinal epidural abscess that I showed you earlier, really the emergency room physicians, PTs, OTs, nurses, everybody should have
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been going up the chain of command in that case looking for a second opinion from a spine surgeon asking why that surgeon was not operating on that patient emergently. That might have saved her from
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having a lifelong corticorna syndrome, but it wasn't done in that case. The present standard of care is to operate on these patients immediately if they have a corticorna syndrome.
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You can read about this is an article that actually that I just wrote for SNI, download for free, obviously in our journal, updated perspectives, that surgery for corticorna syndrome is what you
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really need to be doing, surgery for corticorna syndrome, You've got to do these emergently. Time's going to run out fast and it can make the difference between a partial versus a total lifelong
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deficit. The old timing for these upper procedures and in a review article, guess what? You quote the older studies. I can't tell you how many times in depositions, they say, well, doctor,
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you're writing about the fact that when you're including the article about 48 hours and I said, yes, but that's what a review article does. It tells you what the errors were in the past, what the
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data were in the past, 48 hours, 24 to 48 hours, less than 24, waiting anytime between zero to 24. That's not the way to go. Now, stat surgery is what should be done and there should be no
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delays in obtaining this stat surgery. And that was written all the way going back to 2011,
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avoid the partial becoming the total quadrant syndrome
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Here is an instance where a patient. developed low back pain the next morning, went to the emergency room with severe lower extremity, bilateral weakness. And over the course of just a few hours
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in the emergency room, the weakness and the numbness became really severe. In the emergency room, there was just that initial examination, no further neurological examinations, just somebody
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coming in and say, hey, how you doing? No hands on nothing. They discharged the patient on medications, including steroids. It discharged the patient in a wheelchair. Why? Because the patient
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could not walk by then. Okay. Next am. the patient woke up at home, severe pain, bladder out to here to there, urinary retention, completely paralyzed. A friend had to get him into a truck to
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get him to the emergency room. This time a stat MR was done. The lumbar disc filled this spinal canal
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They operated on that patient in a timely fashion, but this patient now lives with the permanent corticorna syndrome and loss of bladder and bowel function, making it very difficult to go out and do
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things and enjoy life. This was a huge settlement. You can't always rely on that happening, obviously. But the big failure here was the emergency room, what? They did an initial exam. They
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didn't do any subsequent exams. They just hit the MR, ditto, ditto, ditto, fill in, replete, you're designing a beautiful electronic medical record that bears no resemblance to the truth. And
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you're failing also to get the proper study. No MR, no x-rays, nothing.
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Just discharge the patient, getting them out. And obviously, this was not the patient's images, but the patient had a huge disc herniation similar to this, literally filling the spinal canal. So
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had they done that MR immediately upon that patient coming to the emergency room the day before. this patient should have ended up completely neurologically intact and life not ruined. So I'm
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telling you that, you know, this has been the standard of care is to operate on the corticorna syndrome stat, and it's been the standard of care for well over a decade. And this is a study going
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back to 2014, chow at all in world neurosurgery. And he said, this is a quote, debunk notion that corticorna surgeryshould be laid up to 48 hours Well, unfortunately, two to three doctors agreed.
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The ones that I'm encountering in multiple depositions all across the country, Oh, well, I thought I had up to 48 hours. You know, that's what the literature showed. Well, that's what I thought
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the literature showed because they're reading older literature and not the better literature. The conclusion was from chow, best outcomes are with that earliest surgery and that, quote, There is
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no strong basis to support 48 hours as a blanket safe time point to delay surgery. So I'm gonna show you how further it's going to get to operate immediately without delay. In this next study from
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spine 2015, early surgery, less than 24 hours, gave you not only the best results regarding the quarter-quiner deficits, but also an 88 incidence of recovery of bladder function. And that's been
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the biggest problem so far. Quarter-quiner patients, incomplete deficits, 139, total deficit 61 Decompressions were done within less than 24 hours in one group, less than 48 hours in the other
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group in less than 72 hours. So again, if done emergently, you have a good chance of recovering bladder function, which is one of the most difficult problems to resolve in these patients. So ASAP,
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immediate, stat, that's how you do it. This in Thakur study in 2017, this was over 4, 000 patients, again, advocating early surgery, within less than 24 hours. Patients were divided in three
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groups in this study, less than 24, less than 48, and greater than 48 hours. Early surgery, less than 24, the best outcomes. And that was the better outcomes for not only those with an
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incomplete deficit, but those with a total cordicoidness syndrome. So you have the opportunity in both of these groups. You still have the pressure. The pressure is on, operate on them as soon as
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possible. You're gonna get the best results Hogan in 2019, over 21, 000, or nearly 21, 000 patients. And he was saying, oh, you know, the sooner the better, basically, is zero to less than
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24 hours. There's no reason to wait. There are fewer complications and less mortality if you do these patients the sooner the better. And he said, quote, It's amazing. Surgical management for
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cordicoidnesshas not changed appreciablybetween the years of 2000 to 2014,
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despite mounting evidence for early decompression. In short, too many, we're still focused. focusing on and dealing with the Stone Age, not the way to do it. In 2022, I summarized the best
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results of surgery for over 25, 000 quarter-quarter patients from those two studies that I just mentioned to you, where basically the sooner the better is basically the message and that you're gonna
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get the better and the best results if they're done as soon as possible in both those presenting with incomplete or complete deficits Many medical legal suits are due to the failure to diagnose
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quarter coin of syndromes. I would say of any of these suits that I reviewed, and I think that's true for many of my compatriots, huge number of these suits are quarter coin syndromes. Failure to
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diagnose and treat. It's like the blind leading the blind. The first person in that emergency room sets the stage. If they set the wrong stage and they do an incomplete evaluation and they don't
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start doing the correct studies and you end up with that CAT scan that's normal, That's just going down the Roan Garden path. They typically have histories of repeated emergency room visits.
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Patients are discharged as soon as possible without a diagnosis. Just get them in, get them out. It's a failure to obtain not only labs in these patients, but the right studies, the MRI scans.
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Catscans are going to miss the diagnosis. They say, well, the CAT scan's cheaper, and some of these are full-time employees. Well, the CAT scan's faster. Patients are going to tolerate the CAT
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scan faster Oh, we have to call in technicians to get an MRI scan done. Oh, well, if they need an MRI scan, then we have to transfer the patient. We'd rather keep the patient because the
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hospital needs the money, something to that effect. Finally, then, those patients show up in the emergency room and they're paralyzed. They've lost bladder function. You get the statomari, you
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get the stat surgery, but they have permanent irreversible deficits by then, all of which could be remediated by starting out in the very beginning. You've got maybe the medical student or the
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resident seeing this patient. You've got the nurse seeing the patient. You may have an NPC in the patient. You may have even physical therapy, might show up and start seeing these patients.
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You've got many opportunities. Your spine surgeons, your orthopedic surgeons, your neurosurgeons, everybody seems to be missing the boat in these cases.
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Any spine surgeon, much less really, any surgeon, talking about the fact that, oh no, no, no, you really don't want to operate on these patients in the middle of the night, because the
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morbidity, the complication rate, the adverse event rate is much too high. Well, here is a study, here are two studies actually from Britain saying that that's just not the case, and this dealt
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with spine cases, and basically said, your surgeon does not need their beauty sleep, and that's an image of the beauty sleep, but here are the two studies, British journal neurosurgery, and
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Kumara's British Journal Nurse Surgery 2024. You know, two years ago, these are emergencies, corticointed syndromes, do the operation any time of day or night, and the results are gonna be
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comparable. It's gonna help you prevent that incomplete becoming the complete deficit. There, they found in these studies, no increase morbidity by operating on these patients in the middle of the
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night after hours. And they focused in this study on
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microscopic, endoscopic, discectomies. So no excuse to wait saying, oh, well, the patients are going to do better if I wait 9 am. to whatever. And again, the patient with these final epidural
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abscess that I presented where that surgeon said, oh, no, I'm just going to wait until tomorrow morning. And because that's when I have my better crew, et cetera, she sort of operated on the
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middle of the night. There's no excuse there. Even the American Association of Neurological Surgeons,
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This was written in April of 2024, or the statement, prompt surgery is the best treatment for patients with quadricorna syndromes. And the last I checked, and I checked with the Merriam-Webster
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definition of prompt, it meant immediate or without delay. So there you go, the diagnosis for quadricorna syndromes has to be that STAT MRI. If you can't get that MRI transfer them to an
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institution that has an MRI scanner, that's better than doing a myelogram CAT scan. If you're in a situation where you don't have the option to transfer, do a myelogram CAT scan, but make sure you
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just don't do a non-contrast CT alone. It's gonna miss the diagnosis. And do STAT surgery where it's indicated. You don't wanna be in the instance here where you have clearly that malpractice makes
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imperfect So you don't want to - create a situation where you've missed the diagnosis for too long, you've missed doing an operation in that timely window, you know, just like time is brain,
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that's what they say for stroke, time is spine also. You need that stammer and stat surgery for corticuanas syndrome in order to get the best results because time is not on your side. In fact, you
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know, tic-tac, that time is ticking away and your job is to work as quickly as possible to get the best treatment for your patient. Stat surgery is the standard of care for treating acute
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co-ordicuina syndromes. Read the article, that's
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a free download as are all of our articles on SI. And please, you know, think about the patient and the outcomes. Think about how you would wanna be treated. And now practice specialist, great
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rates, free quotes. You're just, you know, looking to be sued, but more importantly, you're looking to treat that patient right and do the right operation in a timely fashion. Thank you.
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That's really good. I think I have some thoughts and questions as you go here. First, as we look at it from your perspective,
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you're getting, you're seeing a selected view of cases that have been, there's a question about whether they've been properly treated or not. So your sample of the world is a subset, a sample of
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people, where there's questions about how they've been treated because they had a bad result, right? Right, right, yes. And if you look at that and that's not a criticism, it's obvious, okay,
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if you look at what it says is of all the cases that you see, And we've talked about this before. This has become an extremely prominent cause of malpractice suits that don't succeed. And is,
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would you say it represents 50 of what you see or the most common mistake that you see? I'd say it's most common, I would say at least 30, 30 of what you see. It's 30. So this is not, even
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though you have a selected sample, this is not inconsequential, it's not like one of a million. No, no, no, not at all. This is a common problem. So now the question is,
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why is
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this? Is there, as you, in your experience, I doubt that there's any papers written about this, I don't know, you know, are these malpractice cases, are the cases that reach this level,
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basically from orthopedists, which people soon may not be well-trained, or from DO. 's who may not be well-trained. Is it equally distributed across that? Or are these people that come from poor
34:19
quality training programs? Is there any trend that you can see? Or everybody? I think it's pretty much everybody. I think on the one hand you have emergency rooms that are responsible for the
34:34
delays. And the emergency room physicians could be trained in emergency medicine, internal medicine, family medicine, family practice. So that's, I would say, about half of the court-acquainted
34:49
delays are because the diagnosis have been missed by that group And then on the other side, you have equally orthopedists, neurosurgeons, DOs, non-DOs,
35:02
doesn't seem to matter. I would say it's equally distributed. But the most common mistake then amongst the orthopedic or the spine surgeons is that they are saying, almost to a person, oh, well,
35:15
you know, it's a quadratic point of syndrome. I have up to 48 hours. They're not even thinking the 24-hour thing. They're just thinking, well, I could fit it in conveniently at this time. And
35:27
if they say, well, I'll do it tomorrow. They're not necessarily even putting them on as the first case in the morning I mean, much less doing it as the case in the middle of the night. They're
35:35
using the middle of the night argument, or I say, you know, incomplete argument, incorrect argument to that, oh, well, I've got a better team starting in the morning. But that's not right,
35:47
not for these cases. These are pretty straightforward surgically. They're typically decompressions. They're not cases where you need to necessarily do a fusion at the same time. But these
35:57
decompressions can be done readily
36:01
with whatever crew you have. Or if you don't wanna do it, send it to an institution that does. Well, that comes into the second point. And that is if you're working in a system that has its own
36:17
care patients, and our Ramses Cali has talked about this, and there's a disincentive for you to send them out. Yes, yes. And therefore an incentive to keep them there because the hospital doesn't
36:31
want to lose revenue. So that's one. Second thing is I could see where neurosurgeons might be covering a number of hospitals, and
36:43
they're depending upon personnel to pick up signs that would help them. That would be another. Another would be lack, obviously. I can do it another day. That's an education. So the question is,
36:57
well, how do you fix this? The first thing would seem to me. you gotta train the ear physicians, 'cause that's where they wind up. And so there needs to be education for them. The way you get to
37:08
them is to get to the CEOs of the hospitals and have them educated about, this is why you're gonna have a malpractice suit of multi-million dollars. Is that right? Oh, I think so, yeah, yeah.
37:21
So the suggestions are this needs to go to the CEO of the hospital and he needs then to notify the appropriate people and the first people in line of the ER physicians to be trained. Now we know in
37:35
medical school what happens now is people may not be well trained in neurology or surgery, they may have very little contact with neurosurgery and they go through training as particularly general
37:47
medical training. This is an emergency, it may have been one sentence somewhere if at all and so they don't know about it And so, it should be. should the other personnel in the nurse and the
38:02
emergency room be trained? The answer is yes. So you need to be trained. But you know, the other thing they need to be trained to do is call consults.
38:12
If you're not specialized in that area, why are you not calling a consult? It's almost like they see that as a black mark against them. Well, it's true it could be held against them or they feel
38:26
that they're in a way that they're being silently intimidated, not to call them.
38:32
Well, they don't even have those consults in the hospital. Oh, it's still lines up when they see you or the hospital's lap to do something about because the end result's going to be a huge
38:43
malpractice payment. So, I'm trying to think of what's the cause? You said it's not related to the training because you've seen in all different kinds of of people who are doing this surgery.
38:58
what about the personnel in the hospital? We just figured out how to do that.
39:04
So what else can be done? They
39:08
could do the spine industry, could put ads in the doctor's lounges or
39:17
dressing rooms
39:21
about just a poster about this kind. I'm just trying to think, what do we do to fix this? That would be one way to do it.
39:29
At least, you know, in the hospitals, they're supposed to have in services and all these different disciplines. And it could be part of an educational in service that's required for anybody in the
39:42
emergency room or any of the PTs and the get OTs. I mean, they require that we take all of these infection courses and the sexual harassment courses. Why
39:54
could they have some content that would add, you know, education for a quarter coin syndrome, you have to be on the look out if you're in emergency room, you know, something like that. Now, if
40:04
you come in and they, you tell the, uh, the ER, uh, that I've got chest pain. Yes. Ah, you go, you're, you are in a pathway. That is, they goes for certain things that they have to do to
40:20
check off to do it. You have to have that EKG within 10 minutes. Yeah. You have to have that TPA and the revitalization within the hour. That's right. Right. Uh, or if you come in and you say,
40:33
I have a stroke,
40:36
uh, I lost control of my arm and leg or something like that. And they try to narrow it down to that you had a stroke or my doctor sent me here because I have a stroke. Boom. There's a certain set
40:46
of steps that they go through to do this and people see you and know. And if they don't meet those time requirements, they can lose their stroke certifications. if you come in with a fractured neck,
40:59
and the only way a fractured is to do an x-ray, or you have a sudden neurologic deficit after an accident, yes, they would treat you. This is, this then falls in a category of an emergency that's
41:15
treated as not as an emergency. Yes, yes, not in the same way at all, that's right. Yeah, so what does that mean? That means it's an education program Falls in the CEO's point of view,
41:28
obviously falls in the neurosurgeons, the orthopedic surgeons point of view to make sure everybody knows about it. But you've already shown in previous cases that there are experienced neurosurgeons
41:42
who still believe that delayed surgery is acceptable. Definitely, again and again and again. Staggering is that is - So this means it needs to be presented at national meetings.
41:55
as emergencies and that need to be taken care of. That's not done. So we're doing it. No, and in fact, in fact, you know, I mentioned the ANS statement about STAT, et cetera. The next
42:10
sentence in their paper is
42:14
one that neurosurgeons could misinterpreted as allowing them to delay or to operate on a patient a little later, which obviously is incorrect. Right, but if it's told to them that this is, and
42:28
this is the standard of care, those words become almost open the door that I gotta pay attention. It just means immediate treatment, immediate diagnosis and treatment. A media, that's what you're
42:43
saying. So I'm trying to figure out, you see 30 of what you see is the same mistake being made over and over. We talked about this for years and it's still being done. And so, what are the ways
42:57
to solve that in today's healthcare system, which is probably a heck of a lot worse than you and I grew up with? It's multiple people involved, multiple heads. It's very busy. Everybody's going
43:11
to the emergency room and it's overflowing with
43:17
people, and unless these people understand how to put this together, it's going to be missed
43:24
And the neurosurgeon is not even consulted. The guy sends you to the emergency room and let them take care of it. So I think that the message here, this is a message to the CEOs of the hospital and
43:41
the emergency room personnel, this is something you've got to know about.
43:47
That's what I mean. That's what I would take away from this results are devastating.
43:53
So the question is How do we tell the CEOs of the hospitals that they have this problem if they don't recognize that they have the problem so that they then seek to educate themselves that there is a
44:07
problem? I mean, that's, right? Well, first of all, the national organizations, neurosurgical organizations and spine organizations should be presenting them at their meetings. Number two,
44:20
they should be presenting at the hospital meetings, or the hospital CEOs are. And thirdly, the instrument companies need to be presenting, need to be presenting this material in poster form so
44:36
that people understand what these warning signs are. Their warning signs up for heart disease and stroke. This is time is spine, time is in a time is spinal cord. So I'm trying to think of what
44:49
can you - Actually then, you know, that comes under the purview of like the ACLS protocols. because the ACLS protocol is the one that has developed, you know, the protocol for, you treat that
45:04
patient with the MR, with the MI immediately, right? Same thing for stroke. Everything is within that hour and they outline, you have to do A, B, C, D, and E. So maybe the ACLS folks really
45:18
should know about this. That should be part of it. I think that's true too. I think you could write a short article Well, I mean, short, one page, which is just a summary of this is a very
45:29
common mistake. It's cost millions of dollars in malpractice suits and deficits and misery among patients. You need to bring this attention to your personnel in the room you could call a
45:48
the Hospital Association of America and bring it to their attention. The reason I see that is somebody can say, Well, what have you done, Nancy? You say, I've done all these things. And they
46:01
didn't do anything. Well, so what are you gonna do? And so I think it might be something to think of it as certainly as editor of a journal who has strong evidence about this. I think you
46:17
could do that. You could get some representatives who see you guys in practice and say, Look, you're gonna bring this to the attention of X, Y, and Z, or go down to the hospital where you see a
46:28
CEO. You say, I'm just telling you my experience, and this is not good, and you're gonna be into a lot of trouble unless you pay attention to this.
46:39
I mean, if you don't do anything about it, it's not gonna change. Yeah, interesting. So, some of those things you can do,
46:49
you can't advertise around the country, but you can bring into the attention of some and say, This is what I'm saying. I suggest you talk to your hospital association or your emergency room
47:03
physician association. I think you should do something about this. And at least somebody's gonna ask you, Well, what have you done? This is what I did. And unfortunately, this is a result.
47:16
Yeah, yeah, no, good suggestions, okay. Yeah, that's what I would do. Okay Okay, I think that's excellent, all right?
47:26
Sounds good. All right, so thanks a lot. I think we got some other things in the queue to do. In the coming weeks, I wanna get Carol and Cynthia. Next weekend, next weekend is the 11 am. And
47:41
that's for South America. Yeah, he said I'll notice his late, but I think we should do it. It's gonna be Palm Sunday, I think.
47:51
But we'll see what happens, okay? The talk that I have is on thoracic discs. My main point there is to debunk using a laminectomy, and the others are just some interesting pictures and reminders
48:05
for whatever discussion they want to have. You can have
48:14
this as a backup talk. If nobody brings cases, there's a backup. Do this as a backup, okay? Okay, okay. Okay, thank you very much. Perfect. Terrific, appreciate it Okay, thanks a lot, Jim,
48:21
okay. All right, bye bye. How's Carolyn? Are you okay? Any better? I think she's stable, which is good 'cause her blood pressure was fluctuating. It's hard to get dinner to drink water and do
48:32
all that stuff, but I think we're getting there. Okay, thanks a lot. Okay, thanks a lot. Okay, thank you, bye bye. We hope you enjoyed this presentation. The views and opinions expressed in
48:46
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