Hello, everyone. So, we're back with case studies and Q&As. We have quite a few questions from the last presentation. Unfortunately, Dr. Prasad, as usual with the neurosurgeon, has to run back to the OR, but Michael's going to take some of those questions for us, the ones he can answer, and Dr. LaRue's back with us as well. There's a few housekeeping issues to address. Yes, Saturday is on demand, and look at your resources tab, and you can find additional information. We've added some information about the frequently asked questions. So, please go there first for all your questions, and hopefully, we've been able to answer them. So, now, throw in any Q&As that you have for both Michael and Dr. LaRue, and we'll get started. Please put them in the Q&A and not the chat. It's kind of hard to go through your chat responses sometimes. Okay. So, Michael, first question. How do you respond for a consult for a transverse cross fracture? Transverse process fracture is the tongue twister. Certainly. So, our hospital has some protocols on whether or not a consult is required for a transverse process fracture. So, definitely look into what your hospital's protocols are. Less than three non-consecutive lumbar don't necessarily require a consult. Cervicals certainly do, and they need to be kind of managed appropriately, but I certainly think a cervical or thoracic transverse cross fracture or transverse process certainly needs to be evaluated a little more, depending on the presentation and the mechanism will guide further imaging, but understanding what your hospital protocols are as far as expectations are is important. As always, expectations make the outcome, right? Indeed. For everything. Okay. How long are you bracing fractures for and at what interval are you getting x-rays? That's a real general question, and there's a lot of nuance to that. It depends if we treat the fracture or not treat the fracture. I think a general way to say this is we're following these people very closely, and we're looking at probably seeing them in clinic with x-rays in six weeks is kind of it, and it depends. There's no way to say this in a blanket way, but I think six weeks is a pretty safe way to say whether you're sending home someone in a collar or you're sending home someone after a fusion or in a TLSO or something like that. Six weeks, to my understanding, and this is just kind of the way we do it. I don't have the evidence in front of me to say what's correct, and then I don't know if there is any, at least not good evidence to show, but I'm generally following my fractures closely for six weeks, and then we're doing x-rays in six weeks. Dr. LaRue, you're up. We have your rationale for shunting before cranioplasty. Our surgeons in practice, cranioplasty first. Well, I think the answer is really staged versus one or the other. I just find it easy to do the shunt first so you don't have to deal with a lot of swelling at the time you do a cranioplasty because why do the hydrocephalus develop? I think the important thing is don't do both at the same time. Some surgeons think, well, if I put the bone back, the hydrocephalus will resolve. We don't have good evidence one way or the other. The only evidence is don't do both together. But just going back to the last question about bracing, there's a lot of ways to skin the cat. I don't brace anybody that I instrument, period. So if I've got a cervical fracture, a lumbar fracture, a thoracic fracture, and the post-op CT looks good, I don't put them in a brace. That's internal fixation. It's better than external fixation. We have another question about fixation. Is your surgical approach anterior-posterior different for unilateral facet dislocation versus bilateral facet dislocation? Usually with bilateral, I'll go posterior. In some circumstances, you might go anterior and posterior in that circumstance. With the unilateral, I'm assuming they're talking about on the cervical spine, either is okay. Then there's a question about strict spinal precautions. Are there general guidelines for patients? That's an entire session, a whole day-long session. The AAS guidelines, again, we can talk about the cervical spine first. The AAS guidelines in 2013 said immobilize the spine. This is based on mechanics but not on evidence. It was actually what they said. There is no evidence that blanket immobilization works. There are some studies that actually say it makes it worse. There's a randomized trial going on in Canada right now where the EMS service decided about immobilization in the field. Selected immobilization is what some places recommend. The important thing to recognize is that a cervical collar does not sufficiently immobilize the cervical spine. If you want to practice immobilization, it's a collar plus, not just a collar alone. The evidence is not very good. It's all based on anecdotal data from the 60s and 70s where there were a handful of cases described where people got worse. You really look into it in detail. Secondary deterioration of the cervical spine injury is about 10% of patients. Very few of those are related to mechanical issues, i.e., lack of immobilization. Spinal precautions are important but like anything else, they cannot be a one-size-fits-all. If somebody has, for example, a spinous process fracture or a transverse process fracture in isolation with no neurologic deficit, you don't necessarily have to immobilize them provided you've got good imaging. A high-quality CT is good imaging and they've got no neurologic deficit. In somebody who's got, say, midline cervical tendons and a neurological deficit and you haven't done any imaging, I would immobilize that patient because their risk is higher. Then if you get imaging and it does show a fracture, keep them in immobilization, which at that point in time is a collar. This thing goes into this whole question of cervical spine clearance. Obviously, we're not discussing thoracic and lumbar spine right now, but cervical spine clearance, the Canadian CT rule nexus criteria are very well validated in prospective studies as to who needs imaging in the first place. It's also very well validated and EAST guidelines, for example, say that if you've got an individual with a high-quality CT and you do not see a fracture on the CT, you don't need to do anything at all. It's sufficient at that point in time to take the collar off. You don't need an MRI just because the CT doesn't show anything. It's sort of a 99.9% specificity and sensitivity. You obviously want to err on the side of caution. The interesting thing is now the process is more selective. As I said, there's a randomized trial in Canada. They might have actually accumulated all the data but not published it yet. EMS can decide based on nexus criteria in the field, do you put a collar on a lot? If you put a collar on, you've got a high-quality CT that shows no fracture, you can take the collar off. Again, that's following nexus criteria, which means they don't have a neurologic deficit. If you've got a neurologic deficit and your CT demonstrates a fracture, you don't necessarily have to do any more imaging, right, to then clear the spine. You know they've got a fracture. I use the MRI than if I'm going to do surgery, so for surgical planning. So there's a lot of debate that goes, but it comes down to one size does not fit all. Common sense prevails. There's a reasonable amount of evidence as to how to do it and one applies it. You know, err on the side of caution probably is a good piece of advice. For spinal cord injury, are there benefits of using Realizol to improve cord perfusion? A good question. Not a lot of data. You know, people have tried a lot of things. You know, the sort of theory with spinal cord injury as aggravation is hypotension. So just as there are secondary cerebral insults for brain injury, there's secondary spinal cord insults, which really sort of follow the same rationale as brain injury. Hypoxia, hypotension, fever, hyperglycemia, they give you the same negative effect. I don't think there's good evidence that Realizol makes a difference. It's used and I think in some patients it may help. So, you know, those are often what people use locally and, you know, they may have good evidence for it and so long as you've got reasonable evidence and a reasonable protocol, it's okay to follow that. Personally, I don't use it. The institution where I work, we don't use that. You know, and if you go back in history, early 90s when NASCS came up, everybody swore by high-dose steroids and now that's almost a no-no. But if you really sort of tease through the data, the high-dose steroids may work in a small group of patients, but in others it absolutely doesn't. So again, it's all about patient selection. So as you said earlier on, you know, expectations beget outcome, patient selection begets outcome. Thank you. How long do you brace type 2 odontoid fractures in the elderly? Do you do cervical flexion extension x-rays at the end of the brace period? Again, you know, when I was a resident, at the end of the year we used to have our award ceremonies and every resident got, you know, the good and the bad. And I remember getting the fictitious award for the bad doing flexion extension x-rays. One of our orthopedic spine surgeons said you never, ever, ever need to do flexion extension x-rays. You can tell from x-rays and CT. This is in the 80s and 90s where we didn't really use MRIs. You don't need flexion extension x-rays. And if you look at the x-rays carefully, in retrospect, the patient I did the flexion extension x-ray on, if I'd looked at the x-rays carefully, I would have recognized the problem. So with the odontoid fractures, they are frequent, probably the commonest fracture, and certainly in the elderly. The number of patients that I do surgery on is not that very frequent. I brace, and one has to recognize that the really elderly, the 90 plus or demented, they don't really tolerate bracing very well. I usually will keep them in a collar that's comfortable if they can tolerate it up to about three months with sequential x-rays along the lines. If the pain's less and they've maintained alignment, I'm okay with that. At the end of that point in time, if they've maintained alignment and they don't have any pain, I just get rid of the collar and I do a follow-up x-ray. I don't do flexion extension x-rays. And I go by the premise that there's reasonable fibrous union, which is good enough, right? So in the patient who has increasing pain or neurologic symptoms or your follow-up x-rays show a shift in alignment, they may become an operative candidate. One has to recognize in the very elderly, so those 80, 90-year-olds, your morbidity and mortality with a C1-2 fusion is actually pretty high. It's in the 10-15% range. So it's a fairly morbid surgery in that group of patients. Younger patients, a different matter, also have to take into account what their lifestyle is. I had a patient once, it was a young woman who was a professional dirt bike rider with an odontic fracture. I operate on that because of lifestyle, right? I'm not going to tolerate a fibrous union in somebody who rides a dirt bike as their profession. So again, it's patient selection, but as a general rule, take the elderly and you can define that however you want. If I'm bracing them, I'm going to go for a minimum of three months, provided they've got no pain and they've maintained alignment. I don't necessarily do deflection extension x-rays at the end. You recommend or refer a good concussion treatment protocol taking into account when to return and increase activity. It's ever-shifting. You know, everybody was about rest. Now there are trials that are looking at very early return to activity, saying that if you're going to... And again, let me just digress slightly. One has to separate sports concussion from concussion in a non-athlete, right? Because we have different views on how that works. So some folks are suggesting return to work. If you return to work within two days, you actually do better than if you delay your return, right? Secondly, rest is important, but it's not just rest to nothing. There is some data accumulating. And again, there are trials that are ongoing now that look at sub-threshold aerobic conditioning as enhancing your recovery versus absolute rest. So if they've got a lot of symptoms, you sort of back off on your activities with a gradual return to activity. There is no single protocol that exists that is perfect. So you sort of have to listen to the patient. You can do a symptom inventory, and there are a large variety of symptom inventories that are necessary. One has to recognize now that the term post-concussive syndrome is no longer used. We use the term persistent post-concussive symptoms. And the reason for that, if you analyze people with an injury, 30% of people fulfill the definition of a post-concussive syndrome or persistent post-concussive symptoms in the absence of any head injury, right? And that incidence is actually up to 90% in injury people who are involved in litigation. So you have to be very careful about how these patients are labeled, because how we label concussion is very subjective. You've got headache, you've got dizziness, you've got photophobia, you've got sleep disturbance, you feel tired. Well, if I worked all last night and didn't sleep, today I'd have a headache, I'd feel a little slow, I'd feel fatigued, I'd have photophobia, all of those symptoms, but I never had a head injury. So there is a subjective nature to it, and it is a fair amount of judgments that are involved, but the shift has occurred from absolute rest to sub-threshold aerobic conditioning at an earlier stage. And there is some data that actually enhances recovery. You know, if you look at animal models of recovery from concussion or enhancing cognitive function and dementia, enriched environments actually work, which is a paradox. It's not rest. What works best in the enriched environment for a rat, for example, is running on a wheel. So it's not to say you tell everybody to go running, but that's where the concept of sub-threshold aerobic conditioning comes from. And they are very strong correlates with, say, BDNF upregulation, which is very involved with dendrite plasticity, and then some folks regard that as the morphologic correlate of cognition. So I think how we manage concussion today is different from, say, 10 years ago, where that absolute rest until you're absolutely asymptomatic was sort of the gospel. And now it's the symptoms are improving. You can start sub-threshold aerobic conditioning that may enhance recovery. There's some other studies that also demonstrate the value of nutrition. Again, better defined in animal models with very high bronze chain amino acid intake being valuable. So that's whey protein at the GNC store, but that's 60, 70 grams of that a day. Pretty tough to absorb that, but some people are starting to use that, you know, high protein intake. So it's a complex problem. I don't think there's one size fits all. There's data with persistent symptoms, whether it be concussive symptoms or neck pain after a neck strain that actually overindulgent medical attention actually aggravates outcome. So too many visits to the doctor makes them worse because they've seen the doctor too many times and they think we can do things. And sometimes we just leave them alone. They get better and advise them. So it's a complex problem. Fortunately, as a surgeon, we don't see that many patients. It's more in our neurology and physiatry colleagues. And it is a difficult problem, particularly if it gets to a year later and somebody's got symptoms. Sometimes they just have to be reassured. You know, there's data that comes out of TrackTBI that perhaps more patients have persistent symptoms than we necessarily thought. A lot of those are often related to pre-morbid issues. So did they have ADHD before? Did they have depression before? Did they have behavioral issues? Do they have social support? So our therapy needs to start getting very holistic as well, looking at the whole patient, including what their social environment is to really sort of counsel them and help them. Thank you, Dr. LaRue. There is a question regarding shunt and cranioplasty at the same time that you'd mentioned before. Is there evidence to be referenced regarding that? There are a handful of papers that are more clinical studies and observational studies. There are a few meta-analysis of those observational studies, which, you know, sort of garbage in, garbage out kind of thing when you do that form of study. But in essence, when they looked at outcomes, most of these clinical observation studies say the simultaneous performance is the least likely to have a favorable outcome. You do better with staging. Now, again, can you apply that as a blanket statement to every patient? Probably not. But I just find it difficult to do a shunt and a cranioplasty at the same time. And I do think it aggravates the outcome. I want to solve one problem at a time. And then sort of, again, it's a simple philosophy that I use in surgical approaches is trying to deal with one problem at a time and not sort of kill multiple birds with one stone. It's just philosophically, I think it makes a difference. And it seems physiologically to be sensible, and the clinical data, albeit not strong, suggests the same. Thank you. And along the protocol route, Michael, it's been asked that you share your hospital protocols regarding transverse process fractures, if possible. I think I, you know, as far as whether or not it needs to be generated consult, so whether or not it's a consult is our protocol, but each one needs to be managed independently. So if you don't have more than three non-continuous lumbar spine, then that doesn't necessarily require a consult in our trauma department's eyes, but anything else does require a consult and should be managed individually. There's no blanket way to manage them per se. Thank you. Dr. LaRue, can you briefly outline the data or usefulness for steroids and chronic subdurals? I think we kind of touched on this earlier, if I recall correctly. If used, what course is generally recommended? I do not think there's a specific course. It's, you know, again, clinical series and it's anecdotal. I think if you've got a patient with a chronic subdural and all they've got is a headache, and they've got many medical comorbidities that might increase their surgical risk, some of them get better with steroids. What I usually do, if that's the case, and it's not frequent that I do it, most people I do a Bohol and a local anesthetic, and a Bohol takes me 10, 15 minutes and they add a surgery quickly. I don't like many craniotomies, which some people do, and that just increases operative time. But if you're going to use steroids, I would give them 10 milligrams of decadron as a one-time dose and then maybe 4q6 for 48 hours and then go cold turkey. So they're just trying to reduce the inflammation and that makes the headache better. I do not have a great sense of rigorous science that supports any one protocol. So it's a little anecdotal to each individual surgeon. On patients that are intubated and unable to give an exam, if CT is negative, do you clear the collar or get an MRI? Again, if you've got a high-quality CT, that's all you need. You have to have a high-quality CT, and if that CT is negative and you don't have a neurologic deficit, obviously sedation does cloud that exam, but a high-quality CT is adequate. A patient has anterior lascesis on uprights for compression fracture. How do you decide if this apart from their baseline versus caused by the fracture? If you choose to manage conservatively, what role does flexion-extension play in this decision? When you're looking at your films, whether it be a lateral x-ray or a sagittal CT, I'm getting a sense that you're saying that there's a little bit of anthralothesis and you're trying to decide, is that traumatic or just degenerative? Yes, anthralothesis on the upright for compression fracture. Is it baseline versus caused by a fracture? Do you choose to manage conservatively, and would you get a flexion-extension, or would the results of that play into your decision? So I'm assuming the patient is awake and conversant, right? Let's say they have some neck pain, there's a little compression fracture, and there's a touch of anthralothesis. If there's really no soft tissue swelling, which you can see on a sagittal view, I might just put them in a collar and see how they do, and if their pain goes away, I might conservatively leave them in the collar and just do a plain follow-up x-ray. If there's no shift in alignment, I'm happy with that. You know, people will do MRIs, and there's a lot of debate about what the signal change in the muscle means, right? So does that indicate something? And it's a controversial point. Signal change in the ligaments could imply instability. But if you've got a little compression fracture, let's just say it's a superior end plate fracture, so if you're using AL classification in the thoracic spine, it would be an A1, which is almost the most benign fracture. I just leave them in the collar, in the cervical spine. In the thoracic spine, if there's just a tiny bit of compression on the CT, no neurologic deficit, and their pain's improving, I don't necessarily brace them because the rib cage provides you great stability. And those patients, there is some data that long-term bracing can actually be more deleterious. So you have to be certain, though, of the initial clinical exam, it'd be high-quality imaging. And then you have to follow that, right? Because there's certainly a lot of patients that I've taken an approach where they've got a tiny little bit of management of thesis. I remember a guy once who had been body surfing and had a little bit of tingling in his hand, touch of spondylolisthesis, but nothing else. So stay in the collar. Let's just see how you do. Had him come back at one week with repeat x-rays, and he's one week x-rayed, he'd support a hell of a lot more. Didn't need a flexion extension to prove it. He didn't have any more neurologic deficit, so we ended up operating on him. So whatever you decide, close follow-up is very important, not only x-ray-wise, but symptom-wise. And so if I decide to manage somebody conservatively, whatever their fracture is, I actually will try and evaluate them within a week or two with repeat imaging. Plus, what are their symptoms? Plus, what's the exam? And if that then looks good at one week, then I might spread them out three, four weeks later with repeat imaging. So I'm conservative in that approach, and I think close follow-up is very important. You have a cut-off for surgery and a type 2 odontoid fracture in an elderly without neurodeficit. And if the patient's in the collar but has persistent and severe pain that's intolerable, do you have what's your cut-off, or do you have what's your considerations? I think it depends on the degree of displacement and angulation. So the more displaced the fracture is, the more likely you're going to need operative intervention. The greater the angulation, the more you're going to need operative intervention. One has to temper that with the patient's overall health and also lifestyle. I mean, I've got patients who in their late 80s are out hunting in the woods with their dog, and that's it. And I've got one guy with a horrible odontoid fracture who says, I don't want surgery, and off he went, and he's fine. Another guy who at age 90 got his odontoid fracture cleaning his swimming pool, okay? And, you know, initially conservative. He came back a week later with increased angulation. He got surgery. So I sometimes look at the sequence of events and make the decision because it's starting to look worse on sequential x-rays to intervene versus it's a single degree of angulation or degree of translation. But in essence, the more displacement and translation, the more angulation, the more you're going to need operative intervention. Have you seen any value in using a cystarnostomy for management of hydrocephalus or severe TBI? Cysternostomy, meaning a third ventriculostomy? I'm guessing. I do not do that in traumatic brain injury. Okay. No experience with that. There's a comment on how do you get insurance to pay for follow-up imaging at one week, but I don't. I don't know, and I don't care. I don't know, and I don't care. There's some discussion about, again, your, Michael, if you could share some guidelines for symptomatic management of concussion patients in clinic setting before they're able to see neurology and concussion clinic. Certainly. So how you route them. Certainly. So I see some of these folks, like I said, and to go off Dr. LaRue's point, being able to follow these patients closely is really the most important thing. And so we've just decided as a practice that we'll see these patients if we can't get them to neurology, if we can't get them to TBI clinic, we'll just take care of them. We'll try to see as many of these patients as we can. I'll use, again, I think the CDC has done a great job, their heads up program of concussions. They've got some really good basic information. And to go back to someone's question earlier, if there's an example of a protocol that is helpful, the CDC website is really a good place to start. And it's not perfect, and none of this stuff is perfect, and we have a lot more to learn about it. But as far as if I've got someone who is past the 14 days of what we tell people when we discharge them from the hospital, this should go away. And reassurance is the first thing. We said most of this should go away 10 to 14 days. And if they come in at 10 to 14 days, and they're basically back to minimally symptomatic, or like our patient from my vignette was just a mild occasional headache, but she's taking some Tylenol and not restricted to her activity, I'll just tell these people follow up as needed. If it's anything more than that, I have a short tolerance for making sure that I get them in to neurology or to our TBI clinic to manage it. There's too much we don't know, and there's too much litigation involved in the management of these folks. And the work entry stuff, it's too hard to manage. So if they're past the two weeks, and they're still having symptoms, I will get them into the TBI clinic. And I will make sure they don't leave my clinic without an appointment. I will walk over to the neurology desk. I will say, this patient's going to come over, and I will facilitate to the best I can. We just can't leave these patients hanging. And just to reemphasize that, I mean, the CDC is a good website and resource for concussion, not only for adults, but also particularly for children. And one of the recommendations they do make is, you know, who do you image? And that's very clearly delineated. Secondly, they even talk about when you are being discharged from an emergency room. They're very clear instructions and information is given to the family. And that alone can be very useful, particularly in the pediatric environment, but certainly for adults as well. What are the expectations? Because the vast majority of patients improve. Now, TRACT-TBI is demonstrating that maybe not as many improve as we think they do, but there are other reasons for that. TRACT-TBI has also demonstrated that you can, with sophisticated MRI imaging, see structural correlates. There's not necessarily a standard MRI, but if you're doing a 3T or DTI or something like that, or resting state functional MRIs, you'll see abnormalities. But very interestingly, those actually improve with time on MRI. So, the important thing, I think, to emphasize to people is the reassurance that more likely than not, they're going to improve. It's difficult to know the quantification of that improvement and what time they will get improved. A lot of people are very concerned about, well, am I going to get chronic traumatic encephalopathy, right? And one has to recognize that that, while in our face through the media, is still a fairly controversial topic. And chronic traumatic encephalopathy may be only something that develops in a very small select group of patients with multiple concussions. So, a lot of studies will suggest that the negative impact of concussion is probably three or more. So, a single isolated concussion, the vast majority of people are going to recover and want us to reassure them about that. You know, sometimes what happens is they end up going to occupational health, and every week they go to occupational health, and every week somebody's asking them questions and they feel obliged to say there's something wrong. The occupational health people say, well, come back next week. It's a case of sort of, if you're getting better, you're more likely to continue to get better. And that reassurance can be helpful and certain guidance about things that they can do, as I said, that sub-threshold aerobic conditioning, attention to diet, you know, good lifestyle can make a difference. And then reassurance about, you know, we all get headaches. We all have sleep problems. You know, is that because you have the concussion or it's just part and parcel of regular life? So, one has to have honest conversations. Now, that can be difficult for a neurosurgeon to do if you're in a busy clinic, and it might be better done in a concussion clinic or a TBI clinic. And I think some of the rehab doctors do a very good job with that. Again, it's set up expectations for patients. Information is important. The CDC website is a very good website to help guide patients and also clinical care. Absolutely. Just to go back to the CDC stuff, some of the, I did a little webinar for mild TBI last year, and some of the stuff about making sure the patient is safe when they go home, but, you know, who's to say that their caregiver didn't harm them. So, making sure you're sending them home to a safe place and making sure that the responsible adult is home and they've got access to return to the ER, and making sure that these discharge instructions are absolutely plain and thorough is paramount. And I think the holistic aspect of care that becomes important is understanding the environment the patient is in as well. Absolutely. And the resources that they have. Thank you both. Just to answer to the other question, which was recommendations for those that do not have a concussion clinic available to them or access to get a neurology appointment. So, I think the CDC guidelines would be the best bet to go there. They would like also both of your thoughts on regarding kyphoplasty, vertebroplasty, spine jack with stable traumatic compression fractures. What about after failure with bracing or with osteoporosis? How often have you seen adjacent segment fractures? You want to go first, Dr. LaRue? I'm sorry. I don't do kyphoplasty. I don't like it. I don't do vertebroplasty. I don't like it. I think in true osteoporotic fractures, it plays a role in pain relief in some patients. There are randomized controlled trials that demonstrate it may actually not make an overall outcome in a population as a whole. So, you have to sort of individualize that. So, you can see adjacent fractures or fractures elsewhere in the spine, which is not necessarily because you did the kyphoplasty. It's because they just got a bad spine to start with. So, again, if we're dealing with compression fractures in the elderly where it's got an osteoporotic basis, you know, whatever you do, you want to make sure you're not dealing with something else pathologically, like a cancer or something, right? So, assuming that to be the case, it's just osteoporotic. Not only if you're going to do a kyphoplasty, you also have to speak to them about diet, nutrition, you know, vitamin D, calcium. Sunlight actually plays a role because if I remember my biochemistry correctly, one of the vitamins doesn't work unless you've got sunlight. They did that in a Ricketts trial in North Scotland where they gave all the kids milk and they were surprised they still got Ricketts because there was no sunlight. So, you know, again, you sort of have to make sure that the patient, if they're getting kyphoplasty, it's not the end of the story. There are other components to it. So, like I said, I don't do those procedures. I don't like doing them. I don't think they make a difference in the vast majority of patients. Some folks will benefit if there's a lot of pain, but, you know, if you've got a completely compressed fracture, I'm not going to do a kyphoplasty. If it's a minimal super end plate fracture, I don't think there's any role for it. So, in between, in some patients, it might help their pain. How important... Oh, I'm sorry, Mike. I was going to jump in. I, you know, I come from a facility where we do a fair bit of these and we've had some luck with these osteoporotic. We don't do much for traumatic unless, you know, you're dealing with a little old lady who's had a small injury and then that's the trauma. So, in that case, we have some pretty good outcomes with kyphoplasty and spine jack. And, you know, I don't think insurance pays unless you've had a trial of bracing anyway. And it's important to understand that these are pain relieving procedures. So, you can get a, you know, referral from a doc with a lady with a, you know, patient with osteoporosis and a terrible compression fracture, but the first thing you want to ask is if the patient has pain. And if you don't have a lot of pain, which they may or may not, even with an acute fracture, it's really not an indicated procedure. With spine jack, I think the data suggests from the European trials that you are getting fewer adjacent segment fractures. I've not seen that necessarily in my practice just yet. We've only been doing spine jacks for about a year, having good results with them, but I haven't seen our specific, the US data on adjacent segment fractures yet. But we do a fair bit of these and for the right person and the right selection and the right circumstance, they are fairly amazing. The people come in in a wheelchair and walk out. So, there is a role. So, the comment is that yes, and what somebody has practiced, they found a lot of division in the docs within the practice that some do kyphoplasty and some are against the kyphoplasty. What are their concerns for micro fracturing and are there any typical things to do to help the acute phase with pain? I think it's not just in Ms. Chatwell's practice. I think it's universal throughout our specialty of spine surgery that there's not good data to say whether or not kyphoplasty is the right thing. Again, to get someone into the acute phase, you should always try the least invasive thing. So, again, I don't think Medicare will even pay for this if you've not tried something conservative. But everything has its ups and downs, right? You want to give pain medicine to an old lady and then put her in a brace, you know, there's morbidity to that. So, if you can proceed and try a kyphoplasty, maybe you'll save somebody some bed rest and a UTI or a decubitus or pneumonia and get them up and moving, there's value in that. And I don't think that that can be understated as well. So, I don't think the division between ear surgeons and practice is unique. I think there's a lot we don't know and a lot more we could know. I've personally seen good results even in the acute phase, even when we push it along. Someone who's just hot, miserable from very specific fracture that we can treat, we'll treat it and usually make them better. What is a spine jack? Alice, sorry to interrupt. I have to leave, unfortunately, but thank you. Great question. I hope everybody realizes, you can hear from our discussion, there isn't necessarily one easy answer. One has to think very carefully and try your best to do what's best for each individual patient. That's one take-home message, I think, that we can apply to everybody. So, thank you for having me. It's a great honor. Thank you. Great question. Wonderful lecture again and thank you for the Q&A today. Really appreciate it. Thank you so much. All right. Okay. Bye-bye. Bye. So, we're going to continue with questions with Michael. There is one question regarding APP and workflows. There's anybody that could be helping out with that now? I don't know. Some people have seen who we are or whatnot. Michael's a PA in Washington DC with GEW and he loves medical billing and coding and has a little knack for that as well. I'm sure that he'd be happy to discuss that with you. I'm a PA and the co-director of the course along with Robin, who's a nurse practitioner and the co-director and we have Dr. Vess, our physician counterpart. So, between the three of us, you can always reach out to us and ask us any questions regarding APP workflow. We all do things very differently and that's the great part of these types of conferences is that although we do things in many different ways in many different places and we don't necessarily, hardly any of us have the same type of job, we all can come to a conference like this and get something and gain something from this conference. So, thank you for all still sticking with us. If you have questions, please get them in because we are in the last 15. Yeah, Michael. I was going to go over this SpineJack question. Wonderful. Thank you. All right. So, SpineJack is a device that's got, I think, about a year of FDA approval. Essentially, it's a kyphoplasty. So, instead of putting in the probe and blowing up a balloon to create a cavity and hopefully get some in-plate reduction through that, what you're actually doing is you're going generally bipedicular both sides and you're putting in a jack. It's like a car jack. So, you drop these in fluoroscopically, you get them in between the in-plates and then you turn a little crank and then you get a little bit of in-plate reduction. So, the idea is that you're getting reduction from the jacks going up inside the vertebral body and you're actually able to, once you have that reduction, then you get fixation by adding the cement, the methylmethacrylate. And so, that restoration of physiologic height, the idea is that reduces adjacent level fractures, especially those above the level that you have treated. The European data is quite good on that. Wonderful. Okay. So, we have a question. Have you seen DDAVP and platelet transfusion in patients with intracerebral hemorrhage who are on anticoagulation? What are your thoughts on this practice? I have heard increased mortality but have not yet researched the topic myself to see what the guidelines state. I don't have enough information. This is where Dr. LaRue probably would have had more. So, I'm sorry. I'm not in a position to answer. I think Robin is in ICU. She is. Robin, you want to chime in? All right. I was focusing on something else. So, tell me what the question was again. I have seen DDAVP and platelet transfusion in patients with intracerebral hemorrhage who are on anticoagulation. What are your thoughts on this practice? I have heard increased mortality but have not yet researched the topic myself to see what the guidelines state. So, I know that in our ICU, we do this a lot as well for ICH patients who come in on warfarin or something like that, especially if we have to instrument them, you know, like place an EVD or take them to the OR. I can tell you I'm on a QI project right now with the spine, the neurospine and orthospine groups at my institution. And there's a hematologist on that panel as well who absolutely is not into the DDAVP at all. And I also have to look up, you know, a little bit more behind the reasoning for that. But I know that there is that increased mortality, probably increased morbidity as well. So, while it's, you know, this is going to be one of those things in neurosurgery, like, you know, you see a lot of people doing lots of different things, same kind of thing. And I think that a lot of these, especially with intracranial hemorrhage, a lot of these things don't have, you know, there's not a randomized control trial that anybody's done on any of these things. So, I think there's a lot of variation in practice for that reason. So, that was a little bit more, but. Thanks for chiming in, Robin. If you guys take a call, what does your call schedule look like? I have to say that I'm on a NSPA, the PA Organization for Neurosurgery. And we just had the results of our study come out of the questionnaire. And if you look at AAPA as well, it's just a lot of questionnaires that deal with this. Call ranges across the board. Some take call for the ER, some take call for ICU, some take call at home, some take call in house. I think that there was a divide between academic facilities of PAs and residents before, and now it's like a mesh of call as well. There'll be a PA on call and a resident on call, depending on how many institutions are covered. Some people take call, like a shift work for the hospital, which is becoming more and more prominent with the hospital acquiring a lot of physician practices as well. So, where we used to be in the private organization, taking call for our private docs, we're now hospital employees and we're doing more shift work than we were doing a regular 40 hour a week. Michael, if you want to. I'm in a academic resident-based. We don't take call. So, the residents are in in-house call and they just switch to a night float. So, I don't have much experience. I have zero personal experience. Anecdotally, it just varies so greatly as far as what's best for the practice and the positions and the APBs. So, I'm in an academic institution, but my department functions a lot like private practice in some ways. And I am on call two weekends a month, home call, but it's kind of availability for patients, for residents, for things that come in from outpatients who may have had a procedure or patients who are in the hospital who need things. So, it's all home call, but it's two a month or two weekends a month. And then kind of just throughout the week, like everybody, you know, would be. And I was in a previous academic institution and I took call, home call and had to go out periodically. And I probably did about three, three to four days a week, possibly on some time or three to four days a month. And then sometimes increased. Now I don't take call at all. And the residents take call and we really don't have PAs on call unless they're in the hospital providing shift work. The next question is how many shifts of hours per shifts or hours per pay period constitute a full time at your institution? I feel like, I'm sorry. Oh, I'm an exempt employee. So, I work till the work's done. I usually work somewhere between a 40 and 45 hour work week. I will say that there have been some changes in this COVID world that we're all trying to patch it together and make things work. And our teams are covering each other more than we've ever had to in the past. So, there's five of us PAs. Some work three twelves. I work five eights. There's some four tens. And we just try to try to make it work. I personally have some significant child care issues that I've had to work around. But that's something that employers are having to manage right now. So, it depends. Yeah. I mean, in my experience, it really depends a lot too on if you are employed by the hospital or the physician group slash school of medicine or however it works for your institution. If it's hospital based, then a lot of times you do have a specific hours per week that you're supposed to be working per se. But on the other side, at least for my institution, it is very much like Michael's, which is kind of just work until everything's done. Whether that's a little bit less than 40 hours or more, it all kind of washes out. Yeah, I find shift work and hourly it's more hospital related and more salary and exempt is institution related. So, you know, the PAs that we have or MPs that we have in the hospital are all shift work and they work different shifts than we would have the APPs that are in the outpatient setting in the academic world that we work in. Okay, the next comment is, how do you handle OR first assist time on a service with both PAs and residents? Million dollar question. It's always the hot topic. So, one thing you have to understand, if you're working with a residence, then you're not getting paid to be a first assistant. So, that's something that's important to your employer that they can't bill for you if there's a qualified resident and especially if that person is operating. So, I personally at my institution, I don't operate much anymore. There are residents who are trying to get cases and they need those cases for their education. So, that's part of the reason I have a job really is to support the service while residents operate. So, if the service allows for it and there's not other stuff that needs to be done, the physician assistants on my service will go to the OR and I think we all like to go to the OR, but our employer can't bill for it and I don't really want to stand around. I've watched enough surgeries to know that I don't need to watch anymore. So, if I can go and participate and open and close with the resident, sometimes I'll do that, but for the most part, I'll let the residents do the operating. So, we actually, I did a podcast regarding this, Michael Wang, who you saw, I think, yesterday. Was that yesterday? It is a defining feature of the academic world and it is, I think, way back when the PAs and some nurse practitioners first assisted a lot more than they do now. I remember giving up my peripheral nerve cases, even though I love them because it was the thing that every resident needed on their list, even though it takes five minutes, you know, I had to give up every carpal tunnel. I got one every once in a while. So, I think it does, you know, if you've got the more locations, if you have private hospitals that the academic sector covers, you have an increased chance of first assisting, but if you're in an academic world and you're in the academic institution, the hospital, there's a very slim chance of you probably first assisting and again, like Michael said, a lot of it's financially driven, right? You can't charge any first assist fee if a resident is available. So, you have to remember that and you have to make sure that you are aware of what they're billing for you in your academic facility and making sure that they're not billing for you in circumstances in which a resident is available or in the room, especially. There's also some other questions. We have a few more minutes left. There's questions regarding appropriate place to ask if this is it or not, reasonable raise requests. I will say that there's a lot of contract negotiations that go along with our job. We can talk about it. It's part of it. I would get data and metrics for it. There's two and I don't know for the nurse practitioner world, Robin, if you want to chime in. The AAPA has a salary report every year that you can buy and SPA, the AAPA Neurosurgical PA Society, we have one every year as well. So, you can use that data and that information to go to your institution or your private sector or whoever employs you and say with AAPA, they'll actually have you're in the northeast with this salary for this area. You're in the southwest. This is the common salary and then there's areas that if you take call, this is how much you would get paid. If you're hourly, this is how much you would get paid. So, I would really go with that because the institutions are going to require data. You don't want to just say like everybody else I know makes this. Really bring something to them to the table. NPA data can be used for NPs and NPD data can be used for PAs because we're really doing the same job in the end of most of the time. I would take on to that and figure out how it is that your organization is valuing you. Are you on RVUs? Are they billing for you directly? Are they billing for you as an extension of your supervising position? So, you need to understand how you're being paid for and as outpatient, are you billing your own notes and charging under you or are you the providing provider and you're still billing under the other positions NPI? Really make sure you understand how that's being done and then say, all right, so I'm billing under my own NPI number for 90% of my charts. I want to see my numbers for the last two years and seeing what I'm bringing in and then you can say, look, I brought in 20% more than I did last year. We need to talk about a raise. Yeah, and to say on your point, Michael, productivity-based salary versus just a standard salary and does that change with time and do you need it for it to change in time because they were basing your initial salary on something else? Absolutely. And I totally agree with everything that Allison and Michael just said. I just want to add to that sometimes the amount of money that you bill or bring in or whatever independently may not be that high, but you can also make a case that's quantifiable for what you're able to allow the surgeon to be freed up to do. Like, are you freeing up that surgeon to do X amount of extra cases per week because you're seeing inpatients and you're rounding and you're doing the clinic and doing all those kinds of things. That's a lot of where our value comes from in neurosurgery because a lot of the care is post-op and global and we're not really billing for that per se. You could say, you know, I did 60 global visits last week or last month that my surgeon didn't have to do. Like, that's a big deal. That's a lot of work. So, if we can justify ourselves in that manner as well, that really goes a long way. We free them up to do more and do more surgery and that really is the basis of a lot of value. So, I have an issue when they come to the table and say, well, those are your RBUs. I'm like, yeah, did you look at my boss's RBUs? Because his RBUs are indicative of what I'm able, you know, allowing him to do more and that's right. The global period will always get you. You can't go with what's your collections because the global period will kill you because we're doing the global period. I mean, we are the global people, I mean, for the most part in most of the settings. Okay. So, I think we are like two minutes out. We have one more question. Do you work one-to-one with a specific physician? I do not. I'm in a multi-physician group that we are, you know, we have spine, skull base, tumor, interventional, vascular. So, I do a little bit of all of that. I do work one-to-one with a specific physician and have worked with him for 17 years. He does intracranial, aneurysms, tumors, mets, you know, lots of different things. So, it's definitely a different experience working for a group versus working one-on-one with somebody. And I've worked with a physician for 13 years who does intracranial and spine and vascular. But I also, you know, always join in to help out any of the other APPs and cover them when needed. And so, really, I don't think any, even if you work for a one-on-one person, unless you're only with one neurosurgeon in a group, I feel like we all kind of, you know, help out anybody next to us because everybody goes on vacation or is out or might be in the OR. So, I think the one-to-one for all the time is quite hard. Okay. So, thank you, everyone, for joining us. We are going to have a lunch break now and come back and Robin's going to moderate the next section with Dr. Amanda and Dr. Liebman. They're going to discuss neurocritical care. Okay. Thankfully, she's there. You guys are in for a treat. Yes. I'm excited. Neurocritical care is one of my favorite topics. Then there'll be some case studies at the end and some Q&A, so make sure that you throw in your questions. If they don't get answered, I'm sure Robin will take care of it at the end. The resources tab, again, should have all the information you need for CME and handouts and everything. If you're not getting there, please email the AANS. The staff members are Shannon and Krista. If they chime in here and there, they'll be able to help you out with that. So, thank you again for joining and have a great lunch. All right, buddy. Good luck. Good luck with your bits of flare or your badges or whatever it is. So, thank you for having me. Thank you, Michael, for joining us.

approach to first assisting

call schedules

institution

specific circumstances

determining appropriate salary

requesting raises

data on productivity

value provided to the team

comparisons to industry standards