Morality in Neurosurgery – Edward Benzel

Do the right thing! – By Edward Benzel

Amazing podcast from AANS. Dr Edward Benzel talks about ethics and morality in neurosurgery, specifically the issue of spinal fusions for low back pain. Highly recommended! All young trainees should listen and emulate!

Video presentation by Dr Edward Benzel on the same topic.

Anterior approaches to the spine – Booklet

Anterior Approaches to the Spine

Sharing the booklet on anterior approaches to the spine created for the Live Procine and Cadaveric Workshop conducted on 16th Feb 2020 as a part of Asia Pacific Spine Society’s live surgery course held in Mumbai.

The images in the document are taken from various textbooks and articles and I do not own copyright on these images. They are selected here in this booklet for their quality and clarity.

I would recommend the following books for further reading if you do like the images in this booklet.

Atlas of Spine Operations by Robert Winter

Surgical Anatomy and Techniques to the Spine by Daniel Kim

Spine Surgery: Tricks of the Trade

Atlas of Spinal Operations by Rudolf Bauer

How to measure Cobb angle on Xray Films using your iPhone

Step 1: Identify and mark the end vertebrae

Step 2: Open Measure App on Iphone. https://apps.apple.com/us/app/measure/id1383426740

Step 3: There are two options on the bottom screen. “Measure” and “Level”. Choose “Level”. This brings up the inclinometer.

Step 4: Place the iPhone’s edge along the line drawn on the lower end vertebra.

Step 5: Touch the iPhone’s screen somewhere in the middle. The degrees recalibrate to Zero.

Step 6: Now move the iPhone’s edge to the line drawn for the upper-end vertebra.

Step 7: The reading on the iPhone will give you the Cobb angle.

Selecting posterior fusion levels in AIS

I gave this talk at the POSICON 2019 in Mumbai as a part of the instructional course on Adolescent idiopathic scoliosis. I discuss the Lenke classification and how it helps decide fusion levels. The video also includes the concept of last touched vertebra and how it helps to decide the LIV.

Examination of the Spine (Webinar for Residents)

Sharing the recording of a webinar done with Dr Hitesh Gopalan of Orthopaedic Principles on Examination of the Spine. It is a bit long (over an hour) so feel free to skip and navigate via the time stamps in the description.

Also, be sure to check out Dr Hitesh Gopalan’s Youtube Channel for more exceptional educational content and live webinars.

Slides for this presentation (with an explanation for each slide) can be downloaded here ⇩

Goel Harms C1-C2 Fusion (Audio)

Thank you for all your support for the the previous video on this technique. I think, it is the most watched (35K+) C1-C2 surgical technique video on Youtube!

It took me 4 years + to give this video a voice over. Please check out the new version. I have also included the surgical technique of the C1 posterior arch screw in this video (4:31).

History behind the discovery of the passive SLR

In a recent teaching course for residents, I was asked to clarify the confusion in the textbooks of different eponymous names related to the root tension signs (passive straight leg raising (SLR) test). Different textbooks use these names interchangeably, for example, a popular book by Bruce Reider mentions the forced dorsiflexion manoeuvre as the Laségue’s test (pronounced Lasaeg). I would recommend that one should avoid using eponymous names to describe these neurological signs, especially because there is so much confusion about them. Nevertheless, the medical history behind these root tension signs is no less fascinating.

Many attribute the first description of the passive SLR to Ernst Charlie Laségue, who was a professor of medicine in Paris. In his 1864, paper he described a syndrome of radicular pain which sometimes was associated with muscle atrophy. However, in this paper he did not describe the leg raising test.

Ernst Charlie Laségue (1816-1883)

The SLR test was actually published in 1881 by Laségue’s 30-year-old student J.J. Forst (not Frost) as his doctoral thesis. Forst acknowledged that his teacher was the discoverer of this phenomenon and dedicated his thesis to Laségue in addition to his parents. Note that Forst described two components of the test. The first was the leg raising test with knee extension and the second component was the relief of pain on knee flexion (verification manoeuvre or the control test). Most descriptions of the original Laségue test forget to mention the second control test.

Original drawing from Forst’s thesis

Interestingly, for some unknown reason, the second component of the Laségue test as illustrated in Forst’s original thesis has a different man (without beard) and the neck is in flexion.

However, both Lasegue and Forst got the explanation of the test wrong. They thought that it was due to the pressure of hamstrings on the sciatic nerve rather than the stretch of the nerve itself. Three years later, in 1884, another Frenchman, Beurmann, disproved Forst’s thesis using a cadaver model. He concluded, correctly, that by lifting the leg the sciatic nerve gets stretched and the muscles play no role in compressing it.

The twist is that another physician came up with this test independently of Laségue and Forst. Laza K. Lazarević, the personal physician of the Serbian King, published a description of this test in a Serbian language medical journal, a year before Forst’s thesis (1880). He later in 1884 described it elaborately in a German-language journal and compared the sciatic nerve stretch with the strings of a violin. He even measured the distance from his own PSIS to the heel and found that in the supine position it measured 103 cm and in maximum SLR it was 111 cm. He concluded that this 8 cm increase was responsible for the stretch of the sciatic nerve.

Lazarevic may have published it first, but Laségue’s name stuck and became popular. This was not surprising considering that he was more well known and was the pupil of the famous neurologist Armand Trousseau (known for another eponymous sign) and headed the Trousseau clinic in Paris.

Modifications of the passive SLR were later described. The crossed SLR or the well-leg SLR test was first described by a Polish neurologist J. Fajersztajn (1867-1935) in 1901. I tried to search for how to pronounce “Fajersztajn” but had no luck, so your guess is as good as mine. Fajersztajn conducted cadaver dissections and showed that traction on one sciatic nerve pulled the dural sac caudally and ipsilaterally which displaced and stretched the contralateral roots along with it. So the well-leg SLR or the crossed SLR is eponymously known as Fajersztajn sign.

Fajersztajn also described, in the same paper in 1901, that the pain during Laségue test was worsened by forced dorsiflexion of the ankle. But this manoeuvre is usually attributed to Karl Bragard (1890-1973) who published it much later in 1928. So the forced dorsiflexion as a qualifying test to passive SLR is called Bragard test, even though Fajersztajn described it first.

Classically, the original description by both Fajersztajn and Bragard is performing forced dorsiflexion at the point of the start of pain. It is considered positive is when the pain is exacerbated. We usually practice a modification of this test. The leg is lowered slightly until the pain is relieved and forced dorsiflexion reproduces the pain (first described by A J Mester in 1942). This manoeuvre has been shown to improve the specificity of the passive SLR – hence it is a qualifying test that is commonly done along with the Laségue test.

Also remember that these tests were described before the so-called “dynasty of the disc”. In 1920 to mid-1930s, the cause of sciatica was attributed to neoplastic processes. The surgeries with lesions diagnosed as enchondromas and chondromas were in retrospect intervertebral disc herniations. Most credit Mixter and Barr (1934 publication in NEJM) for linking the syndrome of sciatica with intervertebral disc prolapse Interestingly, almost five years before the publication of this famous report, there is a lesser-known description of this association by none other the famous Walter E. Dandy!

Hope this was interesting! If you have any comments or interesting additions to this story please comment below.

Further reading:

Karbowski, K., Radanov, B. (1995). The History of the Discovery of the Sciatica Stretching Phenomenon Spine 20(11), 1315-1317. https://dx.doi.org/10.1097/00007632-199506000-00023

HALL, G. (1930). NEUROLOGIC SIGNS AND THEIR DISCOVERERS JAMA: The Journal of the American Medical Association 95(10), 703. https://dx.doi.org/10.1001/jama.1930.02720100001001

Weinstein, J., Burchiel, K. (2009). Dandy’s disc. Neurosurgery 65(1), 201 5- discussion 205. https://dx.doi.org/10.1227/01.neu.0000346267.60064.3d

WOODHALL, B., HAYES, G. (1950). THE WELL-LEG-RAISING TEST OF FAJERSZTAJN IN THE DIAGNOSIS OF RUPTURED LUMBAR INTERVERTEBRAL DISC The Journal of Bone & Joint Surgery 32(4), 786-792. https://dx.doi.org/10.2106/00004623-195032040-00006

Neurological eponyms by Peter J. Koehler, George W. Bruyn, John M. S. Pearce, Oxford University Press.