Interactive Transcript
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So, Dr. Schupeck,
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we're back here.
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Vignette number three of our 57-year-old man
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with low back and leg pain,
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operated on at the wrong level.
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They went up to L1-L2,
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or what we would call L1-L2.
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We've been talking about counting.
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Now they get to the right level,
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they extract the extradural soft disc abnormality,
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and lo and behold,
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you know,
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what can go wrong, does go wrong.
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And now the patient has discovertebral osteomyelitis.
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They have all the findings.
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They've got holovertebral disc edema,
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they've lost the endplate.
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It's discreet and dark
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and then becomes fleeting and ephemeral.
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It's gone anteriorly.
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There's high signal intensity in the disc space.
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The T2-weighted image,
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not that impressive in terms of the edema.
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This is not a heavily water-weighted sequence.
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So the T1 much more valuable in that regard.
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And then the contrast-enhanced image,
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not particularly valuable.
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It's a pejorative kind of routine
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thing that people do.
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Not really necessary in discoverT osteomyelitis
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a little bit of dural enhancement consistent with
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infection. And so now they counted right,
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but they ended up with a complication.
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So in finishing, I want to ask you one other question.
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Because you've lived this for a quarter of a century.
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You talk about
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how you get to the right level in the OR.
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Let me ask you in the world of politics and
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big hands and little hands and big feet.
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And little feet. Tell me about your big feet.
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Yes. Explain that to me.
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Yeah, I had big feet.
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Every surgeon has their own crazy way of
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trying to keep from making a mistake.
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And one of the things I did,
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I had a seven-step program to make
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sure I was at the right level.
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But step number one was I had big rubber feet made
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that the OR staff would put on the proper side.
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And then my first step was standing
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in these giant feet,
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so at least I was on the correct side of the table.
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Okay. Because that's easy to do.
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And then I would orient myself like the patient.
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I'm left-handed.
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I put something in my hand so I knew what was left,
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what was right, and then I just take it from there.
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Then I go over the X-rays and I had a series of seven
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different types of counting the level.
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Okay. Then there's intraoperative ways of doing it,
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right? There's a needle that goes down before you make
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the decision, incision. So you're over it,
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make an incision, clamp on the vertebrae,
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additional imaging. So by the time you're there,
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there are probably twelve different ways of doing it,
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starting with the big feet or whatever it is that
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you need to. And they weren't your own feet.
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They were not my own feet.
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They were much bigger than my own feet.
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But whatever you need to do,
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and however crazy it sounds,
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and I've seen some even crazier ones,
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that's what you need to do, because that is key.
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I can tell you, even with all that,
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you will get all the way down the line and almost be.
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Wrong. Let me ask you one other question.
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If you had to pick one single thing that the
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radiologist can do to make your counting accurate,
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would it be a bony landmark or what would it be?
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Yeah, I mean,
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the key is you're localizing in the OR
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with basically a lateral X-ray, okay?
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So something that you can see on a lateral X-ray.
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Now, if the lumbosacral junction is very obvious,
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not complicated,
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not additional levels or a bony landmark,
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but something that there is no question
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that will be seen on a plain film,
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because that's what they're going to like a giant spur
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that looks different. Giant spur is which level?
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Something that they will definitely see.
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So simple, even on a big patient, right?
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And you got to go to the OR sometimes to see
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the position that the patient's in.
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We used to do patients in the sitting position, right?
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So that has all these other problems.
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And thoracic is very difficult because
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the patient's face down,
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how many ribs do they have?
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How do you localize it?
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So thoracic,
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sometimes I would spend 30 minutes trying to localize
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the level just for a kyphoplasty or something.
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So the higher you get up in the spine,
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at least up into the thoracic area,
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the more difficult it is.
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And it seems like it should be a slam dunk,
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but it is not,
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and it is the key and probably where the radiologist
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can help the most. And if the radiologist is wrong,
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it'll never be forgotten.
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So a couple of comments for the audience.
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I always use the term for accounting purposes,
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and I do it narrative style, too.
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I'm going to call and I try not to speak in the
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first person. We're going to call L5-S1,
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one this lowermost disc-based level that we've imaged
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for this reason, then the other thing I'll do is,
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for landmark purposes,
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if I can pick out a spur that looks different than
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all the other spurs, great.
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If I can't do that,
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then I'll start looking at compressions.
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Now,
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if I've got a 20% compression and a 30% and a 32%,
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that's not that helpful.
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But if every single vertebral body is of normal
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height, but I've got one that's 50% compressed,
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we're golden. So use your common sense,
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use your words, use the anatomy.
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It doesn't have to be fancy.
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You don't have to show them how smart you are.
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All you have to do is show them where to go
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using the easiest and atomic landmarks.
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