I'd like to thank Praveen and Pat for inviting me to give this course. My job is to talk about anterior cervical stabilization, and also talk about some basics from spine surgery, fusions, etc. This is a brief outline of what we're going to talk about. First couple of polls. Also, if you have a question, just throw something at me. If you have a question somebody else may, we're going to take a little poll here. Who's done an ACDF-P? Who's done an anterior cervical discectomy with fusion and plating? Who's done a CDA? Cervical Dysarthroplasty. Probably mirroring the general population at large. ACDF alone? Who's done an anterior cervical discectomy with no plating, fusion? Some of you have old professors. Who's done an anterior cervical discectomy alone, with no fusion? Okay, define, what is a cervical plate? Can you give me a list of people who are here? Who's Mr. Nixon? Or Ms. Nixon? point. What's a dynamic plate? Anyone want to help her? What's a dynamic plate do? Excuse me? Correct. Your name is? You go to Walter Reed? Army or Navy? No hard questions. What's a cervical? I spent a few years there. What's a cervical inter-retrieval body device? So who here does, when they do their ACDs, very good, does their ACDs with peak versus bone versus autograph? Who uses peak? Good. Who does a standalone? We'll talk about this a little later. But how do you, how do you, how do you code that? Do you code that inter-retrieval body device? Do you code that as a fusion? Correct. Why is that important? For functionality, what you're doing makes no importance. But if when you get into a billing situation, you start doing this, you put an inter-retrieval body device, put it in fusion, and you do it long-term, you could be wearing stripes because that would be called fraud. So there's, it gets into a different mode. We're now talking about the billing component to it. The device is simple. Your goal is to fuse something, which we'll get to in two seconds, but those are actually different constructs which actually make different coding. And when you get out into the real world, you actually have to know the difference between the two. Same thing with a cage. Who is Cloward? What did Cloward bring to this field? Excuse me? And then how did he do that? What was his goal? Correct. So the goal there was to get fusion. We'll talk about that in a second. What's the Smith-Robinson technique? Who here has done an ACD? I guarantee you knew of Smith-Robinson. The Smith-Robinson technique, we'll talk about it in a second. They're the one who actually essentially designed the cervical, anterior cervical discectomy that you guys do now. Anybody know who Kaspar was? Any significance to that plate? It was probably the first anterior cervical plate that was ever used for instrumentation. So the reason I bring these up, because we're going to talk about the history of this in a second. Actually, let me finish this. What's Wolf's Law? I'm sorry, put your hand up. So if the bone is under compression it will heal better, okay? What is stress shielding? Anybody else? If this was an orthopedic group and you guys didn't know this was first years, you'd be like trounced out. So one of the problems we have as neurosurgeons, which I'd rather be a neurosurgeon by the way, is that a lot of biomechanics when you see with bone healing, etc., our orthopedic colleagues know because they have a dungeon through their head and they need it on an early basis. Stress shielding means that your construct or your instrumentation is taking the stress off the bone, but that may inhibit the bone healing. To some degree, it's the opposite of Wolf's Law. So we're going to talk about anatomy and biomechanics. You guys should know this, obviously. You all know what your pathology is. You have the bone, you have the disc, etc. I'm not going to spend a lot of time here. At Allen Ferguson, a long time ago, they designed different forces when you have a traumatic injury. Has anybody seen this chart before? So essentially, if you look at it, those are all the different forces, distraction, compression, flexion, extension, that can happen when you jump off a poor building, your car accident, etc. The reason I show this, you have to understand those forces. If you understand these forces for where the spine failed, your job is also to correct those forces and make sure that you bring them back to normal, bring everything back to balance. So you have to understand, is it a flexion injury? If you have a flexion injury, so if you have an extension injury like this, ACD alone, and I think we showed one of those cases yesterday with patient AS, angiospinalitis, it may be a bad injury, but a simple anterior procedure may work. With this injury, we talked about bilateral distraction. I think Michael was showing that using Casper pins to distract up and put that back in, but your failure moment is back in here. An anterior procedure may not be the best. Some of this is common sense. If the patient has a distraction injury, you're going to have to correct for that. Obviously, if you have a major distraction injury, you've also seen OC dislocations, you're not going to be putting 125 pounds of pressure on somebody with a C1-2 injury, so then they'll start being GI Joe and the head will kind of flip around. You have to understand, whether it's in a traumatic situation or it's a chronic deformity situation, what forces you're trying to correct. Okay, it's imperative. Joe, right, from Walter Reed? Do you still have your own clinic? Okay, so when we trained, I had a clinic the day I started. I was seeing my own set of patients from day one. I was stupid. I would see maybe one or two a day. Okay, and somebody was constantly watching on my shoulder, but was beating to me what the indications for doing surgery were. You guys, unfortunately, because a lot of this is ADL work week, are spending a lot of time in the operating room, but you're not spending a lot of time in clinic, correct me if I'm wrong, so you're not looking at these little subtleties that, you know, your attendings may see. So it's really inherent upon you to learn the small things first. For being dumb, you know, if you show up in the operating room, I'm sure for you guys will tell you, if you have not looked at the patient ahead of time, looked at the films, have a battle plan before you get there, you'll probably not be doing much of the case. You may have to, who's the other guy who puts people in the corner with a gun tap? So look, listen, and feel. Know what you're doing. Know what your goal of your surgery is before you even start, and you have to be a very good diagnostician. Your imaging should only confirm what you're thinking about doing with the patient. Does the patient have somebody that did a really good job yesterday with that C7 radiculopathy that Pat showed? So you know ahead of time, this is a C7 radiculopathy. The exam, consistently, it looks like a duck, smells like a duck. Your imaging should tell you it is a duck as opposed to a, you know, Chinese duck with, you know, which would be the tumor or that, you know, kind of zebra out of there. It's also important you have to, unfortunately, document this. You know, in the old days you're gonna have a 3-line note, and that's what a neurosurgical consult was. Unfortunately, in the era of billing and etc., and it's important to put all these things in there. It's also gonna be important for you for risk stratification when you start documenting down the road that your patient is a fat, slob, smoker, diabetic, osteoporotic, etc. So when your construct falls apart and your buddy next door goes, oh mine don't fall apart. Yeah, but you're doing 35 year old yoga teachers, you know, with, you know, healthy bone, etc. You have to be able to stratify from that. Also, you're gonna be stuck with informed decision-making. When you talk to your patients, make sure you're telling them here are their options. The young woman again with that C6-7. That C6-7 case that Pat showed yesterday stimulated a 45-minute conversation with the staff two years ago. Everyone in the background about whether they would do that from the front, the back, the ACD alone, etc. So there's a lot of different ways to do it. So informed consent is not informed decision-making. It's gonna be inherent upon you to tell your patients, just like you were thinking through those board questions yesterday, tell your patient, here are your options. This is why I think this makes sense to you and down the road. You also want to low-speed that person who's doing the wrong operation on the wrong patient at the wrong time, okay. If you have to follow this patient, once you start going out like Dom and I, where you're really in the community and you're seeing everybody at ShopRite and stuff like that, you screw them up, you will know about it. Also, these comorbidities are gonna affect how you design your construct. Okay, I'm gonna do ACD, ACD, ACD, ACD, you know, a metric laminectomy of my workhorse, etc. All of a sudden you're gonna come across, hmm, I got a patient who had a radical neck. Fortunately, they don't have a lot of radical necks these days, but up where I live, you know, where they have Sloan Kettering, they do them, so it's like this guy did an ACD, but he had had a radical neck. Clearly, that was not gonna be a great operation for him because he already had a hard time with swallowing, etc. There's all the scar tissue been radiated and chemo, etc. The approach for that, which is pretty easy, most people became extremely hard, so you're gonna have to adapt around that. Also, you have to make sure if you have things like OPLL, you know, think about it ahead of time, because you're in there, popping that disc out, having a good day, and all of a sudden you see, as orthopedicists say, a lot of bone water coming up through your ACD thing, you know, someone's gonna be having a bad day. Also, make sure you metric yourself, benchmark yourself. It's really easy to say, yeah, I did this many cases, I just made a collection, I just did this many RVUs, but how did your patients do? And I think more and more, as people start getting into regularly projects, etc., these things become more commonplace. What was my SOSB before, what was my SOSB after, what was my MGOA before, what was my MGOA afterwards, etc. Learn those things, they're not just research tools. As you go out into private practice, whatever kind of, you know, neurosurgery you do, those kind of metrics will become more and more in vain. You have to take, you know, embrace that early. Also, act locally, think globally. You guys, somebody picked up, if you had asked me, if I was a member of this course 10, 15 years ago, it's hard to balance, those were people for shafting, not those, deforming T10s, you know, iliac screws. What do I need to know about that? You know, early on, I probably screwed up a whole bunch of patients, because I was acting, I'm going to fix the neck, you've got a kyphotic deformity, kind of like that patient I showed yesterday, and you guys also have a flat back syndrome, so, you know, their neck pain is actually coming from the fact that they have, you know, significant sagittal imbalance in front, and if you actually fix the back, the lower back, you know, that would bring the neck back up, and that patient does not necessarily need that operation. The goal of any spinal procedure is the decompression of the neural illness, number one, that's why you're neurosurgeons. Two, is restoration of normal alignment. Three, stabilize those pathologic segments, and four, is prevention of further deformity. Every procedure we talk about for the next two days, these are the basic principles of spinal surgery, okay? Everybody's heard these before, correct? There should be no real goal in this. Joe, I keep tapping on you, this is one of the most important things I learned about neurosurgery and spine surgery was from a Marine Corps gunnery sergeant. What are the six P's? Anybody know what the six P's are? Proper planning prevents piss-poor performance, okay? The other thing I banged into my head when I was a Navy resident is plan the dive, dive the plan. You know what you're gonna be doing ahead of time. There's an honor to operate on patients, okay? You're the captain of the ship when you're attending in that room, okay? You're in charge, you don't want to make sure, you got to make sure everything else around you is going right. You have to have a plan, because if the plan doesn't work, all of a sudden you need other, you know, out, you have to figure out what I'm gonna do, what if happened, okay? You got to embrace that thought. Okay, now I'll get back to the real part. Here are the indications, you know, you got to use imaging, MRI. Who was the person yesterday who showed, forget who, it was Patchcase, the ACD case, who did that yesterday? They said two to three week history of neck pain, arm pain, no weakness. Okay, what did you say yesterday? What did you want? An MRI? Okay, I would have failed you. If I was a complete quality geek on this side, I'm going partly on the quality geek side. If I was a complete quality geek, they would say, why are you getting imaging studies? Why are you doing anything? Why are they seeing a nurse? It's only two to three weeks in, the patient's not having any weakness. Okay, getting imaging before six weeks is a bozo no-no in the quality world, because now you're over utilizing the resources. Okay, as residents, you order stuff willy-nilly. You know, people, and Dr. Ward and I were talking about this last night, is that you start ordering this stuff, and I think, why are you ordering all these tests? You're going to be an outlier. Okay, that's kind of a loaded question. Unfortunately, these days, you guys have to kind of think about that. But imaging, MRI is obviously the imaging modality of choice. We're not going to belabor this too much, because it gives you a lot of information about what's being compressed, where, you know, if it's a trauma patient, or, you know, the ligament's ripped, is there OPLL, is there adenine in the cord? It's only a simple disc, there's no cord compression. I probably don't need monitoring. There's a big central disc with a lot of adenine on multiple levels, and I have to correct the typhoidic deformity. I probably will use imaging on that. Those are the kind of things that the MRI scan tells you, and it gives you such a great knowledge of the anatomy that's perfect. You know, this day and age, within Mars, you know, when Pat and I trained, there's more plain films and maybe CT myelography, and you had a lot of, ooh, I thought that was going to be a disc, but it's a juxtaposetic. With MRI scans, there's very little surprises about what you're doing. CT, obviously, is important for bone, okay? Has anybody here ever ordered a CT myelogram? Why? Can't get an MR. Damn cardiologist. But also, it shows, obviously, the bone morphology, and if you're, once you start doing a lot of these, and besides your trauma, I'm talking more from a degenerative standpoint, knowing what the calcification of the disc is, especially if you have a thoracic disc, which I don't think I'm going to talk about, it really helps some of the OPL patients to help you design your construct, not just the measuring of the screws ahead of time, etc. Plain films for the cervical spine, you know, certainly in our trauma center, we don't get it. They don't write that, you know, fast, the CT is faster than getting, obviously, it shows you a lot more information. However, dynamic films, flexor extensions, and as we've always kind of alluded to, it'll probably be banging your head through a lot of the different people talking this weekend, is 36-inch scoliosis for you to see what your coronal and sagittal thing is going to act locally, think globally. Okay, quickly, the reason I'm showing this history is because if you learn from the mistakes of some of the masters in the past, you'll figure out why the tools everybody put in your hands are being used. It helps you design these constructs. So, really, first anterior cervical fusion was done back in the, by Bailey Clowden Smith with the reforming technique. Clowden, who was in England, essentially took a Hudson brace, drilled a hole into the disc base, put a bone plug. They did not, I mean, just opened up. Who's here used a Hudson brace? Real old school, way to go. They would just drill a cloud. His concept was, you've got to put a bone plug in there, and it fused, and most of these patients had spondylitic ridges. If you fused a segment, the spondylitic ridges would go away, and B, it would stop moving and irritating the nerve room. That's about as, obviously, as indirect as it could possibly be. But part of that, again, the reason I'm bringing that up is the fusion is important, because that helps prevent some of the symptoms going forward, but obviously it's not restoring anything. Smith-Robinson technique was a technique that we pretty much all use now. It's actually going through the disc, better illumination, better magnification, et cetera, that you can actually go in, take the disc out, and directly, you know, eyeball on pathology, remove it. Again, if you can see it and you can illuminate it, you can probably operate on it. So they designed the original technique, which we all pretty much use now, going in, directly taking out the disc, decompressing the neural elements, whether it be the root, et cetera. The problem is, you now have a hole there. So they would then put in the technique of putting a piece of bone in, which would be taken from the iliac crest. Who here has taken iliac crest grafts or ACDs? Three. I haven't taken one out in eight years. It was on a cop who didn't want anybody else's bone. He made me do it, and I told him, you cannot bitch about your iliac crest pain. Forever from this goes forward. Okay. A little bit of disclosure. I have a two-level ACD in my neck. I got fused two and a half years ago. I have bone, and I have plate. Somebody else's bone. I don't know who it is. Okay. But they had a problem with that. So when they put those in, A, it hurt, et cetera, but they still had a pseudoarthrosis rate, and taking bone, as you all know, hurts. Casper originally designed the original plating technique that became more widespread. This was a Casper plate, and who's put one of these in besides Rusty and Pat? I did mine. That was, of course, when I was 1991. You can't actually learn from Casper. This technique is very technically dependent. The first one we could actually put bone in, the iliac crest, but then the plate would actually transfix it. So that took your pseudoarthrosis rate with an iliac crest graft from the 80s up into the high 90s, because you all started to stabilize it. However, this was a plate-screw construct. What does that mean? I'll point to you. So what's a plate-screw construct? It's a construct that requires you to place the plate first and the screws after you put the plate on. It's a screw-plate bone, but they're independent pieces of equipment. In other words, the screw is not locked in. It's not a constrained plate, which I'll talk about in a second. The other thing to make this work is, where do those screws go? Where do those screws go? You might not be happy with my English today. They're bicortical. So to get good purchase, you had to tap. Pat and Rusty could talk to me about it. You had to tap, go to drill, slow, slow, slow, and then when you feel it break out, it's almost like when you're doing a burr hole. You're drilling and drilling. Then you find that just before it grabs what you're going to plunge in, plunging the brain is bad, but I'll tell you, plunging the spinal cord is probably a wee bit worse, especially with a deep plunge. Okay, so it was really highly technically dependent because you had a field going through that back. If you didn't, then your screw would go through the anterior cortex into marrow. That was mechanically not a sound technique. Correct. So if the screw started wobbling, that was a problem. They also had, you can see here, these screws actually slide. A little bit of wool slaw kind of built into them. It was really, at the time, it was like revolutionary, but it was very technically dependent. This was followed soon after by the synthese plate. This is a constrained plate, which means what? It means the screw goes in, but now it's locked into the plate, which means you didn't have to go bicortical because you did not have to worry about the screws backing out. Okay? The reason I'm kind of going at this is these are the mistakes that were made in the past. They can still happen today if you don't design your construct correctly. So it's not just a historical vignette. Okay? So, but the beauty of this is, the one problem with this plate is what? Does anybody know? They're fixed angles. To get the screw to lock in, you had to drill exactly in the plane that the locking mechanism was in. Okay? So if you have abnormal anatomy or you're at operating extremes, C7-T1, C3-4, you're trying to get a down-angled screw up there, you're really having to crank to get in there. Sweet spot, 4-5-5-6, depending upon how high it is, 6-7, was a great plate, and it would just fit right in. Off you go. Okay? Over time, the next kind of major milestone with these dynamic plates, to be honest, I never put one of these things in, but you can see this would probably not lead to a very good flying problem because it was very bulky from the front. But the concept here was that when you put this in, it was constrained. This is kind of the best of both worlds. From Synthes and the Casper plate, it was constrained, but it would allow some stress onto the graft to roll slough, and you could have some degree of subsidence, but we're not going to have too much that you're not going to be stress-shielding it. Does everybody understand that concept? These are kind of the dynamic plates. They don't really last that long. The real plate, and most of the plates that we work on today, the original one was the Atlantis plate, and this is where you could put fixed screws in and variable screws in. You put the fixed screws in to lock your construct, and variable screws you can then go at different angles, and you can work around the pathology that you're going. Okay, so some of the learning points for this, and most plates, you can see the kind of evolution of this. I stole this from Dr. Suntag's slide, where all these screws all kind of develop, and now there's different cams and locking screws and bolts, and there's more plating constructs out there you can shake a stick at, as witnessed by this timeline of anterior cervical instrumentation. But the basic principle is over there. You want your screws relatively long to get a good bite and mechanically sound. I still occasionally, if I have a really osteoporotic patient, and I don't want to do a really big extension, I'll pull out of my bag of tricks my Casper technology. So I will dill long to get bicortical purchase. That's a very strong construct. It's just that you have to be very precise in your engineering of that to make sure you're out so you don't get that. Having a CAT scan ahead of time, and having fluoroscopy allows you to do that much safer in the old days, so you get one or two screw pitches through the back part of the bone. But I'll tell you, that is a very strong construct, if you can get it in. And again, it's part of your armamentarium, but you just have to think about it. Fifth one, I don't want to go anywhere near the cord. Well, now you're asking, depending upon the quality of the bone, if you're at the extreme screws, if you're really short on that, you've got a much more chance for pull-out. You have to design these constructs. Again, this goes back to the Ferguson slide I showed you earlier about where your failure are and what your goals are from the surgery, if you're trying to correct the formula, etc. Obviously, this is a very complicated construct, but you need to think ahead of time, how am I going to build this? I use cage metal as opposed to just the easy 4-5-5-6 ACDFP. That's relatively straightforward, though there's a lot of different things you can do now. Think ahead of time of what you want this to look like. You don't also want to do this necessarily all in the operating room. People were showing yesterday, putting people in traction, etc. If you can get them when they're asleep, you get them into a neutral, balanced position, as opposed to relying on your technology, on your screws, etc. You're going to save yourself a lot of aggravation, a lot of stress on the screws, and bone will heal more naturally, a more neutral thing, as opposed to over-stabilizing, over-dynamically changing it with your instrumentation. The approach is important. Again, I won't belabor this point, but you have to think ahead of time what you're going to do. It's imperative that you know your anatomy. That's why your neurosurgeons should be useful in the neck. Mark ahead of time where you're going to put your screws. I'm anal about doing thoracic surgery. When I'm looking at my most important level, I want to make sure I'm going to have a straight shot through. I'm not having to peek about an angle. Plan your incision based on where your goal is. I learned this mostly from Dr. Spetzler. When he designed it where he was going to do an aneurysm, he wants his incision to be straight, so he's looking straight down, as opposed to working around the corner. It may be a little bit different from a cord, but more commonly, you're going to be looking at the cord, etc. Plan your incision ahead of time, prior planning, depending on the number of levels you're going to do. Who goes right, who goes left? How many here do left-sided approaches? All the time, they're routine. How many do right? Why is the left side a little bit better? Technically, you're at a little bit higher risk of injuring the recurrent laryngeal nerve coming from the left than the right. I think there's a mitigation of that. I had every minor complication you can have with an ACD. I had to get scoped. I had swallowing issues. I had hoarseness, etc. Mostly because the guy who did it was trained by Rusty and Praveen, but that's a different story. These are real things, and you start thinking about it. It's nice to empathize with the patient. Who puts trim-line retractors in, or some variant? Trim-line is when you dissect out your lungs fully, you put those retractors. Assuming everybody. Use sharp blades or dull blades? Smooth blades. Mediolateral, sharp or dull? Sharp. I do too. Who uses Ross-Ricardo blades? This is not a trick question. Who doesn't on a routine basis? I had neck surgeons show me how to do that, and I actually moved my retractors per level, and I found out the incidence of my swallowing problem dropped dramatically because all of a sudden I'm trying to crank on that north-south retractor. That puts a lot of stress. Who's here ever heard of... You probably all use this technique, but who takes an endotracheal tube and diminishes the pressure after you put your blades in? We're going to have to have some Dr. Atkins. Good. Again, you want all these soft tissue things, because you can do the best decompression, et cetera, but if your patient wakes up swallowing and having problems like that, that's what they're going to remember. They're not going to remember the fact that you relieved their myelopathy, but the fact that you can't swallow, you're going to be complaining about that for a long time. I'm a big fan of Willie Horton's theory of neurosurgery. Willie Horton, the White Rock Banks, that's where the money is. Design your approach where the pathology is. This one you'll probably do more from in front. This one you could probably do more from back in, depending upon what other factors are going to be there. Laminectomy can still be a good pressure. We're going to do this. Again, establish a target where you're going to decompress, locate that target using your imaging, and then remove it. We all know about the anatomy here. I'm not going to spend a lot of time on this. With the ACDs, there's a difference between what you have to expose to between ACD, anterior cervical discectomy, and the cervical disc arthroplasty. I'm not going to talk about cervical disc arthroplasty because Don Cork, who's probably one of the experts in that, is going to talk to you about that next. But when you do the ACDs, if you start using it with the artificial disc, in some of the contracts, when I was taught you did not want to violate the bony end plate. Especially if you're doing artificial cervical disc, you need to do that because that's going to help support them. If you're going to be doing a decompression, you can take those end plates out, especially with the newer constructs. But again, I would caution you, when you're doing a real one, in the old days when you had big pieces of bone you had to put in there, people did wide exposures. Nowadays, I see some of my partners, they use these stand-alone constructs where you just take a little bit of disc out, pop that thing back in there, and then you're out. To me, you're actually heading back more towards the cloud theory, where you're just jamming something in there, but you're not doing an adequate decompression. If you're doing a decompression for myelopathy, take measure. Measure ahead of time how big the canal is. If you all of a sudden say, I'm done, that was great, let's get the bone in, and then you put a graph, man, this is a 14mm graph, I'm going to have to really jam this thing in there. Think to yourself, you've now gone to the next stage where I'm doing my fusion, like, if you only did 12mm, and the canal is 15-18mm, did you do an adequate decompression? Again, what's your primary goal is decompression. Everything else should be somewhat secondary to that. But if you're not going wide enough, and especially not ahead of time, that's why you have CAT scans and MRs, measure it. They have little doohickey tools on it. Measure how wide you did. Take a piece of paper ruler, cut it to 15mm, drop that in, damn, I'm nowhere close. Did I really get out into that perimeter? Once you've gone in once, it's relatively straightforward. Going in a second time, trust me, is a pain in the tush. So make sure you've done your adequate decompression before you finish doing that. When you go to one stage, finish it thoroughly, because that sets you up for your next aspect. Fusion techniques. Again, we've talked about this before. The workhorse for most people is going to be structural allograft versus some type of a peak or alloy-type construct. And there are pros and cons. I've been using bone and plate, I have bone and plate on my neck, for a long, long time. Peak is good in certain circumstances. Who uses infuse in front? One person does. And he probably is very, very intelligent about how he puts that in, as opposed to the old, say, well, if small is good, large would be a lot better. And that would obviously have some repercussions. But again, you want to think that your bone is just there to help stimulate the bone to grow from one level to the other. In Lawson's concept, the fact that Iliac crest is good because it's got the osteogen, all the factors involved in it. But don't short that. There's a lot of different techniques. Personally, when I drill my discs out, I use a cylinder burr with a mitus, a little Lucan's trap. Lucan's trap, you scrape out and do an aggressive discectomy, then you drill out the bone. Those are the patient's bone cells. You collect it in a Lucan's trap with some blood, put it off the table, squeeze it through a telco, and you're not having your own cheap BMP. You didn't pay for anything, which is why my cost versus one of my younger colleagues and orthopedists are much lower per level because I'm just using standard bone patients, etc. You are going to be economically credentialed in the future. They are going to look at your cost. Trust them. They will look and say, how come you're using this much more than that? And the junior guys are all of a sudden like, well, I'm $3,000 or $4,000 per case more, but they're putting PEEK and BMP, not BMP, but PEEK and all this other kind of stuff, these new fancy plates for a simple thing, and there's like $2,000 more per case. As Don will tell you, if you're in a surgery center, that's money coming out of your pocket. Every bunch of us have been using it for 12 years, 13 years, and you use 0.5 milligrams per level, and once it's contained, the complications are extremely low, basically the equivalent. So what's interesting is now every healthcare that our institution will no longer let us use it. It's too expensive, it doesn't get reversed well enough, and if patients want it, they have to pay for it up front before admission. So it's going to go away except for pre-level or greater cases. Again, and as Russell was telling you, think ahead about what you're doing. As we used to say, downstream implications of everything you do, and you want to be focused on taking good care of your patient and your hands, et cetera, but outside forces are a measure. They can actually do it now, and unfortunately they are. So again, pick your structure. Whatever works, as Dr. Sontag beat in my head a long, long time ago, there's a lot of instrumentation companies out there. Find out what works best in your hands for the way you do things, and then just stick it, because if you do it more and more, you're going to be much better. As Michael showed you in that picture with the socks, which is on demand, that graph right through there, you want to find what's going to be comfortable in your hands for your workhorse situations, and you'll be better off to take care of those zebra situations when they arise, not if they arise, when they arise throughout your career. Again, so the main ones that are out here are structural allograft, structural oolograft, and I don't think that many people are using iliac crest all the time. It does hurt, as well as intervertebral body devices. How many here, when they do their ACDs, are doing a typical bone-slash-interspace device and plate versus a stand-alone device? Who's using here for routine use stand-alone? LDR, Anchor C, things along those lines? Single level. How about for the faculty? Is anybody doing those for other cases? I use them for adjacent level. I couldn't have been on the internet. I just did three cases last week of people. When you're old and you've been around enough, all of a sudden your ACDs start coming back about 10, 15 years later. For C4556, I had three in the last couple weeks. Instead of having to take the plate out, these things are great where you actually clean it out and you don't have to take the plate out. You can make a virgin incision, come in. I just saw her back this week. She tolerated C3-4 from a swallowing and hoarseness problem much better than she did the three levels she had to have a while back. If I had to go back in the old days and rip the plate out, that's a long day. There will be hoarseness and swallowing difficulties. If you can do a virgin approach, it's nice. Don't be that guy. Don't cheat. To me, it's just a clower. The technique is really decompressed. If you're just going to go in there and whip that in, you're done. You don't have to take out the ox plates. That way, you don't have to take the end plates down. We'll talk about the plating in a second. You have to be meticulous about taking the end plates down to get your plate to fit flat. If you have these bone plate things, like the early Casper ones, if you left the ridges there, and your plate is proud, trust me, it's not going to hold well. If it doesn't fuse, you're screwed. You're going to see the screwing esophagus for the plate and esophagus, etc. That obviates that because we don't need to take all the ox plates down. There's a balance between shorting it and finding a shortcut to do it, as well as being safe. I think those things do not have a great fusion. They're easy to put in, but there's not a lot of bone to put in there to fuse across. However, for the adjacent level disease that breaks down, or if you're at a terminus, you're a relatively fat neck like me, and you want to, for whatever structural reason, do a C7, T1, ACD, or you have somebody who's relatively tight and you're doing C3-4. C3-4, your hoarseness and swelling difficulties will go up. There's more important structures up and through there. Then it's a relatively nice technique to get in there because you don't have to do as much soft tissue retraction to get up there. In the old days, when we did it, you want everything as wide as you can because that allows you to visualize. If you're a minimally invasive guy, which I'm kind of the more my bent, you want to get in there without the tissue trauma because that's those secondary injuries that are going to really hurt the patient or are going to be annoying for them going forward. We kind of talked about this already. Think about what your bone can fusion. The instrumentation is there to provide an environment for your bone to heal, period. We all know that if you just went in there and put the plate in without the bone, you'd fail. So your instrumentation provides an environment for your bone graft to heal, help correct the deformity until everything kind of sets up. Most of these are not stand-alone. Everybody understand that? Use whatever construct you want. There's various different aspects of it. In my personal hands, my opinion is your firm belief, is I typically use a filler plate but I use essentially the Atlantis. I use a fixed and I learned this from Dr. Hayde. He used to be a partner and trained a lot of people in the faculty. I'll use a fixed screw down below as my support and variable screws above. The variable screws are some degree of subsidence but provide some stability. If it's a trauma patient, everything is loosey-goosey. So if you're doing that bilateral lactose set that Mike showed yesterday, you do it from in front. That's about the only time I ever use casper pins, by the way, to really kind of distract that. Then you would probably use something like a fixed construct because you want that more immediate support. You're relying on that instrumentation on something that's much more delayed as opposed to some arthritic, AS, spondylitic masses. It's probably relatively inherently stiff. You don't have to use that. You have to over-engineer that to that degree. Again, part about setting that up, when you start distracting a lot to really view it and I used to do it all the time, once I stopped doing that and I went to a technique that was just exposing per level, cut down the swelling probably, also cut down what I call settling pain. When you start cranking up on that, unless you're trying to correct a deformity, different, either an acute deformity as in trauma or a kyphotic deformity or something along those lines, once you start cranking up on those facet joints, you open that up, they're going to have pain between the shoulder blades. Again, it may be a good reason, but if a routine disc, etc., they will complain about what I call settling pain, pain between the shoulder blades, because you put the facet joints under distraction. Again, these things are very strong mechanically. You're going to put a lot of stress on them and you're going to now change that stress to something else. Professor Rooks. Another point is that the cast bar blade, as Jack showed earlier, has slots in it and they're biparticle approaches, so it allows some dynamism, allows some settling, and the wool slot will take effect. Then the whole deal went backwards because the next set of plates that came out were extremely rigid and all of the screw plate interfaces at the top and bottom were rigid, like the Orion plate, the Sensus plate, the Saw, all of a sudden made more complications than we ever did with the original cast bar plate. There was too much stress shielding and autologous grafts and allografts wouldn't necessarily heal, so that's what led to the next generation of plates like the Premier plate, which also had slots, or others where you could have variable screws or non-fixed screws that could rotate and fix screws as well. That's just a concept to know why the whole technology went that way, plus learning from some of the mistakes that were going on. Exactly, and again, those variable screws, think about the depth, think about what you're going to be putting into, but it allows you to work until it's, you know, the technology's great because now you're not constrained to power current term, but you're not fixed, which is also a bad term, you're not having to use that fixed constrained screw because if you don't put it in, it's not going to sit, it doesn't sit, it's going to back out, etc. You have a lot of variability and you can work around the patient's anatomies. How many people here do a lot of corpectomies? I haven't done a corpectomy in five years. Partly because with these screw systems, if I had rather have, and there's going to be debate about this, so if you do a corpectomy, you only have to fuse two segments. I want the C4-5 interspaced to fuse the C5-6 interspaced to fuse. The longer you're putting in there, the harder it is to fuse. So if I have a three level disease patient that I'm going to be doing from in front, I'd rather save part of that middle bone as a screw purchase point as opposed to relying, because one long system tends to break. Once you start going over corpectomies of a certain size, then they become wiggly in the beginning and you have to now take them back and do a 3-6, reinforce them from behind. With the screws being able to wiggle and you can change your target, change your trajectory, allows you to keep some of that portion, almost keep the middle portion for a screw purchase and do relatively aggressive discectomies above and below. As we all know, this patient is really congenitally stenotic. Most of the compression is going to be at the disk space. The mid-portion of the body is usually a pretty open area and there's not much going on there. Again, this is advanced tinker toys. You have to think ahead of time, how are you going to build this plant? If all of a sudden you rip your screw out, you go into a bag of tricks. How am I going to fix this? There's various different techniques to do that. I will again count to you. This is obviously on a saw bone model. The hardest part here is anybody who's over the age of 50, which is my patient population, are going to have spondylitic bridges there. One of the best things you can do to make sure your plate is going to sit flat is use the most important tool in your chest, your finger. I guarantee if you put your finger in there and rub it, if it feels flat it's probably going to be relatively flat before you start putting tentative plates in there. If you put your finger in and it feels sharp ridged, there's a part of that spondylitic bar from in front that's there. Get out your diamond burr or whatever you're going to use and burr that down. If you can put your finger in there and it feels relatively flush, that's going to set you up that you're not teeter-toeing. The hardest part for these plates, once you go more than one level, is that it's not going to rot. Do we understand? You want it flush. This is where the carpentry comes in. You want that to be as flush as possible with the bone. It'll heal better. It'll be less proud. There's going to be less chance of having a patient having swallowing difficulties. That's the hardest part of this procedure from the instrumentation standpoint nowadays. Because the screws are relatively easy. Don't short the screws, especially in older women or people who are on steroids, etc., who are going to potentially have a soft bone. Find the technique you want, but don't short just going in there. If you have those bars there and you put it down and it seesaws, it's not flush enough. Take it out. Do the job right. The second time through, again, it's not that good. Here are a couple of cases. I don't think anyone would argue that's probably something you could just do a standard ACD on. This is where you start getting into as I said before, that hybrid construct. Here's a patient that has a three-level disease. The bottom one is not all that bad. The top one, you do a corpectomy to correct his deformity. You do a corpectomy graft there, but instead of doing a corpectomy from here to here, kind of like that old slide I showed you, that big cage, etc., I opted to make sure I could keep a point of fixation into there. To me, it's a stronger construct. Even though there's more interfaces to heal, the instrumentation can help stabilize that. Also note, you can and can't do from in front. This is a patient with ankylosing spondylitis, obviously. You can see that someone had tried to do an ACD from in front. There's the plate there, and it completely did not hold in this construct. I like ACDs if I can reduce the fracture from behind, because it's better for the patient. Certain areas are not going to heal, and that's when you have to use something like this. When you have these big deformities, I tell patients, one or two levels will do from in front. Three, you have to think of that. I've done a lot of one or twos. I probably do about maybe one or two threes a year. I've done fours three times in my entire career. Anytime you start going over two or three, unless there's really good reason, I typically go from behind, because it worsens the swelling difficulty. You also don't want to be fixated by this anatomy. I had a patient recently that came up to me who had been done down and stayed elsewhere. He had 3-4, 4-5, 5-6, 6-7, 7-1 done. Because of pain down his arm and to his hand. He had swelling, difficult whole nine yards. It was a couple of stand-alones at the extremes, three or four levels in the middle. I'm looking at the guy, and he's like, I never got better. Because he missed the spondylitic ridge coming at T1, T2 that I did a metrics on, and he got better. The person who had done that, one of my pros, don't be that guy, you saw the ACD, he had a bunch of disc degeneration, but no radicular, no cord compression. His MRI looked a lot like these at every level, so he did every level. Yet still, because he was in a rush, missed his appendic pathology because of his hand ulnar weakness and his C8 distribution. All he really needed was a relatively simple, 4-5 level fusion. So, look, listen, and feel. Know your patients ahead of time. Establishing your diagnosis is the most critical thing to preventing failure, period. Plan appropriately. Think about what you're going to do, what's good in your hands, not in Dr. Rhodes' hands, or Dr. Quark's hands, what's going to be good in your hands to keep your patient safe. Know your anatomy. You have to be an anatomy dweeb, and you have to be a little bit of an engineering dweeb to be a spondyl surgeon. If you start going to minimally invasive, you really have to know this stuff, because you're going for a specific target, and you're bypassing all those other secondary injuries. But if you don't have a firm grip on your diagnosis, your patient's not going to do well. Use your technology. Help you, not necessarily to direct you. There's a lot of fun toys out there to do. There are procedures looking for indications. Try to avoid that. Like I said before, some of these stand-alones, people can put them in so quickly that they're essentially going back to their clouder technique, because you're missing your original goal, which is to decompress the neural elements. Don't be that guy. Especially when you're early on in your career, you don't want to be doing these goofy things, and realize, why did I do that? A lot of self-introspection. The best neurosurgeons I've learned from, especially spine, guys like Reg Hayden trained Rusty and indirectly trained me. Dr. Sontag trained me as well. They showed you their screw-ups before they showed you their good cases. You want to be kind of like that mindset. You don't want to be, don't be that guy. Once and for all, thank you for being a neurosurgeon, not something else. One of the other hats that I wear is equality. You guys in the registries and stuff along those lines, you guys are going to be judged a lot more on this, measured a lot more on this than I was, certainly when I was in your point in career. It was a matter of just getting the cases done. As I alluded to at several points in this talk, you're going to be measured by your performance, not just economically and clinically, etc. Know that, embrace that, and you'll win that battle. Questions?

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