Forward Time Field with airSlate SignNow

Forward time field

so i'm here with dr ryan goodmanson one of our outgoing fellows um go ahead and step in there yeah there he is um he's gonna help me out today um and so just a few things uh if you could come down to the field here we've kind of prepped out and done uh the beginnings of our perk screw so um so if we could move the camera down onto the field there we go um so if you back out here we basically just took the same setup from the lateral and put these in when we're not concerned about sterility it's not really a big deal but one of the things you really want to be aware of as you can see here this table is very close we're able to get these in but we were very close to hitting this table which would have really altered our trajectory so if you don't have a table that actually turns you want to make sure that you have the patient positioned all the way up to the edge that will give you more range you may have to lift the table up so that you're not coming down out of sterility when you're doing these bottom screws are really the ones that are challenging some of the tables that can actually turn make this much easier so if you can really stabilize the patient have them in a lateral position turn them just maybe 30 degrees it makes the whole procedure much easier rather than having to come in at an angle like this you're just coming straight in and you can even do that after you put in these top screws so we've done a lot of the work ahead of time here but really that's the main thing with the single position lateral is that you want to make sure that you're not going to kind of drape yourself out or have any problems with not being able to hit the appropriate angle and amir do you have any preference on whether or not to do this this lateral first and then the screws or the screws first and then the lateral so theoretically um you know i like the idea of getting my reduction of height first um i think that was really interesting um earlier this linda larry's talk how he talked about doing a little bit of both i think that would give you even more control especially when you're not taking down the fat cassette completely ahead of time as you would in an open approach but i usually in my workflow want to do my lateral first try to get some height back and then compress across that fulcrum posteriorly afterwards so go ahead so give us a shot there um so we've got our first three wires already in um and go ahead and come across to an ap and if you can just see here another another thing with the lateral is that um putting in perk screws from lateral um your radiology tech is a huge part of this case so if you can do a dry run ahead of time just going through the workflow that can save you a lot of time because the time that you save not flipping you may lose having to do a whole lot of different shots especially if it's at a 30 degree angle you know just having a radiology tech who's kind of familiar with that ahead of time so we're getting our starting point at that lateral aspect of the four pedicle here and um always want to make sure as we're coming in with the ap once we've gotten in we're still lateral to that medial border of the pedicle okay and we can see here that we're still well back away from the vertebral body so as we come up right to the edge of the vertebral body keep coming in there great we should be right at the edge of the body there and then we're just going to check another ap to ensure that we haven't violated that medial wall i went through the body so yeah so a little bit deep there but again you want to see that tip of the gem sheeting needle just at the medial aspect of the pedicle once you've gotten up to the um he's going to back it up just a little bit to demonstrate chat there okay great so from that position now come back to our lateral and amir what what type of table do you use um are you breaking the bed at all and um like are you using like a wilson or or gel like what's your setup for these so i i've never uh gone out on a limb and actually done it i have done a couple times but um that was back in residency um and definitely have struggled in different ways i've seen the the wilson frame used which gives you a little bit more support if you're on a table like a standard bed where you're going to actually be able to turn that laterally and it gives the patient a little bit more support so they're not falling off the table you can use the gels or you know it's kind of dealer's choice but you want to make sure that you do those shots ahead of time to know that you're actually going to be getting be getting them correctly and then also that the patient's not going to be falling off the bed but i i would use a wilson frame with just a standard bed so you have that lateral twist to it got it thank you actually i'll put the screws on all right so we're going to go ahead and put some screws in now and you know with this one you can see if we back out um really just the angle that we're placing them in um pretty easy from the top the bottom half we may run into a little bit of a challenge and that's what we want to look out for ahead of time x-ray okay and one of the things make sure we're co-linear you can even move this guide wire a little bit within the um cannulated screw to ensure that you're not going to bite into that wire so this is fairly osteo product bone we're not doing any sort of tapping here shot okay coming down nicely and i'm just checking again to make sure that the the wire is free okay all right we're down there and this is probably the point where you want to pull this wire to ensure that you don't bite into it sure okay so what um what parameters do you use to know that the screw is deep enough um you know i like to you know if you have a kind of ratchet mechanism you can actually feel um rather than putting it all the way down on power you can put those last few turns by hand got it and know that you actually have that tactile feel whereas if you're just using power you you know you can either not put it down far enough or you can kind of break that pedicle or um really mess with the track of the screws and lose your bite there how about you jeff what do you feel like is a good indicator for you um i i i agree with you like um the last few turns sort of by hand because the power can actually you know you can either do one of two things to the screw the screw can and really off the product bone it can actually kind of drive it forward yeah beyond the posterior elements but the other thing you could do is it could it could get stuck um add the tension between the the um the tulip as well as as the dorsal elements and then it'll it'll essentially just core out um the the vertebral body so it'll act as a post and not a screw um so where you where you have that first screw is almost perfect where the bottom of the of the um tulip is really adjacent to the um sap and you can see that that that that little area is almost exactly where i like it to be you know so for that for this i'd probably maybe if you wanted to you could probably go go in another couple of turns you know to seed it and um and i probably and then and then just like what ryan is doing right now sort of make sure that the tulip heads match up yeah actually and that's also another consideration um you know when you're making your skin incisions um in a single level not as important but always want to look at that cascade of the incisions because it's going to really challenge the placement of your rod if you have to go through and even in a two-level case if you're trying to go back and forth it's it's going to be really difficult with the perks set up who put in that cage that looks great i know right except we might have gotten a little subsidence there right way to go bencher so ryan what are you feeling there as far as like from a tactile sensation yeah you can kind of feel it engage as it comes down into the pedicle so you'll feel it go through the cortex kind of right at the starting point like where we feel the mammary process is supposed to be and then you'll feel it get a little bit loose as you go through the pedicle but then as you hit the body you feel a little bit of resistance and then as we get in further and the tulip head gets close to the uh the iep there um you can start to feel even more resistance since then i'll take a shot and we'll see if we're down or not these screws are a little short but that's what we have maybe just a couple and then if we want we can try and do a hand turn here just to make sure that we're feeling give a stab and grab the screws are looking great i will say that lower screw yeah so that's a good feel there shot there that lower screw trajectory is difficult i haven't done these for a while and we don't have a robot so we are the robot [Laughter] but getting your ml is a little bit more difficult in this position just the feel of it shot there shot and you guys did a really nice job of placing those incisions but um i've also found that if if if you don't position it well and there's a skin that's sort of folding there and you make the incisions you'll end up with very asymmetric incisions left and right and so uh hold on this is actually a good point here if you can focus in here on the skin um we're actually kind of catching the skin a little bit oh yeah that's something that can definitely um really hurt one of your screws because especially in osteoporotic bone if you're pulling against skin or fascia that's going to cause the screw threads to pour out the trajectory rather than biting in and keeping grip that's really good just adjusted the skin there and we're going to keep going down okay thank you can i have the handheld shot there and so we can see from that lateral we've got a nice concordance of the screw heads um make sure my medial lateral was on i'm pretty happy with it guys i love that um the symmetry is great i love the on the lateral that it's parallel to the superior end plates and then when you take a look at left and right you can really see that it's like a mirror image of each other right yep um especially at the four screw that's almost like a perfectly placed screws bilaterally at that level they they look really nice nice work guys we have great fellows here he did those wires i did the bottom ones that's why that one [Laughter] right anything else um we're just going to go ahead and um place the rod in cool again you know we've got a little bit of time here so um so any tips and tricks um with respect to putting in the rods in this lateral position so um one of the things is making sure that you really get that tip of the rod down first because one of the things that i've seen in some other cases is trying to basically put that rod in super fascially and you get stuck and you really drag soft tissue down into the actual um screw track where you're trying to have you know your your construct and sometimes it won't go so that's definitely something that i've seen and you know you can put these in from the top or the bottom it's kind of what kind of feels better for you but really getting that tip down into the track first and then turning and once you get down you should actually be able to see that this um this head right here is no longer able to turn so that that'll give you an indication that you've made it into the um the trajectory and so you're heading low yep um and so just try and maybe rotate this up a little bit it's going to be a little bit up towards the sky hey mary can you talk about using straight rods versus gap rods in your preference shorter rod sorry i can't hear that well what about using cap rods i think the question was um straight rods versus curved or pre-bent rods so yeah you know obviously it depends on the area of the spine we're using a lordotic rod here as you know we're in the lumbar spine we do want to keep that lordosis and then also you know as we've got that nice anterior graft as we compress we want to be able to bring it down so i tend to use lardotic in the lumbar spine if you were at thoracolumbar junction for instance in a trauma case you might not need it just trying to get my rings back on and so ryan how are you confirming that the distal aspect of that tip of the rod is within the l4 um blade actually just visualization i can see it as you come down you may be able to see that with the camera too you know uh you don't always see this interoperatively but we've actually got a nice view here um if you kind of turn this down you can actually see it right there so if you move back and forth that's actually the rod that's down and this is fortunately a very thin patient if you've got a deep hole you may not be able to see that but that's the rod and then you can see that this oh yeah you can see it that looks great okay shot there shot there perfect it looks great guys um there's a question about unilateral versus bilateral screw placement because i think there are some surgeons who place in unilateral screws um at the top but don't do it on the on the bottom because of the fact that you're going from bottom to to top so one of the things that uh you know there is a study out there um sorry i don't know the offer if anyone out out there can remind me but there there have been some cadaveric studies that have shown that if you have unilateral screws and a plate with screws on the contralateral side that's similar in construct strength to having bilateral perk screws but again in order to get that stability you want to have the lateral with the screws coming in this way and then from the opposite side the perk screws so if you're doing all on the same side that's not going to be as strong of a construct so meaning that um you you want screws on the contralateral side of a t-lift for instance uh no so if you're doing a lateral cage with screws and a plate oh i see what you're saying that's that's similar strength to a bilateral perk screws got it but if you're doing a screws in a plate and ipsilateral screws percutaneously that's not as strong of a construct got it but then that would mean that you would need to put in the um the screws on on going from bottom to top right the difficult side yeah so with uh image guidance that does help quite a bit um because you can raise the patient up and you can place those screws without having to worry about the imaging and the table as much but it is it is possible if you if you plan ahead of time so give us a shot there all right and so we've got our contract there we also want to maybe do a little compression i got to loosen though and if you were to really want to be getting compression here i would recommend doing we haven't done a facetectomy but even just a small facetectomy bilaterally would allow you to get a little bit more compression there and continue to work with that lordosis that we gained with the cage um a question from um robert huang how do you decorticate mis so you probably you need to do tubular decortication so you can place a tube down and sometimes you can see where we've got our scripture directories you can make one of those a larger incision and place a tube and actually look at the facet and really either with a drill or with an osteotome take down that that joint and you can place bone graft in there some people will do it with some of the modular systems where you've just got the screw head without the tulip that gives you some more room or you could do it ahead of time or you could do it with just the wires in place so this is just kind of demonstrating we have the compressor there um and it gives you a fulcrum to kind of compress along mis obviously we're not going to gain anything here because we don't have that facetectomy done um but this this device here will give you a fulcrum to kind of compress before placing those uh locking those screws down we don't have the right final tightener so i'll be the final tightener there you go i have to loosen this one though right there so that's loose so you guys are trying to compress to try to get a little bit more lordosis yeah and just just going through the technique here again you would need to do it up a little bit um with the facetectomy at the very least but you can see by locking the back here you can place uh this compressor in and we'll actually squeeze across those two screws nice and so we've got one of them locked we'll compress down give us a shot there one more time oh yeah you can see that absolutely all right and that's really the workflow for our single position lateral um really i think the main thing in doing this technique is getting the workflow done ahead of time i'm still gathering the courage to do it in an actual patient but um i i think it's a great technique if you do have the right people working with you well amir you made it look so easy you got to do this on a regular basis i'll let you know how it goes okay sounds good nice work guys thank you really nice work