I'm Khoi Thanh from Duke University, and along with Adam Kanter from Hoag Neurosciences Institute and Corinna Zurgarakis, I'm still learning your last name, from Stanford, I'd like to welcome you to the second afternoon spine section here at the AANS. Our first speaker is, we've entitled a visionary speaker, and truly a visionary, as it's Dr. Kanter himself, immediate past chair of the spine section, and he'll be speaking about the importance of leadership skills in surgery. All right, thanks everybody for finding this spot. Took me about 20 minutes just to see where I was going here. All right. Let's get started. Thanks for everybody being here, as I said, and to my co-moderators, we're looking forward to a great session. We've got some incredible speakers over the next several hours, and I'm sure everyone's going to enjoy this and learn a ton, I know I am going to. I was asked to talk a bit about the importance of leadership, and specifically in regards to urgent surgery, I know that's the general theme of this on-call meeting, and I want to make sure that I'm true to that, however, leadership skills are something that, it's not something that you pick up, right? This is something that you develop, that is nurtured, and the truth is, is that we are all leaders, everyone in this room, all neurosurgeons, all surgeons in general, whether you're leading an operating room, whether you're leading an organization or a society such as this, whether you're leading a division, whether you're leading your clinic and your staff, but your behaviors, your actions are going to be reliant upon all those around you to how the dominoes fall, especially in urgent situations, so something really important to think about and consider that we all have, and we've all been in that, in those positions. So, I was very fortunate, is that I got to train at the University of Virginia under an incredible leader, and that's right here, Dr. John Jayne, and Dr. Jayne led, he was the chair for four decades at the University of Virginia, as well as the residency director, and he was an incredible role model, a great leader himself, and a lot of people often would ask, how is it that you lead leaders? He had these visionaries, these giants, Chris Chaffrey and Ed Laws, and it was just, you know, the names of neurosurgery, and you'd say, how is it that you lead these guys? And Dr. Jayne, you know, had lots of answers, but Dr. Jayne responded that he would create a vision, he had a vision that he created at the very, very start, and got folks to trust in that vision, to trust in him and that vision, to join the team, and then he would empower them, and most importantly, he said, once you empower them, then you get out of their way, and you let them do what it is that you hired them to do, and that is the true sign of a real leader, is when he's able to step back and let people plow themselves forward, and one of the hardest things, he said, was actually trying to get this group, this massive group of leaders to work together, and I'm going to tell a short story, because I feel like this is a nice way to bring it together and look at true leadership, is that everybody's familiar with the Dream Team, everybody remember this? There's a few students in here that probably weren't alive at the time, but the Dream Team was when Larry Bird and Michael Jordan and Magic, you know, Michael Irving, they were the elite basketball players, and back then, the Olympic Committee decided that the NBA players could actually play in the Olympics, so they put this, the Dream Team, together, and not surprising, they destroyed the competition, the average margin of victory was 42, and a lot of these games, they were just having fun at the end, so it was kind of a no-brainer, and of course, four years later, the next Dream Team, USA, they picked, they got Shaquille O'Neal on the team now, and just incredible players, again, the elite, and of course, again, Olympic gold, this time was by 30 points per game, right, so the margin is not quite as high, but still a very solid win, and taking home the gold, in 2000, what we can see is that we've got another group of amazing, incredible leaders, and these guys, of course, brought home the gold, but interestingly, they won the semifinals by only two points, and that was pretty darn close, and actually, Yugoslavia tried for three, and if they had hit it, they would have, the US would have lost, and then they won the finals by 10, but what you notice is that the margin of victory kept shrinking, but also the game was changing. Remember, at the beginning, it was Larry Bird and Magic Johnson, these guys had more assists than they did points, right, at any given time, and so we had a different group of players that were now engaged in the game of basketball, still elite athletes, but the game was a little bit different, 2004, where things went a little bit awry, again, amazing, incredible players, you can see LeBron James joining the team there, remember how that ended, though? The US was embarrassed, in fact, they barely got bronze, they got their medals, but look at these faces, this is after winning an Olympic medal, these guys were not happy, right, they lost three games, in fact, Yugoslavia had a better record, who came in fourth, but something went wrong, right, what happened, how did the US go from the dream team to five and three, and they did is they hired this guy, Mike Kraszewski, who was an extremely winning coach at Duke University, and they asked him, what happened here, what went wrong, and he dissected this for months to try and figure out how these amazing, incredible elite players didn't take home gold easily, and what he found is that you have these amazing, incredible elite athletes, and they were playing their own game, so you had LeBron James playing his game, each of these guys was playing their game, but they weren't playing together as a team, there was no team, and also, what he found is that they weren't playing for a purpose, at the very beginning, when the guys first started playing for Team USA, it was their first time representing, and each time they're on, it just seems like they lost the purpose of why it is that we are here, and what is it that we are doing, what are we representing? Four years later, so he started working with his team, he picked his own team, and said that he was going to create a group that were going to play that game differently, that's what Mike Krzyzewski did, Coach K, and he brought them all to the Statue of Liberty, and he reminded these folks, he said, I want you to think of your ancestors, not yourselves, I want you to think of your ancestors, way back, the folks that came to the United States of America, the hardships that they endured, for that you not only have this amazing, incredible opportunity to play and do what you do, but for you to have the freedom to do what it is that you do, and it just changed the morale, changed the morale, and he also introduced them to the Wounded Warriors group, so he was, again, refocusing them, providing them with the purpose of what it means to represent the United States of America, and these guys played with a different level of passion, in a different format, and we all know what happened from that point forth, right, these guys played as a team, and they played with purpose, and I don't know if you know this, but at the end of Olympics, of the team sports, all the athletes get a medal, but the coach doesn't, and at the end of this game, when they got gold, that's what this team did, is they all put their medals on Coach K, because they knew that he was the reason, he's the one that brought them all together, and made them remember what it's like to be a team, he was their leader, they were all leaders themselves on their teams, but for Team USA, it was Coach K, he gave them purpose, and he reminded them what it's like to be Team USA, and this isn't just in the Olympics, year after year, so 2012, 16, 2020, Olympic gold, Olympic gold, Olympic gold, Coach Wooden, very similar, another college coach, did something very similar, at UCLA, Jack Clark, with Cal Rugby, head coach, we're seeing this in sports, right, the most important thing for him, was your performance in teamship, you're a member of this family, as long as you remember this rule, but we see it outside of sports, right, we see it in business, with Steve Jobs, if you asked him, he was asked, what is the most impressive thing, something you're most proud of, that you were able to create, think of all that he's created, and he said, it's the team, I'm most proud of the team that we put together, to be able to bring this forward to you, and then of course, he empowered each and every one of them, so let's think back of other qualities, right, obviously, you want to be able to lead a team, particularly in times of stress, everybody knows the game of chess, we know how many pieces there are, we know what those pieces are, where they belong, the rooks and the kings and queens, and the knights, we know the board, we know how to set it up, in fact, good players can think three or four games, or three or four moves ahead, and they can adapt as necessary, but what happens if the rules change, what happens if all of a sudden, there's more pieces, we're different pieces, what happens if all of a sudden, there's a whole bunch of boards, and all of a sudden, the rules are different, there's chaos, right, there's uncertainty, and this is where leadership really shines, when you can come in, when you don't have the answers, you don't have all the pieces of the puzzle, but you're still willing and able to take risks, and put your neck out there, and try and come up with solutions to problems, in times of chaos, and crisis, and urgency, Nelson Mandela, everyone's familiar with Nelson Mandela, another incredible leader, was the first black president of South Africa, after having spent 27 years in prison, and there's a short story about, a true story about him, that he was actually on a prop plane, he went to go on a trip, and this was when he was president, and they put him on a prop plane, and he grabbed his newspaper, as he goes on, he loved newspaper, because that was his, you know, a sign of freedom to him, that he could read the newspaper, so he was always reading newspaper, about midway through the flight, he was reading his paper, and he looked out, and he saw, that one of the engines, one of the props had stopped, stopped spinning, and he kind of calmly motioned over, and brought over the attendant, and said, can you let the pilot know, that the prop is, doesn't appear to be working, and so she went back, and she talked to the pilot, of course she came back out, and whispered into his ear, and said, he's aware of the engine failure, and they're preparing for an emergency landing, and they're foaming up the runway, and doing everything, and put these bands out, and doing everything they could, and he said, thank you, and then he picked up his newspaper, and started reading again, and everyone in the airplane behind him, was getting a little freaked out, thinking, what's happening here, what's going on, are we, are we going to crash, and they noticed, that president Mandela was reading his newspaper, calm, poised, collected, because he knew, he knew what would happen, if he reacted in a way, that everyone else was, was beginning to react, and that was his role, as the leader, during that crisis, and when he landed safely, when he landed safely, he actually went up to the pilot, said, my god, that was scary, and no one else knew, how terrified he was, but the point was, he maintained that leadership presence, during that moment of urgency, and crisis, he said, it's okay to be afraid, but you can't let that control your actions, or your influence on others, because as a leader, you're going to be influencing everyone else, that's looking after you, and we all acknowledge Dr. Ed Laws, here, for a Distinguished Achievement Award, earlier, just two nights ago, and I was lucky enough, and fortunate to train with Dr. Laws, at the University of Virginia, and he was a leader, and a gentleman, and everyone knows, that trained with him, that he could be a tough, he could be a tough guy, to work with, he could be loud, and he didn't even have to be loud, to be loud, but I remember one of my, one of my colleagues, one of my co-chiefs, there, had a little issue, and got into the carotid, through the cell, at one point, and of course, you know, tremendous bleeding, and Dr. Laws, took over, calmly, and quietly, and helped solve the problem, helped fix the problem, without, without raising, raising his think, without getting upset, he just took over, and maintained his poise, his calm, and collected, Dr. Laws, and that was him, and that is why, and this is, this picture's from just two days ago, at his, at his celebration, he has created a legacy of leaders, because he was someone that we, we looked up to, was our mentor, and one thing that he brought up, which was interesting, and I want to, I want to actually bring up myself, is that he has written thousands of papers, his very first paper, his very first essay, he wrote on collegiality, and I think it's important to make note of that, as well, and again, I'm still learning from Dr. Laws, even two days ago, is that he said that, just be collegial with people, and everything just seems to go so much smoother, when you're, when you're a leader, and you show that, people behind you, as well, maintain that collegiality, and it's, it's, it's quite refreshing, so as we move forward, and consider the important, the important traits of leadership, create a vision, and every now and then, check back in with everyone, with the folks in your operating room, the folks in your clinics, and make sure they remember why it is that they're there, because it's easy in the day-to-day, to lose the why, and it's really important to, to bring folks back, and remember why it is that we're in here, create an environment of trust, amongst, amongst the, the group itself, of the team itself, and those that, that you communicate with, have a leadership presence, know that everything that you do, is going to influence all those around you, and, and really, to get the gold, is empower, empower everyone, so thank you very much, appreciate the opportunity to speak to you, and I'm going to have Shea Bestcomb, come on up, because also being a part of leadership, is leading research efforts, and we're going to hear a little bit from Shea, about that, great talk, thank you, super talk, thank you, well, thanks for getting me in, I, the United Airlines is pretty typical, it moved my flight up an hour, and they said, well, that's what you have, so these guys graciously got me in, so I think you got to pick my, my, oh, I'm sorry, that's all right, and here, and then just click on myself, click on yourself, and then click start, perfect, oh, it's good, awesome, so, um, what, it, it, that's a great talk, Adam, I mean, I think that it really, you reflect on yourself, as you, as you listen to these talks, and, and, you know, what, what are we doing with our, our careers, and, you know, what's happening with me, and my career, so I've been asked to talk about the impact of multicenter research to unify spine surgery, and improve patient care, so a background on me, I am the president and founder of a non-for-profit research foundation called the International Spine Study Group, which really is blind, I think, to orthopedic surgeons and neurosurgeons, we're all spine surgeons, I think, I think everybody in this room probably feels that way, that's just a function of our training, so what I'm going to do is go through how we have formed this foundation, the impact that the foundation has had, and then maybe, you know, as all of you look toward the future for yourselves, your careers, or where things are going from a research standpoint, you know, how this remains impactful, and how that could apply potentially to your career, I got to click it here, all right, so here are my disclosures, most of it comes under the ISSGF research support, so again, we're a non-for-profit research entity, most of the funding, though, comes from industry, and so if you look at the formula for high-impact research, right, typically from some of the older papers, Twin Cities, Wash U, Jefferson from a spine standpoint, UVA from a neurosurgery standpoint, a shock trauma, Harborview maybe from orthotrauma standpoint, you know, the single center dominant with a few visionaries that were then able to compile cases and then do research based upon the experience at that institution, but I think what we're seeing now is this emergence of multi-center groups from a research standpoint, the question is, you know, why is that spine deforming group, the HARMS group, and then more recently the ISSGF, or International Spine Study Group, is what myself and Adam and Coy are a part of, it's much more than just the success of a large membership, you can pull a bunch of people together, but you have to make them be able to work together, right, and so that the big thing that we get from this, from a success standpoint, is not only high volume for cases and ideas, right, as we pool our cases together, but we have this concept of collaborative intelligence, and as we work together more and more, we tend to have this machine learning, as Jake can attest, working with us initially, that as we work together more, and I'm sure you find it with your peers, you find this gel or this synergy as you further then synthesize the research that you're able then to put together, and so I think this really has given us a new concept now of academic medicine, right, and so the benefits of a multi-center versus single center, I think are multiple, right, so number of cases and collaborators, but more than just the collaboration, right, it's diversity in the cases, the diversity of ideas that the collaborators then bring, and then because we're a private foundation, right, we're able to form this nimble entity, compared to bureaucracy, which is typically seen from a university, the other piece also is that we own our group, and we own our data, and so with that ownership, I think that we take tremendous pride in terms of what we do, and so again, what I'll go through is the structure of productivity, and then show how this is a viable model for the others in the room, so here's our mission statement, we're a private independent foundation, we formed our 501c3 in 2010, and the idea then is to improve the education research for all spinal deformities, including the cervical, thoracic, and lumbar spine, and the mainstay of this, you can see in this next bullet point, is we engage in prospective observational multi-center studies, but the big piece, they are prospective studies, so it's level two evidence from a prognostic standpoint, level three evidence from a therapeutic standpoint, meaning that we have these a prior hypotheses that we then put out, and establish, and register with the NIH prior to engaging in all of our research, and I think if you are going to form a study group, it's extremely important to do that, so you aren't just seen as somebody that is just kind of mining the data, and then we have standardized CRFs, both written and electronic, where we capture the data, and then we host all our images, all the radiographs, and all the data together on one online platform, and then we have four full-time personnel hired to then query, and go through the data, and we do a weekly data query at all the sites, as they upload all the data onto our online database, and then we have weekly meetings to go through what that looks like, and then each site has a study coordinator, we then have an executive committee, and then accountants, and a legal group, so it really functions much like a business, so here's who we are, about 28 sites in the U.S., Canada, 40 surgeons, and again, no real differentiation whatsoever between neurosurgeon orthopedics, in fact at this point, it means absolutely nothing to me, in terms of how you train, we're all spine surgeons, but I think especially, we're all clinical researchers, and the clinical research that are with us, have the same pull, the same access to data, the same rights, as do the surgeons. We meet four times a year, the big thing for us, is the members fund all their individual airfare, all their individual food, and lodging, which is critical to maintain our budget, and it's not this big party, as we all get all together, and blow through all our money, I think money talks, and if you're going to sit down, and if you're going to actually pay to play, and pay to be involved in the process, you really take ownership in this. The other piece also, if you look at the meeting standpoint, for example, in 2021, we had 107 ISSG Zoom calls, so roughly one, a little under every three days, in terms of preparing, getting our data ready, and then getting things geared up for us. The other piece also, that Adam talked about, was, and hopefully that, like John Jane did, was namely dividing the data, and the effort into these working groups, and you can see we have about eight working groups here, and that allows us then, to then divide up the data, and then provides really strong function, and leadership within our meetings, and oversight to the data. So the MIS group is run by Praveen Mumineni, for example, Complex group is run by Manish Gupta, Chris Ames, and Justin Smith on the cervical group, and then so on, and so I think that what this does then for us within the group, is going to engender leadership work synergies, as well as relationships, forcing us all to work together, which has worked out pretty nicely. So here we are, not a ton of patients, about 4,662 patients enrolled. The big catch about this, which you'll see next on our CRFs, is we have about 5,000, between 5,000 and 500, 5,500 data points per patient, so extremely granular data, in terms of how these patients are treated, and what their associated outcomes are. So here's one of the studies that we registered with the NIH, it's called the CAD study, complex adult spinal deformity study, and so what we do, what we want to do in this study, is look at then the patient at the higher risk, based on our previous study, so then based on a regression analysis, we then found the patients that had the longest length of stay, had most complications, and so you can see three different criteria, in terms of enrollment, which I think is critical, as we look at things now, not only from a patient demographic standpoint, and a deformity standpoint, but also a procedural standpoint. So once they meet any of those three criteria, they are then enrolled, then in the study, and this is actually a 10-year study, and so you can see these standardized follow-up windows where we collect the discrete data categories and variables within it. The other piece also is that all our data, which is now housed online, now follows this same exact windowing and platform, which is gonna allow us then to compare cervical deformities to outcomes for open thoracolumbar deformities to outcomes associated with MIS deformities, all following this same then assessment platform and data collection platform, which I think really homogenizes the data for us so we can compare apples to apples if we can. Here's some examples of the CRFs, right? Surgical implants and biologics data that used at every level on each and every patient, inner body and osteotomy data, then all the patients, and then here's our economic data for these patients, and then we also obtain frailty and functional assessments as well as using the PROMIS-CATS for these patients to look at then outcomes from a psychological as well as functional standpoint for these patients. And then what we do with the data then is we look at how each site then is performing. This is the open group. This is one of our last polls that we did over December. We have another big poll coming up, and then we assess each site. We see what they promised to enroll. We see what they created, but the big thing also is we wanna see diversity in total enrollments, namely it's not all coming from one site, but they also then track the percentage of usable data for these patients, and you fall below a threshold, then you're asked to no longer enroll in our studies until you can get the quality of your data then back up, and then if you can't quite get it back up, then you'll be asked to leave the group. So here's what it looks like from a quality tracker. We go through this on a weekly basis, seeing how each of the sites are performing at each of the follow-up windowing metrics. Namely, they've created some events, but we can't use the data until all of it has then been QA'd, all of it's complete, all of it's been then approved for then final use, and then we track how much of the data that you then put in, in the two categories, and assess the amount of data that then is usable. So the question is why would you put up with this torture? Meeting schedule, flying yourself to four meetings per year, 107 Zoom calls, why incur the cost, right? Airfare, hotel, food that you're paying for by yourself, time away from work and family. The other piece also is we're productive, but actually approximately one third of all abstracts that we create then internally are rejected internally before they even get out of the group, and so we use our own internal policing and act as our own internal review board to hopefully get out products that are then high quality and polished. And so what we found is the tremendous research and productivity. We average roughly now about 70 to 90 abstracts per year. We've dropped it down to 60 some of the years, and here's our productivity from the SRS standpoint, and then here we are from a NAS standpoint. It's interesting, because what you see here, I'll pull away from the microphone, is you can see, and this is what you'll see probably in your practice or any entity that you then create, right? You have this initial lead up here where you're kind of sputtering along, trying to get along, your data's trying to get right, and then if you can then persevere, that's that big jump from 2752 to 76, and so we're at a point now, namely that we know we can be productive, but then the real question is now how do we maintain relevance? How do we put out compelling concepts and generate ideas that are then seen as then relevant to our societies, right? About 400 publications, we have about, average about 35 to 40 publications per year, and then actually Dan Shuba gave us an idea a while ago. H index for our entity is about a 58, which tends to be a little better than actually most university departments. So lessons learned, I think, from RSSG. This is kind of a snapshot of what we do and what we're trying to pull at them with all this time, and same with Coy and Jay. I think this really represents an evolution in terms of academic medicine, right? Using now technology for data capture, hosting everything online, and then using video conferencing when we can't get together to actually share concepts, ideas. Probably I think that this represents a true unification based on then the platform of research for all spine surgeons. We're totally agnostic in terms of what you do and how you do it, just so long as you can capture high-quality data and contribute. The other piece also to our success, and much as what Adam had talked about, right, is camaraderie, friendship, mutual respect for each other. And the big thing that has allowed our success is that platform of mutual respect, but then also this collaborative intelligence and true ownership that we have in our data together. And I think this represents a viable model for really all generations of spine surgeons. And probably the mainstay of our success, I don't know if anyone's heard, is the amount of wine we drink. So I highly encourage you guys to drink a lot of wine if you endeavor on this. Thanks a lot. Thank you. Thanks so much. It's truly an honor to be a part of it. And I think what, for myself, it's, as that one slide said, is membership is conditional. And it's about quality. And what I believe the ISSG really has brought, for myself and many others, is that it brought us back to the why. And oftentimes we'll put three or four abstracts out, and it'll come back, and they'll go, this is great, guys, but that's one abstract. Let's put it together, and let's improve the quality. So thanks for being a part of it. Oh, it's a pleasure. Yeah, and I think that the other piece also is that in terms of the why, constantly reassessing what we're doing and why we're doing it. Namely, how do we stay relevant? Can we just pump out a bunch of abstracts? What's the value of that, really? How do we then remain relevant? But I think that remaining relevant and remaining current are probably two different concepts. And I think in your career and in the research that you do, if you've had an impact, you're gonna be relevant, but you're not always current. And so I think that that's a big effort that you need to then constantly check on is are you current? Are the things that you are doing now current and impactful at the current time? So thank you. Thanks. Great, thanks, Jay. We're gonna shift gears a little bit and invite three panelists up to the stage. So that's gonna be Dr. Anthony DiGiorgio from UCSF, Dr. Yi Liu from the Brigham, and Dr. John Shin from MGH. And one of the focuses of this year's meeting was really to address topics that would be useful to all of us in order to take a call effectively. And so originally the plan was just to have each of these speakers talk about a specific entity, but in the spirit of conversation, I was asked to put together a few cases that will then be addressed by our panelists here. So I thank you guys. And so this is a first case. So a 77-year-old woman with low back pain, let's just say started a few days prior, worse withstanding and transitions, also has lower extremity pain and numbness, fevers and malaise. You can see her past medical history lists there. And then labs obtained in the ER demonstrate these elevated inflammatory markers. So this is the imaging, and for whatever reason she wasn't able to receive contrast. But why don't we start with Anthony and talk about how you go about evaluating this patient. Yeah, so I think the primary thing to see is is there a progressive neurologic deficit. That's what makes this from urgent to an emergency. She has some paresthesias, it sounds like, some numbness and tingling, so I'd certainly be worried that she is, that she's developing what will become a neurologic deficit, possibly cauda equina. I think it's important to get a PVR in all these patients, post-mojo residual. So that'll tell you if there's true cauda equina syndrome or not. I know we'll get to that too, but whether or not she has compression of the cauda would make this an emergency. You mentioned the pain with movement. I would like to see if she has weight-bearing X-rays, standing or flex-X, to see if that slips. But I think regardless, this is someone that's gonna need an operative intervention somewhat urgently. Okay, now let's say she's completely intact on exam, but she just has the lower extremity sensory issues. Does that impact your management compared to if she has a neurologic deficit, or is this someone you fire up for surgery regardless? Yeah, if she's otherwise a good surgical candidate, I think there's some data showing that with this large of an epidural abscess, the chances of it resolving with conservative management are low, but I certainly think this is someone that could be observed, but I'd be really worried and ready to pull the trigger if she starts developing any sort of neurologic deficit. And I think, all things being equal, she's probably gonna head towards surgery at some point. Yi or John, any other viewpoints? Yeah, and this is, I think, for targeting for more of the on-call residents or young neurosurgeons, and a lot of time, the diagnosis for epidural abscess is actually the most difficult part before the imaging study. A lot of time, we got presented with imaging showing the epidural abscess already, but for a lot of the ED physicians or PCPs, how to make the diagnosis is actually the most difficult part. Like, low back pain is such a common thing, and how to screen the patient to say which patient need imaging MRIs. And I think that this patient presented with a classic triad, back pain, fever, and focal neurologic symptoms, and those are the patients that require the imaging studies. For this patient, yes, I would say surgery is definitely needed because clearly, the abscess has caused the destruction of the disc space, which seems to be causing instability. So for that particular reason, he will need surgery. And for the abscess drainage, the study has shown that most of the time, you do need to drain the abscess to be able to clear the abscess, especially with a lot of MRSA that's prevalent, that's very, very resistant to medical treatment. Thank you. I think these are really tough situations, and I think, subject to so many factors and variables, and I think that I acknowledge these are very difficult to manage, and even contemplate, how do you decide taking that patient to surgery? And I think that if they have a deficit, that sometimes just triggers us to do something about it. But I think looking at this MRI and CT, I don't know what everyone else thinks here, but I see something that is involving almost every single level that's here to varying degrees, with discitis, maybe air in the disc space. Especially higher up there, you can see, that's, I think, a thoracolumbar junction. And I don't know how it is with the panel here, and you, Coy, but I know at my institution, infectious disease want us to operate on almost every case. And we talk about antibiotics, and do a needle biopsy, oh, it's accessible, just ask a radiologist to get a little bit of something, dorsally. And they're like, no, it's not gonna work, why waste your time, just take this patient, and get muscle, bone, fat, epidural stuff. Because they know that's what we can get and access. And so I think there's a little bit of that, too. So I think that also pushes us, at least at MGH, where the infectious disease team, they're really aggressive in terms of trying to, pushing us to get tissue and to do that. Because maybe it's, I don't wanna say they're jaded, but they also think that they don't wanna really rely on antibiotics alone, knowing that there's such extensive bacterial load, potentially. So, I don't have the answer, but I'm just throwing it out. That's the kind of things that I'm thinking about. I think that's interesting, and that's a good point. Our infectious disease doctors are all about source control, as well. They mention it in their notes all the time. And I've looked at their literature, and it does tend to back it up. And I think this is, interestingly, one pathology where the medical literature is actually more surgically aggressive, and the ID docs at our institution are exactly the same. You know, they want source control. And if there's a source that you can easily access, and identify the bacteria to be MSSA, and if the epidural abscess is relatively small, I think there's option for conservative treatment. And I think, actually, Mitch Harris published a paper that indicating that MRSA, for example, in patients with diabetes, that tend to not do well with medical treatment. But if it's MSSA, small epidural abscess, there's a potential. And it's in the lumbar spine. We're not to worry too much about spinal cord compression. There's a potential for conservative treatment. Yeah, so, you know, this person obviously has some areas of compression, but as John pointed out, pretty significant involvement in multiple disc spaces here. So let's say, I mean, she has a deficit and needs surgery. Anthony, what type of operation are you doing for this person? At the very least, an open laminectomy. Probably at least three, four, and five. Whether or not to put instrumentation, that's a tough call, and there's no real good data either way. I think there's plenty of data showing it's safe to put titanium in an infected field. You obviously wanna stay with, if you're gonna put an inner body or anything, you wanna stay away from peak. That's the one thing you absolutely don't wanna put in in an infected field. But titanium, there's pretty good literature showing that you can safely do it. But I think, again, depending on how healthy she is, otherwise, it will depend on the amount of surgery. If you can get away with something minimal, you know, I think just a laminectomy to start. You can always get weight-bearing x-rays after and assess and go back and fuse if they develop an instability. This is probably unstable, just with these images here. But you could still just start with a laminectomy, I think. Yeah, for this patient, clearly it's unstable. But if you want to avoid metals first, which most of the time you don't need to, but if you want to avoid metal, you wanna stage it out, and you don't want to destabilize the patient by doing a laminectomy to increase the instability, you can consider an endoscopic. Endoscopic will be a pretty cool tool for this kind of approach. Access the disc space without destabilizing the patient. End the stage in the patient later on for instrumentation. Yeah, I think clearly the location of the major infectious process here, like it's lumbosacral, I think plays a role. But I always, same thing, I'm asking actually more questions than providing answers, but the one thing that I'm thinking about all the time is, you know, whether, in a lot of cases, they have some type of deformity, right? Kyphosis, especially thoracic. They may have fracture or just horrible-looking institutable bodies, and what I always think about is, do you treat, or should you consider that deformity in acute setting, or are we just trying to decompress, spare how much bony resection we're doing, and then deal with the deformity later as a post-infectious deformity? So I agree, I mean, I think that L5-S1 looks terrible, but I don't know how many here would do, like, an ALIF and T-tentapelvis in that setting, right? I think that they most probably just decompress, get some tissue, and do the best that you can. You know, the back pain is likely multifactorial anyway, so I think it's hard to quantify. I mean, I think we go with that, like, what's mechanical, we do that in cancer, too, right, this mechanical pain, but it's hard to really quantify that to a degree, so I would say, if you're really forced to, my own take, I would probably just decompress there. Yeah, and let's say, you know, for whatever reason, you do decide to instrument, how do you guys typically manage antibiotics in the post-operative setting? The ID doctors are gonna want, you know, rifampin added to their regimen, and probably a PICC line, and usually six to eight weeks. I think the bacteria will be very important. The treatment for MSSA and MRSA will be very, very different. Yeah, I'm curious what everyone else is here doing. Is anyone putting in stimulant beads in infection cases with antibiotics? Are you guys doing that at all? Does anyone know who that is? Paul? Has this patient had an infection before? He has had four bites, he's already fused. It certainly looks like it. What's the natural history of somebody that you can do an evacuation, and the Bureau of Lab says, but you don't fuse? Do they eventually fuse these? Do they fuse melanin? I think if you have the luxury of keeping the patient bed rest for months, then they're probably eventually gonna fuse, but. Are they then unstable? The 5.1 looks very unstable. I'm concerned about 5.1 here. Paul, you had raised your hands about antibiotic beads. Do you have a comment on that? Not a comment. I'm not aware of any good literature in the spine surgery world, but I think it makes sense. I mean, these beads, I think you can get them in different sizes, and then over the course of weeks, there's at least antibiotic in place of beads, so I've used it before. Honestly, I feel like it makes some sense. I mean, they all get antibiotics anyway, so it's hard to tell. Honestly, I've never heard of it. They're expensive, though. I mean, so I don't know what anyone else feels, but spine infections, if you could kill someone, I think every doctor would give you the treatment, so I think it's worth the cost. I don't have a good sense of that. There are plastic surgeons at the time of, if we need to, if we are doing a case where there's a wound infection or osteo, our plastic surgeons will like to use these beads with gentamicin, vancomycin. I think they're vancomycins, too. Yeah, yeah, okay. In the sake of time, we wanted to make sure we addressed the other sort of two common things that we'll see on the call, so thanks, guys, for your feedback on that case. Let's just talk about this one. So, a 63-year-old woman who presented with a left foot drop. So, three days of low back pain and a left foot drop, as well. No particular precipitating events. Extensive past medical history, and on exam, has a left tibialis anterior. That's a one out of five. So, MRI here demonstrating this disc herniation. John, you wanna talk us through how you go about managing this? Sure, is there radicular pain with this, or is this painless foot drop? How does your approach change based on? I don't know what to say. I'm just trying to pass the time. Radicular, we'll say, yes, pain. You know, I think that, I would say, in the context of having acute pain, radicular pain, and I'd have to obviously see, you know, you see the patient, assess them, and if they're just writhing in pain and miserable, you talk about doing an urgent operation. You know, the qualifier to that, I'm sure many have here of experience, is that, you know, I see patients in clinic who come to me maybe sometime, you know, months after having an acute period, and then they tell you, oh yeah, I had a foot drop, but it got better. You know, and then you get the MRI, and there's still something there. And so, there is something to be said. I think that there is improvement, but I don't know how you predict or anticipate, you know, those patients that are gonna have improvement after an initial profound, you know, sort of pain crisis and injury. So, I struggle with that, but I think that it's kind of just talking to that patient, seeing really how miserable they are, and how feasible it is that they're gonna get better, and just having that open discussion and saying, hey, we could do this, you'll probably feel a lot better. But, you know, there is a chance that without it, you could also improve. He, Anthony, any other thoughts? Yeah, I think the level of weakness is very important here. I'm very worried about if one out of five, and that would prompt me to take the patient to the OR sooner than later. If it's three, four out of five, then there's much better chance of recovery, that depend on the level of pain. If there's a risen pain, then yes, you want to take the patient to the OR sooner. But if the patient had painless weakness with a three, four out of five foot drop, you may not want to take the patient to the OR. At least give a little bit of time to observe. I think this is a good case to reiterate the importance of knowing how to interpret the support trial. So the support trial randomly assigned people to conservative versus surgical management. And the neurologic deficit was not an exclusion. So there were patients with neuro-deficit in that trial. And the long-term results essentially showed that the surgical candidates got better quicker, but in the long run, it evened out. But if you look at the crossover rate, there's a 30% crossover rate from non-operative treatment. And they didn't intend to treat analysis on that. And so I think that kind of reflects what we're talking about in real life practices, that you may try conservative management in some of these patients if they can tolerate it. You know, if this patient maybe gets better with a medical dose pack or something like that, maybe you could try. But if they're sitting there writhing in pain, not able to walk, not able to go back to work, there's some way that even if they were assigned to the medical arm of the support trial, they would have crossed over into the surgical arm. And so I think that the support trial really just reflects real-world practice, and that you can try conservative management in some of these. But if they're unable to tolerate conservative management, you have every right to go in and take the disc out. Let's just go through Cauda-Quinoa syndrome quickly. So a 37-year-old man with back pain, leg weakness, bowel, bladder incontinence. Some past medical and social history there. And essentially, you can see profound weakness in the ankles with diminished rectal tone and morbidly obese. So this is the MRI here, so just some specific questions. First for Anthony, I know at UCSF you guys have done neuromonitoring and spinal cord injury. Is there a role for neuromonitoring here? Does it serve any sort of prognostic value? There might be, but I don't think that that's well studied and I certainly wouldn't wait for neuromonitoring to show up to take this case to the OR. I think this is someone that needs to go relatively urgently. And Yi, I know you do some MIS surgery. Something like this, are you treating open, just to make sure you get a really nice, wide decompression or is there a role for MIS, especially given this patient's morbid obesity? I think either option is you want to make sure whichever method you choose, you want to get the patient good decompression, make sure all the colloquial nerves are fully decompressed. I think that's a key method, it's just a tool. And I would say that the cases you present to us, you're too nice to us. That's like a very clear diagnosis already. And a lot of time, we do see patients may not have such a severe compression, presented with questionable bowel and bladder symptoms, back pain, then that's become a difficult issues with what to do with those cases. And John, any final thoughts on this one? No, I think that the BMI is obviously a factor, but you can't modify that in the acute setting. And I think here, there's clearly pretty bad compression, maybe even some epidural hematoma or something else going on in there. So I agree, this is one of those cases where you just decompress from what's been presented. The patient seems like an extremist, so it's not really any other recourse. All right, well, please join me in thanking our panelists. Appreciate it, guys. Great patient care. We will ask John Shin to stay, as he's our next speaker, sort of segueing to two more topics. Okay. Okay, good afternoon, everyone. Thank you for being here, and thanks to the organizers for inviting me to speak. So I think for the next several talks, we're gonna focus on tumor a little bit. And my topic is follow the patient, spinal metastatic disease and neurological deficit. And I'm gonna share with you a case that I had in the last year, six to 12 months, that I think really emphasizes the value of following these patients through and through, even beyond when we operate on them. So this is a 52-year-old woman, otherwise healthy with known diagnosis of colorectal cancer, who's had numerous rounds of chemotherapy and radiation related to the primary site of disease. She presented, I saw her initially for this T12 virtual body lesion that you can see here. Some representative example slides here. There's, you can see marrow replacement there, but there's no core compression. Overall, the height looks pretty good. We discussed this patient in multidisciplinary fashion, and this patient then proceeded to get conventional radiation, 30 fractions, I mean, 30 gray and 10 fractions, which is pretty typical. And this, as you can see here, that's the axial section over time. You can go back here, but basically, after the radiation, she developed fracture and retropulsion, and with epidural compromise and extension to the pedicles. So after that, considering her previous radiation, I took her for a posterior-based approach with vertebrate T12, anterior column reconstruction. That's with a carbon fiber cage. I also used carbon fiber screws above and below that level, anticipating this patient was gonna get stereotactic radiosurgery afterwards. And at our center, that's 24 gray and two fractions. And that's what that looks like. That's a hybrid construct using titanium screws above with carbon fiber screws, carbon fiber rod, and you can see the reconstruction that's there. Now, the next step was gonna be SRS, but one month after surgery, she had urgent surgery for bowel obstruction, and then she presented with leg weakness, three out of five, and severe pain. And initially, when I saw her, you can see on the X-rays, you can see the red flag. There is subsidence of the cage there on lateral and AP, and repeat MRI demonstrates cord compression right behind that cage and also above that somewhat. Axial section, just show that. You can see the artifact from that cage, but also you see extensive amount of tumor posterior to that, also compressing and displacing the spinal cord and the fecal sac. So now what? So initially, the patient didn't have a deficit. Now she has a deficit and already had an operation. Thankfully, everything had healed, but now what we're faced with. So I took her to urgent surgery, explored her that night, took her to the operating room, opened everything up, extended the instrumentation. And again, I try not to fix the cage as ugly as it looks on the X-ray. This was clearly an aggressive cancer. My goal was to maximize the separation and get the spinal cord decompressed and get her to stereotactic radiosurgery. Our radiation oncologist had agreed we're gonna get her treated right away, and so that's what we did. Her leg strength improved. She ambulated prior to DC to rehab. Then three weeks later, as we're planning the stereotactic radiosurgery, she came from rehab to the radiology suite. She had a CT myelogram, and I got a panicked call from the radiation oncologist saying, hey, there's something bad going on here, and she's really not that comfortable. And these are the images from the CT myelogram. The arrow points to the contrast, and you can see there's nothing flowing above that level. And on the AP and lateral, and this is the actual CT myelogram image that's there. Limited mobility, she looked terrible. Saw her in clinic, and now her legs are two out of five severe pain. Sent her to the ED, and this is what the MRI shows. It almost looks like I did nothing that last operation, and my heart really sank at that time. And you can see here the extent of spinal cord compression. It's everywhere, and whether on the T1 or T2, can't really make out any CSF, just like what the myelogram would show. And so based on that, again, she had previous radiation, surgery times two. Thankfully, she never had any wound issues, but now she's been off of systemic therapy because of her spine-related issues, and now what? And so we made that tough determination to take her to surgery, and this is what it looked like. This is how it started, opening this, previously irradiated wound. Hard to see normal, but everything looked abnormal, and so had to take this apart, take down the scar tissue, the epidural tissue, find the spinal cord in there somewhere. So extending the laminectomy above, finding areas of normal and working towards abnormal, and then finally something like this where I ended up resecting essentially T11, T12, and L1, and reconstructing that, and providing stability across that. So the good news is she finally recovered. Five out of five, she actually walked, went to rehab, and again, this is the reconstruction. It's three-level vertebrectomy with inter-column reconstruction, and this myelogram shows that we're able to do exactly what we wanted to do, which is restore CSF in front, get her to radiosurgery, and get her back on clinical trial. That's a tough case, and I think really accentuates the value of following these patients along because they're always gonna have some other issue, especially with all these oncologic cancer factors, and just briefly, what are the goals? We have to think about all these goals. We have tools like the SIN score. I know Dr. Rines is gonna go into this somewhat. We do have these tools to think through these difficult processes, but as this case shows, you may have a patient with a neurological deficit. You can think about instability. You can think about their cancer and the radiation, but as surgeons, we're really not that good about thinking about the survival. We're really not great about predicting complications and thinking about what surgery's too invasive. Is it too much surgery, and is it worth it? And my last slide, I'll end with this. It's important to follow these patients. There are a lot of considerations here to consider, including their nutrition, their frailty, in addition to all the things that we look at on MRI imaging. So, thank you very much. So, before we move on to our next speaker, our next John, any questions for Dr. Shin? How long did that last surgery take? It took a while, and that last operation, every single time I did that case, I kept thinking, should I call my plastic surgeon? But it was always like 10 o'clock, 11 o'clock at night, and we did, I called them that time because I felt like I was playing roulette, you know, getting this to heal. But that operation, taking all that down, it takes six hours plus for that, which is hard, right? Because these are kind of cases, that's why that second case, I tried to get through it expeditiously and didn't want to make it such an extensive operation. But I think in these situations, it's almost like we've taken this patient so far, I didn't want to get into that situation again. So knock on wood, to this date, it hasn't been a problem. Where do you think her kind of intermediate failure of local control happened? Is it systemic therapy that she didn't get enough, or do you think she was more aggressive in the entire colon control after, or maybe it was on plan, where do you think that? Yeah, that's a great point. You know, in this case, I started off with a vertebrectomy, just an intralesional vertebrectomy, not on block for like, you know, primary, but intralesional, tried to reconstruct it, getting her to SBRT, that was on hold. And she was about to start a clinical trial, but you're right, that was on hold. Now, as a surgeon, like, we like to beat ourselves up, right, you know, about how we did it. And when I looked at each MRI, every time in each case where it seemed to progress was always around the end plate and to the level above. And so that's when I thought, did I, was I too aggressive in preparing the end plate? We know they're not gonna R3Ds, but just to get the cage in there, you know, we curetted and get that prepared. And so that's where, in the last case, I actually didn't go through the disc space to the next level. I sort of just captured the inferior, the edges of the end plates of those levels, because I didn't want to risk seeding that to those next levels, which I don't see often, but it happens enough where it made me reconsider how aggressive to prepare those end plates when we know we're not gonna achieve R3Ds. Do you think any surgical treatment of the original vertebral body lesion might have helped? I think it could have helped, but I think that what's hard, and I think Larry may speak to this too, is that, you know, that patient just got 30 gray in 10 fractions and it's still fractured. And there's a lot of data showing that depending on how you treat, even, you know, with conventional, you can get these fractures afterwards. And that certainly happens with SBRT. So I don't know the answer to that. Okay, great. Thank you so much, Dr. Shin. And we'd love to invite up next John Chi from the Brigham and Women's Hospital. Thank you. Thank you, Karina. And how's that going? Yeah, great. Good afternoon, and thank you. I'm John, the other John in Boston, and I actually grew this beard so that people could distinguish the two of us. We had dinner last night, and we're pretty sure about 15% of our patients think they're seeing the other guy. And it's probably true. But anyhow, I'm here to do something very similar, although I didn't quite know what follow the patient meant. So I'm gonna have a few cases here. And my topic is gonna be myeloma. And just as a broad strokes, I think I'm gonna just group this into liquid cancer. So myeloma lymphoma. These are main myeloma patients, but I think it'll apply to both. Here are my disclosures, none are relevant to this talk. And just a brief overview, you know, multiple myeloma is a plasma cell cancer, at an average age in the 60s, on a spectrum of a solitary lesion, like a plasma cytoma, or a benign type lesion, like MGUS. Of course, we all know it presents with bone pain, anemia, renal dysfunction, infections. Very treatable, right? Myeloma and lymphomas now, both very, very treatable. Probably some of the most treatable, quote unquote, cancers that we have. Steroids, radiation sensitivity are high. Chemotherapy, targeted therapies, newer targeted therapies are making advances in the treatments of this. Survival without treatment for myeloma, specifically seven months, but with, you can have a 50%, or probably more now, five year survival. So again, something very treatable. And, you know, obviously we know that myeloma, the multiple part of it is that you have multiple lesions throughout the body, and that, you know, on a PET scan, you're gonna see scattered lesions throughout. And just as a reference point, unlike what John Shin was talking about, with actual solitum or metastatic disease, remember that the PASCHAL study on O5 and the Lancet was specifically for solid tumors. It excluded liquid tumors, right? So don't forget that. Those are considered radiation and steroid sensitive, and therefore were excluded from that. So the data from that randomized trial is the best we have for spinal epidural compression from neoplasm, but isn't necessarily directly relatable to liquid tumors. And I'm sure we've all had the experience of knowing that liquid tumors do respond fairly well, and you can actually have a fair amount of cord compression that can actually, quote unquote, melt away, although it doesn't really melt away. But that patient can respond very dramatically to that treatment, and therefore, there's probably a little bit less of a pressure head if they're presenting with cord compression and with symptoms. However, in that vein, I'm gonna present some cases to help us think through that, even in the setting of these diagnoses. So here's a 65-year-old male diagnosed in 08 with myeloma and presented with your garden variety back pain. And as the oncologists are good to know when they present with it, got an MRI, and you can see here a compression fracture. So this is a while ago, so this is when I was still doing some intraoperative vertebroplasty. We did a single vertebroplasty here, got better, did great, went back to doing the normal treatment plan, but then had another break just above a few levels, did another vertebroplasty. These procedures are very, very effective. I'd send them to radiology now. They can do it much faster, awake. Don't need to deal with the scheduling. And continue with systemic treatment, and as the prior slide showed, after the two vertebroplasties, having gotten better symptomatically, didn't need a high opiate requirement, was able to participate in the rest of the treatment, stay somewhat active, he ended up deceasing a few years later, which is unfortunately still the end with a lot of these patients. But this was a scan that they had gotten through the normal follow-up period, and you can see that the rest of this area was well-controlled. He actually developed degenerative stenosis from being able to live life and be effectively treated and not having to be bed-bound or anything else like that. And so in this case, a vertebroplasty is something that we use often. I don't know how many of us really do them still or not. I do refer them out to radiology for it. But if people have pretty bad pain and they have a history of myeloma, I think a plasty's a very good procedure. Second patient, a different patient, a 56-year-old male diagnosed in 2010 who had presented with an epidural mass, and so had a procedure somewhere else. They did this laminectomy that you can see. Is this it? Oh, no, I'm sorry. Was diagnosed with myeloma in 2010. At Dana-Farber, the patients will get annual or every two years MRIs in the absence of symptoms just to track for data purposes. He had this MRI in 2011 completely clear. Then in 2012, presented with this mass and tumor. It was just under, it was about 11 months as was scheduled. He was taken for emergent radiation, and around this time is when we started our multidisciplinary spinal tumor board where we meet with radiation oncologists, oncologists, orthopedics, neurosurgery, radiology to discuss all these cases, but this one slipped by us. Had emergent radiation for someone who was incontinent and myelopathic. So now you're dealing with someone who's just gotten literally three doses of radiation and has gotten incontinent and myelopathic with this lesion. And of course, it was probably a Friday night, right? Or Saturday morning. So what do you do with this? You know, in this case, even though it's not ideal, I took him to surgery. We did a corpectomy, stabilization. Fortunately, he improved. He was able to walk. Still had some residual symptoms, was able to walk. And unfortunately, in this case, he died of pulmonary complications 10 months later. It's interesting that you could have had follow-up with that original MRI with nothing there at all, and within that year, have a lesion present and fracture. It's not common that they get annual MRs, per se. I think PET scans are used as well. And, you know, talking with your oncologist, if you're seeing these patients in a less developed oncology setting, having some form of serial type imaging to try to catch some of these before they get to this point probably is a good idea. Another patient here, a 34-year-old, so very young. It's a little bit unusual. She presented with epidural mass and paraplegia, had a laminectomy here at a different hospital. That's where they made the diagnosis of an IgA myeloma. She was initiated on first-line therapy, and within four months, represented with paraplegia, basically myelopathic, weak, partially incontinent, while she was on her therapy, her first-line therapy. So very unusual, and at 34, which is also very unusual. And as you can see here, I'm sorry, the pictures may not have looked great, but you can see another extending epidural mass, distal to the prior laminectomy site. In this case, took her back to surgery to extend. This one, I stabilized above and below just because of the length of that laminectomy from her original laminectomy and the one that I had to do at the thoracic kyphosis. She fortunately got better both times, from her initial at the other hospital and from the one that I did. She then went on salvage therapy with her oncologist with decadron, cyclophosphamide, and etoposide, and recovered very well. Again, she's young. Age does matter in epidural cord compression. And she deceased four years later, unfortunately, just from complications of her aggressive disease. The oncologist agreed that this was a very aggressive form of myeloma, one that, fortunately, we haven't seen too much of, and at the time, they hadn't seen too much of, but being aggressive and not just putting her on steroids, thinking, oh, well, she's already, she's not gonna do well with this and be on therapy, and not necessarily being afraid of the wound issues. Now, the wound issues are real, and John, I would've called plastic surgeons on that case, but the wound issues are real, but that shouldn't stop you, right? We all know that we don't like to do surgery because of the wound issues and the breakdown, but that shouldn't stop us. And definitely, definitely, 100% get your plastic surgeons, colleagues involved, up front and early for that. So I'm gonna just end with another case here. This is just about a month ago. A 50-year-old male, zero history, otherwise healthy, but several weeks, about maybe two, three months of worsening back pain, leg numbness, and a 30-pound weight loss that he wasn't trying to lose weight with. Gets an MRI at a community hospital and immediately gets called in and told that he has a problem. So you can see this lesion here, significant fecal sac compression, multiple signal abnormalities in the bone. Here's the contrast. You can see the lesion here. The rest of the scan shows a second lesion in the mid-lower thoracic spine causing cord compression. Some teeter signal change. You can see here multiple bone lesions, multiple fractures. Here's his PET study that you can see multiple things lighting up in the long bones, and throughout the sternum, the ribs, everywhere else. I thought, I got a call, I thought this was gonna be a lymphoma, myeloma. And here we have multiple lesions, multiple fractures, here we have multiple lesions here, bad cord compression, no diagnosis. What do you do, right? Do you take him emergently? This is the classic question, right? Do you take him right to the OR because of the concerning issues on imaging, or do you try to establish a diagnosis? How much time do you have? In this case, we did try to get a needle biopsy. That was, of course, I guess, non-diagnostic. He had a lymph node that then general surgery took the next day to do a superficial subclavicular lymph node. He was in pain, he had numbness and tingling. As you can see from the PET, he had a Foley finally because he was retaining. I admitted this patient because I wasn't comfortable with an outpatient workup, right? This needed to be done fairly quickly. And giving steroids was the thing that I didn't wanna do in case that did get in the way of a diagnosis. So here's his PET study again, and the read on the PET study was multifocal lesions, right, nothing single, nothing singular, right? His SPEP, UPEP were negative. His white count was a little bit high, but not very much. We didn't really know what this was, but we all thought that this was gonna be a liquid tumor. Two days after the subclavicular node, the needle biopsy also then came back with extra stains, and this came back as a renal cell, a renal cell carcinoma, which surprised all of us. And his, actually, his friend that called me about this is the head of renal oncology at Dana-Farber, which was just an unfortunate coincidence. But this ended up being a solid tumor. And as soon as we got this information, I took him to the OR that day and did a laminectomy for the above and then a laminectomy stabilization, one level up, one level down, with cement for the lower lesion. But we had him primed and ready to go because this was something that was teetering. And things that are a little bit less than that, I think you'd have a little bit more buffer. If he were even worse than this, I'm not sure I would've waited. So he was someone that kind of came in at an edge. I'm not sure that was quite following a patient, it was following a bunch, but thank you very much. And now we have Dr. Larry Rines from MD Anderson in Houston. Well, I want to thank John and John for presenting two cases that are really going to feed into my attempt to tie this all up and put a ribbon on it. So in the spirit of the on-call toolkit, I'm going to give you the three things that you need to think about before you take a patient with a spine tumor to the OR while you're on call. But before I mention that, I want to just say that metastatic spine disease, spine tumors, is not an uncommon problem. 1.8 million new cancer cases every year in the US. 10% to 30% of cancer patients will suffer from symptomatic spinal metastasis. So if you take call in spine, you're going to see these patients, and you need to have a thought process going in. The field has evolved quite a bit over the last decades. Major advances by our medical oncologists, our radiate oncologists, our surgeons have made the management of these patients more nuanced. And you can see this from the cases you've seen. At many centers, there's a tumor board to review these cases, including medical oncology, rad-onc, surgery. The strategies are complementary. No one person can know all of the latest evolution in the management of these patients. But that's not what happens when you're on call. Patient comes in. They've got new symptoms. People are freaking out. It's a very urgent situation. You may not have all the information. There's no chance for a tumor board review. And the tool that you have at your disposal is a big invasive procedure with impact on the rest of the patient's subsequent treatment. So what are the three things you need to think about before you take a patient with a spine tumor to the OR? And I would say they're the why, the what, and the who. The why is, why am I taking them? Do they have a surgical indication? The what is, what am I operating on? What's the histology of this tumor? And the who is, who is the patient? What's their medical fitness? Let's take these each individually. There are many reasons to take a patient with a spine tumor to the OR. Some of them are elective, the radio-resistant tumor that is close to the cord, but the patient's asymptomatic. You need a separation surgery, and then do spine rated. That's not what we're talking about here. Here, we're talking about the primary on-call indications. And that's neurologic compromise and intractable pain that is manifesting spinal instability or deformity. Quick word about these two. This is the most obvious of the critical considerations. We know we get neurologic compromise from root compression, from cord compression. And the key point here, as John Chi pointed out, is that the severity of the compression or the symptoms dictates the urgency and nature of the treatment. And that symptomatic spinal cord compression is a surgical problem, except in the most chemo and radiation sensitive cases. So histology does play a role here. And we're going to come back to that. We all know about the degrees of epidural compression. If a patient has significant neuro deficits with high grade cord compression from a solid tumor, this is probably your main indication for an urgent or emergent decompression and stabilization. As was mentioned, we know from Patchell that patients with solid tumors with symptomatic cord compression, surgery plus radiation is better than radiation alone in terms of protecting and improving a patient's neurologic status. And it doesn't matter how you do the surgery. It could be a complete vertebrectomy. It could be a separation surgery. You've got to get the pressure off the cord and stabilize the spine. The other on-call indication is instability, intractable pain that manifests instability. Important to know, there are different types of pain in the cancer patient. They can have local pain, radicular pain. The one you don't want to miss is the axial or mechanical pain. You've got to get the patient up to assess this. If the resident comes and says they examine the patient, patient's laying in bed, they had no pain, you've got to ask them, well, did you get the patient up? Did you make the move? Mechanical pain is pain with loading of the spine. This is an indicator of instability and important to not miss this because instability is not gonna get better with radiation and chemotherapy. The SIN score was already mentioned. It's a way of grading spinal instability. And I think patients with upper level potential instability and unstable group probably will require a surgical stabilization, because again, instability won't respond to chemotherapy or radiation. So that's critical question number one. Why am I taking this patient to surgery? Do they have an indication for surgery? Critical issues number two and number three, surprisingly, are often overlooked and may be as important as the first critical issue. And I want to emphasize this. In spine oncology, you have to know what you're treating. These tumors differ in terms of their biological behavior, their natural history, their metastatic potential. And the practical impacts of this are the histology influences prognosis, response to therapy and vascularity. Now, are there situations where you have to operate without a diagnosis? Yes, patient comes in with severe neurologic deficits. They're cratering in spite of steroids, you can't stabilize them. Well, then maybe you have to go ahead, but that's not the typical situation. Often they have early deficits that can be stabilized with steroids. And in the next coming slides, I'm gonna tell you why it's so important to know what you're treating if you have that opportunity. Number one, this is our MD Anderson data. The tumor histology is the single strongest predictor of the patient's prognosis after surgery. This is very important if you're gonna take a cancer patient and put them through a huge operation. And this is not just our findings at MD Anderson. If you look at the old Tamida scoring system, the most important predictor of prognosis is the primary tumor histology. Even the more current prognostic scoring systems all have the primary tumor type as one of the key predictors of prognosis. This is very important to know if you're gonna take a cancer patient and put them through a big surgery. Other thing that was alluded to earlier is why do we wanna know what we're treating? Because different tumor types respond differently to chemotherapy and radiation, right? You heard from John Chi. Lymphoma, myeloma, exquisitely sensitive to radiation therapy. Don't you wanna know this before you take a patient off to surgery? This graph shows it very well. Lymphoma, seminoma, myeloma, small cell lung cancer, exquisitely sensitive to conventional. You can treat cord compression in these patients with conventional radiation therapy. So when a patient like this comes to the emergency room and has some leg numbness and a little bit of gait instability, the question you should be asking yourself is not whether the operating room is available, but what is this? Because if this is renal cell carcinoma, this patient needs to go to the operating room. But if this was lymphoma, which it was in this case, this patient got treated with steroids and radiation and never needed an operation at all. Gotta know what you're treating. Third reason you wanna know what you're treating is some of these tumors are hypervascular. Renal cell carcinoma, thyroid, hepatocellular. If angio or hemangio is in the name of the tumor, that's a clue that this may be a hypervascular tumor and you may wanna embolize that patient before you take them to the operating room. And lastly, what about this one? What about the primary bone tumor? This is 56-year-old male, came in with back pain, right thigh pain and numbness, and some mild weakness on knee extension of his right leg. Does this patient need an urgent operation? He needs a biopsy. We biopsied this patient. This was a chordoma. If you do a metastatic tumor operation on this patient, you can take a patient who could have been cured and make them permanently inexorably incurable. This patient needed an en bloc resection. You have to know what you're treating. And finally, critical question number three is who? Who am I operating on? Is this patient even a candidate for surgery? We're talking about cancer patients here. We need to understand the medical fitness of the patient. Do they have adequate blood counts to heal and to get better after surgery? Can they clot their blood? Have they been on anti-VEGF therapy like Avastin, in which case the wound will never heal? Do they have adequate nutritional status, adequate performance status, a reasonable overall tumor burden? What's their frailty? We all know that frailty is a big topic now in spine surgery. There are a number of factors that contribute to frailty in the spine tumor patient, including urgent or emergent surgery. And we know that increased frailty leads to increased hospital mortality, increased complications, and increased lengths of stay. This is very important to know before you take a patient to surgery so you can counsel them on the risks, talk to the oncologist about the risks of what you're about to do. And most importantly, one of the biggest complications is wound complications. And we all know that the best way to manage a wound complication is to prevent it in the first place. We need to recognize the patient with the high-risk wound, the who we're about to operate on. If they've had prior radiation or recent or anticipated chemo, if they're malnourished, if they've had prior surgery or gonna put in bulky hardware, they have a large tissue defect or the surgery is in the upper thoracic or sacral region, areas that are traditionally difficult to heal, you may want the help of a plastic surgeon. And in fact, at MD Anderson, for all of these high-risk wounds, we have a plastic surgeon available to do flaps at the index surgery to prevent a wound complication. Not only because a wound complication is an awful thing to happen in general, but particularly in a cancer patient. And I learned this lesson the hard way on this patient right here when I was just starting out. Colon cancer, recent radiation, recent devastan, 30 pound weight loss, losing his ability to walk. I took him to the operating room. I did a bilateral transpedicular vertebrectomy, took out the two vertebra, closed the wound, and the patient's pain and ambulation improved after surgery. But by six weeks post-op, the wound looked like this. And if that's what it looks like at six weeks, you can be pretty sure that at eight weeks, it's gonna look like this. Patient never got back on his chemotherapy and died three months after surgery. Had I just recognized who I was operating on and got the plastic surgeons involved for this simple 45 minute procedure, maybe this patient would have been able to get back on his chemotherapy and not have died three months after my surgery. So I'll conclude by saying that on-call management of metastatic spine disease can have a major impact on the quality of life of a patient. But considering the why surgical indications, the what tumor histology, and the who patient fitness can help you prevent unnecessary procedures and avoid complications. Thank you very much. Thank you. Why don't we sum that up? Why don't we take some questions? We have a few minutes. Any questions from the audience? If anybody does, if you could come down to the mic. I have a question. Great talks, guys. I really appreciate it. John Chin, but to everybody, in the multilevel thoracic corpectomies, how are you typically managing the nerve roots? In the metastatic setting, if I know I'm going to do a vertebractomy, I'll selectively take one or two of the roots on that side just to get access that's there. People always ask about blood flow to that area. We don't really image that beforehand, especially in the urgent setting, not getting a spinal angiogram. But if I'm resecting one or two levels in order to reconstruct that, if I know I'm going to put a cage or something in there, I'll just take the root or roots. I agree completely with John. We take the roots. Fortunately, in the thoracic spine, they're expendable. We do preoperative angiography and embolizations if the patient has a hypervascular tumor with the intent of embolizing the tumor. We don't do it as a preventative. Generally speaking, if you take bilateral nerve roots at two or fewer levels, it's not a huge risk to the blood supply to the cord. If we're taking roots bilaterally at more levels than that, very often, as we go beyond two levels, we'll put an aneurysm clip on the root, assess the potentials over the subsequent 20 minutes while we're doing something else. And then if there's no change, we'll take that root. Any other questions? A quick one. What about that gray zone when you're in that gray zone of instability? Because putting in the hardware, that makes it difficult to get future imaging. But not putting in the hardware, you're more likely to potentially have that pseudo-instability where is that back pain coming because they have that micro-instability? Can you just comment briefly on that? The SIN score is interesting, right? It's the potentially unstable group. There's no prescription for what you do to that group of patients. It's merely recognizing that instability is a spectrum. My feeling on these patients, there's two causes of instability. There's what the tumor has done itself, and then there's what you're doing with your operation. And in my experience, if there's a risk that that patient's going to be unstable, if I feel that between what the tumor's done and then what I've done, there's any risk, I take care of it right then and there. This is a patient population that is relatively intolerant of the thought process of I'll do this. And if it doesn't work, I'll come back. I'll even 40 cross-link so I can find the cord again when I'm doing my revision surgery. We don't think that way. We never want to come back on these patients because, as the case I showed at the end of my talk, we've got to bring them back, their chemotherapy gets stopped, you're now operating in a previously radiated field, the risk factors go up. My tendency, and probably other guys agree, is to stabilize those patients right then and there. If there's any risk that that's going to be an issue. I agree. Just real quick. I think that one thing to keep in mind is that the SIN score is not absolute. It's a framework to think about and have these conversations. And there are a lot of actually institutions where maybe someone who has intermediate SIN score determined by whoever, a radiologist or whoever, and those patients may never see the surgeon. They'll just go to intervention and get augmentation or things like that. So you just have to keep in mind that if you're on call or you're dealing with this or maybe it's not something you deal with all the time, it's not an absolute, they're not guidelines. It's not a guideline. It's basically just a conceptual framework that has been studied and validated, but it's not by any means like a rigid guideline. Great. Great comments. John? I agree. And just briefly, I've been using a lot more fenestrated screws to shorten my constructs. And for those of you who aren't familiar, it is the only real labeled indication for use of fenestrated screws. And the current commercially available methamphacrylate comes in such a way that it is thicker, so it's less viscous. The chances of it entering the bloodstream are lower, so you don't get those complications as much. So I've been using that just to help shorten constructs, make the fusion not as aggressive. Praveen? Yeah, so I'm just curious, how long do you wait in the surgery and radiation for surgery? And how long do you wait after surgery to start acquiring what you're going to use? I'll take a shot at that. So the following radiation after surgery depends a lot on which type of radiation modality you're going to use. If you're going to use conventional radiation, in which the entire wound is going to get the full dose, typically 30 grain, 10 fractions, I usually wait at least three to four weeks until I'm satisfied that that wound is healed, even then I'm holding my breath a little bit. If I'm going to do spinal radiosurgery, or SBRT, stereotactic body radiotherapy, where the radiation is being delivered by multiple beams on an arc, meaning the wound is only getting one or two of all of those beams, therefore a non-dangerous dose, there you can proceed to radiation relatively rapidly, where you sometimes, within a week, sometimes within two weeks, but there's really not that same constraint. With regard to chemotherapy, it's also what chemotherapy is it? You know, it's not like the old days where people were getting adriamycin, cisplatin, big cytotoxic chemotherapies for everything, and the wound was going to be a nightmare. Now they're getting targeted therapies, they're getting immunotherapy, some of these things have a much less significant effect on the wound, some of them can be almost continued through the course of your surgical treatment and recovery, same thing for hormonal therapy, for breast and prostate, by the way, and so it depends a lot on what it is. For something that I know is going to impede healing, I usually, again, try to wait three or four weeks, and then there are the drugs like the Avastin, the Bevacisumab. Oh, for myeloma, yeah, I mean, I usually, they're usually getting conventional radiation therapies, so I'm usually waiting, you know, three, four weeks. Yeah, agreed. My trick is, I tell them two, three weeks from surgery, that usually means they get them in at three for the eval, which gives you another week, minimum, before they start. That's my little, like, trick with it, and then I always have them send a picture or they're seen by me or my nurse practitioner at week two for a wound check. So you can usually tell how it's doing by week two. I think for anticoagulation, I start them pretty much five or seven days afterwards, pretty quickly. A lot of these patients have clots or thrombus elsewhere. You're talking therapeutic anticoagulation? Therapeutic anticoagulation, yeah, therapeutic, like back on Alakliss by plus or minus five or seven. One more question. Hi, Eric Potts from Indianapolis. Two questions. People with myeloma have notoriously bad bone stock. You mentioned fenestrated screws. Are there other tricks you have to deal with that? And then what's your approach to arthrodesis in these patients? Eric, you mean because the bone's so bad? The bone's bad, right? Yeah. So there's a risk of, you know, just... Yeah, yeah. That's where the fenestrated screws come in. Correct, yeah. Are there other things you do, or is it ever bad enough that you say, boy, I don't think I'm going to offer this surgery? Yeah, no, I mean, so yeah, I guess if you can try to get away with it, I suppose you can. But a lot of patients do have very bad bones. So again, for me, my trick has been the fenestrated screws. And then in terms of, what was the second part? Arthrodesis. Yeah, arthrodesis. I mean, like John alluded to before, I mean, they get irradiated, they're unhealthy, they have a hard time fusing, but it doesn't mean you still try. You know, if they're younger, they probably could. So I just do my normal, that's a normal arthrodesis, you know, decortication, some allograft. I don't use autograft because that bone's contaminated. Right, right. Great. Thank you. Thank you very much. Excellent panel. Thank you, gentlemen. We've got one more talk here before our break, and Dr. Glassman's going to come on up. We're going to go on a 20-minute break after this talk, and I request not for anyone to go too far because it takes about 20 minutes to get anywhere from here. So if you could kind of hang around, we'll finish up afterwards. Thanks, Steve. Thanks. Good afternoon. So we're going to change gears pretty substantially here. And I'm going to talk briefly about American Spine Registry and just give you a little bit of an update. Let's see, especially if I can figure out how to make this go. There we go. These are my disclosures. So ASR is a partnership of AANS and AAOS. It's been running about data collection a little over two years, running a little over three years overall. And I think it's important to recognize up front that the primary rationale for ASR is to support evidence-based quality improvement in spinal surgery broadly at the practitioner level. It's not really designed to be a research engine. It may do some of that on the side, but the goal is to have a quality improvement registry across spine surgery. But one thing we'll be able to agree on pretty easily is the data for spine surgery is problematic. It's problematic on lots of fronts. Half of it's in orthopedics, half of it's in neurosurgery. That makes it hard to accumulate. Indication for surgery is really hard to determine. For most registries, the whole issue is what are we going to have as our output? What's going to be our minimum data set? For spine, it's what's the input? ICD-10 codes, which we use routinely, just don't really reflect what we're doing very well at all, and I'll show you some data about that. If you just look within ASR at the primary codes for across the cervical and lumbar modules, there's 215 different primary surgical codes and 288 primary lumbar codes that have been reported. And then there's just a vast array of different operations and implants and constructs. So the data's hard, and the question is how can we use ASR to improve the utility of this registry data for spine? Can we make it a bit more granular and a bit more functional? And we have a number of strategies, but one of the ones that I'm going to talk about here is surgeon-indicated data of why the surgeon's doing the diagnosis or the procedure. So this is an OR smart form. We call it a Vanguard form sometimes. It's a form that's done at the time of surgery. It's largely what happens in the time out. It's a little bit expanded beyond that, where the surgeon can indicate why are they specifically doing this operation, what's the specific targeted pathology. It also talks about the details of the procedure. On your right is a smart form version of that that's in the EMR in Epic at Duke, thanks to Oren Gottlieb's work. And this has allowed us to have a little bit more specific data in terms of indication for surgery. The registry also includes, well, there we go, PROMS. You know, I think that we're moving towards this broadly. There's a lot of increased government regulation. I don't know how much you're familiar with it, but in orthopedics for joints, CMS mandated starting this year that PROMS be collected for these patients. The first couple of years will be voluntary. You can see what's coming, and if you think it's not coming for spine, that might be a bit wishful. This is some of the early data, the PROMS data. We have 35% of the cases have PROMS. That sounds like it's not very good. I'm gonna tell you it's way better than most other fields that where, you know, it's hard to get PROMS. But in spine, we're sort of used to it. It's been the currency that we use for a fairly long period of time. And this is some of the initial data, which shows sort of patients reaching MCID at a year in about 70% of cases, which if you look at the literature is pretty good face validity to what's been published for meeting that threshold in general. The registry also collects lot-specific implant data. So that's not been present in any registry before, which is hopefully gonna get us to get our arms a little bit around specific operations and constructs and how they tend to work. I think interestingly, this is some of the initial data looking at our implant data. And what you'll see there is some of the implant manufacturers that you recognize, but you'll also see is a couple of manufacturers who don't make implants, because this data pull also brings in bone graft substitutes, brings in hemostatic agents. It's not where we're gonna start, but I think over time, it's gonna give us an ability to look at and collect some data on some of these things like biologics that nobody's ever been able to get their arms around in the least. So I think that that's gonna be a benefit. One of the elements of ASR is it's integrated with CMS. What that means is for every CMS, every Medicare eligible patient in the registry, the registry gets their Medicare file. We don't give CMS anything, but they send us the patient-specific Medicare file. What that allows is for you to follow the patient if they have an operation in one place, but have a complication or a readmission or a reoperation somewhere else. For the joint registry, which is a lot more mature at this point, and a lot more patients in Medicare, they're actually not going back to the hospitals at all for long-term follow-up. They're following for complications, readmissions, revisions purely in the Medicare database. And we're certainly, I don't know that we'll ever do that. That's not where we are at this point, but it's interesting that they're able to do that. This is sort of a snapshot of where we are at present with ASR. There's about 200,000 patients in the database. There's about 300 sites. About 220 of them are actively submitting data. That's taken a long time to get there. It's absolutely a work in progress, but it is starting to accumulate a substantial number of patients. There's dashboards. They're generally used by the administrators at this point in time. They have improving functionality. They're not great, but we're starting to be able to filter for specific diagnoses, specific procedure types. I think that this as a feedback loop down the road will allow an individual practitioner to look at how a specific operation performs in their hands. You know, I'm gonna switch from open to MIS. I know the literature says maybe that's better for something, but maybe I'm not so good at it. Is it really better for me in my practice? To be able to look at your own data compared to regional and or national benchmarks will hopefully provide an avenue for quality improvement for surgeons who want that. Not every surgeon's gonna pursue that, as you can imagine. So one of the big issues is how valid is this data gonna be, right? We're gonna collect substantial amounts of data, but if it's not actionable, it doesn't really matter. Can we get it into a dashboard in real time so that it's useful? Can we make it granular enough to drive quality programs? And is it accurate enough that you believe it when you look at it? I mean, one of the problems we've all had if you ever look at a Medicare database study is you think, well, okay, that doesn't make sense because you can't really identify who the patient is. And the question is, are we gonna do better than that? So I'm just gonna show you one of the initial audit studies that we've done to try to look at an element of where we may be able to do a little better than what we can do at present. So this is using the SMART form, and what I'm comparing is the diagnosis as delineated by the surgeon versus the diagnosis that we would have pulled out of the database for those patients if we just use ICD-10 codes, right? So I'm looking now here only at decompression cases. And I did this when there were about 6,000 decompression patients in the registry at this point. And about a third of them were stenosis patients. And for those stenosis patients, the correlation with the ICD-10 code was really good, 90%. So there's a good code for stenosis that is used frequently, right? If you look at the age of this patient, you see it's about 67. So that's pretty believable as a stenosis population, right? And I'd say this is where we do absolutely the best. Now I'm switched over to disc herniation. If you look down below, my average age is 50. So that's pretty believable for disc herniation. It's very discernible from the stenosis population. It's not only statistically different, but substantially different in terms of the cohort. So I like that for face validity. But if I look at how many of those patients have a disc herniation ICD-10 code, there's only a quarter. So what happened to all the rest of them? Well, they're not miscoded mostly as stenosis patients. They're this other. So what does that mean? So we went and chased that. Well, it turns out there's 14 different radiculopathy codes. And depending where you live, people use all different codes. Now you could realistically, it's work, but you could bin those all together. And that gets you to about 75% of the cases. But 25% of the cases where the surgeon said, this is disc herniation, their diagnosis was hypothyroidism or diabetes. No spine code in the chart at all. And we collected 20 codes. So it wasn't like we just took the first code and missed all the other ones. So by doing this physician saying, the surgeon saying, this is my indication, we already pick up 25% of cases that were completely lost. And I'm gonna tell you, decompression is where we did well. If you go to fusion, the very best we did was for spondylolisthesis, right? And we got 75% in that group. But if you look at disc space collapse, right? So we very commonly do T-lifts for disc space collapse and for amyloid stenosis. You can think that operation is good or bad, but it's really widely done. And you know what percent of those you're gonna find if you pull the ICD-10 code? Well, zero, because there is no ICD-10 code for this. So having the surgeon say, this is why I'm doing the operation is all of a sudden gonna let us generate data for some of the things that we think we do really well that aren't spinal stenosis, disc herniation and spondylolisthesis, which is at this point, the only things we have evidence to defend. So, you know, let me see if I can make this go forward. So we think that things like the OR-SMART form is gonna make the data more granular, more accurate, and more useful as compared to standard registry data. It's not gonna go from bad to perfect, but it's gonna be an incremental improvement. This is another example. This is the MELD with the CMS database. And this is really new data. It's not vetted out at all. But just to give you an example, I took 7,300 spondylolisthesis cases that had data in ASR, but also were in the CMS database. And we pulled the standard ASR data, like pulling from any database, and looked at readmission rate, and it was 3%, pretty good. But when you go to the CMS database and pull the exact same patients, the readmission rate's 13%, not as good, right? Now, some of that isn't gonna matter. Some of that's a patient went back in for a gallbladder operation, or something that has nothing to do with us. But some of it's gonna be, well, they had their follow-up procedure at a different hospital, or they went in for an MI that we don't capture because we don't look for that in the standard things that we pull, but it's still gonna be attributable to us. This data needs a lot of work. We'll see how it plays out. But I think the idea that it's gonna make the ASR data more effective and more valuable is probably pretty clear. Third thing we're doing, a little different flavor, is a project with the FDA, where we're looking at how accurately we identify implants. We collect implant data, but the question is gonna be what we have in the registry. If you look at that, is that what it looks like on the X-ray, right? There's a lot of pieces parts. They do this really well in orthopedics, right? But they have one cup, one stem, right? We have obviously a lot more complex data to work with. It'll be hard, but if we can demonstrate we can do that, well, that may be a pathway for post-implant surveillance that lets us both see if something's not performing well, don't think that happens that often, but also maybe is a help in getting things approved more readily. So the bottom line is spine data is complicated. That is both the challenge and the benefit of this approach. We want granular data and we want volume. And by and large in the past, we've had either one or the other. And we hope that ASR is gonna be a step towards having some of both. Thank you very much. Thank you. When do you think we're gonna have that dashboard individualized at the institution so that it can be used not just by them? Well, so it's sort of a two-edged thing and you can tell me what you think. So right now, if you participate in ASR, you can actually get at your dashboard. So right now, mostly the administrators have access to it, but surgeons can have access to their own dashboard. The problem is it's hard to interpret now because the filters aren't that good. Everything's not all that clear. And so there's sort of two choices. We can wait and make it more readily available only when it's really easy to read and it's good, which will take a long time. We could push it out earlier, encourage surgeons to look at it. On the one hand, at times they'll have frustration. They'll say, well, this doesn't really make sense. On the other hand, that feedback's gonna be what makes it better faster. I'll give you an example for me. My dashboard said that I was doing a lot of anterior-interbody fusion for degenerative disease because all we collect is degenerative disease, right? Cervical and lumbar. And the patients were staying in the hospital like a week. And I'm like, well, my patients aren't staying in a week and I don't do that many anteriors because we were capturing degenerative codes and we were excluding all the deformity codes. And I do a lot of big deformity where I do an anterior and then I do a T10 to the pelvis or a T4 to the pelvis. And the data capture was seeing that as the guy did an anterior. We don't see the codes of the big scoli so it didn't capture that. And it thought I was doing just the anterior and then keeping the patients for a week, right? That kind of thing, you only get that when you look at your dashboard and say, oh, this doesn't make sense to me. And this is interpreting that wrong. And as people start to look at it, we get better and better. So I think we're back and forth on whether it's better to push out the data earlier, it exists now, and have people have some frustration that this isn't quite right, or whether people would look at it and say, okay, I'm gonna participate in trying to make this better. This is why this doesn't make sense for me. This is how you have to filter things differently. The more people we get playing in that, the better it'll get faster. But I don't really know how it's gonna go exactly. Okay, all right. Great, wonderful, thank you. Thanks. Thanks. We're gonna take a short break, and then we'll have everybody come back and get another set of great, great lectures afterwards. She did have a dental procedure six months prior. She comes in really with this horrible, horrible pain. She says the last two days have been the worst. I can't walk or stand anymore. And I was at this other facility. They just keep treating me with antibiotics. And nobody would like, she just felt like nobody was listening to her or paying attention to her. So on exam, she's having trouble lifting her legs. And I'm like, when did this happen? She's like, well, I've still been getting weak, but the last two days have been horrible. I really feel a lot weaker. And this was her exam. And you can see that she's hunched over. So these are her, this is her CT scan. And when you first look at it, you're like, okay, there's one fracture, but there's actually two levels that are fractured here. So this is one, and then this is the other one here. And so there's this kind of wedge here, and then this bone is just gone. And this is her MRI. And so there's a phlegmon, both really anterior and posteriorly, and this bone has just collapsed. And there's not T2 cord signal change, not yet. But it's probably, it looks like impending doom. So vertebral osteomyelitis, you know the most common thing is staph aureus, and its most common cause is modulus spread. These are the markers. CRP is really the best thing that you wanna track. You wanna keep looking at CRP, because ESR is sensitive, but it's low specificity. And just because they have a normal WBC, that doesn't mean that they don't have a spinal infection. Procalcitonin is helpful also, but it probably means that there's multiple sites. So there's all sorts of diagnosis. You do all these things. You try not to operate, right? Unless you have somebody who has sepsis, spinal instability, neurologic compromise, or and then you start to get into maybe the later indications. Is it a spinal deformity? Is it medically intractable pain? So let's talk about further about surgery, because that's why we're all here. So decompression for neurological, decompression for neurological instability, that's different than mechanical instability. Let me say that caveat. You're getting weaker, right? Instrumentation for spinal instability. It's a fracture. It's gonna cause more problems down the line. Surgical debridement, because you need to clear that infection. Antibiotics aren't working. And then the question is, okay, deformity and pain are present. There's no neurological compromise. Can they get through this? Do they need a correction or deformity? Or do you really just need to bite the bullet and take care of this? But the biggest thing is if there's a fracture, you need anterior column support. And so you can't ignore the anterior column support. And then how you decide to get that anterior column support is really the major kind of controversy about how, it's not controversy, but how are you gonna do that and how are you gonna do that safely in your own hands? And that's different for every person and that's different for every patient. So this is what I did in this surgery. So I actually took down all the posterior elements. I was saying this is not with the robot. And I did a wide exposure here and took this out. And this is actually an expandable T-lift cage that I just shoved away up front after taking down the pedicles. And then I tried to get some shorter screws at this level here. Just get something in there to have another point of fixation. So again, what approach? What would you do here? Would you anterior only? Would you do posterior only? Would you do anterior then posterior? Or posterior then anterior? And so this is a really nice case. I'm putting this up here. So if you, you can do an anterior retroplural technique. And most of us are more familiar with this in doing, I use this approach for thoracic discs. And pretty much you're doing a lateral tecubitus or a lateral chropectomy. You're removing the rib. And you take the vertebral discs out and you place it with a cage. You can do plaster minus screws anteriorly. It gives you a great wide footprint for anterior column support. It normalizes kyphosis. So I would actually argue that that's probably the best restoration of height and anterior column for these patients. That said, I have a lot of anxiety in doing a retroplural approach on a patient with osteomyelitis. How long is it gonna take? Like how long is it gonna take me to get in there? And especially in the setting of neurological compromise, am I adequately decompressing the phlegmon? Am I adequately seeing from the spinal cord? Am I seeing enough that I need to see? The question is, I'm afraid of getting lost. So increased pneumothorax, if you're not comfortable in this space, it's hard to find this. And so some people do lateral thoracic approaches routinely. Some people don't. And even the setting of doing this, I think you can easily get lost. And so when you're putting in your implants, so the other things that you want to do is avoid structural, if you want to avoid a structural autograft is it might give you an ongoing nitis infection. You also want to think about, it's better if you can kind of get a structural autograft or morselized autograft in there. A titanium is much better than, is much better in preventing that ongoing nitis of infection. And usually you can treat that with your antibiotics. And then your implants, again, titanium treat with antibiotics. If you can deliver vascularized tissue, that's also the best. Sometimes it's just paraspinal muscle flaps. If you're really worried about continuing ongoing infection or you did a surgery for osteomyelitis and it fails, you're probably better off thinking of some sort of pediculized rib flap. Usually we need help for this, right? So you get plastics involved. You can do rotational flaps. And when it's real bad, what other flaps do you need to get in there to get a vascularized tissue? I try to avoid this unless I'm really, really worried about this failure. Usually I do this in times of failure. This is my patient eight weeks later and they're like, good news, Dr. Snyder. She, I was like, oh my God, you gotta be kidding me. She's a car accident. I'm like, it's fine, Dr. Snyder, don't worry. She just has a, she just has this TP fracture. She'll be fine. And then you look at this, you're like, yeah, no. She's settled here, right? And so this is her pre-op MRI and this is her post-op MRI here. So at least there's some restoration of the kyphosis even in the setting of that subsidence there. And I don't know if she got that, I don't know if she just stood up over time and there's some subsidence there. I don't know if she, it was the car accident. I don't really know, right? I don't know if it's just bad enough bone that this happened. The question, you know, in theory, when I look at this from a radiographic standpoint, this is her 17 weeks later, I'm like, you know, maybe I should have done a two-level corpectomy from a lateral approach and put this big anterior cage in there, but I still hesitate that. Like, could I have caused neurological injury or in the time, you know, or caused a big CSF leak because I'm working in Phlegmon. Could I, would have not really decompressed the spinal canal? Would she have gone completely paralyzed in the time I'm futzing around anteriorly? The answer is, I don't know. This is where she is. This is 17 weeks after surgery. She is full strength, which is great. She still is on gabapentin and tramadol and we'll see how she does. Sorry for being over time. Thanks. Thank you. Thanks, Laura. All right, I'd like to invite our next speaker up for our next clinical quandary. This is Jay Turner. He's gonna present case, case presentation of pseudoarthrosis with bacterial infection. Great. All right, perfect. Okay, well, thank you to AANS and the section for the invitation. So, continuing on the theme of infection, start with the case. So, this is a 42 year old female who previously underwent a single level T-lift six months prior to presentation. She had done well for approximately three months and then developed progressive back pain, right-sided thigh pain. The x-rays looked essentially benign. Same with the non-contrasted MRI. CT, on the other hand, had some concerning findings with osteolysis of the end plates at the instrumented level. You can see in the axials, also some lucency of those L3 screws, and some periscrew erosion as well. So that prompted additional infectious workup. Patient clinically was well, afebrile, incision well-healed, neuro-intact, and labs essentially benign as well, just the mildly elevated ESR, CRP. The MRI with GAD, not really remarkable either. But given these erosive changes and then the concern for infection, that prompted a needle biopsy and then blood cultures, and then kind of the remainder of the infectious workup, which did return with a P. acnes positive culture. And so then we're left with figuring out what we wanna do at this stage. And so just see if we can get this audience poll to work. But first option, so we got a P. acnes infection, setting of a pseudoarthrosis, six months after a single-level T. lymph. Do we wanna debride, explant everything, you know, screws, rods, inner body cage, treat with antibiotics, eradicate the infection, and return to the OR if and when that's necessary. Second option, debride, remove and replace the instrumentation at the time of that index operation, or that return to operation, and then treat with antibiotics afterward. Or debride, revise, only replace the failed instrumentation, antibiotics, and then potentially chronic oral suppression if necessary. And the last option, which may be tempting for some, just bypass, go right to D. So let's see if we get this to work. So if you texted a number at the top with that code, see if we can get this to work. Hopefully we don't get 100% of D, so we can have a discussion. Just give like 30 seconds to register here. So take everything out, remove and replace. Essentially just deal with the pseudoarthrosis and replace what's easily accessible. Yeah, give it a few more seconds here. Did you say it was a titanium cage, or? It's a titanium cage. Titanium screws and rods, titanium cage. Was it a dynamic explosion, or was it a vacuum? Not clear, it sounded like it was probably for a collapse and foraminal stenosis. No dynamic instability on the x-rays that were provided with the setting of a pseudo, so that was my assumption. All right, very ethical audience, nobody referring to our junior partner, way to go. But you see the variability. Oh, there's one. Well, it looks like Dr. Uribe just showed up. Where's he at? Just kidding, he would never do that. So yeah, so this is a different situation with Dr. Snyder present this. Surgical site infection, which is common. It's common in instrumented fusions, more common with greater invasiveness, and certainly with high-risk patients, even more common. And we have instrumentation involved that presents unique challenges. Early infection is typically with the more virulent organisms. Staff, predominantly implicated, but the various others as well. These delayed infections can be very challenging, both in diagnosis and in treatment. These are typically indolent infections, as was the case I presented. In order to get a positive culture, you often have to have prolonged culture times in anaerobic conditions, and need to grow for up to 14 days, so it can really take some time to establish the diagnosis. With these indolent infections, and some of the acute infections as well, you can get biofilm formation. It really makes the eradication of the infection challenging and certainly clearing the infection from the instrumentation. Workup, Dr. Snyder covered that pretty well. The history and physical, a host of labs. I think one key consideration with the labs is ensuring you get cultures before antibiotics are initiated. Can't count how many times we get a call from the ED after a dose is given, and your whole workup's compromised. Imaging, the standard group of imaging. There's also descriptions of using PET CT nuclear medicine to look at infection, which may have some advantage in these instrumented cases where we have a metal artifact on your contrasted MRI. So how should we manage these? Is there a right answer from those different options? There have been a host of papers, all based on essentially low-level evidence, but this is the most recent that I found, a systematic review out of Hopkins, which essentially showed almost even split of the different options we discussed. So always remove, it's okay to retain, versus, this is I think how most people at our institution operate, retain for early infection and remove for late. So what's the downside of explantation? Your ID doctors will always want you to take it out. One edge is always take everything out. Obviously, there are challenges. One can be safety, so you have a big infection after an A-lift, getting everybody out safely with the vessels can be challenging. If they're not yet fused, you can expose the patient, so there's I think an important question, were they unstable before surgery? If they are unstable, you're setting them up for instability if you take everything out. And even if they are fused, some patients still may be vulnerable. This was a pediatric study looking at patients that were confirmed to be fused that still had their deformity progress after explantation. Closure, most of these cases can be closed primarily. We were talking about oncology earlier, and this is another, infectious patients are another high-risk group. But so for anybody, there should be a low threshold for getting plastics involved and potentially wound vacs. For this case, we ended up debriding, explanting, and replacing essentially everything, and primarily closure and doing antibiotics. So to summarize, deep infection setting of instrument diffusion pose unique challenges. Important to obtain cultures before antibiotics. When possible, taking everything out is attractive for eradicating the infection, but it's not always practical, and there are different considerations where it may not be. Important to work with your infectious disease team to really come up with the best treatment plan for each individual patient. So thank you for your attention. Thank you. Thank you very much, Jay. Okay, thanks, Jay. So what we're gonna do next is Irene is gonna present a case, and we're gonna take that case and invite three experts up here to argue or discuss what they view as the appropriate treatment of the same pathology. So we'll start with the case. Okay. Hi, good afternoon everyone, thank you for coming today. I'm Irene Tsai and I'm an assistant professor in the Department of Neurosurgery at UCSF. Today we're gonna have a little bit of a conversation and a debate about how we handle soft disc herniations at C4-5. And so just to introduce an example case for our panelists, this is a 50-year-old female who came in with one week of severe left-sided neck and shoulder pain after doing some Pilates. And she noticed weakness really at her left shoulder and it was at her deltoid that was about four out of five. And so you'll see her x-rays here, x-rays here really showing no significant dynamic subluxation with flexion extension and then this is her MRI. And so we're gonna invite our panelists up to the stage right now to really present their take and their approach for how they would handle this. All right, thanks Irene. So a case we all probably will see or we do see and now we're gonna look at three different approaches from three experts and Eric Potts is going to take the ACDF approach. All right, so thanks everybody for coming to the session. Thank you to the Scientific Program Committee. My name's Eric Potts, I'm from Indianapolis. No relevant disclosures. Here's our case. So as Mike outlined, we have three options, an ACDF, arthroplasty, or posterior discectomy. So let's go back to the case. The first thing that I look at here is the C45 segment is kyphotic. And for me, if you look at the IDEs for most cervical discs, abnormal cervical alignment was an exclusion criteria. So this is for us. We tend to be very conservative in Indianapolis. I'll tell you, I don't think any of my partners is gonna put a cervical disc in. Or perhaps one of my partners will put a cervical disc in. He's sitting right there for this patient. So ACDF has been around for 70 years. Described first in the early 50s by Smith and Robinson and Cloward independently. Has a solid track record. It's the gold standard. How does it do outcomes-wise? So here's 159 patients, 10-year outcome. If you look early on, up to three years, greater than 95% satisfaction. They'd recommend it to their friends. And even out 11 years, 85%, 90% of people would still tell their friend to have that operation for the problem. If you look at Goodman Campbell in our QOD database, this is a good operation, right? It works for arm pain. It works for neck pain. NDI improves. And if you look at NAS satisfaction, 90% out at 24 months. The risks of the surgery, pseudoarthrosis. So in a single level fusion, that's really low, 2% or 1% or two. But adjacent segment disease, and that's the thing that people really want to try to avoid. And that's the thrust of arthroplasty or posterior operation. And the seminal article on this is Hillebrand's study from 1999. And the quoted rate is always 2.9% for adjacent level disease. But if you look at this, out of the 374 patients, 55 reported as having adjacent segment disease. But only 27 of those people required additional surgery. And in the magical eight to nine year, nobody developed that. So between 2007 and 2009, three arthroplasty devices that are shown here were approved. And it's touted as transformational. At meetings like this, everybody would say, boy, single level ACDF is going away. Has that happened? Not really. If you look at the region of the country, single digit percent exists for arthroplasty versus ACDF. In some areas, maybe it's as high as 30%. But certainly, single level ACDF is not going away. How do you get a disc approved? It's a class three device. This is an onerous process, taking years and years and millions and millions of dollars. And in any trial or any study, talk about bias or worry about bias. I just want to talk about performance bias. That's the bias that occurs when patients or clinicians are aware that the assigned treatment were performed differently as a result. So they know what's going on. For most trials, it's hard to blind people to what's going on. And the outcomes that we collect are subjective outcomes. So if we look at a meta-analysis from Moe Biden, looking at 10 meta-analyses, so it's like a meta-meta-analysis. Studies published before 2012 reported significantly lower odds of reoperation after TDR versus ACDF. So could there be bias? Is there some bias in reporting this? Yes, and I think as you see longer term studies come out, or studies that are not involved with IDEs, you'll see maybe slightly different results. Heterotopic ossification is something that we talk about a lot with dyskectomy, or with arthroplasty. And the biggest risk factor for this is time. So as time goes on, more and more people develop heterotopic ossification. And not just limited, but really severe, maybe up to 50% when you get out to 10 years. Here's a study from a registry in Sweden. Propensity matched cohorts ACDF versus TDR, 185 patients in each cohort. The TDR had a higher reoperation rate early on. And what they concluded was that TDR surgery did not result in clinically important difference in outcomes versus ACDF over five years. So what kind of operations? Well, this is a mobile device, right? So you can have the implant move. And that's something that you won't see with ACDF. Here's a randomized trial. And this is kind of an interesting study from JAMA. 2021, 136 patients were randomized, half arthroplasty, half ACDF, five year follow-up. The patients were blinded to treatment. And so if you look at first two years, no patient knew what treatment they had. At five years, only 63 out of 102 patients that followed up knew what they had. So that's half the arthroplasty group knew that they had an arthroplasty. And about three quarters of the fusion group knew that they had a fusion. It was only at C5-6 and C6-7, the most common levels of degenerative disease. And the doctor was blinded as well until the decompression was finished. There was no difference in outcomes of adjacent segment disease or re-operation. Our third option is a posterior operation. And here's a study from Dr. Treinellis and what we learned from this meta-analysis. There's no clear superiority between a posterior operation and ACDF or TDA, total disc arthroplasty. So what's the answer? This is a nice problem that we have in neurosurgery in that if we look at, say, NAS satisfaction for all three of these options, ACDF, arthroplasty, or posterior decompression at two years, really high scores. People like these operations. People get better with these operations. So we have good options. But for this person, kyphotic, you have to go with the ACDF. I'd invite everybody to come to the spine section next year in Las Vegas, Caesars in February. It'll be nice. Thank you. from Rush University. I needed help from my competitor. Here are my disclosures. These are all three great, excellent operations, and they're all going to work. We have to look at our goals, though. What are all of our goals together? First we want to get rid of the pain and weakness as best as we can. We don't want a complication, and we don't want an adverse long-term consequence. What do we get with ACDF? We get loss of motion, and I'm going to give you some other data on adjacent-segment disease. I will say about the studies, early on I think bias is an issue, there's no question, but now when you look at these natural implant sample studies and these huge studies with thousands of patients who weren't in studies, you see there is a trend that does favor arthroplasty in the properly selected patient, which was also mentioned. Another problem is symptomatic non-union. We start with this. With arthroplasty we have preserved motion and no problems with non-union. The long-term benefit, I believe, is a lower rate of adjacent-segment disease, which we know is exceptionally likely to occur when there's already significant disease at the adjacent segments, as there is at 5.6 here. If we look at the data, this is a meta-analysis we did of the IDE studies, but this is seven years out. So theoretically beyond the placebo period, and it wasn't just USA studies, it was some Chinese studies, all RCTs, and a couple two-level studies, but I'll just show the one-level study data because that's our case, and to not exhibit any bias, I'll illustrate the old Fernstrom balls from the 60s, which were not involved in any of these studies. Here are the data. We just jump pooled data, seven years. Index-level surgery, disc replacement on the bottom, ACDF on the top. Adjacent-level surgery, same thing. And the split is at five years. These things track, so the two-year data is not surprising, in retrospect it all looked the same, couldn't tell who got what. But as time passes, you tease out that there is a difference between these two technologies. And so I would argue that if we look at the long-term results, that we have a better option with arthroplasty. And I'm gonna show some of my measurements across the segment a little bit later. They're not quite as kyphotic as you've shown. They weren't lordotic. But we have to remember, if you have a hot radiculopathy, that patient may be splinting, may have a little focal angulation there that you might have to take into account. So in the study, I would not have enrolled this patient. But at this point in my practice, I think that these kinds of changes I think are acceptable for arthroplasty, given the fact that maybe dynamic films show no instability. Posterior discectomy versus arthroplasty. So preserved motion, preserved motion, equal. But we're at C4-5, and we have other issues to think about. And I labeled two of those as kyphosis, which would be at any level, but C5 palsy. And we did a review looking at C5 palsy, and what we chose to do, since the numbers, if we look at all the series across the board, is we wanted to find controlled, randomized trials who published the data with sufficient granularity that we could tell if someone got a C5 palsy. We expect these are meticulously followed. These studies are gonna be good evidence to see what the numbers are. And there's 26 of them. And most of them are not the arthroplasty studies, because a lot of those publications, you can't tell if someone had a C5 palsy or not. So it takes out some of this commercial bias, but, and they were 14, nine and nine were good to fair. One, two, three levels, so it's a little bit bigger than some of these. And we'll just jump to the bottom line. 2,060 patients, 19 cases of C5 palsy. And if we look at posterior approaches, 20.2 per 1,000, anterior, three per 1,000. So I don't want a C5 palsy. And it's not just for this case, but it's for many cases. If I can go anterior, I go anterior, because I don't want the immediate complication. And I believe that favors arthroplasty. What about kyphosis? Kyphosis following for aminotomy, 18 to 30% illustration from Jaganandam's paper. And you see at 48 months, kyphosis develops, and if you follow the curve out a little bit, next thing you know, we're getting an ACDF. So it's not an insignificant problem. But what are the risk factors? Well, we all know overzealous resection, and it's a tension between how much are we going to get off of the nerve, and how much facet are we going to take? And sometimes you got to stop. Pre-segmental angle less than 10 degrees, risk factor for kyphosis. I actually measured them at pretty parallel. We can fudge a couple degrees here and there. It could be a little kyphotic, but I'm going to give it the benefit of the doubt. But it's definitely less than 10 degrees of lordosis. And the second risk factor, identified in least 30% cases, was a Furman classification grade four. And this is T2 signal, which is intermittent between gray and black. You can't really define the annulus from the nucleus, and some decrease in height. And so here's an example from a publication on Furman classifications, and here's our patient. It's a little bit hard to see with the line there, but probably pretty close to Furman four. So here we have two risk factors for post-op kyphosis. We have series saying 20% to 30% will get it. And each of those had decreased patient outcomes in the kyphotic group. So something we want to prevent, and something I feel speaks against posterior decompression. And so there's only one obvious choice, it's arthroplasty. Thanks Vince, well Jack told me earlier he thinks both of you are money-hungry aggressive surgeons we don't need implants and it's going to talk to us about the frame anatomy. Thank you everybody for inviting me to this talk my main disclosure here is I am NOT Don Cork who's supposed to be giving this lecture and he'd be far more entertaining than I'll be and I just want to thank my two you know friends and colleagues for making my point for me in this case. So here we have this patient 50 year old the key thing is here she has acute disease and she's middle middle-aged clearly has a C5 radiculopathy. And on the MRI scan, and we can argue a little bit about the kyphosis at the segment, but I would also bring up what's going on at five, six, and six, seven. So again, here's a case, point that disc out, it's soft. And again, I think we would all agree, all three options are relatively safe. We're also talking about what's the long-term implications of that procedure. So again, ACDF, CDR, both potentially good cases, as well as an MED, or microforaminotomy. Obviously, we all know, if you're like Reg Haid, who's been around, who's been doing keyhole foraminotomy since Christ was a corporal, it was a great procedure. It was a mainstay for treating cervical radiculopathy. It was published by Scoville back in the day, until the development of the Smith-Robertson-Clarotectomy, the development of ACDF, and then later on, the total disc arthroplasty. But one of the reasons for not doing, but part of the problem with that is the whole concept of adjacent level disease, and what's gonna happen after it, which they've already gone through. But a lot of these folks can require further operations. And it's also, again, which I go back to the original case here, is what's the natural history of that disease process? Is this herniated disc, or shot over the bow, of more progressive disease at C4-5, which then is gonna make 5-6 and 6-7 a problem down the road? We all know that Mo Smith and Kevin Foley first popularized the MED with the tubular retractor system, and it became much smaller, and then it replaced the techniques, because a lot of us didn't do it, A, because we had a better operation with any of the ACDFs back in the day, but if you did a lot of these back then, the patient complained bitterly of the muscle stripping and all the soft tissue dissection that went along with the keyhole foraminotomy. I was in the Navy, did a whole bunch of these, and these Marines had these big, thick necks, and that was their biggest complaint. But with the MED, now we're using new techniques to do an old operation, which had really good track record up until the end of the fusion. Tim Adamson at CSNA was one of the first ones to adopt this on a wide scale. I think he still has the largest series of these cases, and has shown that they're very effective. So what are the main indications for doing a MED cervical foraminotomy? Obviously, in this case, cervical radicular artery, refractory conservative measure, no myelopathy, very little spondylitic deformity, and I'll talk about that in a second. We'll talk about the C5 palsy, which I agreed Vince with, as well as a soft disc herniation. In addition, you can actually do this for patients who have failed. Total dysarthroplasty, and or ACDFs when they're incompletely decompressed from behind. And it's also good because you can get back to work. So again, here's this case, boom. Is there any myelopathy? Not in the patient, but you have to worry about that disease and I would argue that if you're gonna do ACDF there, what do you do with 5, 6, and 6, 7? Trust me, after reviewing a lot of post data, there's a lot of people who would immediately go to a three level ACDF for this case. It's a soft disc. The apex is which is outside the confines of the canal, and it's obviously just pushing on the root, but it's really not pushing on the cord. The biggest concern I have when I do, and I do a fair amount of microforaminotomy, these guys do too, in the right indications, but C4-5 I always stop, because what's going on with the C5 root? Now again, kudos for you guys picking this case, because it brings a lot of that in. In my experience, if it's a soft disc, you can go from behind. I would, if it was a hard disc, which I think is a much more problematic problem, I usually get a CT scan to see if the pressure is from behind or from in front. And if you have some degree of facet disease that's pushing on the root, then I think it's worthwhile going from behind. But if you have a big spur anteriorly, I think the amount of drift, and by definition almost certainly have lack of foraminal height, then an MED's not gonna risk, and I think the risk of a C5 palsy goes up dramatically. Again, we already went through the ACDF, the risk of doing this, again, how many levels would you do in this case? You know, we're not gonna poll the audience, but a fair number of people would do a three-level ACDF on this case. The cervical disc arthroplasty, again, I'm not as skilled with this, but I think the patient's already in a degree of lordosis here. And you still, as I alluded to earlier, is this just the first shot of the bow? What's gonna happen in two years when this patient starts getting a little bit of a cervical radicular myelopathy at 5'6", so you see already, see the degree of pressure there. When not to do it posteriorly, as we said before here, anything that goes past midline, so if something's pressing on the spinal, on the cord and there's cord infringement, or there's severe foraminal narrowing, and an anterior osteophyte, I would not do this case. Again, what are the patients gonna like? All these are benefit, but in these cases, the patient's going home. You can do this in an outpatient in a hospital, a surgery center, and they're gonna be back to work. And you can follow the natural history of that adjacent disease. I think Vince's point about developing a kyphosis through that region is real, but then you have to look at the specifics of this particular case also. Again, posterior decompression with preservation of motion at the segment shows the advantage of arthroplasty without the need of instrumentation, and it's very much more of a cost-effective and benefit for the patient. Thank you very much. We'd like to invite Dr. Redhade to moderate. 13. 13 minutes? Yeah. Two to 13? Okay. 12 minutes, sorry. You've used a minute already. We eventually. No, just a film. You're down to eight, MRI. Down to eight minutes, okay. Not about this case. Not about this case. In general, who here, not this case, does anterior cervical fusions? Raise your hand. Everyone. Who here does arthroplasty? Who here does posterior foraminotomy? That's a lot. That's good. If we were in a group of orthopedists, and I'm orthopedically trained too, Vince, we were there at Vail. Very few young orthopedists do posterior foraminotomies. That's kind of a lost art that came out. Jack, do you own an ASC? I'm part of one. Okay. What's the difference in surgeon reimbursement between fusion, surgeon reimbursement, between ACDF, foraminotomy? Let's just put it out on the table. Fusion, arthroplasty, and posterior foraminotomy, Jack. Not even close. Well, tell the young man. So, six to go, whatever. I forget the exact posterior code. Decompression versus doing a two to five by one. It's a lot of bucks. Is it 30% less, 40% less? Okay, fusion versus arthroplasty. Surgeon gets what, 40% less? Arthroplasty's less. Arthroplasty's less. It depends upon the widget you put in. Okay, good contracts. If you use allograft bone on a plate, that's probably gonna be cheaper than an arthroplasty. I thought we were talking about surgeon reimbursement. Are we talking surgeon or facility reimbursement? I think they're relatively close. They're close, but arthroplasty's less. Yeah, typically arthroplasty pays 40% less. Arthroplasty pays 40, 50% less than a fusion. I'm sorry, posterior foraminotomy. So, surgeons are more enticed to do fusions, right Vince? Correct. Okay, so Jack, if this were four or five, you're still going to do a posterior foraminotomy? Yeah, I think for the soft disc, and again, the long term history, I mean, again, my own particular bias, you'll own the condition. So, I'm thinking five, 10 years down the road, is that gonna be symptomatic or not? I said, if that was hard, I would absolutely do it. I would do it, in my hands, I would do an ACDF, but counsel a patient a lot that you may need something down the road at five, six, and six, seven. Instead of 50 and only, never had symptoms, assume you never had symptoms. So, Irene, we're gonna assume there's normal flexion extension here, right? And we're gonna assume that there's no neck pain. So, let's not complicate the issues. No, no, we're not gonna do that. Because, we're not gonna do that. He's on a roll, let him go. No, no, we're not gonna do that. Because as soon as you have, okay, Vince, if this were single level disease, and not five, six, and six, seven, what's the role of neck pain in determining arthroplasty versus fusion? Or is it? At what levels? No, single level disease, not this patient. Patient has neck pain. Does that change when you do an arthroplasty versus a fusion? It can impact my decision making. If they have a severe painful radiculopathy and neck pain, and it's a soft disc, no. If they have a good deal of a high percentage of their pain is axial pain, it still could come from the disc, but I am more than concerned that there could be some sort of instability or unsonate problem or something. I'm more prone to fuse those people. Praveen, I'm gonna, Vince is kind of waffling here all over the place. Single level disease, not this case. Single level disease. Neck pain, significant neck pain. Okay, do you do any other test? Somebody has neck pain, they're flexing extensor, normally do you get a CAT scan? Do you get a SPECT scan? Do you get a facet injection? Okay, it's not OPLL. Do you ever get CAT scans to look at posterior facet disease? The patient's your age. They're an old fart. Okay, and if they have significant facet disease? Vince, does that change anything? If they come in the office and they have a CAT scan? And I'm more concerned about this. This is 50? I thought she was younger. 50. I'm still more concerned about the incision scar on the front of her neck than some of these other issues, because it's another thing. Okay. Tell us about that. You're worried about your scar? Well, you know, if you- Can you not close a wound? No. In fact, at my institution, no resident closes a woman's neck. I do it. I mean, but some of these people- So now you're being, so now you're a misogynist, as well as. Ladies, do you handle that? If everything is equivalent, and that's my patient, I will choose to go posterior. Because I am not waffling on any of this. I'm trying to customize what I'm going to do for that one patient. Vince, if this were not C4-5, if this were C6-7, and we've got that soft posterior lateral disc at C6-7, you're telling me you wouldn't do a posterior foraminonomy? Me? Yeah. Totally. If it's anything but 4-5, I would have done this posterior. Okay, so the fact it's a 4-5, and you're worried about the C5 root. Does whether the patient have weakness, preoperative weakness, does that influence you at all, Eric? Yeah, I think it does, right? She already has a C5 radiculopathy, and the last thing you want to do, it's a sizable disc herniation. You're going to have to manipulate the nerve to get out posteriorly. Yeah. So I think that weighs on you. So just let's flush this out. So if there's weakness pre-op, you're less likely to go posterior? I think it's C5. Or else you're thinking- I think it's C5, yeah. You can't look back because the patient's already weak, which isn't. No, I think at C5, I'd rather not manipulate the root. I think at C7-T1, for example, with films that look like this, go posterior all day long, with a weak hand, and they'll do well. The other thing that, I don't want to steal your show, but- no stealing anything. We're friends talking. That, you know, we talked about the surgeon reimbursement. If we want to talk about incentives or disincentives, you know, if you look at the facility reimbursement for a posterior operation versus the facility reimbursement for an anterior operation, either arthroplasty or ACDF, they're worlds apart, right? So there's- Tell us. So I can't tell you exact numbers, but, you know, for a well-run ASC, you're going to make a lot more money, probably by $15,000 or $20,000 going anteriorly for the surgery center versus if you go posteriorly. And so if you're going to say cynically that that's the only thing that motivates you if you own your own facility, then you'll say, well, that's, everybody goes anteriorly. Now, if you look at Charlotte, where Dom is, they do a ton of posterior operations, and yet they own their own surgery center. So- They're doing the right thing. Right, they are. Because they're doing the right thing. But that's an even, I think, a bigger level of incentive, right? Because it's not a difference of a couple thousand dollars. It's big money when you start talking about, you know, what the difference of these operations are. So do you, so let's just say, let's make a statement. Let's just say arthroplasty, let's take the facility fee out. Arthroplasty pays a surgeon on average 40% less. Has that influenced adoption of arthroplasty? Yes. Yeah. Of course. You're gonna do more work, and you're gonna get paid less. You're gonna sit there and make sure everything's- It's a harder operation. A harder operation, potentially. It is. Okay, good. Thank you for putting that out there. Vince. Vince, Eric talked about HO, heterotopic ossification. He said something I disagree with. He acted like it affects outcome. He acted like, he said it's the duration. Do you agree with Dr. Potts about that? That it increases with length of time. Yeah. Tell us about, tell us about HO, and what that means clinically, and is there a difference among the type of disc, type of arthroplasty you use? Well, first of all, if we follow these patients out seven years, we see, not only do we see the ACDFs fail and go to surgery, we see loss of motion in the arthroplasty. So there's some indication either they're aging and the facets are getting stiffer, or some of these people are fusing. And fusion is still a good operation. And if you look at the IDE studies, and I was part of them, and pull out the failures because they fused, their results were the same as everybody else's. So I look at arthroplasty and I say, if it does fuse, which I don't want it to do, then it's like I did at ACDF. Now, in rates of heterotopic ossification, I think with all discs across the board right now are much less. ProDisc-C was a big offender there. I think the rates are much lower. There's an understanding of using NSAIDs around the time of surgery and waxing bone and things. And I don't think it's that great an issue. Yeah, if you look at the HO, right, if you look at the Bryan disc, the HO is in the longus coli. And that's within the Bryan disc. If you look at the ProDisc, the first ProDisc-C with the big heel, the HO was higher. Look at the Prestige-ST, the Pervine was on. And if you look at what they classified as HO, it's actually fusion. And when you look at those studies, Pervine, the disc is not adequately sized. On the Prestige-ST disc, we did not have big footprints, right, Pervine? So when you look at the HO on Pervine's original paper, the discs were too short and they did not have end plate coverage, correct? That's a different disease. So the ProDisc-C HO and the Bryan disc HO, and when you don't cover the, your foot plate does not cover, that's a fusion, right? And people didn't know to irrigate, people didn't know to use bone wax, people used a drill. Vince, to use a drill, is there a technique difference when you do an arthroplasty? Yeah, there's a lot of technique difference because I want that. Okay, drill. I burr, but I want the technique difference is it's got to be precise. You can't, you have to have good end plate coverage across that implant or it can shift. So you use a drill with an arthroplasty? It's a burr. A drill makes a hole. I don't. Okay, it's a burr. It's a burr. Yeah. It's a burr, not a drill. He's in Chicago. Pervine, drill or just kerosene when you do an arthroplasty? I tend to kerosene more, but I drill a little bit at the end. Okay. I do have something. If this patient doesn't have it, but maybe a touch of it, but most of our patients pick up some calcium and post your longitudinal ligament as they age. It's not really OPL, we just see it. And if I see a good band of darkness in that disc and at the other levels, I have had those patients fused with arthroplasty and I think there's something about their biology that they want to put bone down and they want to fuse and they're more likely to start fusing in the uncinate. So if I'm on the fence one or the other, that may push me to fuse. People that want to fuse, want to fuse. Yeah. Right, okay. Thence, is there a difference? Two-stage question. Then they're going to take a poll, then we're done. Is there a difference in what arthroplasty device you put in? And is there a difference of the arthroplasty device between C3-4, where the IAR is more anterior, and C6-7? So are there optimal arthroplasty devices for different levels as we gain more sophistication? Now you may not be sophisticated enough to answer this question, but what do you think? There are some real differences between some devices in terms of hypermobility. So tell us. I do not think that we have enough data to subdivide what disc goes where and what patient with how much preoperative motion, and I don't think we're there. Do you think that's something we should look at? Absolutely, and I think as we see series, when new discs come out, it's a low-yield paper, say on my series of 100 of these, but we can learn from that, and from the registries like Steve was talking about, and we may find that certain devices are prone more to failure. Yeah, because it could. What do you think? No, I totally agree. I was gonna ask a question. Is there a disc-based configuration, like if somebody has a very concave end plates that push you to one device versus another, or saying I'd rather do a fusion in that patient? Some devices are built just to drop in a concave end plate, and so I'm certain it influences some surgeons how they pick things. Yeah, so there are, right, just like L45T lifts. There are some discs that are more flat and some that are very lenticular, and discs that are shaped differently. So there's differences there, differences in design. C34 has a very different IAR than C67, correct, and we don't, so a disc is not a disc is not a disc, and a level is not a level. So just to finish up, in this, so we have three, we have one, two, three. How many people would do a fusion in this particular case? Raise your hand. How many people do an arthroplasty? Raise your hand. How many people do a posterior framinotomy? Raise your hand. There we go. We know the answer. Pretty close. Thank you. What did you do? Where is she? And how'd she do? Did she get her strength back? There you go. She's tribonic with ACF. And she's gonna have an ACDF next week. Great, that was a great discussion, very engaging, and real-world problems. That's the whole purpose, or the whole meaning behind this session here. So we're gonna kick off with our second discussion, looking at, again, something that's common that we see. It's a patient with stenosis, herniated disc, and a mobile spondy at four or five. Really something common, still somewhat debatable on what's the most appropriate way to manage it. And Paul Park's gonna kick off and give us a discussion of a T-LIF as the appropriate treatment here. I think I've figured it out. Everyone has trouble. So I have to preface this by saying, originally I was asked to talk about a different scenario. The scenario was acute foot drop with stenosis and mobile spondy. And I was supposed to contrast T-LIF versus lateral. Then when I looked at the agenda, it looked like it just said T-LIF, which I don't think is that interesting. So this talk still is geared toward T-LIF versus lateral. And I think Juan Uribe's gonna follow up with lateral versus prone. So I think it would work pretty well. What? Debate yourself, yes. So, but I'll debate the lateral one. Juan can tell us why laterals are better. Just to prepare my disclosures. And so here's a clinical scenario as in the agenda. It's a patient with stenosis from a dispronation of mobile spondylolisthesis at L45. Unfortunately, the case I had was very similar. So often with a grade one spondy, you see pseudodisc, right? With the slippage, the disc is exposed. It looks like a disc herniation. In this case, it's a bit more prominent, high grade stenosis. And you could very easily have a foot drop with this. But a typical scenario, just back and leg pain. We see this all the time. So, as a way of contrast, so I'm gonna talk about million invasive procedures. So it's MIS-TLIF versus a lateral, which is a million invasive procedure. And stylized diagram showing the procedure. We're very comfortable with this. I know everybody in the audience does TLIFs. And in fact, I bet most do laterals or know of laterals. And just again, the technique is very straightforward. Here's a million invasive version of it. Muscle splitting procedure. Sequential dilation. And placement of the tubular tractor. Again, stylized diagrams. We all know how to do this. We do a facetectomy. Maybe a little bit of laminotomy. Place a cage. Works well. Workhorse of neurosurgery. Lateral technique, fairly straightforward too. Target the level on the skin. Flank incision, small incision, tubular tractor. Classically transverse procedure. And place a larger cage. Again, technique that's well described. And I think a lot of people in this audience does the procedure, or do the procedure. So how do you pick between the two when you have this mobile grade one spondy with stenosis? Well, I think like anything else, you'd have to individualize it to a patient, right? Patient characteristics and pathology have the biggest impact on inner body selection. Spinal level, classically with the transovas, really 5.1 was not approachable. Although with the new oblique approaches, lateral a-lifts, very doable. It just elevates the technical difficulty, if you ask me. Vascular and psoas anatomy are very important when you're talking about any sort of lateral anterior procedure. When I was doing, I think, I trained just posterior approaches. You kind of ignored the vascular issues. You didn't really look at the psoas. But when you're considering a lateral anterior approach, it's very important to look at your vascular anatomy as well as your psoas anatomy. Stenosis type is very important as well. With the posterior approach, you're doing, direct decompressions with a lateral. Obviously, you're not doing that. You depend on indirect decompressions of certain types of stenosis, which can happen with a spondy, like calcified disc herniations, osteophytes, a migrated disc herniation are not as amenable, if you ask me, to indirect decompression. The final criteria, if you ask me, is surgeon comfort and experience. So if you're not comfortable with a lateral procedure, and it's a case with acute problem, like a deficit, I just wouldn't start off with that. So your comfort level is obviously important. And I'm not detailing anything that is not obvious, I guess, to a certain level. It's intuitive, but you need to consider these characteristics when you're looking at these procedures. And in many cases, both are reasonable. So here's an example of a patient, just a more typical example. Spondy, mobile, stenosis, back and leg pain. You know, either approach would be reasonable. So what are our pros for a T-lift? Well, it's a familiar approach. Everybody learns how to do this. We're very fast, always just out of training. I think anyone can do this approach. Laterals, I think even to this day, I think training is probably not as pervasive when it comes to laterals. So if you're not comfortable, I think that's obviously a con. A T-lift allows a direct decompression, I've mentioned this before. And I call these less risk of devastating complications, because with a posterior approach, I think we're concerned about durotomies, may cause a neurologic deficit like a foot drop, but it doesn't cause a femoral nerve injury, which you can see with laterals. And you can't really walk with a femoral nerve injury. Can't lock your knees, you can't walk. Foot drop, you can walk. And I know I'm trying to distinguish the two. We don't want a complication at all, neurologically or not, but you have to look at what you're gonna get from that. And if you've seen a femoral nerve injury, it's pretty devastating for the patient. Vascular injuries will kill you. And with a lateral procedure, it's actually feasible, and I think anyone who's done a lot of laterals will know of someone who's had a vascular injury that was life-threatening. Bowel injuries are an issue as well. So cons, it's really difficult to perform a complete discectomy with a T-lift. We get away with it, I think with biologics and techniques, even without a complete discectomy, effusion's achievable. Smaller cage, there's a risk of subsidence, and subsidence, it's still not clear-cut what's clinically impactful. It just doesn't look good on radiographic imaging. And I think the biggest issue, if you're talking about alignment, we're always focused on alignment these days, is with a T-lift, you're just not gonna get as much segmental lordosis. Here's a case example. Again, that example I showed you. He's got stenosis, a mobile spondy, and MIS-T-lift, the unilateral approach for bilateral decompression. The contralateral decompression here. I guess my arrow's not projecting, but it's a top-middle picture. It's just decompressing contralateral side, and it's a procedure I do routinely. I trained on it, and you get a very good decompression directly with a T-lift. And here, the x-rays, I mean, alignment in this case looks okay. So when it comes to laterals, obviously pros, I think it's the least invasive procedure. I'm a big fan of laterals. I've done a lot of T-lifts, trained on it. I learned laterals early on as an attending or a faculty member. And over time, I've come to understand the nuances of the procedure better. I didn't believe in indirect decompression early on, because it was not part of my training. In fact, my mentors really discounted that as a viable option. I was trained as everybody needs a direct decompression, and it took me a long time to come around. And I'm gonna show you some examples where I think it works quite well. You can do way better, or a discectomy or facilitates a better discectomy in a larger cage. And I think subsidence is less of an issue. Fusion rates, if you look at the literature, it's not really different. You don't really see a difference. But I personally think fusion with any sort of anterior-lateral approach is at a higher rate. Whether that's significant or not, I can't say. But I do think there's a higher rate of doing that. And I mentioned a complication profile before. The biggest con, if you ask me, is the approach is less familiar. You just have to be comfortable with an anterior approach or a lateral approach. And it just takes a little bit of time. If you're not trained during your residency, it just takes a little time to develop that skill. And I do believe navigation, robotics, will be helpful with that when you have three-dimensional image guidance. It just facilitates or lures a barrier of adopting this technique. And I think Juan's gonna go through this quite extensively. And he's gonna contrast the two different lateral approaches. And so, as I mentioned, psoas and vascular anatomy is very important. When it comes to L45, these are both L45 stenosis cases. This is a lateral recurrent disc herniation. But you can see a psoas anatomy here is not amenable, if you ask me, to a lateral approach. Your anterior psoas, people call it Mickey Mouse, stumble ears, whatever you wanna call it. But with an anterior psoas side, the risk of a neurologic injury is elevated. So I wouldn't approach this anteriorly. Or actually, I wouldn't approach it with a classic trans psoas lateral. This is an example where the vascular anatomy, you have an early bifurcation of L45. Again, when you're looking at an MRI, you have to very clearly look at your vascular and psoas anatomy. A psoas is okay here, but you can see the early bifurcation, the iliac vessels preclude a classic OLLIF approach or anterior psoas approach. And even a classic trans psoas approach, if you look at it, the iliac vein is actually fairly close to the midline of the disc space. It's a little risky here. I would be very careful about doing a classic trans psoas approach in this circumstance. This is an example, different patients, stenosis, spondy again, that I feel is ideal for a lateral approach. Low-lying crest, vascular and psoas anatomy is actually very typical of what you would expect. And you could do a lateral here and use the expandable cage in this circumstance and realign the spine, get discite restoration. And as I alluded to, you depend on indirect decompression for a lateral procedure. And again, it took me a long time to come around to it, but I'm a big believer in it now. And I think it works so well. It's a great operation. And you can see I have a little bit of a bias now. But the principle is very straightforward. Ligamentotaxis, realignment of the spine. Here's a couple examples. Here's a 4-5 spondy with stenosis. And you can see that this is what happens over time. You stretch the ligament. It actually erodes or involutes. And you have a very good decompression. I do think it takes a little bit of time to see that ligament thinning. Here's another example. This is a patient who I did, the original picture I showed you. Ended up doing a lateral here. This is two years later. She comes back with adjacent segment disease. You can see the amount of essentially canal improvement you have with a lateral procedure. Okay, I gotta go, quick, quick. So radioreferring clinical outcomes, they're essentially equivalent. Other than segmental lordosis, this is a paper from our group. And you just have improved segmental lordosis with lateral. Same thing of group with UCLA. Laterals are superior for segmental lordosis. Clinically, no different. I could go on and on about it. But pain outcomes no different on a meta-analysis. Same with ODI. So clinical complications are no different between the groups when looking at meta-analysis. So for this approach, or this scenario, either approach is fine. The original scenario where they had a neurologic deficit, I think an MIS-T lift would be a better approach because you get an acute direct decompression. And so in summary, I think both options are effective. You know, it just depends on the patient characteristic and type of stenosis and your comfort level. Thank you. Thank you, Dr. Park. We'd like to welcome Dr. Uribe from the Barreau to discuss lateral versus pronolateral. Okay, so I'm going to put my timer in here. In the next eight minutes, I'm going to show you, actually, debating myself, lateral, in lateral position versus lateral in prone. Actually, it's great because Paul gave you a really good tour about TLE for lateral, why not? So I can tell, you know, I've been doing lateral for more than 10 years, and to be honest, the best cases for lateral are spondys and adjacent segment. You know, that's like a golden application. So the question is, now that we have the new kid in town, is how would you want to do, I will just put it this way, how do you want to put your screws, in the prone or in lateral position? Because the cage, actually, when you go lateral now, we go prone or we go lateral. So there is a difference, and I made a little bit in here of comparison between when you put the cages on lateral versus when you do it in prone, talking about single position surgery. And as you see here, each one has the green part is the advantages, and the X, obviously, when it's not that good. So you see prone lateral have a, you know, significant advantage, you know, obviously, prone position, we like it, surgeons, we were born doing surgery with patient in prone position. It's very friendly with the screws, especially in the spondys when you want to have a good reduction, a good purchase. Then, obviously, it's very efficient in terms of time. If you're a really good lateral surgeon in lateral position, and you feel comfortable putting your screws in the lateral position, it may be good, but I can tell you, reducing spondys on lateral position, single position surgery in lateral, is tricky, and I wanted to know, how many of you guys in here do single position on lateral position? One, two, okay, so it's not, the adoption is not that big, you know? How many of you guys do lateral surgery? Watch, almost everybody. So it seems like a lot of people flip the patient, yeah? And how many of you do prone laterals? There you go, he's getting there. So what I think is, as long as, I think when we put the prone lateral where we wanna be, probably is going to take a lot of the laterals in lateral position. The problem is, is right now, there is some unique things on the prone position, I'm gonna show you in the next slide, but I will say, they're not really competing, the lateral and the prone, when we're talking about lateral access, they're kind of complementing a little bit. For example, if you have to do L5-S1, and you're not a T-lifter, you want to do an A-lift, so you do it in the patient with the lateral position, you do the 5-1 in lateral, and then you do your laterals in lateral position, and then you do the instrumentation. And then, but in the case that you don't have to go to 5-1, actually prone is a really good option, yeah? And then the other thing is also, which I'm gonna show you in the next slides, is these are very unique things of the prone position. One is, you know, there's a potential for saved times, and that's very important. As you know, if multiple papers, you know, a minute of OR is at least $62 per minute, so when you are flipping the patient, you absolutely lose time, so you're able to master the prone lateral in single position, you can really flow very good. It's extremely friendly with navigation. All you guys do navigation, you know when to navigate patients on lateral position. Lateral position, the patient tends to cork a little bit, so you lose everything. In prone, it's amazing, you tape it, patient stays as it is, and then navigation is very friendly. And then, but then, there is another thing that is very interesting, is if you really believe and understand lateral and how it works is all about indirect decompression, so you have to learn how to recognize which ones are the good patients with indirect decompression actually can take care of the problem. There is something very good and unique on the spondylolisthesis, that's what we always say when we do lateral. One is, when the vertebra moves forward in spondylolisthesis, the lumbar plexus doesn't move with the vertebra. The plexus stays, and the vertebra moves. That's why you always do your dilation, the numbers with the monitor is not bad. Second, every time you have spondylolisthesis, most of the time you have loss of this height. It means like, if you regain the height, you decompress indirectly. And the third factor that is very unique on spondylolisthesis is the anterolisthesis. As long as you make a total anatomical reduction, then you have the whole package. You regain the height, you move the vertebra back, and that one makes the entire indirect decompression. So you have to understand what patients are doing. This is, you know, we have this nice paper, published a couple of years ago, but factors that you have in direct decompression is vacuum phenomenon, hyperintensity on the facets, on T2, it's a bunch of things that are not, today I don't have time to go over that, but I invite you to read, for example, this paper that has all these factors. So, and then the other thing that is very unique on prone lateral, this is a very unique small amount of patients, but we notice in very awkward, when we do this prone lateral, we're having more lordosis when we compare from our own patient that we're doing laterals with the, you know, lateral and then the screws in prone. We found that actually we're getting more lordosis. It's kind of weird, I still don't have a good explanation why we need larger numbers, but it seems very interesting. In terms of the technique, also, we're not gonna go deep today because of the eight minutes that I have, but I can tell you this is a good paper that we also put together. We have a lot of little bit of nuances on the prone lateral approach. I invite you to see it, there's some good videos, and you'll see what is unique. But in three words is, when you're doing the surgery in prone position, get ready because you're gonna work deeper and everything is gonna move a lot of anterior. It's gonna be a little more challenging than the normal one. I'm gonna show you one example just in prone lateral as you see here. This is a classic spondy with part defect moving on flexion extension. This is the MRI, not to buy in terms of the stenosis. This is the CT pre-op. Pretty much what you see, loss of this height, anterior lesthesis. This is the patient in here with nothing too much fancy besides the Jackson table and taping. Then you mark your incision similar when you do a lateral. Then once you have that, you dissect the abdominal muscles similar to when you do lateral. It's just a little bit different ergonomics. You're working in a different way, but it's basically the same. Then you do your monitoring, which is very similar. Let me see how the time is. We're still doing the time. So you're looking here. You define what is your lumbar flexor. Make sure you're doing the front. Then the next step is start putting your dilation. You do your disc prep work, which is pretty much similar. We like to use these little cameras because in the wrong position you have a better ergonomics. You can see more and everybody in the room see what's happening. But it's nothing different than the regular lateral approach of your implants. And then make sure that you're trying to do your good anatomical reduction. So this is the time. And then this is basically what you get after this case. And you see here, MRI pre and post, you can have a really good reduction. And CT as well. I'm going to show you just to finish. This is a similar case to the one that we have today. You see here, 100% indirect decompression. You have a decent correction, a good symptoms. But then sometimes you have cases like this. This is when prone lateral becomes very good. Adjacent segment, very stenotic. You know that the indirect decompression is not going to work. In those cases, this is when we like actually do the prone lateral and simultaneously you can do the direct decompression. So this one has the advantages of the T-LIFT. Basically, you open and you do direct decompression. But then also the advantage of the lateral approach that you use a really good cage and you can have a good fusion. So that's the case, for example, where prone is a really good option. Just to finish, so let's keep connected on the social media and share all these new nuances on lateral surgery. But I invite you to give a try to the prone lateral. I think it's a really good option. Thanks very much. Thank you. All right, thanks Juan. Thanks Paul. Now I would like to invite Chris Chaffrey up to give us some summary statements and pearls of wisdom. You guys aren't going to stay and have. He's going to tell you how you guys are wrong. That's all right, the thing didn't load. So the summary statement is, I think all of us, whatever operation that we do best is the best operation for us to do. So if you're most comfortable doing a T-LIFT, if you have somebody who has a general spinal anesthesis, there are certainly multiple ways to kind of skin that cat. And what I would say is that for me, I'm kind of a T-LIFT person, so 90% of what I do, the world looks like a T-LIFT. And that doesn't mean that if I was Juan and the lateral thing could make a better case for it. I do think that with the T-LIFT, I think there's more and more technology, the use of things like liposomal bupivacaine and other things to make people very comfortable after the surgery, but I think the hospital stays are becoming shorter and shorter. So I really think that this comes down to, particularly at the L4-5 level, your level of comfort, which I think Paul really outlined well, is your level of comfort. Would you rather have the small chance of a femoral nerve palsy versus a very small chance of having a foot drop? And I think that either one of them are distinct but remote possibilities. And what's happening is I think that, again, if you were a very experienced, very quick person who recognizes all of the nuances, I think a lateral approach is a very reasonable direction to go if that's, in your hands, what works best. In my hands, as I said, I'm much more comfortable doing a direct decompression, putting a bigger T-LIFT cage in and doing it. The final thing is I think that there's an increasing recognition that alignment, even on a single level, has some importance to adjacent segment degeneration. So I do think that how you're best able to align the spine does impact long-term durability. So I do think, or durability, and I do think that you've heard a really honest appraisal from both speakers about the pluses and minuses of the technique, and I think that it's up to you to decide what works best in your particular hands. So I think very great presentations, and I think that it's given an honest appraisal of the choices available. Thank you. Thanks so much. Chris, can you stay up here, and let's invite Sanjay and Jack to come on over. We're gonna wrap this up in the next 10 to 12 minutes. So we're at the tail end here, but we're gonna talk about something that I think, you know, on average, you know, a neurosurgeon faces what I'm gonna show you once every three years, a malpractice case. So this is a neurological deficit in the post-op patient, how to be proactive to avoid potential litigation. We have slides? We gotta go over here. Ravine's gonna show my complications. I think that's the UCSF series. Slides. I did the same thing. That's why I'm wondering. Yeah, hopefully. Okay. Okay. All right, so here's the case. Here's my disclosures. So 65-year-old, has low back pain, radiates to the legs. Previously had a L1 to 4, just simple LAMI and a cervical fusion way in the past. Tried a whole bunch of steroids. That didn't work. TENS unit and physical therapy didn't work. Here's the films. So the patient has the ischemic spondy and has a collapsed disc at 4551. And the patient has degenerative arthritic change. The patient also had stenosis. So somewhere down the road, elsewhere, the patient disappeared for a while, came back with a LAMI above and they didn't do anything down to the bottom part. So then the patient had lots of back pain, radiculopathy. I did a four-to-one ALIF and then I did a four-to-one MIS posterior. And I did a little bit of foramen itemizing when I did the back. And the patient did fine post-op, discharged home on post-op day four, had a little bit of ileus. Ileus went away, went home. And patient comes back at the six-week follow-up time point with bilateral dorsiflexion weakness at like two out of five. And so now we've got a post-op neurological deficit. So of course, we got some imaging, and here's the MRI T1s. There is some still, a little bit of foraminal stenosis there, because we did an indirect MIS posterior decompression. You can see a little bit of a hook of the L5, the arterial body, sitting up under the nerve. And here's the CT scan. The L1 to 4 LAMI was done before the patient came back to me, but I did a 4 to 1 ALIF, and then I did a posterior, and the patient had this issue six weeks later in the clinic after going home four days later. So how are we going to avoid litigation in this scenario, where you had a patient who now has bilateral partial foot drop? Maybe I'll start with Jack. Yeah, that's a tough one. I think part of the problem is that, we were talking about T-LIFs, and I mean laterals and postures, and I tend to be an anterior person, but L5S1 is, just like C4F5, L5S1 is a level, I tell every one of my patients, it's the only one I've ever had a problem with, from a medical legal standpoint, very much similar. I think the incidence of developing L5 radiculopathy, especially in this patient who's got significant foraminal disease, et cetera. So the bottom line is, the patient's got it. So what are you going to do from it, especially on a delayed basis? I think that's part of the whole traction injury of the nerve, as opposed to doing the workup, making sure there's nothing there, you didn't put a screw there, there's not an asymmetric component of the implant, et cetera. But you're stuck with it, the patient's stuck with it, how are you going to address that to the patient? I think you just, you have to be honest with them, so yeah, A, prep rate, proper planning prevents piss-poor performance. So this kind of case, I would absolutely tell a patient, there's a risk of developing an L5 radiculitis, and patients I've seen have had temporary and more radicular pain, which can be neuropathic and can be quite disabling for the patient, without even having much of a dorsiflexion weakness. Just tell them, yeah, be upfront about it. When the patient has it, say, yep, this is what you have. I think you have to, in this particular case, it's not like it's a calamitous injury, and it's not right away, and there's no real rectification that needs to be done. Is there something that needs to be done to make the patient safe, forget the litigation? Then you have to read the patient. I think it's a lot about how you deliver it, but at least my opinion, you'd be straightforward, saying, yes, you have a deficit, this is what we're going to do to rectify it, and be forthright about it. And because I think there's pressure on you, as a surgeon, and there's pressure on the patient. So you just, A, clearly do not just say, I don't worry about it, it's going to get better over time, take some Advil, blah, blah, blah. You have to be looking at the patient's perspective. And then, at least most surgeons, people who don't get concerned about it, that's a problem. But you're going to, so you tell a patient, I tell a patient, I think it's easier to tell a patient upfront, and make it a team decision, we're going to help you work through this process, as opposed to being dismissive, or hide it, or saying, it's not my fault, you have a neuropathy, or whatever. So let me just tell you, in the patient's mind, they used to have a good ankle dorsiflexor, now they don't. So saying, it's not your fault, doesn't really help anything, at all. No, no, that's my point being, is be empathetic to the patient. Every patient may be different. This patient's had like several surgeries already, so this is not like their first time through. But I think honesty is, in some ways, the best policy. And then, A, make sure there's nothing that needs to be done, B, just say, yeah, you have it, we're going to work through this, but don't sugarcoat it, but don't amplify it. Yeah. So this is the preop CT. I don't have the CT post-op right now. Or maybe I do. I don't know. Maybe I do. I don't remember what I put here. Maybe I have it. Yeah, we have CT post-op. So. That's the. All right. So in any case, Sanjay, you do a fair bit of medical-legal testimony. What do you got to say for this person? Yeah. I mean, I think I'd start by saying, you know, I often, actually just this morning, told my kids, it's not my fault are the four most annoying words on the planet, you know? And so I think our patients are probably equally annoyed when we say stuff like that. I think if there's something I've learned from reviewing those cases and also my own personal experiences is, you know, to Jack's point, we are all going to have complications and sometimes they're mysterious and they're frustrating, like this delayed onset neurologic deficit. You know, it kind of reminds me of a case I had where the patient, you know, I never did figure out why a patient developed a foot drop after a T-lift, you know, with everything looking perfect on imaging, but it happens. But I think the mistake that so many of us can make is putting our head in the sand and not, first of all, not talking to the patient about it. Second of all, not working it up. Not getting help, right? Not referring the patient out, you know, to maybe get a second opinion. Or sometimes when you have a weird case like this, should they see somebody who does a lot of peripheral nerves or some other etiology, getting workups, EMGs, studies, and I know you, you know, obviously I know, Praveen, you're good about that, but like, I think that that is what I have seen be, you know, it's not, it's kind of like the Watergate phenomenon. It's not exactly the same, right? It's not that crime is the coverup, you know, it's sort of a similar concept though, right? It's that second mistake that can get us, right? So really bring in all the help, do the extensive workup, spend time talking to the patient. It's painful. None of us want to do that when the patient's unhappy with a complication. But I think that does spare us when it comes to litigation. All right. Chris, what do you think? You do a good bit of medical legal testimony as well, I think. Yeah. And so, you know, I think this would have been a more difficult case had they woke up immediately following surgery with foot drops. Let's go through that scenario too then. Because I really do think that, you know, so much of this is, you know, how you prepare the patient beforehand. And so again, with an ischemic spondylolisthesis, about, if you look at the literature, about 5% of people are going to get a foot drop with it and they've got to understand, hey, this is a real possibility. Probably another 10% are going to have some kind of severe radicular pain. They need to know that in advance and you need to document it. And so, so many times people will do something. And then how you evaluate it, you know, and so what's happening is I really do think that you need to image the patient immediately following with any significant neurological deficit, at least with a CT scan. The scary thing is a lot of people have some screw where there's one or two millimeters of thread sticking through the, you know, the medial wall or the inferior wall of the pedicle. And then what do you do? And that's why people are always a little nervous about getting it. But the fact is somebody's going to get it sometime in the future. It's better you and for you to have that discussion. If there's a reason, if it's on the side, for example, in this case, you did an A-lip, but let's say you did a T-lip back to our thing and it's on the same size, it could be nerve manipulation to do it. And, you know, you need to have that discussion that, you know, you've manipulated the nerve. This is particularly true if someone has had previous surgery and has had scar tissue. We're in A-lips. That's where I've had a couple of my foot drops where I've done an A-lip and I've clearly stretched the nerve in the scar tissue milieu when I'm doing it. There's certain things that are really, really, really important. And that is if you do it, you need to talk to the patient and the family. This isn't something to pass off if you're in an academic center to have the resident talk with them and then you disappear. That does not work well. Just to the point, I think what Jay just said, you've got to own it. You say, clearly, something that we did made this happen. But a lot of times, this is a step back, but you're going to have two or three or four steps forward. And most people with a neurological deficit is going to recover. You know, I had a patient, I was sent for a second opinion. I got an EMG. The person had a clear-cut peroneal neuropathy. And what happened was that they fitted the patient with an ill-fitting AFO and the strap for the AFO, they were a little weak, and the strap for the AFO over six weeks ended up causing a peroneal neuropathy, which was very clear-cut that it was the strap from the AFO that did it. You know, and the patient had a mild one, but it was the AFO, which may have even happened in this case. You need to dictate your operative reports right away. You know, again, if you've had a disaster, this is a minor disaster, you have somebody that dies or paraplegic or something like that, don't put it off. You know, if you put it off two weeks or a month or you give it to the resident six weeks later to dictate, you're just opening yourself. And what happens, every jury, and just for background, so I just was told by one of the attorneys that I'm now 19-1 in court trials. People want to believe you as a neurosurgeon, okay? People want your expert witnesses, if they're credible, they want to believe them. The whole thing that the plaintiff's attorneys go is to knock into your credibility, and anything that you can do to damage your credibility damages your standing with the jury. So you want to see the patient, you want to make sure things are adequately documented. If you didn't document it beforehand, you need to document it afterwards, but you also don't want to, in your op report, have nine pages on how you discussed all the risks. If your preoperative visit and your consent don't show that, it shows you to be defensive. You just say, look, if it's your normal thing is, and that's why, for me, everything I have are dot phrases. So I have a dot phrase standard complication discussion, and I click the dot phrase, and I said, if you had, over my last four years, every single person, and I have dot phrase, you know, T-lip, dot phrase, A-lip, dot phrase, anterior, dot phrase, posterior cervical, dot phrase, laminoplasty, where I go over it, and I actually print that off in our epic record, and I say, this is what I discussed, please look at it, and have the nurse say, this is the discussion, if you have any question about doing it. So what I'm saying is, is that, you know, if this is an acute wake up, you need to get images. If it shows something, then you need to discuss the benefits and risks. You know, if I have a threat or two through, and I think that there's a reason I pulled on it a little bit, or I stretched it a little bit, I'm going to probably tell them, there's a threat or two through, but I don't think it's done, but if in six or eight weeks you're not getting better, the option is to go, if, you know, I don't think that's what's causing it, but you need to make them an active part of your decision. All right, so Juan, let's put some, you know, some scenarios here. You did this A-lift, the patient wakes up, and the post-op, and, you know, they were five out of five, now they're four out of five post-op. Are you going to do anything that means immediately post-op that night? Yeah, first, I just want to finish what Chris started. I think it's very thorough, and I will, the only thing that I do different that Chris not doing, which has been very efficient, I don't know if you're doing it right now, is we have, we record the entire visit of the patient, so it's a video recorded when we tell of the risk and benefits to the whole consent. That one helps a lot, and we have a recent litigation cases where actually the insurance company increased the coverage, because that's a really good proof of that you did that. Well, and then the second part of the question, Praveen, I always do, you know, first thing that you have to do is can you, is reversible the complication, so right away you have a CT and MRI, you know, and make sure that you rule out the obvious thing, you know, screws in the canal as, I mean, too much media, high or low, make sure that it's not a, you know, very rare, but you have to rule out hematomas. Yeah, let's say you did an immediate CT, okay, you see, you know, there's still some osteophyte in the frame, and it was an MIS posterior decompression, it wasn't a Gill-Lamy, so you still see some osteophyte in the frame, and they're four out of five, do you do anything? No, I will, normally, to be honest, if it's a minor decline, I mean, it's not a true foot drop, I will just watch it, sometime I will do is I put a short trial of steroids, you know, and then give it some time, but what you don't want is to get into rabbit hole, like you see a screw, as Chris mentioned, a little bit medial, and then you go next day and open the patient, and try to reposition the screw, because you know that two, three threads medial not really dictate the deficit, I don't know what you guys think, but sometime I've seen that you overreact, and then you bring the patient next day, and take cages out, and crazy things. One thing I was going to ask, which is a constant medical legal issue, is whether you monitored this patient or not, so for a delayed one, it probably doesn't matter, but if you wake up with somebody with a foot drop, and you don't want to, well, so Juan just said if you don't monitor your dad, a lot of people don't monitor. I don't monitor my a leg. That's actually a good question, how many people here monitor routine lumbar cases? As in decompressions? Not transos. Are you talking decompressions or fusions? Even a simple decompression. But what about A-lifts? I monitor every five, one A-lift, I'm so afraid of that. What about posterior one level fusions, who monitors that? Some more people that. I'll tell you, our practice is that we don't monitor the decompressions, because it didn't make any difference, you don't really have issues on a decompression, it costs money, it takes time, you're like extending your day, so we don't bother with decompressions. For A-lifts, we give so much muscle relaxant when we're doing that retroperitoneal approach, we don't bother monitoring that either. For the posterior MIS, I do monitor. So I did the A-lift, I flipped posterior, we did monitor at that time, and the motor was fine. So, Paul, you say you did monitoring, it looked fine, the patient is four out of five the night of, the next morning they're two out of five, what are you going to do now? Well, if it's progressive, that's a different story, obviously, I'm going to echo what everybody else said. I mean, you need to image, talk to the family, and if you're a spine surgeon, this is going to happen to you. I had a delayed dorsiflexion weakness, just like you described, actually, about a month back. I mean, she did fine in the hospital. She came back and she was, I would say, four minus. And I talked to her about it, I said, I'm not sure what happened. She wasn't sure when it happened, but she was clearly weak, ordered an MRI, just sort of, we're just going to give it some time, and she improved. But you know, this happens, so you have to be prepared, and talking to the family, explaining the situation, explain the plan. You need to have, I think, a detailed plan. We're going to get imaging. If the imaging shows this, we're going to do that. If the imaging doesn't show anything, we're just going to watch a physical therapy. So I think if it's in a hospital, and the next day she's weaker, obviously you'd image. It depends if you found something on imaging. If you did not find something on imaging- Well, you're always going to find some smuddle of osteoarthritis, some little thread that goes through. Nothing catastrophic. Right. So what are you going to do with the little bits and pieces things? It just depends on what you find in imaging. I've taken patients back, and often you don't find much. I mean, the last time I can recall taking someone back was after, it was actually a PSO, and had developed a foot drop, and with a PSO, and you get the imaging, it always looks bad, actually, and I didn't really find much. Some blood, maybe a little bit more bone, and that patient didn't improve, I'll be honest with you, but we discussed it beforehand that it was a potential risk, and it never became a medical legal issue, honestly, but I think the important point is it's important to have the discussion beforehand. You know, Chris was absolutely correct. You need the discussion documented, and patients will remember if you just take some time and talk about it. Yeah. Chris, any final words of wisdom? Yeah. I mean, I think that, you know, the one thing with this being a mixed-violence thesis case, the more slippage you have, the higher the risks are, and I do monitor and do motors in particular, and do nerve root monitoring for the real grade three, grade four spondyloptosis cases. With this one, I just think that this is, you know, a relationship issue, and I do think that, you know, two years down the road, I'm sure this patient is doing just fine, but guiding them over that two years, and God forbid that, you know, they don't have a relationship with you. They go to somebody else. Somebody re-operates on them and screws them up worse, then, you know, then depending upon what state you're on, it's the initial injury is the thing that's at fault. So if somebody's trying to correct what you've done wrong, the liability goes back to the initial surgeon, and all you need to do is have, you know, somebody else really screw this person up, and then you're in deep doo-doo. You want to, you know, as I said, the bigger the complication, the more you need to engage the patient. Yeah. So Chris, are you saying that, like, restarts the statute of limitations? No, it actually, there's certain states that they assign either total or a proportional liability depending upon what goes on. So if somebody goes, oh, I had a foot drop to do it, and then they go back in, let's say they did a T-lift, and the cage is a little funny, and they go in and do an A-lift and have a major vascular injury, and the patient dies, you may get 60, 70, 80 percent of the liability because you screwed up the initial T-lift. So that's why you don't want these people drifting off, you know, particularly in certain states, to go do that. I don't know if the audience has any questions for the panel. You've got a very experienced group of people, and this is stuff that we all face. A question that sometimes comes up in these cases is should you or should you not apologize? And obviously there can be a nuance associated with that. Maybe it's not the exact right question for a case like this, but at what point and how should you apologize to a patient in the event that you really think there was a technical misadventure or something of that sort? Yeah, I think that's important for you to know what your state is, because there are certain states, and I was just testifying in a trial in a state in the northern U.S. where all admissions of apology are excluded. It's like peer review, it's excluded for an apology. There are other states where it's not, and if you say, hey, look it, I screwed up and I did this wrong, I think in all cases to say, hey, I tried my best and this happened and I'm sorry that this happened, I don't think that's going to get you into trouble anywhere. If you said, hey, look it, I was doing your cervical disc and I plunged and I pipped your spinal cord, I'm sorry that happened, you may have a difficult thing if you've gone and admitted that something like that happened. So I do think showing sympathy, showing engagement, and I just said the thing is, it's still ultimately whether you believe it or not, it's your fault, and if you never operated on them, they would have never gotten a complication, and we all recognize that complications is part and parcel, but the patient saying, look it, I did my best for you and I'm sorry that this ended up happening, I think is most times protective. I did an orthopedic residency and a neurosurgery residency. I worked with a total hip guy when I was a resident who was a butcher, was the worst surgeon I'd ever worked with, but his patients, he was really, really nice to the patients, both before and after he butchered them, and when I would go in and get their consent, I used to think to myself, oh my God, should I really tell them, run, run away, but the fact is, he never ever got sued, and again, this is 35 years ago, but he never got sued because everybody liked him. If you have a good relationship, it's very protective, and it's usually the person, it's like someone's daughter flying in from God knows where, who's mad because mom now has to use a walker, that is the one that precipitates this, usually more so than a lot of patients do. All right, last comment Sanjay, what's a malpractice attorney going to say about this case if it does go to litigation? What are the kind of picky, choosy things that they're going to try to pick out? You mean the plaintiff's attorney, like what are they? I mean, I think that this specific case, I think at least the plaintiff's attorneys that I've met, and I've met very few, would be reluctant to take this on based on what we've talked about, right, and what we've seen, like the ones that, again, like I've seen are Vanessa Defender, it's that the stuff that happens after or doesn't happen after, which has led to legal problems for the surgeon, right, you know, the, you know, I've seen surgeons not willing to see their patient post-op, right, like the Christmas pointer, you know, they'll send the resident or, you know, they, we're human, right, like we don't want to face our mistakes, whether they're at work or at home or whatever, right, and so it's natural human behavior. I think those are the ones that have, based on what I've seen, have gotten people in trouble, but this kind of thing, you know, or it reminds me of a similar but not that similar case where the patient actually needed to see a peripheral nerve surgeon and then ultimately did like a year and a half post-op, and the surgeon, peripheral nerve surgeon actually wrote in their note, if I had seen you within six months of this, I could have done something for you, but now it's too late, and that precipitated the lawsuit, right, and that was the linchpin of the case.

spinal metastatic disease

cauda equina syndrome

decompression surgery

patient outcomes

American Spine Registry

data collection

quality improvement

soft disc herniations

C4-5 level

anterior cervical discectomy and fusion

total disc arthroplasty

posterior foraminotomy

proactive management strategies

litigation prevention

neurological deficits