Monday, June 28, 2010

Week Two: Hit the Spine Running...

The week started with a meeting between Dr. Hartl and I to set up a project for the remaining 6 weeks of the summer immersion. We decided upon a retrospective studies to look at. In the first study, I would look at the outcome/results of patients who had degenerative scoliosis and stenosis in the spine and were treated with a new technique called the Extreme Lateral Interbody Fusion, or XLIF technique. XLIF is a minimally invasive spine repair technique, that is characterized by approaching the spine from the patients side through small incisions so as not to disrupt the back muscles, as when the spine is approached posteriorly, or the abdominal muscles and organs, as when the spine is approached anteriorly. As the XLIF is quite new, compared to traditional approaches, it is important to ensure that patients who have this procedure maintain the same degree of health as those who get more traditional procedures to alleviate scoliosis and stenosis. In addition to this, Dr. Hartl would also like to look back at revision surgeries and complication rates for surgeries he has also done.

This week was also my first week in the clinic, and there was no lack of interesting cases. The first patient we saw had had a successful spine surgery, however, the incision, which was about 1 to 2 inches wide, had never closed and was fairly deep. The solution was more or less to stuff the wound with iodine and gauze, and watch it for signs of infection. Eventually, the wound will heal. I was later told that this kind of case happened very rarely in people. The next case was even more interesting. A patient with severe osteogenesis imperfecta (OI) presented with tingling and numbness in the tongue and jaw area that was causing him to slur his speech. Now, OI is a genetic bone disorder that causes defective connection tissue, or the inability to create connective tissues, due to collagen deficiency. In this patient's case, he legs had been severely stunted, he was prone to fractures, and his spine was severely malformed. Dr. Hartl consulted with other physicians to determine what exactly was the cause of the tingling and to determine how best to perform surgery on the patient without further damaging his spine. After the consultation, Dr. Hartl and the other surgeons decided to contact more physcians at HSS to get further consultation on the case. The other cases I was able to see this week were more routine, however, it was interesting to see how much a slight disc herniation could impact the various patients' lives. Additionally, Dr. Hartl let me read MRI and CT scans to determine if I could figure out what was wrong with each patient before he diagnosed them. The most striking case was a man who had breast cancer, a rarity in men, that had metastasized and was impinging on nerves near the base of his brain. Dr. Hartl had removed the tumor and the patient was in good condition. When the patient saw Dr. Hartl again, all he could do was cry and thank him.

I also got to go into the O.R. this week with Dr. Hartl and see various spine surgeries. I very quickly learned that a routine, simple surgery, such as a laminectomy and decompression, was actually at least a 2 - 3 hours, if not more when prep time and anesthesia are considered. Additionally, all surgeries were performed with X-ray and flouroscopy, so lead vests, kilts, and thryroid gaurds were worn for most of the duration of the surgery. During the course of the routine surgery, the discectomy was more or less the shortest part of the surgery, which was surprising. Cutting through muscle tissue took a long time, however, Dr. Hartl is committed to preserving as much tissue as possible (a staple of minimially invasive surgery), so it was not surprising. Additionally, I had not realized that the spinous processes had to be removed in order to get to the disc and cut it away. I actually brooched this subject with Dr. Hartl, and learned that it was the only way to get to most herniations when using a posterior approach, even if it leaves the spine more exposed in those areas. Additionally, it was interesting to see that even in the O.R., the attending physcian is just as much teacher as he/she is surgeon. Dr. Hartl routinely pointed out tips and tricks he'd learned in practice to the resident surgeon to make the surgery easier on and more beneficial to the surgeon and patient.

In the cases that required spinal fixation with rods and screws, it was interesting to se ehow the dynamic of the operating room changed. The O.R. became full to bursting, requiring not only the usual staff, but also a doctor tracking EMG in various muscle groups effected by the nerves Dr. Hartl was drilling near, as well as vendors from the company that created the equipment. The vendors were quite knowledgeable about how to use the product, and even what surgery would be most appropriate for each case. I was also introduced to a device known as the Brain Lab. Using Brain Lab, the surgeon first takes a 3-D X-ray scan of the patient and that data is imported to the Brain lab software. Then using cameras and special utensils, the physician can have an image of the screw he plans to implant super-imposed on the 3-D scans to ensure the screw is going exactly where it is supposed to. All surgeries were performed with a posterior approach, and I hope to see an XLIF before the immersion term ends.

On saturday, I got to get an MRI of my right knee through Dr. Yi Wang's laboratory. It was even more interesting because a radiologist was on staff to guide me through the MRI. It was my first experience, and I learned alot about how functional MRI for all joint spaces. It was also nice to see that besides a few deformities from an accident I had in high school, my knee was in pretty good shape!

I look forward to next week, both seeing more patients and more interesting surgery cases. I also plan on making a larger dent in gathering data for my research project, and that will be the focus of my week.

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