Disclosure is very important. These are my disclosures for this talk today. So, first thing, why spine? Who wants to do spine? Come on, is this like they're interns or is this boot camp or? Okay, why spine? Well, when I was at your stage of my career, I thought I was gonna be doing all this cool stuff, you know, brain type stuff. But then I realized that spine's awesome, okay? And actually, we do a lot of really cool stuff, right? Tumors, fractures, deformity, MIS, all this really, really cool stuff and we really make people better. And Michael Puzo, who's one of my mentors, told me that, you know, one of his mentors who did spine had like this anteroom, kind of like Spetzer has, full of canes and walkers. And he would say, well, when you come in here, just leave your canes and walkers because you're all gonna be healed and better. So, as opposed to like creating neurological deficits, people were actually getting much better after our surgery. So, very exciting and most of all, we have great friends, right? So, we get along great, the spine guys love each other. We have some great times with the Pervenes eating giant pieces of meat. I don't know how that's possible or hanging out with Chris Chaffee with my wife and live in Miami. We have a great time together. So, let's start with a case. So, Pervene said, let's talk about fractures and facet dislocations. So, here's an example of a case I did a long time ago. Dan actually, Dan Ho might remember this case from USC. 38 year old officer, she's female. She's wrestling with her husband. She hears a pop in her neck and she gets weak. So, what do you guys think about this? Anybody wanna say anything fun about this? Do I have to pick on them or do they just volunteer? Well, you can ask for a volunteer. There's someone who was really... I'm all about the front row here. Okay, behind Jerry, behind, I'm sorry, next row up. So, let's start over there on the end, way over there. Yes, yeah, you. Here's a hint, when you look behind yourself, that's you. So, what do you think? I mean, you can't, there's no way to get this stuff wrong. Like, what do you think about this case? She, I mean, on the scan, she was turning, was concerned for injuries, something acute. And she, now this girl, that's the... but it looks like a unilateral Trump facet. Right, okay, so let me just say, what's your name? Melissa, what is that called? I hear it, there's like a rumbling and a whisper. It's called the reverse hamburger sign, right? It's like the two buns are flipped around, right? So this is, it's one of those things that you just hear about and you never forget it again, right, because it's so obvious, right? So she's got a unilateral Trump facet, right? So this case brings up a lot of obvious elements, right? People know, well, duh, right, that's trauma and it's like maligned, so we gotta do something about it. So, but there are some questions about this, like what is the diagnosis really? And what are the relevant issues? Are we gonna need other tests? How are we gonna treat this? What's the urgency and what's the pitfall of the various treatments or non-treatments? So when we get a call in the middle of the night from you guys, we wanna hear like a concise, right? Praveen, you get what? Three sentences. Three sentences, no run-ons, couple conjunctions in there, okay. So you get three sentences to tell us what's going on, right, exactly what the deal is. So what are we gonna do with this lady, right? So what would you do, Melissa? So here is what her MRI looks like. She's got some mild deficits. I'll tell you right now, she's in Asia D, right? So she's got some weakness, but she's, you know, she's not profoundly weak. And, you know, what would you do? What would you do with this kind of case? Where are you at? University of Chicago. Okay, what do you do with these cases? We're not at a trauma hospital. Wrong answer. Okay, so answer your approach, post your approach, front, back, pre-op cervical traction, right? Do you do steroids? Anybody do steroids at their institution, ever? Couple, where are you at? Cincinnati. Cincinnati, yeah, some people give steroids still. And what about the timing? Who thinks this is an emergency? Okay, who thinks this is an elective case? Okay, well, let's see. So let's talk about close reduction. We'll come back to that timing issue. Who does close reduction in the ER fairly routinely for cases like this? Wow, that's amazing, Humperfine. It's like 5%. Wow, so yeah, close reduction is important, and this is the old spinal cord injury standards. So there are no standards or guidelines, but early reduction is an option, and it's important to understand what about reduction is the big controversy, Melissa. Like, if you're thinking about reducing a patient, what is your attending gonna ask you, or what are you gonna ask yourself about this before you do it? Like, their exam, are they gonna tolerate it away? Can you? Couple thousand years ago, there was a guy named Hippocrates, right? And we talked about the concept of us not hurting people, right? So you wanna know that you're not gonna hurt the person. So a couple things about traction. One is delaying treatment, right? Another thing would be, do you hurt them? Well, how can you hurt them? Well, if you go and you look at the literature, you can occasionally hurt them by stretching the cord, or if they have a big disc herniation. Actually, University of Miami has one of the only two documented cases in the medical literature of this happening, of a patient going into traction with a large cervical disc herniation and actually worsening, okay? So if you're gonna put someone in traction, you either have to know they don't have a big disc herniation or you have to be able to monitor them. You have to be able to check them out and they have to be awake as you do this so you know that they don't get worse because traction is the fastest way to get someone reduced, right? There's this legend, it's an urban legend, I don't know if it's true, Pat might know, about two neurosurgeons that went skiing. One fell and was completely paralyzed, right? Jerry, you know about this? Russell, you know about this story? And he was complete quad, and the guy reduced him on the slopes, like in the snow, and he basically regained function. Now, who knows what that is, right? Maybe it was the hypothermia, right? Maybe it was the hypothermia that did it. So, bottom line is, what do we do with this? Like, we went in the front, right? So we said, look, we're gonna do an ACDF, okay, and we're gonna clean that stuff out, and that's a very reliable way to go because you can get that disc herniation out whether you have an MRI or not. If you don't have an MRI, safer probably just to go in the front and clean out the disc just in case you got a big disc herniation. So what do you think about this? So she gets better, but she's got a lot of neck pain. So Moza, what do you think about this image here? This is post-op in a CT. Say again? I'm sorry, say it one more time. Yeah, this is right after. This is like post-op day three or two or something like that, yeah. Yeah, so there's still a widening here, right? So there's something that suggests this might not be right. So did we choose the wrong approach, right? So if you look back at her original MRI, she's got a lot of hyperintensity on T2-weighted imaging suggesting that there might be some ligamentous damage. So we ended up taking her back in a delayed fashion and doing posterior instrumentation. So there's a lot of ways to skin a cat, right? We could have done this posteriorly first. We could have done it anteriorly and posteriorly as well. But we elected to do it this way because we wanted to decompress the neural elements first and we thought that this was the best way to do it. So I think this is one of those cases that you can discuss and people can say, well, I'd do it this way or that way and it's sort of open. But what does the evidence show? So this is classic for guidelines, right? There's no standards, no guidelines, options. Okay, closed or open reduction recommended. External mobilization, prolonged bed rest and traction. Obviously, these are things that we don't really do even though they remain as, if you want to call them guideline options, right? So why go in the front, why go in the back? So if you go in the front, you know, positioning's really easy, right? There's no issue with flipping a patient. There's no issue with getting that done. You can get a big disc herniation, especially if you don't have an MRI. If you're rushing a patient to surgery, I'll probably go through the front. You get anterior load sharing with a big graft and you have less muscle trauma. But in the back, you can actually control the spine. You can put the patient in a Mayfield, you can extend them, you can rotate them, you can flex them. It's really hard to do that when they're supine. Your fixation, so lateral mass screws or pedicle screws allow you to really manipulate the spine as opposed to an anterior plate and that applies to thoracolumbar as well. You can drill out the facets that lock and you can approach any level. There's some levels that are really hard to get to from the front. So looking back at it, would you have gone posteriorly instead of going low and anterior? In general, no. So when we're going to an emergency surgery, we're generally going to go through the front. Now this is open to debate. I'm sure a lot of the other attendings here will say no, we go through the back. If I'm going to go to an emergency surgery in someone with neurological deficits, I'll tend to just go through the front, just in case. Because maybe there's something I'm not seeing there. Maybe there's an epidural hematoma I'm not seeing. There are things like that and I can always go back and do more surgery. So if it's that kind of situation, I'll tend to do that. Now that's very different from a facet dislocation in a person who's intact or someone who has a little radiculopathy. Well then you have all the time in the world, right? So here's another way to look at it. Forget about the advantages, what about the complications, right? So if you go in the front, all the complications go in the front, like recurrent laryngeal nerve palsy, dysphagia, dysphonia, cosmetic issues, and potentially getting into the vertebral artery. If you go through the back, persistent neck pain. You got to talk to people about this. 25 to 40% of people are going to have persistent neck pain any time you go through the back. You can drill the muscle, I mean, you can drill the facet, you can go through the muscle, and we're not really sure why they have this pain, right? So that's really the big thing that holds us back from going through the back all the time is that they have a lot of pain afterwards. And also, are you able to decompress them as effectively through the back? So if we look at a meta-analysis of all these papers looking at anterior versus posterior surgery, what do you think this is going to show? So next guy after Melissa, who's, yeah, in the orange. Nick. Nick, what do you think? I just put this to cover up. What do you think if you look at anterior versus posterior surgery, what do you think is going to happen in terms of reduction? Which one do you think is better? I think they'll be the same. You think they'll be the same, okay. How about delayed instability? I think they'll be the same. You think they'll be the same. How about kyphosis? I think anterior would be better. You think it'd be better, okay. How about graft displacement? The same. The same, okay. And how about mortality? I think posterior would be better. Okay, so I think you've got them almost all right on. Did you read this paper? It's pretty awesome. Where are you trained at? Penn State. Penn State, all right. Okay, good. So, Bob Harbaugh. Okay, excellent. So, exactly. Reduction is very similar. Delayed instability is low and similar. Delayed kyphosis is higher when you go through the back because you're not getting anterior load sharing. Graft displacement doesn't happen from the back. Mortality's a little bit higher through the front. Maybe that's a selection bias, right? So, this kind of shows you that both techniques are excellent, right? But here's another case. This is a lady that comes in, 39 years old. She's now grade C. So, Asia C versus D is worlds apart, right? So, she comes in and she's got this injury. So, what would you guys do? Who would put her in traction first? Okay, who would go straight to the OR? Who would wait and do the OR at the next available time, like the next morning? Wow, you guys are really excited to go to the OR in the middle of the night. I like these guys. Okay, so this case is quite different from the last one because you have to be very attentive to the kind of imaging you're seeing. It's not at all like that last case. This case actually was taken to the operating room for us. Eight hours is actually quick because of all the delays and MRI and all that. And then we used a standalone anterior technique and she recovered really well from this. This is a very different animal. She actually has a soft disc herniation. That's very significant. So, the key is getting at this early, right? So, it's easy to look at this. You see the reverse hamburger sign. You say, that's a facet dislocation. It is a facet dislocation. It's like the patient who walks in, spine's very different from cranial, and they say, well, which diagnosis is it, Dr. Wang? And I'm like, okay, so it's a deformed patient, right? So, they've got facet cysts. They've got stenosis. They've got disc herniations. They've got congenital stenosis. They've got scoliosis. They've got kyphosis. They've got blackness. Basically, if you were in the ER checking the ICD, you'd check every box, right? So, you have to be aware, what are you really trying to treat in spine? It's not like tumor and head surgery, right? This is very different. You have to be attentive to what exactly you're going after. Here's yet another different case. This is a patient comes in with, I'll just give it to you, bilateral jump facets, and this is what we did. This is very different, right? You say, well, I don't get it. Did you suddenly learn a new technique, and now you're doing different surgery? This is a very different approach to a patient who has, technically, a facet dislocation, right, and why are we doing this? We're doing this for a lot of reasons. Anybody want to guess? And you can argue that that's not the right thing to do, but the next over after Nick? Robert. Robert, yeah. Why do you think we did this in this case? So, she's got bilateral facets that are jumping, and she's intact. What's that posteriorly of the, I guess, the satin here? This little thing here? Yeah. I think it's just a disrupted ligament. Sorry, I didn't put any more. It's not a trick, right? Because you can argue this is too long a construct, right? But I'm putting this up on purpose so you guys can see the difference. So, I went long because, number one, it's bilaterally jumped. Totally different. I'm going to take both facets, drill them down. Number two, it's intact patient. So, bilateral jump facets, intact patient, that's high stakes, right? That's like a fracture dislocation in an intact patient. The last thing you want to do is have them fall apart. Third, this is at C7T1. It's at the cervical thoracic junction. You have a natural stress riser at the thoracic junction. Next, you have a long lever arm. So, either way, you've got that long lever arm in the thoracic spine, and then you have difficulty fixating C7. It's not always easy to get the fixation you want, whether it's lateral mass screws or a pedicle screw at C7. So, this is why we chose to go for the easy, like, low-hanging fruit in terms of the fixation to get this patient fixated, and she ended up doing very well with that. So, this algorithm kind of shows how you would approach patients. So, this is a complete patient, right? So, if you try emergency traction, let's say, in a complete patient, because there's not a lot to lose, right? They're complete already. Reduction, right? So, if you don't get reduction, we go to surgery. If you get reduction, the question is what's really going on. Are they too sick to have surgery, right? Then you hold them in place with a halo vest. Does the MRI show a large disc herniation? If so, you go right to surgery, right? Does it show a significant disc herniation, right? So, you could talk about, can you get this from the front, back? Is it like a radiculopathy associated with this? Can you get a segment back in terms of a complete patient, right? What about an incomplete patient? Very different, right? So, is the patient awake and responsive, right? So, you can go, you know, emergency MRI, if they're not responsive. I'll tend to do that because you don't know what's going on with them, and then you see, do they have a disc herniation? You can take this algorithm through and take a look through it. This is not a hard and fast algorithm. This is kind of how I do it. I'm sure that if Praveen or Pat were to do this, maybe it's slightly different in terms of the thinking. But you have to be organized in looking at this, right? And here is, if there's no cord injury, so radiculopathy allowed, you can get an elective MRI almost. You can almost wait on these people, and then you can make a decision, even sometimes days later, if you really, really want. Okay, so we're about halfway through real quick. Yeah, go ahead. I think you know how you said, if you have bilateral jumper sets, you're not gonna want to go anterior because you want to drill them down. Even for a unilateral jumper set, I've never seen acutely going for an anterior approach without closed reduction ahead of time. So if you're only doing anterior surgery, how are you getting a reduction of the unilateral jumper set just by putting them down? Oh, I'll show you in a minute. Yeah, that's a very complex question to ask, by the way. But you said you always get closed reduction. Is that right? If there's a jumper set, most people who use ESF will do posterior. I haven't seen. Yeah, okay, so we're gonna go over that next. So this is sort of the midpoint. I'm sorry, I'm a little bit behind. That's me falling asleep there. Okay, so let's talk about some specific reduction techniques, right? So let's go through this, because that's a great segue. So first, lateral mass screws, right? There's a lot of ways to do this. This is the most robust procedure we do. I remember when I was an intern, when this was first being done, it was like a big deal. It took like four hours to do lateral mass screws. It was crazy, right? And so there's roycamille, magrel on. Most people use the magrel technique, right? But if you look at going to the front, so one of the ways to go to the front is to do an anterior distraction like this. You do your discectomy, then you put like a cob in, and you spread it. So you're basically distracting the spine, right? And that will frequently get it. It's also helpful to have your anesthesiologist or one of your other residents kind of extend and flex the neck as you do this. So that's one way to do it. Another way is to put in two cast bar pins. Anybody do this? Yeah, so this is a great way, right? Cast bar pins, this is like Ed Benzel talks about this, gives you enormous lever arm and fixation onto the vertebral bodies. Really, it's the only way to get rigid three-dimensional fixation through the front and to allow you to manipulate because the other methods are all just distractive, right? So that's a method through the front. Through the back, right, there are other ways. You can put a cob or some type of device into that jump facet and wedge it back. So you're making a little ramp and you're gonna basically lever that facet back. Or you can drill it out. So you can drill out that facet, and that's probably what you're talking about at UCSF, and that makes the reduction really easy, right? Okay, so those are your various techniques, and there are others. Here's a nice paper from China. They talk about doing front backs routinely. So basically, putting the graft, of course, then you have to use a buttress plate, right? You don't want a graft and plate across there. You plate them into that position. So you put a buttress plate to keep that graft from kicking. Then you go through the back and bring them back into lordosis, right? So that's another way to do it. So here is an example of that kind of technique. They go through the front big disc, take the disc out, you see that's a buttress plate, and then they go through the back and they do the heavy lifting through the back. So if you're gonna do front backs, that's an excellent way to approach it, right? So there's some other considerations here, too. Praveen spent some time talking about the vertebral artery. Here's a CT scan. Anybody seen a vertebral artery injury? Intra-op? Anybody seen intra-op vertebral artery injury? Only people in the back, that's great, okay. Yeah, it's a lot of fun. So this is a paper by Mitch Harris. They looked at three trauma centers. They looked at like 1,200 patients. And 21% of the patients with facet dislocations or cervical trauma were tested for, they got like a CT angio, right? And 17% of those had a vert injury. 14% of those that were having an injury had a stroke and 5% mortality. So this is a pretty significant injury to detect. You wanna really be sure that you're looking for it. But how do you know when you're gonna see that, right? So their predictors were low GCS, high ISS, injury severity score, DISH or ankylosing spondylitis, and greater than one millimeter of transverse foraminal violation. So that's pretty subtle, right? One millimeter on a transverse foramen is a vertebral foramen is pretty subtle to look for, right? Here are the guidelines. Very vague, right? Do you stent them? Do you embolize them? Do you anticoagulate them? Do you observe them? Essentially, I think if you polled the attendings here, we do all these different things. My general feeling is just anticoagulate them first, if you can, if there's any risk of stroke. But the problem then is you have to do that after you do your surgical intervention, right? So that's really the issue there, right? There are minimally invasive options. We can talk about this at length or do this in the lab of trying to get fixation. And then of course there are other disease entities in the spine, like ankylosing spondylitis. So here's a gentleman comes in who has a significant disruption. This is a complete dislocation as well as a facet dislocation. And the problems with these are legion, right? These are legion because they basically reduce themselves when they fracture, right? And then you have this issue of how do you position them? Here's an example of a case we did with five steps to get up there, to get the head above the heart. And this patient still became blind in one eye after we did that operation. So there's a lot of issues with these patients. They're very, very, very high risk. And how do you get them reduced and fixed and to heal and all of that? So ankylosing spondylitis is one of the real banes of the spine surgeon. So in summary, I would say, treating these cervical injuries is really complicated in some cases, but also extremely rewarding. Every patient is really unique, right? So really look at the detail, their imaging and the case. And you need a lot of arrows in your quiver, right? That's what the lab's for. You don't want to say, well, I just do this fixation technique. You're going to find that some cases you're going to need bailouts, like Praveen was talking about, all these different ways to attach the C2. And this is one of my favorite slides. I didn't come up with this, but I think it's great. Everyone thinks there's this learning curve, like I suck and then I kick ass and it's like this, but it's really not like that, is it? It's really like this, right? So I'll be in the middle of a case, I'll be kicking ass, right? And the next thing you know, the door is torn, oh, I suck, right? Stuff like that every day, right? But that's how we get better. That's how we get smarter. That's how we advance the field because we're always in this zone. If you're always up here, you're either kidding yourself or you're too much in your comfort zone. It's always good to sort of be around this area right here, just touching the sort of, I suck, but not really being living there or anything like that. So thank you. Thank you.

disclosure

spine surgery

case study

reduction techniques

complications

cervical injuries