TILIF #15: Testing 1... 2... 3...

Test #1: I'm (hopefully) done with my pediatric boards! As mentioned in my previous post, I took this 9-hour exam in mid-October and will hear back about if I passed at some point in the next several weeks. It was grueling but so was every other major exam I've taken up to this point, so here's hoping I survived. Next up, Pediatric Critical Care Medicine boards in 2024!

Apologies for the absence of blog posts in the past two months. I had planned to take some dedicated time off to study but then some serious family health issues came up that stopped me earlier than expected. I hope all three of my dedicated readers can forgive me.

Test #2: TILIF, towards the end of the major work of a spinal fusion surgery, the patient is briefly allowed to wake up to make sure they can still move all their limbs. This is crazy.

A spinal fusion is typically the last resort for kids with terrible scoliosis, where the spine weaves side to side like a big 'S'. The procedure it truly the goriest surgery I've ever seen.

{WARNING: Gross details ahead}

from Spinal News International at https://spinalnewsinternational.com
/depuy-synthes-receives-us-fda-clearance-for-cement-
augmented-pedicle-screw-systems/

The surgeons place the patient face down and then splay open the back, spreading apart the muscles to expose the spine. They then clip away the ligaments and extra pieces of bone to make space for their hardware. Next, bolts with slots in the heads are drilled into each side of the affected vertebrae. Then comes the hard part; you have to you have to weave the misaligned vertebrae onto the straight steel bar. This take A LOT of force - specifically the amount of force of two grown men putting all their weight onto some wrenches attached to a child's spine.

Right as they are starting on placing the second bar, the anesthesiologist turns off all sedation, with the hope of timing it such that when all the hardware (and bones) are in their final place, that the patient will briefly wake up just long enough to wiggle their finger/toes before being quickly re-sedated and then sewn back up. It is wild that we woke up a child with her spine fully exposed, just to ask her to wiggle her toes.

{End of gross details}

Test #3: The other test to monitor for nerve damage during spinal surgery is the aptly named intraoperative neurophysiological monitoring system whereby you place dozens of electrodes all over the body and monitor for electrical signals being transmitted by both sensory and motor neurons. It's finicky and prone to equipment problems, which is why the crude-but-effective method described above is also performed. The sensory nerves can be monitored continuously but the motor ones can only be tested by making the patient move. So once every 10 minutes or so, the technician asks the surgeons to hold off on cutting/hammering/cranking/etc for a few seconds to send a twitch pulse to all the electrodes and see the response as the patient briefly convulses.

Whenever a patient is brought to the PICU post-operatively, there is a verbal hand-off from the surgery and anesthesia teams to the PICU team. More than once I had received hand-off after one of these big spinal cases and been told what seemed like gibberish about them having "lost SEPs on part of the left leg, but had good movement during the wake-up test." Thanks to sitting in on this case today, I not only got another intubation attempt (which was successful, BTW) but also learned how orthopaedic and neurosurgery folks monitor for nerve damage in surgeries that often land patients in the ICU for a few days.