Good afternoon, I'm Chris Kaufman, I'm a TCA board member and trauma surgeon. I live in Myrtle Beach, South Carolina and have the honor of being able to participate as a moderator in several of our spinal cord injury webinars, which the Education Committee, as after soliciting questions from our membership, determined that this was a really hot topic that we know we feel like we know a lot about spinal cord injuries but we realize that there's a lot we don't know. This is a series of eight webinars, this is part four of eight. We're honored that our invitation has been accepted to be our presenter today by Dr. Yu. Dr. Kevin Yu is an established neurosurgeon in San Diego, California and has been practicing spine and neurosurgery for over 18 years. He's always had a passion for patient care, which led to his practice of course becoming a flourishing one. He has been trained in minimally invasive surgery of the spine and specializes in degenerative spine conditions as well as brain tumors and brain and spine trauma. Dr. Yu is dedicated to the intimate care of every patient he treats by always making himself available to his patients. With a meticulous attention to detail, Dr. Yu is a problem solver who strives to provide comprehensive, individualized care to each of his patients. So without much further ado, I will ask Dr. Yu to start his presentation. I will just say up front that I'm jealous he lives in San Diego because it has the most beautiful weather of any place that I've been in the United States. So thanks for helping us out, Dr. Yu, and the stage is yours. Thank you. I'm actually honored to be here to make this presentation to a very large audience and then I believe this is going to be used to educate others. I am a neurosurgeon that takes a trauma call at a couple of hospitals in Southern California, including San Diego. So I have been working with patients that have spinal cord injuries for many, many years. So I will be talking about spinal cord injury and care following or procedures as the part four of the series here. I want to give a little bit of credit to a couple of pre-medical students, Ronnie and Gabby, who you see on the slide, in helping me make this PowerPoint presentation possible for you guys. As I go along here, you'll notice that almost every slide can be an entire talk by itself. So I do apologize. There'll be so much information coming at you, but hopefully you can share and distill down the pearls of, as they say, wisdom about spinal cord injuries and care with or procedures and so on. But please stop me at any time if you want to ask questions. You can ask them at the end, but if there's something you want to ask, I prefer to be interactive talk. Okay, so let's go on to the first slide. So the objectives of the talk that I was sort of given these points to cover. Identify key concerns for patients before and after surgery. Prevent issues relating to improper use of C-collis and other immobilization devices. Analyze the effects of being prone for a long time in the operating room. Decision making in the operating room when complications arise. I think there was a particular interest in what to do if a patient coded in the operating room during spinal surgery. So I'll speak about that just a bit. And then there is a very important topic that we are asked all the time that I'm going to try to do some justice to at the end of the talk about DVT prophylaxis in patients who have spinal cord injury and had surgery of the spine because of their spinal cord injury. So let me go on to the next slide to start from the beginning. So key concerns for spinal cord injury patients before surgery. These are some of the things that just came to my mind, and there may be some things I've missed, but some of the things that I thought were worthy of discussion. So these are the five things that we're going to cover in the next few slides. So for me, a key concern for spinal cord injury patients is immobilization. And when I say immobilization, the questions that I have to answer as a, let's say, neurosurgeon, spine surgeon, trauma surgeon that's on call and I get called about a patient that has spinal cord injury is to determine the stability of the spine with respect to the injury. And it is something that just takes years, obviously, to sort of master and understand. But as you can imagine, just like any disease process in medicine, it's a spectrum. You can't say a spinal cord injury or spine is stable or unstable. You just can't. It's not black and white. And so there are certain spine injuries where there is injury, fracture, whatever it may be, that's really totally stable. And then there's some that are just grossly unstable. And so besides those two categories of injuries, which you can really see, understand, if you study the films and so on, most of the spinal cord injuries sort of are in the sort of unstable kind of category in the sense that there is some instability to the spine because of injury. But it's not necessarily grossly unstable and it may not even need surgical stabilization. So understanding that will help you determine what the patient needs, immobilization, whether it be a collar or, as you guys all may have heard of, people get placed on spine precaution, right? They can only be log rolled. So those kinds of things and those kinds of questions can be answered and should be answered with the understanding of whether the spine injury is stable or unstable. And I'll try to cover some of that for you with pictures and so on to help you understand the differences. The next obvious category that you have to really consider before a patient has spinal surgery for a spinal cord injury is the imaging studies. We are now in medicine where we have spectacular images. We have different modalities, but they fall under the three categories of X-ray, CT scan, MRI. So I'll cover some of that. Spinal shock is something that you guys have probably all have heard of or deal with and treat. That needs to be considered. So I'll cover a little bit of that. And the last two categories are just obvious things. Obviously, we need to have labs and we need to be worried about bleeding tendencies. Why is that important in spine? And I put epidural hematoma there and I'll talk about that because that really is the main thing that we worry about with respect to bleeding and having normal blood values, blood workup. And I put diabetes and age on there as something to also sort of interesting to talk about because, again, not all patients who have spinal cord injury all come to us in one type of patient, one age, one sex. So age is very, for me, a very important factor in what we need to consider for patients that undergo, let's say, spinal cord injury surgery. And we'll talk about that a little bit at the end. So let me go right into it and start with the first topic. So immobilization, as I was telling you, that you've got to really understand and determine, is the spine injury unstable or stable? And we in the Neurosurgery and Orthopedic Committee, when we are dealing with... Are you guys hearing an echo? Yes. Is that me or someone else? I think it stopped. Okay. So when we're dealing with spine injuries, we have come up with classifications in our community to help us understand whether spine injuries are stable and stable. It started with Dr. Denis a long time ago, who really divided the spine into the three-column classification of one, two, and three. The front of the spine here, where you have half the anterior vertebral body. The posterior half is column two. The third column is all the posterior elements and ligaments and so on. But this was way too simple. And so we used to say that if you have injury of two or three columns, it's an unstable injury. And that actually was way too simplistic and really missed some subtle fractures that would either be stable or unstable. So the AO organization that you guys may be familiar with came up with AO classification of different types, A, B, and C. Again, each of these topics could take a whole talk to talk about. So I won't go into details, but know that this was a better way to classify fractures, particularly in the thoracic and lumbar spine, and really helped us understand whether someone should or should not have surgery. But this was also, as over time we realized, has some inadequacies and really helped me understand whether a spine injury was unstable and needed stabilization. So the latest classification is called TLICS, Thoracolumbar Injury Classification System. That again, AO was very much involved in bringing this up, where they talk about the morphology of the fracture, the integrity of the posterior ligaments, which is really, really important in understanding spine injuries and whether they're stable, and the neurologic status of the patient. So taking these three variables, assigning them points, we're now using this a lot to try to understand if patients need or do not need surgical treatment and stabilization. So it's gotten better over time in terms of how we understand whether something is stable or unstable. So if you determined, whichever classification system you use, or however you determine whether spine is stable and unstable, then you determine if they need immobilization, whether it be a collar, a brace, or for that matter, they need to be flat in bed and only log rolled and so on. Because if you put collars, braces, or you restrict them to bedrest, you're going to have consequences of that, which we'll cover, that may not be necessary if you understood whether the spine injury was stable and stable. So those questions should be and can be answered for you by obviously the spine surgeons. Okay, so let's go to the next slide. I want to talk a little bit about, again, as an education to help you understand why is a fracture stable or unstable and do they need all the immobilization. So I want to cover one particular fracture called burst fracture. So actually, this comes from the Denis classification, in the sense that there's compression fracture, which should be just simply the anterior half of the vertebral body. So compression fractures, by definition, are supposed to be just the column one is compressed. But if you have a burst fracture, like this one here, you can see that the posterior half of the vertebral body is fractured. Not only is it fractured, there's a piece of bone that's going back into the canal, therefore probably compressing the neural elements at this lumbar spine level. So this, by definition, because it involves two columns, is considered to be a burst fracture. So one of the ways to tell you why the Denis classification was inadequate was that we were taught, again, when we only used the Denis classification, that a burst fracture, by definition, because it involved two columns, two or three columns, right, is unstable and therefore needs to have surgical stabilization, or for that matter, immobilization. But I want to assure you that even this picture here, this may be a stable fracture, and that it does not necessarily need surgical treatment, and does not necessarily even need, perhaps, immobilization. Although I would say that this is a patient you probably would want to put in a brace and keep in a brace, particularly when they're moving. But this is not necessarily an outright, clear-cut, no-questions-asked surgical case. A lot of different things have to be considered. You've got to get the patient standing and get x-rays and see if it even deforms even more. That would be a sign of instability and likely needs surgical stabilization. Does the patient have neurologic deficits? If the patient has a lot of weakness in the lower extremity, yeah, this patient needs surgical treatment because of the fact that you've got to get this decompression done, push the bone back in, right? So a lot of different things must go into consideration as to whether the spine is unstable, stable, and needs surgery or not. So it just takes art. It's the art of medicine. You've just got to understand the fracture, and over time, and with good training and so on, you can determine these things that need to be determined for the trauma service. Okay? So let's go on to the next slide. Appropriate imaging studies. So I would say to you that x-rays, with a few minor exceptions, are, for me in particular, this is sort of me, are not as nearly as helpful as they used to be because we have CT scans. We have high-speed CT now, and almost all facilities now have MRIs as well, right? So the x-rays are not nearly as helpful, and I often don't even need them, per se, if I need to treat somebody. For instance, this patient on the right-hand side, you can see clearer on the x-ray that the patient has basically a dislocated cervical spine at this particular level here. Now, the x-rays will be helpful in showing me that, but the CT scan, without question, as you can imagine, will be tremendously helpful in helping me understand not only that the patient has a dislocation, but that the facets are fractured, they're perched, they're jumped, all those things that I look for that are very helpful that would be much better delineated on a CT scan. The MRI is not as nearly as available. Some facilities may not even have MRIs. But I do want to tell you there is a big discussion we always have with a particular injury, this one in particular, the perched facets, the dislocated cervical spine, do we need an MRI or not? And I would say to you, if you look at the MRI of this individual, posteriorly, you can see there's a tremendous disruption of the posterior ligament, the disc space, there may even be a small epidural hematoma. So the MRIs, if you can get it, I always ask for it, will be helpful in knowing that there is something there compressing the spinal cord that you can appreciate as well on certainly x-rays, but even CT scan. Because what this patient needs, this patient needs basically a reduction of their dislocation, right? So there is a report that may have really actually cursed the spine committee or not, but there is a report of a patient who became worse with the reduction of this dislocated cervical spine because of a large disc herniation that compressed the spinal cord even more. So for that reason, getting an MRI, especially in cervical spine, especially in dislocated cervical spine injuries for us are very helpful and almost is sort of medically necessary. So getting these studies, you really think we need to think about it before surgery because they're very helpful for the spine surgeon in determining lots of different things. Okay, let's go quickly to spinal shock, something that you guys are all familiar with, the spine surgeon. And I bring it up in the following way, because this is what I struggle with, or this is what I think about very seriously because spinal shock would exist in patients that have spinal cord injury. Obviously with the age of grade, if you have E, you should not have spinal shock, but it's the cervical spine injuries where it's either complete or serious spinal cord injuries that may be incomplete where there's no motor and very little sensory. So there's a debate or discussion always, does a patient have incomplete or complete spinal cord injury? And I would tell you that many Asia A patients really are Asia B, why is that? It's because of the spinal shock. So it appears that, let's say in the emergency room trauma bay, they're graded Asia A, but within a day or two, certainly with surgical treatment perhaps, but even without surgical treatment, they convert to incomplete because of the fact that the spinal shock sort of masks the injury and made it even worse. But it's the Asia, so I always treat patients that come to me as Asia A, just consider them Asia B in terms of how I approach that patient, especially if I do the surgery, because I want to try to give everyone a chance to gain as much function back as possible. So, however, if it's truly Asia A, and let's say the spinal cord injury came to us late, several days later, if it's Asia A, they are likely to be Asia A, they're not going to be a incomplete spinal cord injury. And those patients, I may actually take my time in preparing them for surgery, get medical clearance, get good overtime and so on. So the spinal shock and the Asia classification is something we also consider before we do surgical treatment. Now, the last two items, normal PT, INR, PTT, hemoglobin, platelets, whether they've been on blood thinners, is simply important because of the fact that we don't want the patient to bleed. They can certainly bleed excessively in the operating room, and that in itself can cause problems such as cardiogenic shock that we can cover later in this discussion. But why is a spine surgeon worried about this? Or these lab values? It's because of epidural hematoma. If you do surgical treatment on patients, and they, even if you did a laminectomy, the hematoma that may develop because the patient has a propensity to bleed may cause a hematoma in the epidural space, may cause compression of the spinal cord, and may cause neurologic issues and deficits. So the patient came to you, very good, a very good, let's say, incomplete spinal cord injury or normal spinal function, but needed surgical stabilization. And imagine if you took them to the OR, did surgery, and they became paraplegic or quadriplegic because of an epidural hematoma. Again, that's the main fear. That's why we worry about these bleeding parameters. Okay? So you can see in this picture, this patient is someone who's got this large epidural hematoma and can cause this compression of spinal cord and can cause deficits. However, I do want to mention that we do get called by the trauma service a lot that someone's got a little tiny epidural hematoma. Or for that matter, they may even have a fairly sizable, not something as big as this, but it could be half this size. And there is some compression, but the patient's absolutely normal. So the neurologic exam is also very important in the decision for surgery or not. If you have somebody who's got a tiny little epidural hematoma, yes, we don't worry about that. We just want you to keep normal values. If you have somebody that's got a modest size epidural hematoma, even a good size epidural hematoma with compression of spinal cord, if their neurologic exam is normal, I'm not sure that we'd like to go in and try to take those out. We try to avoid that because of the surgical morbidity. So sometimes we have, many times we do sit on epidural hematomas, just repeat the imaging studies, certainly watch the neurologic exam very closely. These will get absorbed. They will go away. And so they don't necessarily need to be evacuated in the absence of neurologic issues. All right. So last thing to consider, diabetes and age. I just wrote diabetes as one of the many medical conditions that a spinal cord injury patient may have that could be a problem for the spine surgeon, only because if they've had previous strokes and previous heart attacks, whatever it might be, you still have to do the surgery. And if they get through the surgery okay without any cardiac event, without anything occurring that's bad with regard to their medical problems, then maybe they'll be stable and be okay. But diabetes, as we all know, is a problem in terms of wound healing, in terms of all the other things that can just sort of haunt a surgeon in any specialty, but it's also true in surgical treatments of spinal cord injury. Now, the age is a really interesting or difficult thing to consider. So imagine if you're the trauma surgeon, if you're a trauma service and you're the spine surgeon, and you get called by somebody, let's say they're late 70s or early 80s, and they are truly, let's say, clinically that way. So their body is that way. We all know of elderly patients that are truly very in good condition, but more often than not, elderly patients have poor medical conditions. So if you've got somebody in their late 70s, late 80s, and they have spinal cord injury, and if they came to us with neurologic issues, for instance, I've taken care of many patients, as you may have as well, who are in their 80s and have had cervical spinal cord injury and come to us with, let's say, a very poor Asia grade. I don't remember ever operating on somebody in their late 70s, 80s, doing a laminectomy, decompressing their spine, giving these individuals a chance to reverse their true quadriplegia or paraplegia, and have them ever walk back into my office in good condition and regain function. A quadriplegic injury of an elderly 80-year-old is a death knell. They just don't do well. They don't even get out of the hospital. They may not even get off the ventilator. So sometimes it is humane and ethical thing for us to sell a patient. You're just too old to have surgery. And that decision, once in a while, I have to make and recommend, even though sometimes I do surgery at the patient's request. So that's something to consider. Okay, so let's go on to talk about concerns of spinal cord injury in patients after surgery, if they need surgical treatment, whether it's decompression or stabilization. I'll just mention spinal shock because that's an obvious one. Spinal shock, as you know, is a condition where you lose the autonomic function, the vasomotor tone in the body. The blood pools everywhere and the patient has hypotension. It's very important for us to treat that and avoid that after spinal cord injury because there is growing literature and growing belief that the profusion of the spinal cord is very important in trying to, let's say, maintain, trying to reverse, trying to improve the outcome in somebody who has spinal cord injury and had neurologic deficits. However, the literature is not so good that it's clear that these things actually make a difference. Nevertheless, we are trying to change the way we deal with blood pressures and trying to maintain certain blood pressure parameters to try to give patients the best outcome. So I'm citing this one paper here where they talk about how after spinal cord injury, and this is not even about after spinal cord injury surgery, that perhaps keeping a mean arterial pressure greater than 85, greater than 90, and for seven days for up to a week, it's probably helpful, but unfortunately, we just haven't, this is a class three evidence, as you can see in this citation, we don't have the research, we don't have the studies to prove it. This is truly helpful, but it is something that we need to try to do because we can only imagine that the spinal cord that's injured, let's say they have very bad hypertension, and for hours, if not days, just would have much less odds of trying to, let's say, improve or reverse spinal cord injury. So those are things that I know that our trauma surgeons and our intensivists try to help us do after spinal cord injury, after surgical stabilization or decompression in the intensive care unit, using the appropriate pressors and so on to maintain perfusion of the spinal cord. Okay, I wanna take a moment to talk about draining CSF. This is something I don't do. I don't, any of my colleagues that I work with, the neurosurgical colleagues at the trauma centers I work with, this is not a standard of care or we practice a lot, but I do want you to be aware that CSF drainage, at least in the cardiac literature, the cardiac thoracic literature, where, as you can imagine, when they're dealing with, let's say, abdominal aortic injuries, and they, let's say, take one of the feeders to the spinal cord and cause basically a spinal cord stroke that essentially they are, in order to try to treat that, they believe that perhaps reducing the intrathecal pressure by removing CSF and allowing the spine to, let's say, with the insult of the stroke and the swelling that occurs, maybe that would help improve and maybe reverse some of the injury that occurs with a cardiothoracic abdominal aortic aneurysm, injury to the spinal cord. So does it also work in the spinal cord injury patient population? That's, I don't think we have the data or the reports or literature, certainly no research studies that prove that. That is an option. That is something that could be deployed and used in spinal cord injury patients to try to decrease the pressure in intrathecal space to hope to help patients that are suffering from spinal cord injury. It is something that we don't, I don't certainly do, but it's something you can consider. If you do see somebody coming out of the OR with a lumbar drain after a surgical treatment of spinal cord injury, it'll be because we actually saw CSF leak and we're just afraid that it just can't be repaired and that it just, we need the drainage to help us so that it doesn't come through the incision. So I've done that once in a blue moon, but then because when you have a tremendous high velocity, terrible dislocation of the spine, the spinal cord is terribly injured. You will go in there and you will see the dura shredded and the CSF will be pouring out everywhere. And we do the best we can. Most of the time we can just patch it and not worry about CSF leak, but there'll be times when those are gonna be the bane of our existence of mine and the trauma surgeons as well because the patient just keeps leaking out of the wound, in which case lumbar drain can be used for those reasons. So the last two topics I wanna talk about because this is important in terms of care from the services that will care for a patient after surgical stabilization, after spinal cord injury. So I have this picture to the right. This is a patient that has a condition called either DISH or ankylosing spondylitis. And I want you guys to remember that. AS, ankylosing spondylitis or DISH, diffuse idiopathic skeletal hyperostosis. I just want you to remember that because if you hear that, the fractures that are mentioned, you've got to take up much more seriously than fractures in the other patients and any other patients that don't have this condition because those two conditions are conditions in which the entire spine is fused. The disk spaces are fused and ligaments are fused. It's just a dry twig up and down that if you basically snap even part of it, it makes the overall picture very unstable. So when I hear someone's got that condition, I pretty much think, my goodness, this patient is likely going to need surgical stabilization. And so this individual had a thoracic spine fracture in the setting of DISH. And you can see that they just split the vertebral body. This is an unstable fracture. This is one of those that it's not a question. You can't question and say it's stable. It's an unstable fracture. So he underwent this long construct of posterior pedicle screw and lodge fixation up and down, above and below the fracture line, right? So the reason why I have this picture here in the setting of discussing less immobilization is if you look at that, that's titanium. Sometimes I use cobalt chrome rods, but it could be titanium. That's strong. That's stiff. That is the bracing. That's the internal bracing that we put in patients. And for that reason, the external bracing that you might put on, the TLSO, after surgical procedure, it's just, I guess, what would they say? Dressing on a cake or whatever it might be. It's just, it doesn't do nearly as much as the internal bracing that we put in. So I always tell my trauma surgeons and nurses who ask me, I have really, if I've done this work, I have really stabilized the spine. You don't need the bracing as much. You don't need to log roll the patient. You don't need to keep the patient in bed. It is stiff, it's strong. You need less of it. So for that reason, I certainly tell my fellow trauma surgeons and trauma and staff and nurses, please don't put the brace on the patient while they're in bed, especially if they're intubated. They only need it when they're out of bed and trying to ambulate. If you're trying to sit them up in a chair, they don't even need it then. Look how stiff and strong this contract is. So less immobilization because the spine is stabilized is something you need to really consider and know because next point, early immobilization is great for the patient. And I will be covering why that's great. You guys already know the human body is not supposed to be laying in bed and doing nothing. So you've got to get them up and out if you can as quickly as possible. And the reason why we would put all these screws and rods in the middle in the spine is for that to occur. So less immobilization and early mobilizations are key considerations that you must know and do after spine surgery. Now, excuse me, I've also been asked to cover the immobilization equipment. So let me, in the next few slides, cover that with respect to the different parts of the spine, the cervical spine, the cervical thoracic region, the thoracic region, the thoracolumbar region and so on. So before applying a C-collar or other device, any other immobilization device, you need to understand, is the spine injury stable or unstable? As I mentioned to you in the very first slide, again, this is obviously requires the expertise, training and many years of experience of a spine surgeon. But if you can get that information from either the radiographic studies or the spine surgeons or whatever, that will help you understand if the patient needs a cervical collar or any brace, okay? So I put this slide up because I want to talk about laminar, facet, spinous process and transverse process fractures first. If you look at the slide, excuse me, here's the transverse process to the sides, left and right, the supinous process in the center going straight back and the joints, the facet, the superior articular process. These are structures that are way off to the side. These are structures that are small that if you have fractures of the lamina, I'm sorry, I also need to point out the lamina here, the facet, the spinous process, transverse process, especially if you have fractures that are just limited to those particular anatomical bodies, those are all stable. They don't need bracing. They don't need bracing in any part of the body. Now, I always say, if you want to use a brace because the patient says it makes them feel better, then you're doing it for pain and that's okay, but you don't necessarily need them for those very simple, stable fractures of the TP, the spinous process, the lamina or facet, especially if they're isolated and only those are areas refractory. Now, if they are all fractured, this is a high velocity. This is a tremendous injury to the spine. You'll probably have an unstable situation, but that will be a truly obvious. Ligamental injury, the ligaments that connect the one level to another, if you have that going on, ligamental injury by itself certainly is not unstable, especially if it's just one ligament. You get a lot of MRIs that say they have interspinous ligamental injury. That doesn't bother me at all because you have all these other bony structures and all these other ligaments that are even stronger than the interspinous ligaments that don't need surgical stabilization, right? So ligamental injury can be bad because if you have many ligaments torn and injured, they won't heal. They need stabilization. But in that one ligament, like the interspinous ligament, or even just the ALL ligament partially torn, I'm not worried about that. They're not unstable. Couple of injuries that are spinal cord injuries that I want to mention that you might already know about. Central cord syndrome is very common in the elderly population. So if you have central cord syndrome and they come to you because they've fallen, the elderly patients fall a lot, right? They fell, they hyperextended their neck, and they, in the setting of degenerative cervical spinal stenosis, they contused the cord and they come to you. What is it? The man in the barrel. They can move their legs and feet just fine, but they can't move their arms and hands very well because it's the central cord, the central part of the cord where the fibers that go to the upper extremity are the ones that are preferentially injured in this particular manner. Central cord syndrome is a problem of degenerative stenosis. It is not a problem of instability. So central cord patients don't need to have collars, cervical collars. Skewera, you may have seen young people. This is a problem of young athletes. You may have seen kids come to the emergency room where they had an accident in the soccer field or football field, and they were, for the moment, paralyzed, quadriplegic. But it slowly is coming back. But even in your emergency room, they're hardly moving. They're moving very poorly, but you get CT scan, x-rays, MRIs, and whatever. Everything is totally normal. So there is a condition called skewera, spinal cord injury without radiographic abnormality. They don't need bracing. They'll be totally fine. I skipped Asia patient, and I need to spend just a moment talking about that. If you have an older patient, our tendency, the body, is to fuse as we get older. We get stiffer because the ligaments get calcified. Everything fuses together. So if you have a patient that's an older patient, an odontoid fracture, I get called a lot about odontoid fracture. You see that a lot. Again, elderly patients fall, hyperextend their neck, and they snap that odontoid peg. Sometimes it looks awful, but I will tell you, when I follow those patients, because I don't want to operate on somebody who's 89, I bring them to clinic. They have no longer any pain several weeks later because the pain from the injury is gone away, and I'll flex and extend their necks, and it's totally stable because they don't move at all. They're so stiff and fused. So the age of the patient may determine that a fracture is stable, whereas if there's a young person who's got a terrible odontoid fracture, I will probably be operating on that individual. Ensure the collar is the correct size. It may be too restrictive or too loose. I have rounded on patients where I come and the collar is like a necklace. It's like a scarf. It just totally rotates around their neck. It's useless. You gotta understand what kind of collar size they need and so on. Monitor for discomfort. Difficulty breathing and swallowing. Swallowing is huge in the elderly population. I'd rather you not put on a collar on somebody who may have a pseudo unstable fracture than put a collar on and make them not swallow very well and aspirate into their lungs and get pneumonia. We've all seen that happen. Plan on duration of application. Prolonged use can lead to pressure sores or muscle weakness. Yes, if you have a collar on forever, intubated patient, right? Why do you have a collar on an intubated patient that's maybe heavily sedated, it's not moving, but they'll get that back of the occipital of the head ulcer because of the collar, right? So you gotta be careful. And if you use collar or braces, they will lose their muscle. They will atrophy more so than if you don't. So you gotta think about all of those things in immobilization. Ah, I do have a picture of the cervical collar here that is causing some pressure ulcers in the neck. Even a young person is obviously somebody who's young, but the skin tone and so on. But I also have a picture of an elderly gentleman and this was a soft collar, not even a hard collar can get these ulcerations because the collar is just kept on too long, right? So you just gotta keep that in mind in your care of spinal cord injury patients and cervical collars. Okay, so how about the cervical thoracic junction? If you have somebody that has cervical thoracic injury, you've gotta again, understand the stability of injury, okay? Compression or breast fracture. I've already covered that with you to some degree. Compression fractures may not need bracing. Even breast fractures may need bracing, but may not need surgical stabilization. Ligamental injury, I'll cover that for you as well. And again, the same idea, lamina, facets, spinous processes, TPs, those fractures don't need bracing. But if you're gonna brace somebody in the cervical thoracic junction, okay? Then use a CTO, okay? With a chin extension to get to the cervical thoracic junction or the upper thoracic spine, like T1, T2, T3, even T4, okay? I have oftentimes seen patients with let's say T1, T2, T3 fractures, like a compression fracture or even a breast fracture with just a cervical collar alone. That won't work. The cervical collar is meant for the cervical spine, right? So you gotta have something that goes from the thoracic spine into the cervical spine to keep the chin, the neck stable across the cervical thoracic junction. So just remember that if you have C7, T1, even down to T4 region, fracture that does not need surgery, but does need, let's say stabilization, then you should consider using a CTO brace with a chin extension, okay? All right, so preventing issues. Oh, here's a T4 fracture that you see an MRI of. So this is a pretty bad fracture, but depending on the age of the patient and depending on the ligament injuries, if there is any, this may be someone that I won't do any surgery on. I may just get a CTO brace and just watch them, okay? So this is a fracture that's definitely a breast fracture because it involves both columns. But just by this picture alone, I can't tell you I would do surgery on this patient, but I will tell you on certain patients with this fracture type, I've sat on, just watch them because they're neurologically intact, nothing else is injured. And doing surgery at T4, you can't, it'd be very difficult to do a corpectomy for sure. And doing surgery where you have to go up to screws all the way up to T1, all the way to T7, it's a big surgery, okay? All right. Preventing issues related to improper use of immobilization of thoracic or thoracolumbar fractures. So I repeated myself, analyze the injury. Immobilization of brace may exacerbate the injury. So understand the fracture, the age of the patient. Again, they may be very stiff and not need much in the way of surgery. It may not be unstable. Compression fracture or breast fracture. They don't have to be unstable or don't need to have surgery. Ligamental injury, laminar injury, all of the same ideas apply here just as well. But if you have someone like here with this burst fracture, where you think that they need surgical treatment, again, if they had neurologic deficits, this individual should have surgical treatment because you want to decompress that neurostructures to see if you can give them some reversal of their neurologic injury. So in that case, it should be considered an unstable fracture for that reason and have surgical treatment. If you do that at the, let's say, thoracolumbar junction, T11, T12, L1, L2, what kind of bracing should you use? You can't use an LSO because it's just as for lumbar spine. You should consider using a TLSO, thoracolumbar spine orthosis. Okay, you might even want to consider using a tortoiseshell brace, especially if they're very grossly unstable, like this one here, because this is a much stronger, much more stable than the soft kinds that we have used in patients that don't need surgical treatment and we feel comfortable using them alone. Okay, so this is a special type of brace that you may want to consider getting for the patients that have that kind of fracture. Okay, so the effect of being prone for several hours. I've been asked to cover that a little bit. Obvious. If you have somebody laying prone, oh, by the way, this is obviously patients that need post-surgery procedure, an anterior procedure like in the cervical spine. We certainly still worry about pressure points, but this is much more important to worry about in the prone position because the constant pressure on certain areas of the body is all these green points that you see on this picture are going to be areas you got to be considering and worry that they will get pressure ulcers. Breathing is a problem, especially if you have somebody that's high BMI. I've had patients where their BMI is 40 plus, close to 50, where we would take them to the OR and anesthesiologists would just have decent 90, let's say, sats. Then we turn them over and they drop and then we just can't do the surgery. We got to take them back to the ICU and try to stabilize them, especially in these patients that have multiple injuries. Let's say they have rib fractures and pulmonary contusions. It's really hard. You got to be considerate of that and being and putting somebody prone for many hours. Circulation, right? That's also an issue that especially anesthesiologists have to deal with. There are a few injuries that I do want to mention that you may see that you may run into. Neurologic injury to cranial and peripheral nerves. The lateral femur cutaneous nerve goes right across the top of your thigh. And that's one of the pressure points. When the hip is pressed upon for too long, you might have patients complain of, I have numbness on the top of my thigh. Most of that time, that reverses. If you have patients that have pressure, let's say, on the shoulder area for a long time in a prone position, radial plexus injury can occur. Long time on the elbow because the radial nerve goes through a tunnel in the elbow, that may be causing injury and give you those kinds of, let's say, inability to raise the wrist kind of injury. Even blindness, the cranial nerve to the eye can be affected and blindness has been reported in the prone position. So these things have to be considered and can be seen and you might see them in your patient population. Okay. All right. Decision making for complications, OR complications. So a few things that I mentioned that's relevant in my practice. Neuromonitoring changes. So when you go to the OR to do spinal cord injury, spine surgery, neuromonitoring is an essential part of our OR team. So there's a neurophysiologist that will monitor our patients for basically their spinal cord function, right? So we often get these guys, our neuromonitoring neurophysiologists, to do a pre-flip baseline if you have an unstable fracture that need prone positioning. Many times, if they have spinal cord injury, there'll be very poor recordings, but even that we try to follow. But if they are certainly normal, neurologic exam is extremely important because if you flip them over into prone position and you lose the neuromonitoring recordings, you've got a problem. You got to find a different, you know, you just got to turn them back over and find a different way to do this. So that's occurred to me several times and occurs to spine surgeons here and there. Okay. Changes that occur during the procedure. You're working away, you're trying to decompress and take out like, let's say, this big bony fragment, whatever it might be, epidermal hematoma. If you have changes that occur in the OR, that's an issue. So what do you do in that case? A spine surgeon typically will try to move as fast as they can and do the decompression because maybe something happened in the compression changed and got worse with the positioning and you try to move as fast as you can. But sometimes that happens and sometimes it's just unavoidable, but fortunately that's not a common occurrence. Excessive bleeding. You've got to control bleeding. If you've ever been in the OR with a spine surgeon, especially after a fresh spine injury, especially if there's severe compression as it is in this MRI, the veins get engorged, they're giant. And then if you tear through them while you're working away, especially if you're doing decompression, the bleeding just can be torrential. Thoracic corpectomy for thoracic burst fractures. Oh, it's just, it's leaders of blood loss sometimes. It is very difficult. So you got to think about that and think about what you're going to do. There have been times when I've just done the corpectomy and what I plan to do, post your pedicle screws and say, I give up guys, we've got to go back to the ICU, stabilize this person, give them some blood products and bring them back in a day or two to do surgery. Cerebral spinal fluid leaks. CSF leak, as you can imagine, can be a problem. And the dura can be breached like in this patient with this very triangulated, very sharp fracture that can actually cause the dura to be torn. We just try the best, seal it up, use glue, whatever it is, and then consider lumbar drain, as I mentioned to you on a slide before. Okay. All right. So I think this is, might be my last slide because I was asked to talk about cardiac issues. And what do you do if someone has a, I think I have one more slide if they have a code event in the OR. So if they have cardiac issues, they have cardiac contusions from trauma. And these are things that the trauma surgeons are very good at helping us out with. Should they go to the OR at all? Okay. Who is the patient? If the patient is an elderly patient, again, do they even, should they even have the surgery? What is the spinal cord injury type? So if the patient is very young and they are, let's say Asia grade A or B, you want to try to get them to the OR as quickly as possible, even a setting of cardiac issues to try to get them decompressed so they can get some reversal of their, of their spinal cord injury. Okay. So what do you do when patients code in the operating room? A couple of things has already been mentioned. These are, these are what I would do. Do you just put a big Ioban sticky tape on their back and flip them over? Absolutely. If you got them wide open and they start coding, I either whip stitch shut if I have any time, or I just throw an Ioban and turn them over and they got it. I mean, what good does it do to have a totally decompressed spine when their heart has died? It's silly, right? So absolutely. If you are able to stabilize them, yes. Take them back to the ICU if you have to. Let's say if I can turn them over and close the wound, yes. Whatever I can, I need to do, I get it done if it's possible, but go back to the ICU, stabilize the patient and bring them back. Okay. I do believe I have one more slide. Oh, very important. So let me end it with this, this topic. What is your approach to DVT prophylaxis? I want to tell you my personal approach is, man, if you guys need blood thinners, because you're worried about blood clots, because you don't want the cytoembolism, pulmonary embolism, the patient die on you. Absolutely. We have to use it the sooner, as soon as within a day or two for me, but there are things you got to consider. What does the literature say, first of all? Very little, to be honest with you. Is there anything on DVT prophylaxis after spine surgery and elective spine surgery? No, because it's just all over the place. Everyone practices differently and there's no one type of patient pipeline. It's not like a knee replacement or hip replacement. Spine surgery is very different in many different ways in how you approach each pathology. Is there anything on DVT prophylaxis after spine surgery and spinal cord injury? There's a lot of literature in DVT prophylaxis and spinal cord injury, period. And it is very strong evidence to suggest we need to use it, right? And we need to use it as early as possible. But there is no literature, as far as I could see, what to do after spine surgery in spinal cord injury patients. So what do you do for that patient that already has spine and spinal cord, I'm sorry, spine surgery for spinal cord injury? Okay. So how and when do you use DVT prophylaxis in patients who has spinal cord injury and spine surgery? What are you afraid of? Are you afraid of the epidural hematoma? I am not. I can take out epidural hematoma. I cannot take out a pulmonary embolus. So I'm less afraid of the epidural hematoma than the pulmonary embolus. What type of surgery do they have? There are times when I go in and I do not need to do any decompression. I just need to put screws in. So the epidural space was not exposed. There is no reason why you can't anticoagulate that person right away. What type of spinal cord injury, right? Again, if there is an injury where that requires laminectomy or corpectomy, where the dura and the spinal cord are exposed, yes, we have to be worried about epidural hematoma, but otherwise, no. Who is the patient? If the patient is young, if the patient can move because the spinal cord injury is a high grade ASIA score, then you may not need to use it. But if the patient is old, has a lot of comorbidities and can get DVTs easily, cannot move around, yes, I think the earlier use of DVT prophylaxis is called for and should be used. Okay, I think I've got just enough time for some questions. I hope I try to get through this quickly enough so that you guys can ask me questions. Did I do okay, Dr. Kaufman? Dr. Yu, that was really amazing, and I can measure it by a couple of things. When you said, I only have one slide left, I thought, oh no, it's only been like 20 minutes. What will we do the rest of our time? And I looked and it was already more than 45 minutes because the way you present just makes the time go by. And I can tell why your patients love you because you have a way of explaining things to people who might not necessarily understand the majority of the nuances. And even those of us who have been taking care of patients like yours for 20, 30 or longer years, you've let us peek under the covers a little bit today and kind of see how the neurosurgeons think. Time obviously is our most important commodity in the hospital inpatient care. We have to do things timely and we all have many responsibilities. And so having a conversation with a neurosurgeon like you've provided to us with this presentation is invaluable. And I didn't expect to learn very much, but I wrote down a few things. So as we have a few questions come up in the meanwhile, I just wanted to bring a question or two of my own. I'm happy that we have that three column classification, even though it's inadequate because I have a chance at least at figuring out which some of the fractures, which may be unstable versus ones that are stable or not as unstable. So I'm still happy we have that. And I kind of get that and I don't think I'll ever learn the other classifications. So I'm glad that you and your colleagues internalize all of that. And I wrote down log roll as a thing, which I, you know, we don't teach it very well. I think we assume that our medics, nurses, nursing assistants, doctors, all understand the concept of log rolling a patient. And in ATLS, it was something that was very difficult to translate into other countries. Now that ATLS has taught around the world, other places didn't have this idea of log roll. And the idea that we're going to turn a person as one unit. And I think we've all seen it. We don't know that we've ever heard a patient with an inadequate log roll, but certainly there are some very enthusiastic people that want to help. And you say, okay, we're going to do this on three and we're going to carefully roll him like a log. And we say one, two, three, and this one person goes, whoa. And it's like, you didn't understand the entire patient was supposed to be turned as a unit, not how quick or hard could you pull on your part of the patient. So I'm thinking that as I have more opportunities to teach some of those things that we could probably do a better job with, with teaching that. And with the map greater than 85 for seven days, we've been doing that clinically for a few years now. It's, you know, the class three data sometimes pans out and sometimes it doesn't. Is it okay to put you on the spot and ask what you think about the likelihood of this becoming a standard of care over, you know, more than the next, you know, 10 years until we have adequate data to support or not support it. It's already the standard care. I think in our community, I even use it in patients that are not spinal cord injury patients and that have elective spine surgery that are degenerative stenosis. Because what's the alternative? The alternative is either normal or hypotensive because, you know, situation because the anesthesiologist would take the patient to the OR with me and I'll ask what the pressure is. And it's like, the pressure is like 60 systolic. I'm like, oh my God. So I can only, it just doesn't make any sense that if you have low blood pressure that the spinal cord is going to do well. So I think it is already the standard of care and I think it's accepted and whether it works or not, we don't know yet, but we all believe that we've got to give good profusion to the spinal cord. No, that's great. It can't hurt. It's a little bit difficult sometimes in the IC when we're managing patients to maintain that map. And we have to use a lot of pressors on some occasions for some patients to achieve that. And so it makes a little bit more work, but we're always happy to do whatever we think is best in the patient's behalf, because that's the way we would want ourselves or our family members treated. So if you put that measuring stick against everything we do, you'll always come up with the right answer. I was always also happy to hear that, you know, all the races we put on and all the log rolling we keep doing. Sometimes you wonder, is this the worst fracture you've ever seen? Or was the spine surgeon unhappy with his or her final fixation? Did they have some difficulty? And that's why this particular patient may be required to be in a brace longer or log rolled for a longer interval in bed versus the routine spinal fixation patient that everything went well with it. You can have a brace on when you're ambulating them, but please don't cause their skin breakdown and cause them to suffer with immobilizing devices that are meant to help them, not hurt them. Right. I agree. And this is a another ask your opinion question, and it's probably the most straightforward question possible. But for decades now, in different hospitals, I've been told that if somebody has a spinous process fracture or a TP fracture, or two of each, whatever, don't worry about it. You don't need to consult us unless there's some other reason to consult spine surgery. If it's three or more, then particularly sequential three spinous processes, three transverse processes, could be an indication of a greater magnitude of force, and maybe there is an injury. I wonder with our high-risk CT today, which you addressed, if really there's only three of one or the other, do we need to consult spine surgery? What is your advice to your folks about when to ask you to see these patients and when not to? Yeah, I certainly get asked by our trauma services to see these patients with TP and spinous process fractures all the time. I didn't know there was like a number three type of rule. I would tell you that if you have just purely spinous process or TP fractures, even if there are many, numerous, you don't need us because of the following reason, there is no treatment for it except just let it heal. So I think that those consults, I don't mind being called, but I don't think that you will get anything from us that's different than what you're going to do already. Having said that, I'm more concerned if somebody has four or five TP fractures, I'm less concerned about the spine than let's say injury to the bodily organs, because it did take a lot of pressure to do that, or a lot of stress to do that, right? So I do believe that TP and spinous process fractures, fastly, isolated fractures of those types do not require any treatment and perhaps doesn't even require a spine surgical consultation. Thank you. No, that's perfect. And just a question that I've never understood the different responses to are, what is the latest that you could stabilize a spine and expect there to be any neurologic recovery of a spinal cord injury? We seem to think that the earlier we do things, the better. And that clearly applies to many different injuries, but for an incomplete spinal injury at a level of your choice, let's just say it's very low, like a lumbar fracture, because we talked a lot about that. How late can you do something and hope to see an improvement? Sure. Let me answer in two ways. The literature in our community, neurosurgery and spine community is becoming more and more clear. It's not certainly class one data without doubt type of research studies, but the more and more we look into it and report and gather the data, there's some really good data coming out that the earlier intervention is by far superior. So a lot of us are really, even the central core syndromes, we're trying to decompress them earlier, the better. Having said that, I will tell you, there's no time in which you can say no surgery is necessary anymore. I've even taken patients that are years out from the spinal cord injury, still have very bad compression and done some surgery and recovered some minor neurologic recovery. So the stenosis and compression alone should always try to be relieved if you can at any point in time. But it is true that the reports, the literature is suggesting earlier decompression, the better. And we are trying to follow that. As time goes along, that's becoming more and more evident. So we are about down to our last minute. And in addition to thanking you the best I know how, I wanted to point out that many trauma folks are now much more interested in patient positioning because of COVID and the realization that sometimes proning our patients is the best way to recover some function in their lungs. And so we can share that slide of all the different pressure points and where you need to pad and all that. And probably what you consider pretty routine, you may have saved countless patients some neurologic sequela of poor padding where they needed it more. We're trying to do better with that in ICU. When we first started, we got the OR nurses to kind of help us learn how to position patients. But well, so we are at our hour. And again, you pull this off as one presenter and made it go by so fast. And you presented so much information. And you have such a nice technique and ability to explain it to us. We profusely thank you for fitting this into your schedule and teaching us today, the Trauma Center Association of America. And thank you so much, Dr. Edelman. You're very welcome. Okay, bye now. Bye now.

Dr. Kevin Yu

neurosurgeon

patient care

spine surgery

spinal cord injuries

immobilization

complications

DVT prophylaxis

fracture classifications

post-operative care