Welcome back, everyone. Thanks again for joining us this afternoon. We have some great sessions lined up for you guys. I hope you had a good lunch. The first session is a session on post-operative spinal imaging to include instrumentation given by Dr. Michael Carsey. Dr. Carsey got called to the operating room today. So again, we're pivoting a little bit. So the plan for this next 45 minutes is we're going to play. Dr. Carsey pre-recorded a video for us in anticipation of this case that he had to do today. And then we are going to come together as a group of several of the course directors and host a bit of a roundtable and Q&A and hopefully learn from each other to some respects about how we've managed cases where we've used post-operative imaging to help us solve problems in the post-operative period with instrumented patients. So with that, we're going to go ahead and start the video and we'll see you after. Stay around for Q&A by the course directors. Hello. Thank you very much for the opportunity to present. I'm sorry I cannot be with you in person. My name is Michael Carsey. I'm a clinical assistant professor of neurosurgery at the University of Michigan. I'm here to give you a talk on the topic of spine imaging in patients as well as post-operative instrumentation. So here are my disclosures. The basic outline of this talk are to discuss some basics about spine stabilization, biomechanics and osteology, as well as some information about hardware placement and some modes of failure that are important to recognize in the perioperative period. So the concept of spine stability first was discussed in 1970s by Jean Doucet talking about the cone of economy, basically a balanced state where a patient's spine is able to organize the weight against it in space. And he talked about the instability coming from patients leaning too far outside this cone. The degenerative process of the spine essentially results in various pathophysiological changes that does start to cause the patient's spine to go outside of this cone and the compensating mechanisms of the spine in terms of hypertrophy, ligamentous changes, disc changes that occur try to stabilize the spine against that. So this is an important concept to know and important to think about in the realm of degenerative disc disease which is very common in the general population. Another important concept is Wolff's law in that bones will adapt to the mechanical degree that's placed on them. So any kind of bone fusion, bone formation that's really important for spine surgery depends on Wolff's law where you have to place stress against the bone and you require the bone to heal. A bone is vascularized, it's a living tissue and that's why it's important to get fusions to occur in order to allow the spine to resist forces against it. Instrumentation should really be thought of as a temporary structure, you know, metal fatigues and can break and it really is the bone that's designed to fuse to allow a patient to heal and move forward. So in order to get bone to fuse there's various mechanisms we use to get that to happen osteoconductive materials are those that create a structure for the bone, allow bone cells to kind of migrate through and heal. Osteoinductive properties are materials that help to induce osteoblast differentiation and bone formation such as bone morphogenic proteins and osteogenic principles are actual stem cells and live cells that can be introduced into a spine environment to try to, you know, allow newborn bone formation. So what are important factors for bone fusion? Certainly surgical techniques, the level numbers of levels of surgery and bone quality, patient smoking, nutritional status, genetics, patient frailty, all these are important for bone fusion. Some general fusion rates that can be reported in the literature for T-lifts and basically thracolumbar instrumentation about 60 to 95 percent. ACDFs, you can kind of see this principle that more levels you're adding to an ACDF, a cervical surgery, the lower the rates of fusion. And what are things on imaging that we look for to determine if the patient has fuse? Well it's bone formation, there's various ways that you can look at it. So you can look at bridging type osteo, osteo-formation, intravertebral osteo-formation, posterior column osteo-formation, and certainly on both a sagittal view as well as a coronal view, you can sort of see this bone form. X-rays are commonly used to look for bone formation and fusion, but CT scans offer higher sensitivity and specificity. And certainly dynamic x-rays, flexion extension films help to see if an area of the spine is stabilized. So they are really important for looking at bone fusion. So again, flexion extension films and CT scans, these are the sort of primary ways we use for evaluating bone fusion. So various types of instrumentation that are important to recognize in the perioperative setting. You may or may not encounter all these types, but in sports I sort of recognize the different things that exist. Occipital fixation, basically there are occipital cervical plates. There are these flat plates that fit into the skull. They're very strong. These anchor directly into the skull themselves. They can be connected to subaxial hardware, C1-C2 fusion primarily. There are some newer techniques where we view occipital condyle screws. These are very rare, but kind of a neat thing that can be thought of. The occipital O to C1, O to C2 type fusions are much more common and important to recognize. C1 instrumentation involves instrumentation of the lateral mass. So the entry point typically is just under the vertebral body from a posterior view. There's about a 15 degree medial position in the screw, and the aim of the screw is towards the anterior tubercle of C1. So it's typically a long screw, about 30 millimeters. And so the other thing that's unique about this screw is that it can be partially threaded. So this smooth shank portion is designed this way because the nerve roots at C1 and C2 are typically just underneath this shank. And so if you don't want a sharp thing pushing on a nerve at all, so that's why it's designed as a partially threaded screw. C2 instrumentation, there are various flavors of this. So the trans-verticular screw is a screw that goes from C2 through C1. So you're designing this screw to kind of go through two levels to fix those two levels together. C2 laminar screws go through the lamina of C2. C2 pedicle screws are the blue one shown here, showing this sort of medialized trajectory. And the par screw is kind of this more vertical trajectory. And there are pros and cons to the use of each of these, but often they're selected based off of patient anatomy and surgeon preference. And then these C1-2 joint screws are done anteriorly very rarely, but they do exist. And the odontoid screw done anteriorly is a screw that is designed to go through the body of C2 to oftentimes capture odontoid fractures and can be a very useful tool. And you can do these sort of weird combinations of screws in the subaxial spine that you can't really do everywhere else in the spine. And you can do combinations of screws depending on patient anatomy. And the biomechanical studies are pretty robust for these different combinations of screws. So here's some examples of what a trans-articular screw looks like, a screw going all the way through from the bottom all the way up through C1. And here's the traditional C1-2 HARMS construct, oftentimes done with a bone graft as well between C1 and C2, but this is sort of the general trajectory of the C1-2 screws. The subaxial spine, these are much more common. You're going to see these a lot more commonly in practice, especially for the treatment of cervical myelopathy. Oftentimes fixation is performed. And so there's a variety of different ways to perform these techniques. I would say most surgeons are using this sort of modified magrill type technique where basically you're angling the screw up and out to be able to try to get access of the facet but avoid the vertebral artery and the nerve roots. And this is the ultimate product. You get these screws that kind of look up and out and this is how they're supposed to look. But if you get screws that are a little bit straighter, they work just as fine. There's a bunch of different techniques for doing instrumentation of this area. Some anatomy principles. When you're looking at an X-ray or CT scan, the lateral mass basically is this component. In between it are joint surfaces or facet joints, the spinous processes here. So the screws are aiming into the lateral mass for this particular type of screw. ACDFs are a very common type of procedure that are performed for a variety of different purposes. And so what those entail are a disc spacer, usually made of titanium, a catameric bone graft or peak material followed by an anterior plate. There are spacers that have the ability to place screws through them as well. So there's various ways that this can be done. But this ACDF, this is a workhorse type technique. It works well. Patients recover very well from it. And so this is what you would notice. Basically an anterior plate. It generally should be pretty straight up and down. If it's a little bit tilted one way or another, it's not the end of the world so long as the screws are within bone, but typically should look straight up and down like this. And on a lateral view, the screws should go into the bone. They shouldn't violate this posterior wall of the vertebral body because that's where the spinal cord is. So this is kind of how this appearance should look. The screws should kind of come in, angle to improve biomechanics and not violate the posterior wall of the vertebral body. Cervical arthroplasty are much more commonly used than lumbar artificial discs. And there's various companies making these. Basically it's a combination of titanium that integrates into the bone with some sort of polymer that allows for motion. And so usually these are just kind of malleted into position and then there are anchors that keep these in position. And they should allow flexion extension of the patient. They should be pretty perfect. You can see on this particular implant from OBC that this line is essentially straight. So if it was a little bit tilted, you'd see two lines in place. The reason is all these artificial discs are designed to work biomechanically at place straight in. So if they're rotated or tilted, you lose some of that biomechanic advantage. So placing these, it's really critical to do that. And then corpectomy cages, there are various static and expandable types of corpectomy cages all throughout the spine. This is kind of what they look like. You can put them with a plate, you can put screws through them sometimes. So there's various flavors of doing this. And there's pros and cons of different ways of doing this. Thoracolumbar instrumentation generally uses these fully threaded screws going through the pedicle of the vertebral body. For the thoracic side, because the pedicles sometimes are narrow, you can have these in-out-in type screws where you're trying to go through the rib head and avoid a thinner pedicle where you could damage the spinal cord. And there's various trajectories, a straight in kind of lines up with the end plate versus an anatomical trajectory kind of goes down like this. Again, just based on patient anatomy and surgeon preference. And generally this is what it would look like from a lateral and AP view, these sort of medial trajectory screws all connected. And that's sort of what it looks like. There's various additional hooks and side connectors that can be used. So side connectors, different size tulip heads for the different size rods, cross connectors, transverse connectors, different types of side connectors, all sorts of different tools exist for the spine. And you might see different variations of this in your practice. The lumbar instrumentation is very similar to thoracic instrumentation. Basically you're trying to put the screws down the pedicle here, medialized in this trajectory and straight in, in line with the end plate. There's a type of trajectory called the cortical screw or a different type of lumbar screw where you're basically starting from a medial position and you're aiming outwards. So these look a little bit weird. These are completely different type of screw. And so you would know that these are being used for this purpose. I would say most surgeons in the country are using these pedicle screws and the corticals are kind of the bailout or less commonly used. They have certain applications. And then for S1 and S2 instrumentation, for the sacrum, basically you're entering into the sacrum through bone, aiming towards the anterior prominence of the sacrum. So the general trajectory follows pretty similar to a thoracic screw. And then the S2 or iliac instrumentation is very different. So you have these iliac bolts that you're trying to put down the rest of the pelvis. There's these S2 alar screws, which are designed to go through the sacrum and then across the joints of the sacroiliac joint and then into the pelvis itself. So they offer you multiple cortical surfaces and these have really good pullout strength. So different combinations of sacral fixation. Typically surgeons will use these long constructs. Use these instruments in very long constructs. If you're doing a T10 to pelvis, this is sort of why you do it. With a huge lever arm, you want to anchor it into some solid base. That's kind of why you're doing it. You're putting all the weight of the axial spine, basically coming down and at L5-S1, you've all this weight going onto the pelvis and sacrum. So it's a mechanical point and you want to fixate across it pretty well. The various inner bodies that are used basically have the different acronyms, just sort of describing the trajectory that they're coming down. So anterior, oblique, direct lateral or X-lift, the T-lift or transforaminal and then the P-lift or posterior lumbar. Different acronyms for essentially an inner body used to go between the disc spaces. These are examples of what they look like. This is what a banana cage, T-lift cage kind of looks like. It's got this kind of curved shape to it and comes in at an angle. The P-lift cage is this bullet shaped straight type cage. You can put one or two in them. The direct lateral or X-lift type cages are super long and they try to go across the entire disc space. And then the A-lift cages are done from an anterior approach. They're very big as well. And typically, you can put screws through them like this or you can put an anterior plate. There's different ways of doing that. Important to sort of recognize for these inner bodies that they're within the canal, sort of within the vertebral space and not within the canal, that they're not subsiding into the bone, that they're kind of holding up against the end plate. As you see more of these, you'll get more used to sort of identifying what they're supposed to look like based on your practices. Also, what's important is to note that the screws and whatever the fixation strategy was, a plate or screw, also looks well. So, you have to look at both, all the areas of the hardware. Here's a case example of how the different instrumentation can be used in the spine. This is a 51-year-old patient that was sent to me by an outside surgeon who essentially had a long segment fusion, had adjacent segment disease, meaning that she had wear and tear of this level above her hardware. So, I had a second surgeon to try to place a sort of novel adjacent segment device. And you'll see these different things in practice. This is the first time I've ever seen this particular version of doing this. But she developed some new adjacent segment disease at T12L1. So, now we had a very large lever arm. We're at a junctional level. So, what I did was basically a large decompression. She's developing cauda quina type symptoms with radiculopathy and urinary urgency, perineal numbness. And so, we did a decompression here and extended the fusion. And you can see based on the different tools that were there, you can add additional hardware. We added quad rods to give her better strength across this junction. We didn't remove any of the lower screws. We basically just added on top of it and then strengthened across that junction by putting additional hardware in place. And she had a very good recovery. Some novel devices you might see in practice are these intraspinous devices shown here. So, you might see some of these in practice. There's also artificial discs for the lumbar spine. These are artificial facets that exist. They are coming back into favor quite a bit based on some newer studies. But so, you may or may not see these. There's also some newer devices. This is the barricade device used for trying to reduce disc herniation after microdiscectomy. So, it's a little anchor that anchors into the bone. And then this polymer is designed to kind of keep bone fragments from coming out. So, you may start seeing more of these devices. So, here's some modes of hardware failure that you have to watch out for. The medial pedicle breach is always the worst one because the spinal cord and nerve elements are in this area. So, this is what you have to be very careful of. Usually, a CT scan is the only way to detect this or an O-arm spin, some sort of intraoperative spin. But this is definitely something to watch out for and may require revision of hardware. So, this is a very severe breach where you can clearly see the medial canal is compromised. Lateral breaches look like this where the screw has gone laterally. Not the end of the world. There are not significant critical structures at the level of the pedicle unless you get more anterior where there are important blood vessels. We don't like seamless, but it is a technically safer breach than a medial breach. Other modes of hardware failure are fracture of the screws, which would be very difficult to remove the components. But they can happen. You can have fractures of the rods. And then screw loosening can cause this haloing effect where the screws are essentially toggling in place and having, you know, they're wearing out the bone. Very important to look for hardware failure in post-op patients. Very important to look to make sure all the screws are tight, that you have rods above and below the tulip heads, and also look for bone formation. Those are sort of the main things to look for when evaluating instrumentation. This is another patient of mine, 82-year-old female with a diffuse idiopathic scoliohyperostosis that had a fall. An outside surgeon had done two prior surgeries, one of which was for degenerative disease and one of which was for a prior fusion, for a prior fracture, and came in basically because of this fracture site here, which was a high grade type fracture because of her osteoporosis. We did cement augmented screws across the fracture site and again tried to stabilize against that large fracture area with additional hardware. So these are two sites that I practice at Ann Arbor and Lansing, Michigan. My email is on the slide as well. Please feel free to contact me if you have any questions, and thank you for your time. All right. Hey, everybody, welcome back. I hope you had enjoyed that excellent video, kind of a review of the different instrument adjuncts that we have to use in the operating room and how we have to manage these in the post-operative period. I thought it was nice to have the pictures of the actual devices themselves and then the radiographic demonstrations of it. So we're going to hopefully have some Q&A from you guys, the audience. Again, I'm Mike Johns. I'm a physician assistant, one of the course directors. I'll let allow my colleagues here to introduce themselves. I think you're seeing a new face here as well. Lauren, you want to chat real quick? Hey, everybody. So glad everyone's here this afternoon. I'm Lauren Waldron. I'm a physician assistant in Charlotte, North Carolina and part of the planning committee. So happy to be here. And Laura Prado, a nurse practitioner in Atlanta. I've worked with a spine surgeon for 20 years and doing critical care currently. So this was a nice kind of back from memory lane listening to the lecture. So I think the three of us have done a lot of looking at post-operative radiographs in our time in the clinic. So we don't know everything, but we're happy to kind of contribute our thoughts and our experience with some of these things. So we do have one question sitting in the chat that I'll address right now, or I'll bring up. So asking from Allison Ovett, if we have any thoughts about cadaveric bone versus cage for ACDF, do we feel like there's better fusion with one or the other or it doesn't matter? You guys have specific thoughts or data or anything to share? That's great. I've always been told that the fusion is the same, but that we've typically used cadaver bone in some of the elite athletes in Charlotte. Just for a little bit, I understand that the fusion might be a little bit more rapid, but the total fusion outcome on the trajectory is the same. But that's what some of my attendings have explained to me. Yeah, we always used a cage and we put BMP in ours. You do have to be careful with the dosing of the BMP. And I know it's off label, so a lot of surgeons don't use that. But we had great fusion rates, especially in multi-level cervical fusions. Yeah. I just found an article from Global Spine from 2017, basically saying everybody thinks it does affect fusion rates, but a lot of people use different stuff with peak being the most common at 65% of 5,000 surveyed spine surgeons. So long story short, I don't think we know. There's certainly a difference of opinion on it. This is a great question from Dennis. What are your thoughts about nicotine? Time off before surgery, time off after surgery, how about smoking, vaping, patching, gum or placing? And again, we're watching the chat here. So if anybody has experience with this, please put things in the chat. There's a touch of delay, but I'd love experience from this group at large of the 60 clinicians that are in the room as well. We didn't operate on people who smoke. They had to quit before. Any period of time they had to quit for you guys? About three months. I mean, obviously, if somebody was myelopathic for a cervical fusion, we're a little more lenient, but for a big lumbar fusion, we made them quit. There's some insurance companies that actually make you do testing, nicotine testing before the surgery. Exactly. That's what I was going to add to, especially for the fusions, insurers check levels. And so at least six weeks prior to surgery, I think, unfortunately, not every patient stops smoking prior to they at least reduce their smoking. So we, you know, to Laura's point, if they're myelopathic, you kind of have to do what you can, but you're right. The insurers and some of the Medicare guidelines are requiring testing prior to these large fusions. Yeah, certainly elective fusions and stuff like that. And then when it's less elective, you just have to lay it out for the patient that your incident of infection goes up by 30% and your incidence of fusion goes down by 50. So you have to kind of lay that out there for the patient and manage their expectations. The question of what are your thoughts on bone stimulators in the post-op period? I'm for them. Medicare pays for them and they don't pay for voodoo. Sometimes I have to explain to the patients that it feels like voodoo, but it's not that I think there is value. And I don't, I don't have the data at my fingertips to justify that you guys. That's a great question. I would love to see some of the data on that. I've seen so many of the patients are like, you know, they gave up, you know, they're supposed to keep using the batteries until it's, you know, they're exhausted and they've got like eight batteries. Yeah, no comment. I don't know. I would like to see some of the, any peer-reviewed data on that because it's it's definitely a question we get from numerous patients as far as how effective it is and it's costly and some people have paid out of pocket for it. And so I don't, I don't know the answer to that, that I would love to hear from some attendings or some, see some peer-reviewed data. Yeah, we, we used them on multi-level fusions. We, we said if insurance doesn't pay for it, then don't bother. But I'm kind of, if insurance paid for it and, and the risks are very low other than pace, people with pacemakers, then use it. Right. I'm going to combine two questions about kind of protocols as you will for imaging post-operatively. If practice is customary, do x-ray or CT between 12 or 16, 6 or 12 weeks after surgery? And what are we using? If that's not it, what are we using the most commonly? So you guys want to jump in at that? So the question is just x-rays versus. What are you kind of doing? Yeah. What do you do in post-op? Just AP lats. We don't usually flex them, you know, we just do x-rays as long as the patient is healing as we expected, you know, symptoms are resolving, improving, working with PT, you know, a few months down the road, if we, you know, suspect any hailing or anything like that, or any kind of, you know, new pain or, you know, not progressing as they would, then we do go to CT, but just in the first 6 to 12 weeks, just AP lat x-rays. Go ahead, Laura. Oh, I'm sorry. Yeah, that's what we would do. We just get x-rays unless somebody was, you know, down the road having significant neck pain or back pain where you worry about a pseudo arthrosis. I think from these experienced clinicians you've just heard from, there's a really good lesson for anybody who's kind of new, is that when things are going good, you stick to your protocols, but be aware when things are going bad. And just because we do x-rays at 6 weeks doesn't mean you have to wait till 6 weeks. If somebody did get better, and then they stopped getting better, do something, right? Don't not do anything just because your protocol is 6 weeks. You don't have to wait till 6 weeks. And again, I feel the same way. If I can't explain with the physical exam and the films, I'm going to CT after that for the most part. And it depends. Like if it feels neurologic, I might jump to MRI depending. I think there's a nerve problem that would be better explained that way. So, I think those are good questions. But I'm x-ray, and again, I'm AP lateral x-ray for normal stuff. This is a good question. It's something I wasn't familiar with from Mark. What are your thoughts on lumbar fusion, pedicle versus cortical trajectory? I think he explained there's the cortical trajectory is the bailout. I've personally never seen this. Anybody ever seen a cortical bailout screw? I would be very surprised to see screws going this way in the lumbar spine if I saw a film. But I get what they're doing. If you've blown out the pedicle, you have to figure out another way to get there. But I've never seen them. Another question, thoughts about DEXA preoperatively for patients going to have thoracic or lumbar fusion, treating first, cementing screws, anybody have experience with that? We did DEXA scans on our multi-level fusions and would then send them to an endocrinologist or rheumatologist if they were osteoporotic or osteopenic. There's a surgeon that's been with our group for a couple years now, and he does complex deformity. And so, he gets DEXAs on all those patients. Yeah, I think that's reasonable. And I think that's probably as we are the course planners here, I think this is a good course planning idea of preoperative evaluation of our spine patients for maybe the spring. So, those of you who join us in Boston, maybe we'll have a talk on preoperative workup. I think that's a salient topic for this group. What do you guys usually tell people we should see evidence of fusion on x-rays after surgery? Anybody? It's hard to tell. I mean, I'm basically, you know, following hardware placement in their exam. You know, usually a few weeks after surgery, you can't tell if it's fusing, but, you know, CT really will lend to that. So, my comments are mostly geared towards hardware placement, alignment, and just making sure they're doing as expected. Right. Yeah, I, you know, if I'm hedging, I'll tell them six months, you know, what I want, you know, what an expectation I try to control sometime is when patients get their results before I do, and if they see evidence of lucency of one of their 14 screws, or they don't see osseous fusion formation, and then it's like, okay, you might not see that for a while, or we can expect a little bit of this as long as this haloing as long as you're not symptomatic. So, kind of managing that as an expectation, but I try not to say a specific time. I think we ballpark about six months. Yeah. Good question from Elba. What is your cervical collar use protocol? Do you ever brace cervical level fusions? Cervical, excuse me, single cervical level fusions, single level cervical fusions. So, we don't. Yeah. Sorry, go ahead, Lori, you go ahead. A single, well, actually, even multi-level ACDS, we just had a soft collar for comfort, because the internal hardware really is acting like the collar. Unless somebody's really osteoporotic, and we had to do surgery, then we may put them in a hard collar. Agree. I think one of my attendings would put collars on patients just as a reminder if they thought that they would be too active. It wasn't for stability or, you know, any other reason other than to prevent them from doing too much. But no, we do not put cervical collars on one or most cervical fusions now. Yeah, we don't. Sometimes I tell them it's a game time decision that if, you know, if we missed an osteopenia or your bone quality, which is not necessarily the same thing as bone mental density, if there was a bone density or bone quality issue, you might wake up with a collar. It's an unusual thing to be surprised by that, but I've seen that happen before in practice. Just to bounce off of what you just said, we did see that the DEXA scan would be normal, and we get in there, and the screw would just slide right in the bone. It was like butter. So, DEXAs, even it's hard to tell the person who does the DEXA, but their bone quality may not be as good as what the DEXA says. Right, and the DEXA is density, right? It's not necessarily quality, which may end up being two different things. A really good question, a complicated one, I think. What is your experience with pseudarthrosis in patients that take NSAIDs or COX-2 inhibitors post-fusion, despite educating patients extensively having trouble with their OA patients not wanting to stop their NSAIDs? What do you guys got? We, it's hard because NSAIDs are my drug of choice for everything. So, we stop them before, we try to stop things a month before, like NSAIDs or anything that could thin your blood. We were just real conservative that way. And then I just really try to educate them why they can't take the NSAIDs, that they need the inflammation to fuse. That usually can scare them enough a little bit when I tell them, if they don't fuse, you're pretty measurable with a pseudarthrosis. Lauren? Yeah, I agree. Much of the same, you know, some of the challenges are with your gout patients, you know, things like that, that really want to get back on their NSAIDs. So, it's a challenge. Yeah, pseudarthrosis is definitely an issue. And we tell patients the same thing as Laura's, you know, we need the inflammation there, extra strength Tylenol, you know, we try to suggest that as much as we can. So, and then again, with the bone growth stimulator, and that kind of tied into the last question about the forebone, you know, all those things together, try to help early fusion, if possible, or quicker. Great. There's one more question. Oh, I was gonna give my experience. I'm a little lighter about it, to be perfectly honest, we'll let people have a little Celebrex in the post-operative period, because it doesn't interact with the bleeding quite as much as some of the other ones. And I'm a little freer about the NSAIDs, because it keeps people off the narcotics. So, I think that the trade off is something we're willing to tolerate. I'm looking through the chats. If anybody has any more, speak now forever, hold your peace. I'm just gonna throw out a question. Yeah, go for it. How long do you and your practices follow patients with imaging who've had a fusion? I like to see people at about a year. And if they're not having any trouble, I, you know, beg them to do home exercises for the rest of their life, but I don't make them necessarily, some do, some just want to come in, either yell at me or give me a high five, but yearly is fine. And if they don't want to come back, I'm not chasing them after a year. Yes, it varies from attending in our practice. Typically, an APP sees the patient in first post-op about four to six weeks out, assuming everything is going well. And then the attending sees, you know, six weeks later. So, the first, you know, the three month follow up with the attending. I have some attendings that will say, much like Mike, you know, just we'll see in a year, you know, x-rays then. I have a couple of attendings that do a six month in between, just to make sure. So, it's a personal preference. Yeah. Let's see. All right. There was a good follow up question to the NSAID Cox2 question. Do you get more relaxed about NSAID use after you've seen some bony fusion on your post-op films? This is for you guys. Yeah. Yes, that's really our judgment call on the attending. Most of our attending say definitively no NSAIDs until three months. So, that's kind of our guideline. So, even if you start to see early bony fusion, but then again, they're seeing them at the three month follow up. So, that's usually their call. But the attending follow up post-op is usually when we let patients resume NSAIDs. Yeah. And I said that we discouraged it if, you know, if people came with good reasons why. I said, if you could at least wait four to six weeks without it, that's ideal. This is another can of worms, probably another good one for our fall spring talk. Larger fusions, suggestions on pain management protocols. I would say, make sure you're optimized pre-op. Make sure if you have a pain service, get them in early. And the most important thing is if somebody comes in on narcotics, don't screw that up in the initial post-op period. Like, don't take them off their drugs and wondering why they're, you know, if they came in on tenavoxy four times a day, don't think the regular epic button you push for spine post-op of one to two Percocet every four to six is going to be enough. Don't screw that up. Get help early. They have lots of toys, ketamine, lidocaine, all kinds of things. Get them out of bed. But it's a whole challenging deal. Don't not restart their home meds. That's the bottom. That's the baseline. And everything else builds on that. That's a great question. And I agree with Mike that it gets complicated because, and it's a challenging discussion with every patient, right? Because to your point, you know, some patients come in on, you know, home meds that either weren't restarted or they saw pain management during their hospitalization and want to make sure you resume all that. But then some of our patients hurt for, you know, ten years and then they start seeing us get put on narcotics prior to surgery because they're like, well, what am I supposed to do about my pain until you have my surgery scheduled eight weeks from now? So it's a challenge and I would agree this would be an excellent topic for us to discuss at our larger meeting. But postoperative pain control is a challenge. It is. Call a grown-up. Yeah, make sure your anesthesia attendings are doing the best they can. There's, you know, the long-acting lidocaine I think has helped a little bit as well that we're injecting at the time of surgery. So there are lots of adjuncts. Narcotic dispensing. Do you have quantity max dispense per type of surgery? I don't. I don't. I don't. I think it has to vary a little bit from patient to patient. I have certainly what I would consider my comfort level and I, you know, usually one or two, one refill for me is about all they're getting before I'm making sure they have a pain management provider and making sure you're protecting yourself and you're counseling appropriately and you're documenting appropriately and checking whatever it is it's crisp in my area, making sure they're getting narcotics one place. So I don't have a protocol per se, but it's, I'm cautious, probably too cautious. I don't think you can be too cautious nowadays. Well, you got to treat pain. No, no, it's the balance between treating pain and spine patients are, you know, they're not your typical patient. They're in pain. Yeah, they're in pain, right? This is another from Allison. I think managing expectations of post-op pain for large surgeon is also important. I agree. I tell patients before surgery, we're going to do our best. It's still going to hurt. Like she's a bad word. I think mental preparation on the part of the patient is important. So yeah, my spiel when I'm, you know, counseling a patient before a teeth end iliac is like, so the first two days you're going to hate me. You're going to be demoralized and you're going to be demoralized and you're going to hate me about this as to why you did this to yourself. And I'm going to be the person you blame after that, so on and so forth. And I talk out the timeline, so on and so forth. So then Allison commented that Tordol seems to be pretty effective, but it falls into the anti-inflammatory category. So you got to figure out how you feel about that. Again, risk benefit. I'm a little lighter on the NSAIDs, but yeah, they've got ups and downs. If I can get somebody off of a narcotics a little sooner, I may get them to some NSAIDs. Tordol, I love Tordol. I agree though, education, setting expectations, you know, telling them they're not going to be pain-free, movement is good, you know, get up and walk, you know, encourage them to push through. So, but yeah, everyone has their different, you know, pain is very subjective, obviously. All right, four minutes left. Laura, what is your best lesson learned about imaging in the postoperative period? To bounce off of what Lauren said, just as far as practice, or what you said, you don't, you can break out of your protocol. If I always, you know, if I got a third call from a patient about, or even the second call, the first call, I usually have to just talk them down. They did too much, they have pain, or they have radicular pain. I'll go ahead and get imaging right away. Exactly, yeah. Lauren, any lessons learned? I echo Laura, you know, listen to your patient, you know, it's good to have standards and, you know, methodology, but the education, as someone in our group mentioned on the questions, that it's education and setting expectations is a good part of what we do. Yep. Yeah, my best lesson learned is image the patient, that we had a person come to us, the only time I've ever seen spondyloptosis, someone got an L2 to five fusion at an outside place. And they'd been complaining of back and leg pain for days and days and days and got imaged until they had probably had an unpicked up parsed defect. And they slipped full on spondyloptosis, and they got a big fusion, it was a pretty big disaster. So watch your trajectory, you're, you know, you're holding your hat in your hand, if you just don't do anything, and you just tell everybody, this is fine. So get a picture. And if the picture is not convincing, get another picture, get the next picture. And, you know, take care of your patients. Trajectory is, I think, one of the most important things I learned. So that is, I think, about it. I'm looking at the last, somebody elbow agreed with me that Toradol is great. But again, it's on the inset category. And so we have trouble with that. Oh, someone asked about biologics. And if we have, I have no data on biologics. My experience, I'd like to get people off of their, their rheumatologic patients off of their biologics whenever I can. Yeah, we always try to stop them also. Absolutely. And last comment. Jordan would love this is again, thank you, Jordan, for your comment. I'd love more education discussion future cases regarding peri-op management of patients undergoing spine might include bowel regimen, pain management, drain removal, pre-op, post-op bracing, all that stuff. See in the spring, Jordan, we'll be back. We're learning and we're going to get better and make sure that we have the education that you guys want. So you'll get some information on feedback. So please offer us feedback of things that you'd like to see in the future. And we will continue to plan the best we can. So I think we're signing off of here. And you guys have another lecture in another room here shortly. So thank you for your time. And I'll see you over there. Thank you.

post-operative spinal imaging

spine stability

biomechanics

instrumentation techniques

bone fusion

surgical factors

pain management

patient care