Week 4: Excel, Chart Reviews, and Spine Surgeries

Throughout the fourth week of the Immersion Program, I continue working on my retrospective knee arthroplasty study while getting exposed to the OR as much as possible. As far as my clinical research project goes, I was able to conduct an initial search of different demographic and specific skeletal factors from a retrospective clinical database containing more than 450 patients. The work was quite arduous since I had to review the medical records of each patient individually using their Medical Record Number as the main identifier. 

After spending hours behind a massive Excel spreadsheet, it has been interesting to see how physicians are more concern with some pre and postoperative complications but tend to ignore other factors that could potentially help in the prevention of future complications. For example, a dual view chest X-ray is a requirement in most of the knee arthroplasty procedures that I have reviewed so far. Chest X-rays are an essential portion of the pre-operative assessment that the surgical and anaesthetic team uses to evaluate if the patient is capable of undergoing the surgical procedure among other postoperative outcomes. However, an X-ray of the thoracic portion of the vertebral column is hardly seen in the medical record. As a consequence, some of the patients return to HSS for a surgical revision and is only then when doctors realize that a compressive vertebral compression fracture occurred after the initial surgical procedure something that could have been easily avoided by having a preoperative evaluation of the patient's vertebral column in the first place. I am fully aware that the hospital must be cautious of the different examinations that the patients need before surgery; otherwise, their performance can be compromised. Nonetheless, I believe that there is room for improvement to avoid future complications that can be initially prevented in the preoperative process of each patient.    

Furthermore, on the opposite spectrum of my clinical experience, I was able to shadow Dr. Han Jo Kim who is a specialized surgeon treating scoliosis and cervical spine injuries. What initially struck me about the spine surgical procedure is the noticeable difference in the surgical tools that they use as well as the overall setup of the operating room. During the pre-surgical procedure, the attending fellow used a piece of equipment that I believe was taken directly from an American horror film to position the patient on the surgical table. The surgical device is called Gardner-Wells tongs. It is used for spinal traction to apply a longitudinal force to the axis of the spinal column. What's interesting is the locknuts on each end of the device; these are inserted into the patient's skull to have the device working properly. 

The first surgery was an osteotomy and spinal fusion done on a 17-y/o male patient with scoliosis compromising the thoracic portion of the vertebral column. The second case was a posterior spinal fusion, iliac fixation, and laminectomy on a 71-y/o female patient (Figure 1). I noticed remarkable differences from the two surgical procedures. For example, it seems obvious for the age of the patient is a huge variable on the OR, but seeing its role in the surgical procedure is just a mesmerizing experience. For example, the second patient [71-y/o woman] was allergic to 30 different medications. As expected, her case was quite a challenging experience for the anesthesiologist during the pre-operative planning for the surgery and during the actual procedure as well 


Figure 1. A Posterior Spinal Fusion is a medical procedure used to stabilize the spine and to relieve accumulated pressure on the spinal nerves (http://www.ivanchengmd.com/posterior-spinal-fusion.php). The image was obtained after having initial authorization from the surgical team. 

Moreover, it was my first time witnessing the real applications in of bone graft during surgery. They used two femoral heads from deceased donors obtained from a tissue bank. Bone grafts are crucial during spinal fusion to provide the initial foundations for the section of the spine to fuse together. Some portions of the bone removed from the spinous processes of the vertebrae of the patient were combined with the bone graft to enhance the pre-existent biocompatibility of the latter one. Lastly, the use of electrodes implanted on the head and limbs of the patients was another exciting portion of the surgery. During the operation, a technician is constantly monitoring the neural activity of the patient and sends every 30 minutes electric impulses onto the patient. By doing so, the surgical staff is making sure that all the nerves in the spinal cord are intact during the surgical procedure. 

Over the course of the next week, I would start working on the statistical analysis of my initial findings for my clinical study, determining the next steps of the research, and continuing entering the OR to witness the surgical expertise of doctors and the miracles of modern medicine. 



      

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