Name:
FOCUS25824video10
Description:
FOCUS25824video10
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Duration:
T00H06M15S
Embed URL:
https://stream.cadmore.media/player/ec277ec3-2709-4f04-bcbf-b1d56cab559b
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https://cadmoreoriginalmedia.blob.core.windows.net/ec277ec3-2709-4f04-bcbf-b1d56cab559b/10. 25-25.mp4?sv=2019-02-02&sr=c&sig=NxM92XhB6N1gvJBAraTl0QWSbl6wt5umuxFPiasAACc%3D&st=2026-05-13T19%3A52%3A59Z&se=2026-05-13T21%3A57%3A59Z&sp=r
Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: A 71-year-old male with a prior history of L2–S1
SPEAKER: posterior decompression and fusion presented with severe pain, paresthesia, and inability to walk or stand for any prolonged periods of time. Preoperative standing x-rays demonstrate changes of prior L2– S1 posterior instrumentation and fusion. Dynamic motion x-rays demonstrate increased retrolisthesis of L1 and L2 and increased fish mouthing of L1–2 disc space on the extension view.
SPEAKER: MRI of the lumbar spine demonstrates severe adjacent level stenosis, ligamentum hypertrophy, and facet arthropathy. MRI of the thoracic spine demonstrates diffuse multilevel bony bridging and autofusion. The patient had a BMI of 42.6. Given the patient's severity of symptoms and the instability and stenosis on imaging, surgery was recommended. The risks and anticipated surgical problems are listed here.
SPEAKER: The surgical plan was to perform an L1–2 laminectomy and decompression and extension posterior instrumented fusion to L1. The patient was positioned prone onto the Jackson OSI table, and the initial dissection was started. The baseline neuromonitoring responses were obtained after the initial dissection started. We had good bilateral upper extremity SSEP and MEP responses, but absent bilateral lower extremity SSEP and MEP responses.
SPEAKER: We augmented the blood pressures and verified the temperature, blood pressure monitoring, lead placement, patient padding, and absence of inhaled anesthetic, but there were no changes. The initial intraoperative x-ray demonstrated some retrolisthesis and fish mouthing of L1 and L2. The L1–2 decompression was performed, and some gross hypermobility of the segment was appreciated. Instrumentation was then performed.
SPEAKER: X-rays after this demonstrated some increased retrolisthesis of L1 and L2, likely related to the additional destabilization from decompression of this segment. Bilateral SSEP and MEP responses remained unchanged, and there was no unexpected EMG activity. The intraoperative x-rays are shown here. The orange arrow points to the L1–2 fish mouthing of the disc space. The blue arrow points to the L1 and L2 retrolisthesis.
SPEAKER: These findings can be seen to be exaggerated on the postinstrumentation view on the right. The patient was extubated and examined. He exhibited severe bilateral lower extremity weakness of 0/ 5 throughout and 1/ 5 in the left EHL. He also had increased numbness throughout the lower extremities and in the perianal region. Given these neurological changes, we took the patient back for emergent wound exploration.
SPEAKER: A small consolidated epidural hematoma was noted and evacuated, with further slight expansion of the laminectomy. However, this was not of the degree or compressive to the point where we would expect such drastic neurological changes. His bilateral lower extremity weakness slightly improved to 2/5 in the left EHL and tibialis anterior, but otherwise remained 0/5 throughout.
SPEAKER: Postoperative MRI showed some expected postsurgical changes with small fluid collection but no active compression. And this is the postoperative MRI. The patient was initially admitted to the ICU for MAP goals and steroids. He was eventually discharged to a rehab center on postop day 24, after showing gradual improvement of his lower extremity weakness, despite not being able to walk independently on discharge.
SPEAKER: On the latest 12-week postoperative visit, the patient was able to walk approximately 1000 feet independently with the cane. A comprehensive, standardized intraoperative checklist should be in place to evaluate for potential surgical, anesthetic, and neurophysiological reasons for loss of neuromonitoring signals. Although there were no extreme recorded values noted in our case, hypervigilance, especially during the induction and intubation period, is required to ensure no transient fluctuations that can lead to hypoperfusion in a severely stenotic region of the spine that is likely more sensitive to such changes.
SPEAKER: In this case, there was increased subluxation of a hypermobile segment in the thoracolumbar region after turning prone on a Jackson table, with worsening stenosis and subsequent spinal cord injury. An opportunity for improvement is to identify earlier the signs of neural injury with preflip and postflip baseline monitoring responses. Another opportunity for improvement is to be aware of the potential for a hypermobile segment, especially in cases of severe stenosis involving the thoracolumbar region.
SPEAKER: One can then implement appropriate spinal precautions during positioning to prevent hyperextension. The use of a sling instead of a flat pad to support the legs can be one of such measures to help mitigate an exaggerated extended position. A bowing effect on the spine after extension on the Jackson table can lead to a pincer type of phenomenon, with subsequent worsening spinal stenosis and cord compression on extended positioning.
SPEAKER: Several risk factors for this type of neural injury existed here. There was preexisting severe stenosis in the thoracolumbar region in near proximity to the conus. There was an unstable hypermobile segment with autofusion above and instrument diffusion below. A high BMI also contributed to vector forces during the positioning process and in the extended position.
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