0:00

Okay, this is a 79-year-old,

0:01

Dr. Schupeck,

0:02

with known prostate cancer and has radiculopathy.

0:07

Had a surgical procedure,

0:09

kind of a weird one, and things didn't go so well.

0:13

So, this study occurred pretty soon after the procedure.

0:18

I don't know how many days or weeks it's actually been,

0:21

but we talked about earlier short-term complications,

0:24

like misplaced hardware,

0:25

which is probably present here,

0:28

operating at the wrong level.

0:30

Well, that didn't occur here,

0:31

although we're going to see that they didn't

0:33

really get the job done properly.

0:35

And then unexpected fluid collections,

0:38

which we've shown in separate vignettes.

0:40

This patient doesn't have an abnormal fluid collection,

0:43

although when you see fluid collections,

0:45

you can use diffusion imaging because

0:47

if you have pus or an abscess,

0:49

we're going to see this patient is infected without

0:52

an abscess. That'll diffusion restrict.

0:54

Hematomas diffusion restrict.

0:56

Usually pseudomeningoceles and seromas don't diffusion

1:00

restrict. So that's one to put away in your back pocket.

1:04

So now we're into short and intermediate-term

1:07

complications, and let's take a look at what was done.

1:11

And let's start out with these sagittal views.

1:14

And then I'll toss up an axial.

1:16

And the reason I have the sagittals up is that look at the

1:19

endplate here. This is right up a radiologist's alley.

1:22

The endplates are destroyed.

1:24

They're irregular.

1:26

There's just too much edema for this procedure.

1:29

And you almost have this sort of faceless erased

1:32

endplate. That is a sign of infection.

1:35

And there is a fair amount of edema on the heavily water-

1:38

weighted image, even though it's not that pretty.

1:40

So what can we say about this?

1:42

Well,

1:43

one other point on what you were just describing about

1:46

the signs of infection, there's edema in the body,

1:48

but as we know, in degenerative conditions,

1:50

whenever there's micro instability,

1:52

this person's not fused.

1:54

Could it be from that we see how this kind of

1:56

ill-defined edge of the edema, generally,

2:00

when it's more degenerative linear,

2:02

you can say it starts here and stops there.

2:04

Okay. And that's not the case here.

2:06

Linearity. So we're worried for sure about infection,

2:10

not just micro instability and maybe more than micro.

2:15

Now, when you're thinking about the surgical procedure,

2:19

there's a couple things that could be a problem.

2:21

One is was the proper surgery chosen,

2:26

but the goals not achieved for some technical reason?

2:29

Or was the whole that surgery,

2:33

no matter how well it was done,

2:34

never going to achieve the goals of it?

2:36

Okay. And Dr.

2:37

Pomeranz is going to show you some axial

2:39

images that will bear on that issue.

2:42

Let me go right to the level there.

2:44

Here we are. Okay, so this person has radiculopathy,

2:46

right? So part of the goal is neural decompression,

2:50

and as you can see, severe stenosis remains.

2:54

Surgical procedure. So one,

2:57

this surgical procedure did not achieve that goal, but.

2:59

This surgical procedure is probably not the way you

3:02

want to go if that is one of your primary goals,

3:05

because there's no distraction of the endplates.

3:09

This instrumentation,

3:11

this interbody implant is way out front,

3:15

should be think of where the axis of rotation should be.

3:18

Probably a little bit behind the midline,

3:20

maybe at four or five.

3:21

Sure. That's kind of where you want your cage, right?

3:24

Right. So this thing is kind of hanging out there,

3:27

basically.

3:28

It's kind of

3:30

instrumenting the bone spur. Okay.

3:33

It's not really instrumenting the body.

3:36

It's not really distracting or opening up anything.

3:39

And really, probably even if it did,

3:41

even if it was well placed, this stenosis is unchanged.

3:44

So this person probably needed a posterior approach to

3:48

achieve decompression and then a stabilization augment,

3:53

which could have been interbody from the back.

3:54

Or they could have gone from the front and done something

3:56

like this, but augmented with a posterior decompression.

4:00

Okay,

4:00

so there's a couple of reasons this is

4:02

going to be taken this off, right?

4:04

You need to affect posterior decompression somehow.

4:07

And it looks like they came in from the side

4:09

with some as you pointed out earlier to me,

4:11

that some kind of plate on the side,

4:14

which is a little atypical, kind of like an X lift.

4:17

Right.

4:17

And have a couple of screws coming in from the side.

4:19

You can see the two little screw holes right here.

4:21

Right.

4:22

So an X-LIF is that one where you come in from the flank.

4:25

A transpsoas approach, big cage is put in.

4:28

And in this instance,

4:29

they augmented it with a lateral plate.

4:32

Okay.

4:33

Which you don't always do with an X-LIF because

4:35

if you get the big implant in there,

4:37

you don't often need a plate.

4:40

There was a feeling that they did in this case,

4:41

but that didn't seem to really work either because

4:43

it looks to me like we don't have decompression,

4:46

we don't have stability, there's no fusion.

4:50

So there's a number of reasons this isn't going to work.

4:52

So you got to define what were the goals,

4:54

were they achieved?

4:56

And that's what your report is going to be about.

4:58

Okay? So you have to understand, one, what were the goals?

5:00

Two,

5:01

what were they achieved and what's

5:02

causing the current problem?

5:04

So this guy has ample reasons to have not only back pain,

5:06

but leg pain because of persistent stenosis,

5:09

neural compression,

5:10

as well as instability and maybe even

5:13

a superimposed discitis. Yeah,

5:15

he's got a little synovial cysts here to boot.

5:19

Quick question, but before I ask that usually infection.

5:22

Usually you don't see infection from about

5:25

seven to 28 days is generally the range.

5:27

So somebody with pain 24 to 48 hours later,

5:31

it's probably not going to be infection.

5:33

But what is the difference between an XLIF and a DLIF?

5:37

A DLIF is actually they're kind of similar procedures.

5:44

A DLIF is actually an anterior procedure.

5:47

So it's a different instrumentation but there

5:49

are two different anterior procedures.

5:50

DLIF stands for direct lateral.

5:52

Right? Right. Okay,

5:53

so do they use different instruments for that?

5:55

Slightly, but the concept is similar.

5:58

Okay, so they're cousins of one another, right?

6:00

You're trying to instrument the disc space.

6:02

Place an interbody without violating the canal is the

6:07

theory of these approaches, these anterior approaches.

6:10

In this case, this guy's canal needed to be violated.

6:14

Okay, so in summary, then,

6:16

we've got somebody with failed back surgery because A,

6:20

the prosthetic put at the disc space level

6:22

is too far anterior, b, they infected c,

6:26

they did the wrong procedure.

6:27

They didn't take down the posterior column.

6:30

The patient has giant facets, big ligamentum flavum,

6:34

and a synovial cyst to boot with nasty spinal stenosis.

6:38

And with that, we'll take on another case.