Jeremy M. Steinberger, MD, Director of Minimally Invasive Spine Surgery for the Department of Neurosurgery at Mount Sinai, presents various surgical cases to address a common debate among spine surgeons: whether to approach surgeries anteriorly, posteriorly, or via a combination of both.
Chapters (Click to go to chapter start) Review of how deciding surgical approaches for spine surgeries can be easy, but mostly difficult. Dr. Steinberger introduces two common patterns that tend to yield a difficult decision-making process Dr. Steinberger present a case example that highlights anterior and posterior decision-making and quizzes residents on how they would approach it Second case presentation Third case presentation Final case presentation Q&A/Discussion Okay. There we go. Okay thanks everybody for joining this morning. We have dr jeremy Steinberger. He is assistant professor of neurosurgery orthopedics and rehabilitation medicine. He's director of the minimally invasive of minimally invasive spine surgery here at Mount Sinai. As you can see in his education here. He uh did his undergrad at Yeshiva, he did medical school at Albert Einstein and he's been with us for residency. He did fellowship at the hospital for special special surgery. And today he's going to be rehashing the age old discussion anterior versus posterior. Thanks a lot jeremy. Thank you chris and I'll share my screen. And is that visible with the correct display setting? No. We have the that should be better. Is that better? Got it. Perfect. Thank you. Um So good morning everybody today. We'll be talking about the age old debate and tear versus post here versus combined approaches for cervical pathology. This is going to be case heavy low on pimping and moderate on literature review. I have disclosures, none of which are in any way relevant to this talk. Some cases have relatively straightforward decision making. So this is someone who had a massive C. 67 disc herniation and we did a one level A C. D. E. F. This is someone who also had a massive disc herniation. She was young and she really was anti fusion and we presented both options and she did well with the disc replacement. And this is someone with unilateral for amazon stenosis at one level and an otherwise pristine spine and left handed numbness and this is C. 71. So one level cervical frame anatomy ambulatory surgery home in a day. Um And I think all those are I would say definitely not chip shots but very easy decision making. But I feel that most cases don't and most cases have a lot of subtlety in decision making and that's what I'll focus on today. So I think there's two very common patterns we see as outpatient cervical spine patients. One very common pattern is someone who has severe central stenosis at one level and maybe another level and then the third level that's moderate with moderate stenosis in the framing And the question is do you do them all? Do you do just the most severe? Of course you have to listen to the patient. But let's say the patient has C. 45 and C. 56 Symptom Atala ji are you going to do C. 67 while you're there anyway. I think that's like one of the most common scenarios we see. Another one is a patient who has multilevel significant disease but one obvious clear culprit either demonstrated on the MG or just a very clear ridiculous empathy pattern. And the question is do you just go after the one that's clearly symptomatic or do you take care of them all similar themes but subtly different. Um so take this one for example this is a 72 year old male with left upper extremity pain only and milo pithy meaning no pain in his right arm. He's a sick sick patient. He has coronary heart disease. He had a cabbage pc I hypertension, prior heart attack sarcoidosis. So clearly not a healthy patient. And on his MRI you see has multilevel stenosis, multilevel compression. And if you look at his axles 34 5667 All look pretty significantly degenerated but it's really four or five where he has the most severe cord compression, Cord indentation is a hint of signal change at c. So I think four or 5 is the most significantly Compressed. Most clearly symptomatic. I think you can look at his right sided for a man at 56 and say that's pretty significantly fanatic but he has zero pain in his right arm was only left left arm pain. So we had a lengthy discussion and in the end we only did a one level uh standalone A. C. D. F. One of the reasons I did stand alone in his case is is uh in case we needed to come back in and do another surgery, there would be no plate blocking the other levels. Um but he's now two years out with complete resolution of all myopathy and ridiculous apathy signs. And I think this is one that we discussed in conference and some felt I was being appropriate. Some felt as being too conservative and I think that at least two years out I think we did the right thing for a very sick patient. If he was healthy, I would have had a completely different plan. I would have been more aggressive. But I think there is uh there is a phenomenon I think of being too conservative and I think you want to keep these cases to a minimum. Also. I think we often think about people being too aggressive but I think you can also be too conservative and I think that if you're taking the same patient back three times in a year, you probably were too conservative in that patient and you want to keep those kind of errors to a minimum. And I have erred on the side of being too conservative. And here's an example of one of those times and this is not clear cut. But I would argue that I made an error in judgment but Some may feel that it was a reasonable plan. But this was a 54 year old male with diabetes, hypertension, obstructive, sleep apnea. Also not the healthiest patient. He had neck pain with pins and needles in both lower extremities left more than right. He had shoulder pain left more than right. He had balance issues, felt like his legs were giving out. He was dropping things and had urinary dribbling for years and he was was weak in his left proximal arm, here's his x rays. So you see he has some sponder closest at 4556, a little more mild at the levels above and below. Here's his cat scan showing similar findings. It's really obviously the M. R. I will tell the full story. But you know 34 there's like a calcified disks bulge but 4556 more collapse. And here's his M. R. I. Showing 34 disc bulge. C. 45 C. 56 C. 67 more mild. And then you look in the axles, this is C. 34. So he does have a central disc bulge with court contact four or five really significant centrally and for animal stenosis 56 left sided, significant for animals to notice which matched the symptoms. And then Again this is c. with right sided for animal cyanosis that's severe. But he had no right upper extremity weakness or symptoms. So in his case we ended up doing a two level A. C. D. F. C. Four to C. Six. He left on day one, I was feeling great about myself. He had complete resolution of symptoms. No pain are very nice, gentle benign operations and patients are generally happy. But three months later he was miserable and worse than he was before his first surgery. So after some nonsense with the insurance company who refused his MRI. We did get an MRI And it shows that c. the chronic disclosure that was there really exploded. Uh and he had severe cord compression at 34. That was arguably worse than any issue we had in the first place. Um This is the axle. And you see this is this is not the disk. Our nation. This is also the disk our nation. So he had pretty severe left side and more than right sided cord compression. And we ended up taking him back for a standalone at c. And he did well. But I think that I took him back about four months after the first surgery. I think maybe being a little more aggressive up front was the right decision for him. This is his post op MRI showing that everything looked fine after. Um So I think what I really want to highlight is that it's all a balance. And I think that on one side C. Two to T. Two is a very aggressive surgery with morbidity. And the answer is not to just say if everyone has a disc bulge at every level just to see to to tetouan everyone. That is definitely not the answer. I repeat. This is not the answer. Yeah. This is frank before he, before he quit his equinox membership. Um So and and also you know, you want to listen to the patient. Um And you wanna you do wanna hone in on what is bothering them and what is there there what is taking the biggest toll on their life. But at the same time you don't want to make a habit of ending a fusion construct on a highly degenerated disc factoring in that there will be adjacent segment forces adjacent segment degeneration, adjacent segment breakdown. And of course I think probably maybe the most important is to talk to the patient and involve them in the decision making. And that is uh an extremely important and maybe often underrated part of the decision making is to because then if they end up having an issue it was well discussed in advance and they had a play in the decision making. So I want to highlight some cases um that highlight highlight anti versus post your decision making. So the first one is a 53 year old female with complex medical history. She has a vague blood clotting issue. That was found when she had hip replacements as a child. In 1987 she had severe she has severe osteoporosis, ankle, closing spondylitis, cataract surgery, she had progressive left sided weakness, arms and legs, she couldn't move her neck at all, balance issues, difficulty ambulance. She said she had poor dentition because she couldn't go to the dentist because she couldn't get her head in a position where the dentist could look into her mouth and she couldn't brush her teeth. Yeah here is her ap X ray. And maybe I'll start just with a quick break for for some questions. So let's start with. Hold on. I don't have. Okay let's start with Halima, what do you what do you think of this X ray? So um starting off we can see that she has osteoporosis. Um Her and she um her head is tilted towards her shoulder so like she mentioned in her um was it deal that she probably has issues with keeping her next ray? Um And she has um do we have other views of X rays? Yeah but just on this one I would agree with you said. However how do you know she has osteoporosis on this image um Or all the bone quality looks um like the bone density is not um It's not very high like her bones look let's dance. Mhm. I'm not sure. I could appreciate that here. But um she does have osteoporosis. And then Halima why don't we why don't you just continue and to describe the lateral. Um So on battle X ray again she has uh diffuse uh digital exchanges throughout her spine. Um She has a 23. Um He definitely has Lots of our normal regular doses and at 56 I would say. I don't think I don't think she has loss of diagnosis at c. Maybe she's hyper lord attic at c. six above above. Like she's basically hyper Lord order At c. 5 6. But then like the straightening of her c spine on our levels above. And she has an closing um as a rigid spine About the c. 5 6 level. Yes. The biggest thing. Yeah it seems like she has some auto there's no disk space is she's all it seems like she's auto fused at numerous levels. And there's definitely like a fish mouthing almost of of c. Um What's a very concerning image? Is that in her case? Uh Noah. What do you see on this X ray? Mhm. Or so? Um lateral flex X. X rays here. There appears to be some A lot of motion at let's see. Um 2 3 At 45 possibly some interior list thesis um possibly unstable I would say definitely unstable because this is the and it's it's 23456. So it's C. Five C. Six. And there's a list thesis of five on six. Inflection pretty pretty obvious there. And then it seems to reduce an extension. Uh Now Brandon, what do you see on this corona ct view? Mm hmm. Brandon. Can you hear me? Um So it looks like there's some uh joint joint separation here. Um Or widening of the winding up the joint china's coronavirus on the west side. Yeah. What do you see here that looks like a bony fusion. Yeah. So she has auto fusion with signs of like you know we know she has instability and then you see all the air in the in the facet joint. So it's probably hyper mobile. There here's the CT again, auto fusion, auto fusion, auto fusion, auto fusion. And then auto fusion from here down. But no fusion here here is just a very spanned a logic Axial view at c. at c. five c. 6. And here you see that I find these cts to be very nice reconstructions um And of what you'll actually see and you see it there's almost like it's almost like a she didn't have a fracture but almost like as a I guess the equivalent of A separation of c. five and c. Six posterior Lee making things even more concerning matt car what do you think about this? She has obviously severe stenosis with milo Malaysia. Um But there's a lot of posterior compression from Leslie possibly hyper atrophied the momentum there such as circumferential severe compression. Yeah so this is a very scary picture in general but it's especially scary with the knowledge that in flexion and extension. She's mobile so it seems like with the slightest movement of her of her head she could be paralyzed. Um Very dramatic compression. Um Alejandro. What would you do for this patient saying that um You know she's mobile at 5 6. She has basically two large refused columns above and below I think A C. 56 A. C. D. E. F. And then backing it up. I mean you have to do something posts here here and decompress it post eerily but backing it up. Um Let's see probably You know c. 3222 T. two I think so front and back you want to do? I do yeah. Okay kurt um My initial gut was to say just P. T. But I think um in this case I would I would agree I think this patient definitely needs anterior and posterior fixation and decompression on both sides. So we presented this in spine conference which is one of the which is a great conference that we all can learn from each other and we did discuss anti R. Versus poster versus combined. In the end I felt like she was very prone to fusing. This is just the axel show in the courtroom. She was very prone to fusing and I think we had a few options. One is to get anti R. Columns support within a CDF two is a C. D. F. With post. I mean I think you have to go post here like like I agree with what Alejandro said the question is do you need anti your columns support also in a very hyper mobile area which I think you can definitely make an argument for. But I think she was prone to fusing. I think all we needed to do was really get into that hyper mobile facet joint packet with autographs and get a big infusion above and below And then of course there's other decision making like do you want to correct her deformity that she's had for 30 years? I didn't feel like that was what she needed and we discussed that together. Do you want to do a medical subtraction? As dichotomy of C. Seven or whatever or C. Six. And correct. I mean I think she lived with her head crooked for a very long time and that was not what was bothering us, not what brought her in. So this was not a deformity correction. This was a relief of cord compression and stability of the spine. And we do have a cT followed that showed that she did fuse across that facet joint. Which I think once you have good Anchorage I don't think it's hard to get that set fusion. However hindsight being 2020 I think in retrospect even though she did well I think I think 56 would have been a much more guaranteed outcome because you know you have the support anterior column also. But she did she did do well with the post your column support. Only the next case is a 65 year old female diabetes. And hypertension She was presenting with classic Mayall apathy, falls, dropping items, difficulty with dexterity, upper extremity, lotion, weakness, bilateral urinary hesitancy here is her cat scan. And I'm just going to skip to the MRI because it's so telling she has pretty severe stenosis up and down her entire spine. Uh huh. Her entire cervical spine. Um And for her um you see the axles I think this is 45 right sided cord compression with signal change 56 left sided signal change 67 cord flattening and a broad based disc bulge. Um So let's let's start again, let's go to ray. Is it really that ray? Oh sorry my internet broke off for a second. Could you repeat your question? What would you do for this patient? Um Okay so looking at this patient, well I see pretty severe central canal cyanosis starting from the level of um three. there's a little bit of three about 456. Um And there's a little bit of retro hostesses on 66 and seven. So because it's such a large segment I would um my first thought is going posterior early and for posterior for fusing the fusion construct posterior lee. I definitely want to extend it beyond the beyond the edge of the edge of the beyond the worst levels. So in this case I think I would do a C. Three to um t one decompression and an uh an instrument into the fusion. The only thing I would say about that which is a reasonable plan is that if you're going to do that, remember that the cord floats posterior lee. And it's very important to undercut see to where it's cyanotic there. Uh because you can have the cord basically and you'll see it actually in a second. But the cord will go like this and you don't want to kink off at c. Um And uh And you don't feel like there's any need for an anterior just a post here. Um Yes I think the posterior decompression alone should be should be enough. I agree and that's what I did. Um And uh but there was a lot of discussion about this case whether posterior was enough wood, the cord float back enough away from the ventral pathology. Um We discussed doing maybe a four or five A. C. D. E. F. And then a post area or just or a multilevel a CDF. And the posterior. We ended up doing C. To the T. To decompression fusion. Um And uh post operatively the patient developed a C. Five policy if there was ever a patient who I could have predicted that it was her. Um And we got her a post op. M. R. I. And I think we don't often see it afterwards but I think it really shows beautifully how it's not even close to the ventral pathology. When you have a patient who has you know you do the by vector traction and you give them good extension and you fix the infosys a little as well as a nice wide decompression. You can really, excuse me? You can really get a wide decompression with no ventral pathology remnant. You see she has a little bit of like almost cord hyper intensity there which is which she had pre op but you see it better. Um So I think you can definitely accomplish a lot with the post to your approach. Um And there's literature to support this. So uh this is a patient with 264 cervical spawned a lot of myopathy patients. Um and there was basically equivalent efficacy of anti versus post here but I would argue that it's such a vague discussion to say answer versus post because there's so many factors that go into, it's not as simple as our anterior do anterior patients do as well as posts. It all depends on what their pathologies in the first place. But the arrow study presented 757 patients with no difference in goa India 36 2 years with antivirus post area for degenerative cervical, spondylitis mile apathy. And then of course the K line which I think is a very important concept. So you go back to this film and you wonder is posterior enough. One way to help you make that decision making in that decision making is is the K line. So the principle of alkaline is more important than the measurements. But both are important to understand that the K line and a lateral X ray from C. Two to C seven. You draw a line. And if the pathology extends beyond that line then you're K line negative and the literature supports that there was better recovery scene with the post, you're approaching K line positive patients meaning that if you have enough room, this is the sufficient, this is I think the best summary, sufficient shift to the court were obtained after decompression in the K. Line negative group meaning you can get enough of a post your migration of the court away from the pathology as long as it's not Caroline positive, the eventual pathology is not so severe like in severe oh PLL patients. Um So here are the two K lines. I would argue that Caroline is essentially irrelevant in our first case because it was such an anomaly of a case. It was very it was like the fish mouthing of C. 56 made it very difficult to use this exact measurement. So I think there's times where it's not relevant and it's time this time is to ignore it. And then I think this is uh if you look closely the pathology in the last patient extends slightly posterior very slightly At c. 45. Which can make some say let's do an anterior and posterior. But I think that no, no, no concept is perfect. And I think we as demonstrated by the MRI you can get a very nice decompression from posterior alone. But I think the principle of alkaline and keeping in mind how much ventral compression there is um can help you in this decision. Mhm. I mean doesn't that have to do with then subsequent infosys as well though. Absolutely. Absolutely. And then you get into the modified K line which is M. R. I. Based. And so this is actually the modified K Line and then there are other factors as well. Um But if you have a rigid chi infosys and that also has to be factored in. So if you if you if you do flexion extension and they don't Lord does an extension I think that that kind of undoes the equation also. So ultimately I think spine surgeries not the hardest part. I think picking the right surgery for the right patient being not too aggressive but not too conservative is really everything in spine surgery. And that's I think that's what sets you apart. Which brings me to a 50 year old nurse at Mount Sinai who has neck pain, subtle mile empathic signs. I saw her a couple of weeks ago. She her sister has find surgery and had a major complication of spine surgery. So she is extremely averse to having spine surgery at the same time. I did categorically recommend surgery in her case. Uh And I we had a very lively discussion and spying conference about this patient. Um But this is I think a great one for Alex Xu per to uh to uh to take. What would you do harry? It's tough because obviously c. is the index level. She is just bulging above and below and the all american general diagnosis. But the tricky thing about this is that the eventual compression Comes pretty high up behind the four body. So it's a conversation that I'm going to have with the patient is you know if you will be able to decompress enough just during the versus partial core practice versus total seaport corp ectomy. I would do again enough of the ventral compression. Um it looks like it extends pretty much almost as super important as c. four. So if you really want to get that ventral compression I would I would favor doing a sequel equipment to me. So so tell me your concrete final plan, this is your patient. Okay so yeah. Sorry. Um I would favor again if I want the most definitive surgery for her Pretty healthy and can tolerate it is amenable to surgery to do the c. four crop ectomy. And then I'm in favor of backing her up again. She has congenital stenosis there while pathology is eventual doing Maybe a three or 6 posterior as well. How about frank juche? Is he around? I'm here. What do you think frank? Obviously I don't feel well, has a lot of anterior pathology also. You know I would I don't think that you can get a good ventral decompression. Just posterior lee. And um I would favor doing corp and then backing him up. I would I would say oh PLL you know this disc right here at least is soft. And you see it there on the C. T. There's there's like uh definitely like a bone spur on that osteo fight. And there it's but I I wouldn't call this a classico PLL case. Um Because the the predominant compression is actually a soft piece. But there is that bone spike there which which is relevant to the discussion. So I will tell you I agree my plan was AC. four Corvette to Me. Uh And then a post here back up. So I think I think that's uh that's what I recommended. She is again very hesitant but I think she will end up needing it. Here's the K. Line. So again equivocal right on the border. Um And I think that that like that this demonstrates the point that it's almost never clear cut. It's right on the border. You can make an argument for both in my hands. I would feel comfortable more confident going into the surgery saying we're going to alleviate the eventual compression With a corporate to me. And then I think it's worth. How much time do I have because I could go on. Yeah I have another 15 minutes. Right Chris perfect. So um what can help us with the decision making? I would argue that one thing I have started doing mainly due to uh Tanvir chowdhury Constantinos Margaritis and some of the other spine leaders at Mount Sinai is flexion extension M. R. I. And I think that um they can be very valuable in equivocal cases. So there's now one question is are there any studies studying the impact of flex X. M. R. I. On cervical outcomes approaches or decision making the answer is No I did a little search last night there were five papers talking about cervical flexion extension MRI's none of which um correlated with any of the following any of the outcome approach or decision making process. So I think that we have a ripe opportunity at Mount Sinai being that we're doing a fair amount of them to publish what we've been, what we've been finding on these flexion extension memories. This is a patient of tangiers who had very clear 56 and C. Six C. 67 issues. Uh They were significantly compressive on axle. And there was really no question that C. 56 C. 67 needed to be treated in this patient. The question really was C. 34. This is the axial view. There's no major court compression, there is right sided abdominal stenosis. There is a disc bulge kind of similar to the patient I demonstrated earlier. And the question was should see 34 be included. Given that if you do include seat before that also means you should not leave C. 45 floating between a C. 34 and a C. 5 to 7 construct. And now you're doubling the size of your surgery. This is a patient with a flexion extension at M reflection. It doesn't look that bad. And then extension. It really does look pretty significantly impinged. So in the end I actually don't know what I think. I think the plan was to do a four level a CDF which is what I would do. Um But I think that this is a great demonstration of the flexion extension MRI's and what information that can tell you and how it can contribute to our understanding. And here's another case of a flexion extension MRI. And this is the final case I'll present and I'll just go through my decision making on what I think is a pretty complex case. He's not that complex but the decision making is complex. The actual surgery is not Um he's a 45 year old male. He has numbness in both hands when he extends his neck. You see he has prior surgery. We'll skip the pimping for now. 234. He has a prior 67 A. C. D. F. Uh He had about a year of sorry he had so I had surgery 2018. He did very well and then since then he's had falls he's had multiple concussions. Uh He has one year of neck pain, left shoulder pain, Left arm pain. Sorry his left arm goes numb intermittently and then recovers then it spread to his right arm six months ago. Now we can't exercise anymore. Again he's a young active 45 year old lawyer. gabapentin doesn't help. Physical therapy didn't help and now for three months he feels like it's getting worse with extension. His right arm tightness and pain is worsening right arm numbness, right hand weakness. He literally gets weak when he extends his neck and then and then it resolves. He feels increasingly off balance an exam hyper reflexive but no weakness. And then he was presented. I sent I sent him to a neurology and they presented him. Oh I I I should I didn't I didn't go to his imaging yet. Let me quickly show his imaging. So this is his his cervical spine MRI. And I think this is a good one to ask Trevor Hartigan what he thinks of this MRI. So looking at the M. R. I. C. Loss of cervical Lord doses I see that 34 just behind the four over to our body. That looks like there's some cord signal change, looks like there's some congenital stenosis. And then we see the prior fusion that you described at 67. Also see just above the 67 fusion construct from the previous surgery that it looks like there's some a small little the disc bulge facing the fecal sac but not quite causing any court compression at that level wow agreed. And just as far as the loss of Lord doses I. You're right on the M. R. I. But I think you really need flexion extension X rays. And if there's ever a patient in the history of Planet Earth who has great extension it's this patient who's basically looking almost behind him. Um So I think I think that's worth noting also. But let's go back to this. So he was presented I sent him to a neurologist and neurology was Perplexed by that c. four court signal change at a level that didn't look all that bad. And they presented they presented him at their conference and this is and they wrote a note about what they found at their conference. What they discussed there which I thought was very we don't do that I think is a very interesting thing at least I don't do that. It's a very interesting thing to do. They wrote the bilateral increase single at c. four looks like Milo Malaysia. No significant degenerative changes at the level does not appear inflammatory, less suggestive of Ischemia. So basically they were they were calling it myeloma Malaysia. Um The MRI report, it's worth noting says there's no canal stenosis at any level. And I think this is something that we often see and we often discuss in spine conference that I think cervical congenital stenosis is often very underappreciated. Yes. Um And we got this patient of flexion extension MRI. And you see I think it's pretty clear explanation for his symptoms when he extends his neck. He has congenital stenosis. He extends his neck and when he extends he developed symptoms Mourners mourn his actually was right now it's left again. I just spoke to him. So he has bilateral symptoms on extension and I think this flexion extension MRI is to me a significant contribution to the understanding of the case and and alters how I would approach what we would do for him if he requires surgery, which I did recommend. So I think this is very important also. So Brandon, what is the definition of stenosis? Cervical spinal stenosis? I guess I want to find it as um any kind of narrowing of the canal that causes construction on the on the spinal cord itself or or the um exiting nerve roots. And do we have any measurements cut offs for stenosis in the cervical spine? Objective measurements. Not not that I'm aware of. Okay. Matt car. Yes, I think less than 13 mm is considered fanatic. And this is a question for anybody. Any resident who described first the definition of stenosis in the cervical spine. I'll give you a hint. It was 1956. And the other hint is that it was discovered at the most incredible hospital in the entire universe. Mhm. So this is Mount Sinai 1956. A paper by dr malice, the sagittal diameter of the bony cervical spinal canal and its significance. And cervical spagnolo sis describing a normal cervical ap diameter 17 millimeters relative stenosis. 10 to 13 millimeters, absolute stenosis greater than 10 millimeters. I think these are very important measurements to keep in mind because we see this all the time. The other thing that's important is the torque Pavlov ratio ray. Do you know what that is? No Alejandro. You know what that is. As Saudi Gaitan would say book report next week. Um So the torque Pavlov ratio this um is basically a measurement of a over B. So Spinal canal over vertebral body length. So basically a large they will give you a large capacious canal less than .85 is stenosis less than point is can generally narrow canal with a risk factor for neurologic injury. And our patients 0.47. So pretty significantly congenitally cyanotic. I think this is very relevant because this is a patient who has had an MRI reading no stenosis with severe symptoms, hyper reflexive to can't go to the gym, can't live his life. And if you're going by the M. R. I read alone, you're going to say no surgery. I think he's going to do phenomenally well with surgery and I think he will have significant improvement symptoms. And we recommended a cervical laminar plasticky um which we'll get to. I didn't mention neck pain and I didn't want to comment for two seconds on neck pain because you know a lot of times you see a note recommend laminar plastic versus post your cervical decompression infusion patient has a lot of neck pain. So we're recommending a fusion. I think neck pain is very very complicated and I think that for example if you have this kind of referred pain which is pretty classic and you see it all the time. I think that's different than mechanical neck pain? So this I think this kind of pain gets better with a, sorry um anatomy or decompression of the nerve. Whereas mechanical neck pain doesn't. Of course this is a ludicrous. I think I found it at an orthopedic bracing website that mechanical neck pain is a result when one of the joints loses its normal function which is obviously not true. And a lot of neck pain is mustard and all of us have it including many neurosurgeons and neurosurgery residents. Um But I think that I would just say that the equation of neck pain equals fusion is very over simplistic and definitely uh incorrect. You have to really describe the neck pain in more detail. So ultimately in some this last patient last slide 43 year old male with myeloma. Thehyperfix flexi a no instability, minimal neck pain preserved. Lord doses, congenital stenosis recommended a C. 3 to 6 laminar plastic. Um And that will be coming up in december and I'll stop there and leave room for questions. Is the patient driving the need to make a decision about surgery? Is the patient driving the need I mean does does he want an operation? This 1? Yes. Yes he does. He's he's in he's got enough pain that he really wants something done. Yes. Yeah interesting. Why? Why do you ask? Well because the findings are mild enough that you know you might just try to manage it conservatively with neck exercises or I mean did you talk about that. Are there are there things that you can do to provide biomechanical support so that he's not so flexible. Um Is there is there a way to strengthen the your neck so that he doesn't need even need the surgery or get away without it? I should have I should have painted a better picture. His 2018 surgery was after uh he was doing yoga and and like uh standing on his on his head I think similar to the patient who you had a couple of years ago with the carotid rupture I think. Um I I think that he's a very active guy. He's a he's extremely well built. He's so he has beyond exhausted conservative management. His sister's an E. D. Doctor at Mount Sinai. He's I would say that he's anti surgery and that's I think he's done aggressive non certain but he's also very debilitated Jeremy. I had a question about the patient you presented that did a corp ectomy on at c. four if you can go back to the imaging for that patient. Absolutely. Just f. Y. I did not do it. This is the one whose sister had a major complication of spine surgery including meningitis soaked. Uh So she uh is refusing surgery? Uh And and and this is one of the only times I've ever said I really really really strongly recommend surgery and and and I and I stand by that? I'm worried about I'm worried about her. Uh Not having that's still a present review actually. Sorry? Oh thanks. Um I just had a question about doing a corvette to me and then given the risk for adjacent segment issues, would you consider doing you know in a C. D. F. At the level below? So you were talking about doing a 44 corporate Danny but 56, it also looks like there's quite substantial uh ventral compression as well. That could could get worse. Would you do a a C. D. F. There? Mhm. Um So first of all the plan was not a C. Four corvette to me and then a C. 3 to 5 plate. It was a C. Four corvette to me. And then a posterior. I think you make a really good point which is that you could consider doing a C. Four corvette to me and a C. 56 A C. D. E. F. And then in the back you don't need to do a decompression. You could just do, you can lock it in with fixation and avoid doing the laminate to me in the back which I think is a very reasonable plan. Um But the plan was not a just a corporate to me. So I think the plan was to go below C. Six on the post area part. Okay, looks like raj had a question. Go ahead raj. Had a typed in the question. Great talk. Great talk jeremy. Can you talk about the indications for four level A. C. D. E. F. I thought the fusion rates are very low past three levels. So uh fusion rate for one level is around 97% to level 90%. 3 level 80%. And I think we don't have good data about four level but there's no question. It's at minimum there's a pseudo arthritis rate of one in 5 probably and probably higher. Um I will say that I almost never do before. I think I did 14 level a CDF because I don't like them. I think it's also tough on the esophagus and I think when you get to four levels I prefer posterior. Uh The other thing you could do is if you do a four level a CDF you can vary you can definitely make an argument to just back it up posterior lee with fixation to prevent the risk of studio or throw sis. I think that's a totally reasonable thing that people do. Um But I personally I'm not a fan of four level A. C. D. S. I don't I don't love that operation. I think it's worth noting that even I have a few three level act dress that went as smooth sailing as possible operation in two hours minimal retraction giving esophageal holidays. Um During the surgery and they still have dysplasia. Uh 3-6 months out from surgery sometimes even beyond Not to the extent where they're not eating three meals a day but they say they're swallowing feels different. So I think even three levels can have and his data about it that that there is I think maybe even more than 30% of patients have dysplasia in the longer term, also after multilevel act. All right. Hey Jackson, for a quick question. Um you briefly mentioned cervical disc replacement. I just hoping you could talk about how you counsel patients on multilevel cervical disc replacement. It's been more popular in europe for the last decade but sounds like it's looking for literature. It's becoming more popular here in the U. S. To do three and four level cervical discharge capacities and just talking to patients especially maybe a young more amenable patients of a CDF versus this replacement in the multi level and people in multilevel pathology. Great question. Um I will tell you my personal belief is that I think there are some patients who are great candidates for it and I don't want to be off label. Um and do something that's that's so right now it's approved for two levels and no more. I don't want to be pushing the envelope. There are definitely people who do it routinely and I think it's it's a discussion with the patient. Um And you can have that discussion. But I don't like pushing the envelope until it's FDA approved. Which is unfortunate because I think I think you're right. There's great data from europe that three level arthur plastic is a great surgery for the right patient. Of course. So and I think in general the idea of preserving motion is critical. So I think that we have to catch up to europe and and and get get to the point where it's approved because there are patients who would benefit from multilevel arthur plastic through more than two level arthur plastic. But I've never done it because of the FDA. Hey jeremy. Um I was wondering what were the thoughts on this patient that you had still have up on just doing the anterior work on just uh doing anterior depression future. Again totally reasonable. So if you want to do a C. Four corvette to me and a C. 56 A. C. D. F. I think that's reasonable. I think the patients young with good bone quality. So I think that the chance of them having a pseudo is not very high. Um I I would do a poster back up because I think corp ectomy has a likelihood of sudar throw sis. And I wanted I would want it to be a definitive surgery. But but absolutely someone did that. I would not say that person is wrong at all. I would just say I would feel more confident about the longevity of the construct backing it up posted with it with the quarterback. To me with an active below. Alright, It's 8 28 19. I think we can stop there. Good timing. Thank you, jeremy. Thank you. It's peter on the line. Yeah, I am. Give Me 1 2nd.