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Of you all to sleep. Um So you can go ahead and, and uh why don't we kind of advance? So, you know, why? Spine? Yeah, I personally did not think about spine as a um where I wanted to go, I knew I wanted to go into orthopedics. And then once I got into orthopedics, I was exposed to some really good mentors who were spine surgeons and that was really pretty much just lucky. Um Things I did like was hand upper extremity and hand upper extremity has a lot of connection to um kind of the nervous system and spine kind of brings that uh forward. And there is also really large complicated cases that ii was really kind of drawn to in residency. I think in, in your training, you'll kind of figure out if you're, you know, a big surgery person or a little surgery person also known as outpatient versus inpatient sometimes. Um And what kind of like pathologies and surgeries that you are really drawn to? And I was really fascinated by the spine, the constructs that we, we get to build, which I'll share with you all here in shortly. Um And then the neurological um correlations that we see because often in spine, the what we want to treat is arm pain and leg pain. That's a pretty much an over generalization. But usually where spine surgery has its worst outcomes is for axial pain. Kind of in the back. We're really trying to kind of treat arm symptoms and leg symptoms when it really comes and boils down to it for the most part. Um And that, and also it was the type of kind of surgeries that really kinda scared me and kinda got really, got me engaged and interested and they were all a little bit different. So sometimes in orthopedics, like in joints, your practice is about trying to do everything exactly the same perfectly the same to try to improve your outcomes. Um And that it's kind of like hernia surgery in a certain way. Um And it just didn't speak to me. Um, and then spine really kind of really spoke. I really, really, I also thought that I wanted to go into kind of joints in the, in the beginning. So the combination of the neurologic, the constructs that we build as well as um the bigger cases more involved and kind of the, the thought process that we often go to towards trying to create a plan for a patient. Uh Tim, why don't you kinda move forward? So the, the s the spine, um and it is kinda really the, the, the the structure that really kind of keeps us upright and kind of staring in the, at the horizon. Um It's really the backbone pun intended of, of the body. Uh And it basically protects the neurological structures and why don't you, why don't you advance twice then? So, you know, we, we talk about kind of neck symptoms causing arm pain and which is kind of cervical radiculopathy can be coming from a number of, of issues. Uh Why don't you advance? So, you know, this is I'm gonna give some examples of the, some of the things that we do. I'm trying to keep it brief. Um But this is like a middle aged gentleman who on the right side at the in the MRI as you can see, has three large disc herniations, had really severe neck pain as well as arm pain. Um And what we did and you can advance them is we did kind of a three level ACDF. So we kind of went through the front of the neck, uh took out the discs, uh put spacers which are those white little lines in place and then put a plate on the front in order to hold things together so that he, that he can heal. And the, you know, the resolution of this was that we helped his arm pain, um helped some of his strength in his, in his fingers um and helped a little bit of his neck pain. Um As Well, so all these cases are relatively recent. Um, but hopefully his long term follow up will be, will be great. And then let's move forward again. Tim, this is another gentleman who you can see that, um, particularly on the right side of your screen, you can see the spinal cord as it travels down, kind of the back of the spine and, and, and I realize, and I can't really use the pointer but that, you know, a lot of you, I don't expect any of you all to really kind of know exactly what's, what's going on. But the spinal cord comes down the mid portion or the back portion of the spine. And you can see that there's kind of multiple areas where um or if I could do this and mu multiple areas here that um are, are tight and he's ha having something called uh cervical myelopathy. Why don't you go to the next screen to me? Hopefully, my mark does not stay and he's got something that we call spinal, uh spinal stenosis, which can cause myelopathy, which can cause difficulties with fingers, hands, dropping, items, clumsiness, difficulty walking. And if you advance it t so what we did was we just went in through the back of his spine. Um Truth be told this is a different patient because we haven't operated on that gentleman kinda yet and I guess my mark is going to um stay. Um but what we did was, you can see in the back of the spine, we removed his spine, it processes um and put in some screws into the spine in order to hold things together so that, that it heals and that we open up the spinal cord so that um we can kind of relieve the pressure on the, on the spinal cord itself once you move forward, uh and move forward twice. So the other major thing that we ta take care of is sciatic type pain or radiculopathy in the, in the lumbar spine, um which can be caused by a number of different uh reasons um such as uh a herniated disc. And why don't you move forward, Tim. So you can see that this is a, a young lady who has a disc herniation down at the bottom of her spine at L5 S one that bump that you see all the way down the, the part that doesn't look like the others. And on the axial MRI the, on the right side of your screen, you can see that little bit of a bump that's um pushing into uh the area where the nerves are causing her leg pain. So if you advanced them, so what we, what we do is we just kind of go down there, create a little hole in the spine, kinda move the spinal nerves over like you see with that retractor and then the knife in there, we just cut open the disc and remove that space and she's, you know, roughly about four weeks out from surgery back to work kind of resolution of the leg pain. Um And, and doing really, really well, let's move to the next one. Um So this is a reference to the, the Mike Tyson video I put this in before I decided I wanted to share the, the, the, the actual video itself, but he say he broke his back. So the other thing that we treat is are spinal fractures and let's move forward. Um So you can see that this person has an L3 fracture in the middle of her spine. You know what we do is we kind of go in there and provide like um an internal splint if you will, um, or a fusion depending on if we wanna try to get the bones to knit themselves together or if we're just stabilizing it to give the bones some time to heal. Um, kind of like a cast if you, if you think about a, you know, a kid with a forearm fracture, um, you can advance because it's spinal. I'm sorry, again, these jokes don't hit as well if you don't watch the video. Um And maybe they don't hit that well at all. But uh let's advance again. And then in our older population, we can have spinal fractures and we can kind of put um, cement into the bones. Um that white stuff that you see in the vertebral bodies is uh polymethylmethacrylate um that we can inject in there via the pedicles. In order to help, you know, older people with osteoporosis with, you know, spinal fracture pain, advance it again. So this is uh another gentleman, this is kind of transitioning again and staying in the lumbar spine. But you can see that on the left screen, there's like a darker haziness within the spinal canal. Um and that's something we call spinal stenosis. And it manifests itself as leg pain, neurogenic claudication, which manifests itself as leg heaviness weakness, uh pain uh when you look at the right side, um and Tim hit the forward button one more time, I just put that in there. It's just like a normal. So you can kinda see in the middle where you see the white and all the black spots, it kind of looks like a Dalmatian that's normal. And then on the right image, you can see where it's all kind of compressed. It looks mostly black and, and dark gray. And what we do for that is a laminectomy. We remove the pressure on the nerves and, you know, if everything goes well, which we would expect it to, you know, people do very, very well. Their leg pain is improved, their walking is improved. Um It's, it's up there with like a total hip replacement in patient outcomes uh and um relief and happiness, you know, or, or, you know, feeling better after after surgery. So you can really alter someone's functional life, which is really kind of what we're trying to do in orthopedics in general with that type of procedure and then kinda hit the button forward. So this lady, um, has something we call spondylolithesis, mainly a degenerative condition at the L4 L5, the bottom two, perfect the bottom to the bottom level. Well, the, the bottom two bones and the level in between and what that causes is spinal stenosis and you can advance him. Um This lady has a little bit of degenerative scoliosis, but it's really kind of focused at the 23 level. And on the MRI on the right side, you can see that there's a, a significant amount of bony edema within the, within the bone itself, something we call modic changes. You know, she had a lot of um back related pain on the mid, on the middle ap lumbar X ray, the one in the middle of the spine, middle of the screen. You can see that the bones have kind of translated in relationship to each other um causing that and um that area of um kind of scoliosis. So it's advanced him. So we did something we call an Xlif and these are just some fluoro grabs from the actual procedure kind of us finding kind of where to make the incision. Um It's not the perfect x-ray shot, but we're what we're trying to find is that that disc level right above where the cross is located. So we found it um subsequently we drop a little uh cannula down. You can see that on the top, right, that little black thing is a, a Cannula that we would kind of start to work through. And then we put a retractor in which is the bottom left and then on the bottom right, you can see the retractor kind of from the, from the flank all the way down to um the spine and see if you kind of move forward. You can, and then top left, you can see us kind of putting a um a, a shin into the spine and then top right, we're placing um uh a dilator through there in order to open up the space of the spine. Bottom left. We're looking at the, the cage or the implant that we put in and then bottom right is looking at it kind of kind of from the side, we've kind of regained the height and improved the um alignment um that was was focally out. And if you move to the next page, um this is a lady who has even uh more significant like scoliosis to the, to the right and then she's pitched forward, um and you can advance t and then this is kind of her afterwards. The, the image is a little bit rotated a little bit, I should have like straightened it up, but she's now kinda much straighter. We went through her belly, then we went through her side and then we went through her back with at 10 to Pelvis. Um, so if this is really intriguing to you, then spine might be your answer. Um, but the, uh, this is something we call rotisserie surgery just because it's almost like kind of moving, um, somebody around and kind of attacking the spine from all directions. But there's, you know, really good reasons for going through the front to restore some of her alignment and then going from her side, which is a powerful way of kind of correcting somebody's, um, uh, scoliosis, we can move forward, bless you. And then, uh, you know, pediatrics is also obviously a big portion of the spine. It's more of a, a ped spine. Um, I don't do a lot of this. I pulled this from somewhere, but, you know, we pull, you can see where the, they have a thumb scoliosis and, you know, with the instrumentation that we've kind of straighten them up. This is something that you can do relatively emphasis on relatively easy in the pediatric patient, but it's much, much, much more difficult in the adult because as we get older, we get stiff and I can attest to that kind of just in general. So our spine doesn't, we can't, we can't really manipulate the spine as much kind of in the older population. So, instead of being able to just kind of use re um reducers and kind of driving it back into place. You know, we have to cut the spine, something called an osteotomy. Um, in order to kind of correct some realignment in the older population, you can move on to him. So, besides all the cool surgeries and the hardware and um, that we, that we, that we get to do, we also get to use a lot of technology. Um The one of those uh elements of technology is the arm and stealth where we can um use computer navigation to let us do surgery in a much more kind of minimally invasive um manner. Um So if you click forward again, so you can see here that, you know, we can see where the spine is because of the computer navigation and then we can see where our instrumentation is located kind of in a real time, kind of way to kind of smaller incisions more accurate uh instrumentation placement and hopefully use that to improve patient patient outcomes. And then this is just us kind of putting a cage in just another representation and you can move forward to him. So I'm gonna kinda segue away from kind of the things that we do do, you know spine. Um Let me probably take it back a step back before we get to this slide, but you know, spine in general, um If you choose the right patient with the right pathology, your outcomes are are gonna be very, very good if you choose the wrong patient um with the wrong pathology, then, you know, you can, you can create harm. So the goal of spine first is to try to figure out what's causing the person's pain. Um and then, you know, treat that because as we get older, we're all gonna have degenerative changes kind of within the spine. So it's really a correlation uh uh to try to figure out what's going on. And then we've used neurologic signs and symptoms such as where is the pain going? Where is the numbness located? Kind of what is weak to kind of work backwards from, you know, the tips of our fingers and our and our toes um to the spine in order to try to kind of figure out where the right area is that's causing the symptoms. So it's, it's, it's a lot of fun in the or, and it's fascinating and very challenging also in the clinic. Um even though the or is way cooler in the clinic, um the so different practice types, you can do whatever you kind of wanna do kind of within the spine. Though it tends, you know, it can be academic, private practice hospital based, there's inpatient surgery and outpatient surgery though I would say that it tends to favor more strongly like inpatient surgery. Um just because of patient recovery, though, there's are a lot of movements to move a lot of things that we do kind of to more of an outpatient setting. Um So, but I would say that by and large, most of it is going to be kind of inpatient um or at least ambulatory kind of depending on where you operate and you can move forward to him. So, one of the questions I get is, you know, what's the difference between orthopedics and neurosurgery in regards to spine? Um One simple way is, you know, really there aren't many differences this day and age. I historically, uh the neurosurgeons would do a lot of the decompressions and laminectomies while the orthopedic surgeons would do kind of the scoliosis, the instrumentation and the fusion type of surgery oftentimes working together. Um But over the course of the last few decades, they really have kind of um grown together. So it's almost a uh it's al it, there's not really much difference um between an orthospine surgeon and a nurse or spine surgeon. Um except for maybe kinda intrathecal tumors, intrathecal AVN S um tethered cords. And to be honest with you, they can have that a and as much as they want because, you know, you know, not super interested in that personally, but that tends to be the kind of the small differences between the, the two orthopedics is uh generally a five-year program with a one year uh fellowship neurosurgery is usually a seven year program and a plus or minus uh, AFA fellowship. Um, a lot of times, um, orthopedic, well, a lot of times fellowships can be interchangeable, like an Ortho person, could do a neurosurgery fellowship or a neurosurgery person could do an orthopedic fellowship. Um, certainly if a neurosurgery person does an orthopedic fellowship, they're adding, you know, additional year to their, their training kind of time. So it would be eight years versus six years. Um, so there's some slight differences in, in, in variations there. But, um, and there's some benefits one way or the other and you can make an argument that neurosurgery is the better way to go, orthopedic surgery is the better way to go orthopedic surgery. Certainly the, the, the quicker route. Um, but there's some benefits to either side. But in reality, um, if you, I, you know, I think if you like brain, then, you know, neurosurgery is probably the direction that you, you probably wanna go. Um, and if you like, um, appendages, then, you know, orthopedics, um, is probably the way to go. Assuming that spine is, you know, an interest either e, in either way. Um, oftentimes people come to me and say, you know, they figure out what they wanna do because they found their people if you will. Um, so I would, you know, if, you know, you definitely wanna do spine, I would, I would rotate with orthopedics and I would rotate with neurosurgery and, um, that may be able to help you kind of differentiate the, the, between the two. Um, but based on the fact that this is the orthopedic surgery interest group, I already know that all of you have made good well informed decisions and are even, uh, even killed cool people. Um, the, let's, let's move forward. Uh, aside, I'm not sure, I'm, uh, I'm getting to the point on thin ice where I'm not quite sure what comes next. Um, but this may be kind of near the end, uh you know, like a normal week for, for me specifically. Uh And probably for most folks though, it'll flex a little bit. I have a relatively high administration like percentage to my kind of job um as program director. So, um I add in a little bit of administrative duties on we on, on most Wednesdays. Um So uh other folks may not have that and they may either kind of do different types of administrative duties or are more clinical on that day. But a normal week for me is a Monday. I'm in the or most of the day. Um Tuesday. Um I usually a full day clinic which is at SMI which is about 25 to 35 patients. We have a pa that works with me. He sees his own independent clinic uh and helps my clinic when um you know, he may have gaps in his schedule. Um I kinda oversee him. So sometimes, you know, I'll see some of his patients, um, as well. You know, sometimes I have, you know, specific questions or, you know, issues to address. Uh, Wednesday, administrative duties. I usually do a full day of clinic, you know, once one day a month, um, Thursday and full day in clinic. I do it out inhale. Um, it's a satellite clinic and it's about 20 or 30 patients. Uh, Friday. I do. Um, I've been back in the, or, um, at H VN uh all day and I personally do orthopedic call. Uh I'm not involved in the um spine call. Uh That's purely neurosurgery here for a number of reasons, uh that predate my arrival. Um But uh so I take orthopedic uh call in that pool, um which I actually really like because it kinda lets me engage in with the residents and kind of ke keep up some of my observational skills or surgical skills um from an orthopedic perspective. So that's a lot of fun. Um I think that might have been the last slide. It.