Spine Surgery
ED Department
Let's start off with some of the more boring things I did this week. Regarding my research, here is a brief summary of what I aim to do before the summer ends. Mike Wei, a MD student who is working on the project with me, is looking into how using Methotrexate affects inflammatory markers in hip replacement patients with rheumatoid arthritis (RA). The hypothesis is that using Methotrexate decreases the inflammatory markers because of its anti-inflammatory properties, allowing for less degradation of the hip replacement, which extends its lifetime. So far, we have not been able to see any significant differences between patients on Methotrexate and those not on it. We primarily have been looking at medical reports and pathology reports, but not at actual pathology slices (currently working on doing this). We think that the study is underpowered and confounded by other factors such as patients that have both RA and OA. I have been working on separating patients with OA and RA recently so that the analysis can be rerun without the OA patients. This includes looking at the pathology and comparing inflammatory markers and the medical records. Getting access to the pathology is slow going and may not be possible with the time I have left. Will keep you posted.
As in the past weeks, I have attended the CAP clinic and it was enjoyable. The patient was an ex-baseball pitcher and had severe limited motion of his throwing shoulder. The doctors suspected that he had some RA going on, but he also had some disfiguring of the shoulder and elbow ligaments, as well as some bone spurs, which made him painful to move his shoulder. The doctors thought about doing a total shoulder replacement, but they couldn't decide if they should treat the elbow problems or the shoulder problems first. Apparently, the shoulder surgeries have better outcomes and actually may help elbow alignment problems. Through shadowing Dr. Goodman this week, another random thing that I learned this week was that patient compliance for many types of hardcore drugs (such as steroids, Humira, etc) for RA and OA is not as high as you would think. Many patients are very concerned with the side effects and some do not like taking drugs at all. It is a big problem that doctors have to deal with.
I also shadowed in the Emergency department this week, and it was pretty interesting. A lot of patients were brought in by means of chest pain scares, but there were a couple of cases that were more serious. One of the most ridiculous things I saw was with one of the older patients. He came into the ER after a serious fall, and had some bad problems that he was also dealing with at the time. He had late stage Parkinson's disease, and at times he was shaking uncontrollably. The doctor had a very hard time getting an IV into his arm to take blood work, and even needed help holding him down. His speech was very slurred and it was very hard to understand what he was saying. Overall, it was a scary experience.
Now for the most interesting part of the week: seeing a spine surgery. Greg and I saw a laminectomy with a full facetotomy of the L4-L5 vertebrae. This was to remove part of the spine that was causing spinal cord compression and also to stabilize the IVD of the patient. First, they had to make an incision in the back and use a chisel to remove portions of the lamina (bone that protects the spinal cord) to remove the compression problem. Then, they needed to work around the spinal cord to get the the IVD. They made an incision of IVD and began scraping out some of the IVD's center to place a metal cage to help stabilize the area so that the IVD would not impinge on the spinal cord again. The whole process was pretty gruesome as they had to continuously scrape the endplates of the vertebrae to get good adhesion between the metal cage and endplates. After the insertion of the cage, the surgeon (Dr. Elowitz) had to remove the facet joints that connected the L4-L5 vertebrae to place some stabilizing rods in their place (for added stability of the spine and area). This involved some more chiseling and scaping. Once they were removed, he had to use a drill and a hammer to place screw holes for the posts (perpendicular to the spine) where the rods would lay across (parallel to the spine). This involved using X-rays to continuously locate the screw bits and other instruments to make sure they didn't go to far into the spine (or not far enough). Once the screws were input, they screwed the rod post into the place around the screws they already input. After securing the posts using a torque wrench, they inserted the rods in a slot in the posts and tightened everything up.
By far the best part: they blended the lamina of the patient and placed the ground bone into the IVD space of the patient to stimulate bone adhesion of the cage and endplates. So yes, lamina does blend (if anyone was wondering).
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