What are the difficulties and risks associated with cervical and lumbar spine surgery? ——–‘s professional interpretation of the article “The twisted medical story of a cervical spine patient with multiple diseases including pulmonary embolism and obesity” written by a family member of one of my patients a few days ago has attracted the attention of many friends in the WeChat friend circle. The article “The tortuous story of a cervical spine patient with multiple diseases including pulmonary embolism and fatness. The article vividly recreates the difficulties and risks of spine surgery by describing the patient’s difficult treatment experience. As the patient’s surgeon, it is my responsibility and obligation to explain the issues in this article from a medical professional’s perspective and to provide the interested public with a targeted education on the “difficulties” and “risks” of spine surgery. The spine is composed of the cervical, thoracic, lumbar and sacral spine, and the majority of spinal pathologies occur in the cervical and lumbar spine, and the majority of cervical and lumbar spine disorders are treated by orthopedic surgeons. It is well known that any surgery involves some risk. The difficulties and risks of cervical and lumbar spine surgery are due, first, to the operational difficulties and corresponding risks of the surgical procedure due to the complexity of the cervical and lumbar spine disease itself and the local conditions, and second, to the risks resulting from the poor general condition of the patient. Let’s start with the operational difficulties and risks resulting from the complexity of the spinal disorders themselves and the local conditions. Most spinal disorders are caused by spinal nerve compression due to herniated discs and spinal stenosis, such as cervical spondylosis, lumbar disc herniation and lumbar spinal stenosis, and other congenital or acquired spinal deformities, tumors, tuberculosis, etc. There are also cases of spinal nerve injury due to trauma to the spine. The anatomy of the spine is complex and irregularly shaped, and the spinal canal contains important spinal cord and nerve root pathways. The spinal column and its component spinal canals are hard, while the nerve roots of the spinal cord, which are encased in them, are as delicate as “tofu brains. To use an analogy, the spine is like the egg shell of a raw egg, with a thin pericardium on the outside of the spinal cord, like the inner lining of an egg, and the spinal cord and nerves inside are only slightly firmer than the yolk of a raw egg, with a texture like tofu brain. In most cases, spinal surgery involves opening the spinal canal to release the spinal nerve compression, and in some cases, directly removing herniated discs, spinal stenosis, and other structures that compress the spinal nerve. This procedure can be compared to the difficulty of removing the shell of a raw egg without damaging the thin egg membrane ……. Remember, it’s a raw egg! If the egg membrane is accidentally broken, the egg white and yolk will flow out, and the structure of the spine is much more complex than the egg shell! Some patients also need to be fixed with titanium internal fixation material, which is commonly known as nailing up to rebuild the stability of the spine. With so many surgical steps, the slightest carelessness can lead to spinal nerve injury and, in severe cases, paralysis of the limbs. For patients with severe spinal stenosis, heavy spinal nerve compression, and in addition those with spinal deformities, variants or tumors, the surgery is even more difficult and risky. The surgery itself is intended to relieve spinal nerve compression and improve neurological function, but due to the risks associated with the difficulty of the surgery, in some cases the procedure may result in damage to the delicate spinal nerves like “tofu brains” and lead to paralysis…. … This requires our orthopedic surgeons to have the skill of walking at height and the precision of walking through a hundred steps. Among the risks of the surgery itself are non-healing surgical incisions, infection, loose and broken internal fixation nails, and non-fusion of bone graft. The goal of most spinal surgeries is to improve spinal nerve function. In some patients, the surgical operation goes smoothly, but due to the seriousness and long duration of the disease resulting in severe and prolonged compression of the spinal nerves, the spinal nerves have degenerated, and even after a very perfect decompression and fixation of the spinal nerves, the function of the spinal nerves cannot be recovered and improved very satisfactorily, or it requires a long and arduous rehabilitation to recover to a relatively satisfactory degree. The risk caused by the patient’s poor systemic condition refers to other diseases of the patient’s body leading to the risk of the anesthesia process and the increased mortality during and after surgery. The main factors are cardiovascular and cerebrovascular diseases, respiratory diseases, liver and kidney insufficiency, long-term use of certain specific drugs, advanced age, obesity, and malnutrition, which lead to cardiovascular and cerebrovascular accidents, respiratory failure, liver and kidney failure, excessive intraoperative and postoperative bleeding or difficulty in stopping bleeding, easy infection of local incisions, systemic multi-organ system failure during anesthesia, etc… …and the risk of anesthesia may be increased by the prolonged operation time and increased bleeding caused by the difficulty of the operation, which also belongs to the risk of the patient’s systemic condition. The risk of poor systemic condition often leads to more serious adverse outcomes for the patient, which is the primary factor leading to increased intraoperative or postoperative mortality. When faced with a cervical or lumbar spine patient who requires surgery, the orthopedic surgeon needs to have a thorough understanding of the spine disease itself and the patient’s systemic condition to determine the difficulty and risks of surgery. The orthopedic surgeon is the judge and master of the problems of the spinal disease itself and the difficulty and risks of the surgery. Multiple doctors will analyze and discuss the operator’s condition to determine whether the diagnosis of spinal disease is correct? Should surgery be performed? What type of surgery should be used? What problems may occur during surgery? How to deal with possible problems, etc., and develop a detailed surgical plan and protocol. The comprehensive judgment of the patient’s systemic condition and other comorbid diseases requires consultation with doctors from other related disciplines, and is finally summarized in the Department of Anesthesiology, where the anesthesiologist and the chief surgeon work together to make a comprehensive analysis of the risks. Thereafter, the physician should explain and communicate to the patient and family so that the patient and family fully understand the difficulty and risks of spine surgery itself and the various risks involved during and after surgery. The patient and family should be adequately prepared psychologically, maintain a good state of mind, and actively cooperate with all the preparations before surgery to face the upcoming surgery and the various possible accidents and adverse consequences. Both doctors and patients should share the risks, and the trust and positive and correct mindset of patients and families are crucial and essential components to complete the surgery in Shunli. The difficulty and risk of these two aspects vary from patient to patient. Certain patients have complex spinal problems of their own, the difficulty of surgery is higher, and the risk of spinal cord injury and spinal nerve injury paralysis due to the surgical operation itself is higher, while the patient’s general condition is good; some other patients have spinal surgery as a routine operation, with little risk or difficulty, but their general condition is poor, they have various diseases of one kind or another, and the risk of anesthesia is high, thus during anesthesia surgery, leading to The risk of death or other complications is relatively high. Of course, every surgeon encounters patients who want to have a good outcome through conventional surgery with a moderate risk and a good general condition. The patient described in the opening story is a patient with complex spinal surgical problems and systemic conditions that are very risky and difficult to treat. Trust …… Next, let’s take the patient with the twists and turns mentioned at the beginning of the article as a case study and explain the difficulties and risks of his surgery from a professional perspective. When this patient first came to me, his cervical MRI showed severe ossification of the posterior longitudinal ligament in the cervical spine, resulting in compression of multiple segments of the cervical spinal cord. Prior to the visit, his “leader noticed that he was walking and falling a lot”. In fact, at that time, the ossification of the posterior longitudinal ligament in the cervical spine might have already compressed the spinal cord and caused spinal cord cervical spondylosis. They ran to several hospitals and saw the Chinese medicine and neurology departments, but perhaps the doctors at the time were not very familiar with this specialized condition of cervical spondylosis and did not diagnose it quickly, plus the neurologist found calcification in his brain, and later did find endocrine problems as well. After the next two falls, “the back of his head hit the wall, and he was completely unable to walk and was confined to a wheelchair,” considering that a relatively minor trauma to the head and neck, based on ossification of the posterior longitudinal ligament of the cervical spine and compression of the cervical spinal cord, led to further, severe cervical spinal cord injury. At this point, only through surgical decompression to open the cervical spinal canal and release the compression of the spinal cord can the patient’s neurological function be improved and the movement of the limbs and walking function be expected to be restored. The patient and his family went to several hospitals, and the orthopedic surgeons of several hospitals gave them this opinion, but the reason why the orthopedic surgeons of those hospitals did not admit him to the hospital was because of the difficulty and risk of surgery. One, from the cervical spine itself, this patient has a relatively serious cervical longitudinal ligament ossification, the compression of the spinal cord is heavy, the operation is difficult, the operation process is easy to lead to further aggravation of the spinal cord injury; secondly, the patient’s own surgical conditions are poor, a few meters tall, weighing 120 kg, is extremely heavy obesity. The neck is thick and short, so it is very difficult to reveal and operate the incision during cervical spine surgery, and there may be more bleeding during the surgery. In addition, the risk of local wound infection after surgery is also higher because of the local fatty neck and collar; third, patients with cervical spinal cord injury after trauma have poorer results in improving their spinal cord nerve function after surgery than ordinary cervical spine patients, and doctors may worry that patients and families are not willing to accept this reality; fourth, patients have endocrine thyroid problems, and orthopedic surgeons are not very familiar with this field . This patient’s case is already a difficult case in spine surgery, and orthopedic surgeons at several other hospitals may have failed to operate mainly because they were concerned about the risk of surgery and the poor surgical outcome. For this patient in the orthopedic field, although the surgery is difficult and risky, our orthopedic team at Beihang Hospital has had a lot of success in the past, and as long as adequate preparation is made, the surgery can be done. Regarding the endocrine thyroid aspect, we are indeed not quite sure, and need consultations with endocrinologists and anesthesiologists to clarify the risks in terms of systemic conditions. In fact, the patient’s risk at this time was more in the orthopedic field itself, and from the subsequent endocrinology consultation, the risk in terms of his systemic condition was not very high. Of course, before he could be admitted to our hospital, he unfortunately developed a serious problem such as pulmonary embolism, and his general condition took a sharp turn for the worse. Let’s talk about this patient’s “pulmonary embolism”. Probably because he could not walk and was bedridden for a long time, blood clots appeared in the veins of his lower extremities, which is a complication more likely to occur in patients who are bedridden for a long time. The thrombus in the veins of the lower extremities is dislodged and flows back to the heart, then reaches the pulmonary artery, and finally gets stuck on the branch of the pulmonary artery, blocking it and leading to pulmonary embolism. Pulmonary embolism is a very serious and dangerous complication, just like the well-known myocardial infarction and cerebral infarction, which is an important cause of death. At this time, saving life is the first important task. The surgery of inferior vena cava filter placement performed in the emergency department of vascular surgery in Union Hospital is a life-saving surgery, and the risk is very high, but it is worth to take such risk when saving life. That’s why you saw the thrilling scene of the fight with death at Concordia Hospital described by the family in the article. I would like to pay tribute to the relevant disciplines of the Union Hospital, which also highlights the professionalism and profundity of the most prestigious hospitals in China. After discharge from the Union Hospital, although the patient was out of danger, he could not immediately undergo other surgical operations. Since his coagulation condition was unstable and in a hypercoagulable state, if the operation was rushed, under the stimulation of anesthesia and blood pressure fluctuation, it would be easy to have another infarction of other vital organs, such as myocardial infarction, cerebral infarction or another pulmonary infarction, which would be life-threatening! Therefore, in general, patients with pulmonary embolism, myocardial infarction and cerebral infarction should not undergo general surgery within six months, except for life-saving emergency surgery. Finally the patient and the family spent another difficult six months, and the patient’s coagulation was stabilized and in principle was ready for general surgery. By this time, the patient’s problems in the cervical spine, which had been at major difficulty and risk, had not changed significantly from when he first saw me a year ago and now took a secondary position, while the problems in the systemic condition, which had been at minor risk, had now become very complex and were in a major position. However, since the patient had already passed the consultation of the relevant departments of the first-class Union Hospital in China and was considered to have no contraindications to surgery, we could admit the patient and then conduct detailed examination and evaluation. After the patient was admitted to the hospital, we conducted a detailed examination and evaluation mainly on the systemic condition, formed a multidisciplinary medical team, and invited doctors from related disciplines to consult with each other. At this stage, “pulmonary embolism” became the top priority, while the endocrine thyroid problem, which was considered important at the time of the initial visit, was stabilized and now became unimportant. The respiratory consultation concluded that although the patient had a pulmonary infarction and impaired lung function, he could still tolerate the surgery; in a patient with a pulmonary infarction like this, although he has recovered for more than half a year and the coagulation problem has stabilized, the patient is still in a hypercoagulable state and needs to continue to use anticoagulants to adjust the blood coagulation status and continuously draw blood to monitor the coagulation index, which is why the patient’s family made two trips per week as mentioned in the article. This is why the patient’s family made two trips to Concord Hospital every week to send blood tests for more than six months. Overdose of anticoagulants leads to easy bleeding. Surgery, especially spinal surgery, is most feared for bleeding, inability to stop bleeding during surgery, and continued wound oozing or bleeding afterwards, which can lead to serious incisional hematoma, re-compression of spinal nerves, leading directly to paralysis and eventual failure of surgery! However, insufficient doses of anticoagulants may induce another pulmonary infarction, heart attack or brain infarction, which is a greater threat to the patient’s life! On balance, the respiratory surgeon gave us a window of about 48 to 72 hours to stop anticoagulation before and after the surgery, and thereafter to use anticoagulants to prevent thrombosis! At the same time, the patient, due to obesity, sleep snoring, waking up at night, and the presence of sleep apnea syndrome after admission, which is also a threat to the surgery, the surgery is carried out using general anesthesia, to tracheal intubation, obese patients tracheal intubation is difficult, and there is a risk that after the surgery, the patient still has respiratory depression, respiratory function can not be timely recovery, can not be timely extubation of the tracheal tube Risk ……. Before the surgery, we invited the respiratory department, vascular surgery, endocrinology, ENT, anesthesiology, and critical care medicine (ICU) to consult with each department, and each department came 2 times before and after. The last time was to bring all the departments together for consultation and discussion to make sure that our preoperative preparation was perfect. After the collective discussion of multiple disciplines and the joint discussion of all orthopedic surgeons, it was concluded that although the cervical spine surgery in this patient’s orthopedic department was very difficult and risky, we had previous successful experience; the systemic condition, which was considered risky by all departments, was not absolutely contraindicated and could be operated after adequate preparation. Most of our patients with cervical spondylosis are now ready for surgery in one to three days after routine preoperative preparation after admission to the hospital, but we prepared this patient for more than two weeks after admission. After thorough preoperative preparation, the operation was completed smoothly according to the preoperative plan with the trust and active cooperation of the patient and his family. When the patient woke up at the end of the surgery, he gave us a thumbs up, although at this time he still had a tracheal tube and could not speak. I was sincerely relieved and could feel the patient’s hope and desire for a better life from the bottom of his heart. After the operation, the patient stayed in the ICU for about 3-4 days according to the plan, and then the tracheal intubation was removed smoothly, and he was transferred to the general ward after 2 days of observation and smooth breathing. After the surgery, the patient felt that the movement of his limbs was significantly better than before the surgery, and his limbs were significantly stronger than before the surgery! Thank God! Successful surgery with careful preoperative preparation and judgment. All the problems we predicted before surgery did not occur, and everything went well, more than we had predicted! The patient is now more than 3 months post-op, and the other day, the patient’s family showed me a recent video of the patient, who is now walking on his own, unassisted! Although still hobbling, I believe that with active rehabilitation, the patient will be able to return to a near-normal or normal life. It was the time and time again visits and discussions by all the doctors in our orthopedic department that helped me analyze and judge the difficulties and risks of treatment, and gave me full affirmation, trust and support, which gave me the confidence and courage to complete the surgery; it was the multidisciplinary team’s full cooperation, joint assessment and judgment that helped me objectively and accurately grasp the patient’s whole body condition; it was the cooperation of the medical and nursing staffs in the anesthesiology department and ICU before and after the surgery that contributed to the smooth surgery and the patient’s It is the cooperation of the medical staff of the anesthesiology department and ICU before and after the operation that ensures the smooth operation and patient safety. It was the determination of the patients and their families to seek medical treatment, their strong perseverance, their good attitude, their ability to actively cooperate and participate together, and their courage to accept failure that finally made the operation a complete success. The doctor’s kindness, the patient’s knowledge and the joint efforts of the doctor and the patient are the results. Doctor-patient trust and collaboration are the common expectation of doctors and patients, as well as the expectation of the public, and one of the most fundamental guarantees of a harmonious society. Finally, I would like to conclude with the comment of another doctor in my department on this medical story of the patient’s family in his WeChat circle of friends: “Adequate preparation plus adequate communication, trust of the patient and family plus the courage of the doctors and nurses, plus a little bit of luck, made this patient get a new life after a big disaster!”