0:00

So, Dr. Schupeck,

0:01

we're back here.

0:02

Vignette number three of our 57-year-old man

0:05

with low back and leg pain,

0:07

operated on at the wrong level.

0:08

They went up to L1-L2,

0:10

or what we would call L1-L2.

0:12

We've been talking about counting.

0:14

Now they get to the right level,

0:15

they extract the extradural soft disc abnormality,

0:19

and lo and behold,

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you know,

0:21

what can go wrong, does go wrong.

0:24

And now the patient has discovertebral osteomyelitis.

0:27

They have all the findings.

0:28

They've got holovertebral disc edema,

0:30

they've lost the endplate.

0:33

It's discreet and dark

0:34

and then becomes fleeting and ephemeral.

0:37

It's gone anteriorly.

0:38

There's high signal intensity in the disc space.

0:41

The T2-weighted image,

0:42

not that impressive in terms of the edema.

0:45

This is not a heavily water-weighted sequence.

0:48

So the T1 much more valuable in that regard.

0:51

And then the contrast-enhanced image,

0:53

not particularly valuable.

0:55

It's a pejorative kind of routine

0:56

thing that people do.

0:58

Not really necessary in discoverT osteomyelitis

1:01

a little bit of dural enhancement consistent with

1:05

infection. And so now they counted right,

1:08

but they ended up with a complication.

1:10

So in finishing, I want to ask you one other question.

1:13

Because you've lived this for a quarter of a century.

1:17

You talk about

1:19

how you get to the right level in the OR.

1:22

Let me ask you in the world of politics and

1:26

big hands and little hands and big feet.

1:28

And little feet. Tell me about your big feet.

1:32

Yes. Explain that to me.

1:34

Yeah, I had big feet.

1:36

Every surgeon has their own crazy way of

1:40

trying to keep from making a mistake.

1:42

And one of the things I did,

1:44

I had a seven-step program to make

1:47

sure I was at the right level.

1:48

But step number one was I had big rubber feet made

1:53

that the OR staff would put on the proper side.

1:57

And then my first step was standing

1:59

in these giant feet,

2:00

so at least I was on the correct side of the table.

2:02

Okay. Because that's easy to do.

2:04

And then I would orient myself like the patient.

2:07

I'm left-handed.

2:08

I put something in my hand so I knew what was left,

2:10

what was right, and then I just take it from there.

2:12

Then I go over the X-rays and I had a series of seven

2:15

different types of counting the level.

2:18

Okay. Then there's intraoperative ways of doing it,

2:21

right? There's a needle that goes down before you make

2:23

the decision, incision. So you're over it,

2:26

make an incision, clamp on the vertebrae,

2:29

additional imaging. So by the time you're there,

2:33

there are probably twelve different ways of doing it,

2:36

starting with the big feet or whatever it is that

2:39

you need to. And they weren't your own feet.

2:40

They were not my own feet.

2:42

They were much bigger than my own feet.

2:44

But whatever you need to do,

2:46

and however crazy it sounds,

2:48

and I've seen some even crazier ones,

2:50

that's what you need to do, because that is key.

2:54

I can tell you, even with all that,

2:57

you will get all the way down the line and almost be.

3:00

Wrong. Let me ask you one other question.

3:01

If you had to pick one single thing that the

3:04

radiologist can do to make your counting accurate,

3:09

would it be a bony landmark or what would it be?

3:13

Yeah, I mean,

3:13

the key is you're localizing in the OR

3:16

with basically a lateral X-ray, okay?

3:19

So something that you can see on a lateral X-ray.

3:22

Now, if the lumbosacral junction is very obvious,

3:25

not complicated,

3:26

not additional levels or a bony landmark,

3:30

but something that there is no question

3:33

that will be seen on a plain film,

3:35

because that's what they're going to like a giant spur

3:37

that looks different. Giant spur is which level?

3:39

Something that they will definitely see.

3:41

So simple, even on a big patient, right?

3:44

And you got to go to the OR sometimes to see

3:46

the position that the patient's in.

3:48

We used to do patients in the sitting position, right?

3:50

So that has all these other problems.

3:52

And thoracic is very difficult because

3:55

the patient's face down,

3:57

how many ribs do they have?

3:59

How do you localize it?

4:00

So thoracic,

4:01

sometimes I would spend 30 minutes trying to localize

4:06

the level just for a kyphoplasty or something.

4:08

So the higher you get up in the spine,

4:11

at least up into the thoracic area,

4:13

the more difficult it is.

4:14

And it seems like it should be a slam dunk,

4:16

but it is not,

4:17

and it is the key and probably where the radiologist

4:21

can help the most. And if the radiologist is wrong,

4:24

it'll never be forgotten.

4:27

So a couple of comments for the audience.

4:31

I always use the term for accounting purposes,

4:35

and I do it narrative style, too.

4:37

I'm going to call and I try not to speak in the

4:40

first person. We're going to call L5-S1,

4:44

one this lowermost disc-based level that we've imaged

4:48

for this reason, then the other thing I'll do is,

4:51

for landmark purposes,

4:53

if I can pick out a spur that looks different than

4:56

all the other spurs, great.

4:58

If I can't do that,

4:59

then I'll start looking at compressions.

5:01

Now,

5:01

if I've got a 20% compression and a 30% and a 32%,

5:06

that's not that helpful.

5:07

But if every single vertebral body is of normal

5:10

height, but I've got one that's 50% compressed,

5:13

we're golden. So use your common sense,

5:17

use your words, use the anatomy.

5:19

It doesn't have to be fancy.

5:21

You don't have to show them how smart you are.

5:24

All you have to do is show them where to go

5:28

using the easiest and atomic landmarks.