Week 2 - Mia Huang

For the second week of my clinical immersion term, I shadowed Dr. Riew on his surgery day Monday and clinics day Tuesday. I shadowed Dr. Greenfield on Wednesday and Dr. Hartl on Thursday and Friday.

On Monday I shadowed Dr. Riew and watched an anterior cervical discectomy and fusion at C4-7 levels. He implanted a cage with graft bone inserted in it into C4-5 and C5-6 and implanted only bone at C6-7. The reasoning behind the difference in graft with cage and without cage is that with only grafted bone, it is easier for the patient to heal and fuse the sections. However, in order to shave the bone into the perfect shape is time consuming and difficult, while putting the cage with bone into the intervertebral space is a lot easier. Doctors choose to use cage with bone for sections that are generally easy to heal and put just bone for sections that are more difficult to heal. In this case, C6-7 being the last sections in the cervical spine, uphold a lot more load than the sections above, so C6-7 was the only one that needed just bone graft. During Dr. Riew's clinics day on Tuesday, I saw a patient who had his C5-6 fused about 20-30 years ago. On the MRI images, I didn't see any evidence of plates or screws that could be used to fuse his cervical spines. After asking Dr. Riew, I learned that 20-30 years ago, no plates or screws were used in fusion. After removing the disk, the patient was kept in a rigid collar for at least 6 weeks up to 3 months. I thought it must be very difficult for patients to heal without plates or screws. Nowadays, even with plates and screws and collars, some patients still can't help moving their neck during the recovery period, leading to non-union and continuous pain. 

I shadowed a thoracic cerebrospinal fluid bypass surgery with Dr. Greenfield. The patient previously had her lamina at C5 and C6 removed. This surgery will remove the lamina at C4 and C7 and remove the scar tissue in the dura mater. Since the patient reported sensation loss due to her congested CSF so that her spinal cord and CSF both look gray on the MRI. However, a healthy spinal cord should look dark and the CSF around it should be bright. Dr. Greenfield implanted a stent posteriorly to bypass the CSF. 

On Thursday and Friday, I shadowed Dr. Hartl and watched a lumbar laminectomy and L2-5 and a cervical posterior C3 and partial C6 laminectomy and C4-5 laminoplasty. Dr. Hartl used a navigation system that took the CT images of the patient pre-operatively and with a probe, we can see the location of the probe with a live 3D image of the CT scans on a Brainlab desktop. It was very cool to see how technology has changed the way surgeons operate. The system makes it very easy to locate the precise place, especially in small space such as the cervical spine.

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