Episode 29, Season 2. Chuck and Chris start a new segment in their more structured approach. This is the first episode of "My Hardest (recent) Case". Chuck shares a revision ulnar nerve case post subcutaneous transposition. Chris and Chuck talk examination, nerve studies, technical approach and expectations. Listen in!
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
Episode 29, Season 2. Chuck and Chris start a new segment in their more structured approach. This is the first episode of "My Hardest (recent) Case". Chuck shares a revision ulnar nerve case post subcutaneous transposition. Chris and Chuck talk examination, nerve studies, technical approach and expectations. Listen in!
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu. And thanks to Eric Zhu, aspiring physician and podcast intern.
Survey Link:
Help Chuck and Chris understand better what you like and what we can improve. And be entered for drawing to win a mug! https://bit.ly/349aUvz
Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm doing really well. It's a fine morning here in St. Louis.
Chris Dy:It is it is a good one. It's so good to be back. I feel like we haven't recorded in a while. This my first episode back since coming from Houston. Yeah,
Charles Goldfarb:I know. I kind of have missed it. Maybe missed you even a little bit.
Chris Dy:Yeah, right, right. Sure. You would have called if you actually missed me, you probably just missed the podcast experience.
Charles Goldfarb:I thought about you all the time. Right.
Chris Dy:Right. Well, that was really great having you know, we had a couple of guests recently, we had Macy, and Jeff and Steve. And we hope that those will be recurring episodes or, you know, types of episodes. And we hope that everybody enjoyed them. Chuck, we have a couple of great reviews that were recently posted. Here's the first one. It's from a listener named Andrew. It's five star review. Only kind you're allowed to leave. informative and fun is the subject line. Perfect. Dr. Goldfarb, and dr. D, aka Chuck and Chris, please, thank you for your awesome podcast. It's both educational and fun. I appreciate that you cover topics from patient evaluation to operative pearls to practice development. Thank you for your time and effort. Andrew, thank you for leaving that review. We certainly appreciate it. And we love our listener community. And thank you to all of you for going on the iTunes page, clicking five stars leaving a review and maybe leaving a question for Chuck.
Charles Goldfarb:I love that. Thank you. Thank you for sharing. And you know, it is interesting whenever I think that I mean, I'm proud of our listeners, you know, we have a large number of listeners that does seem to be continuing to inch up. And there are a lot you know, it's always interesting me that there are a number of hand surgeons, I would recently went to a fellowship reunion. And I would say three quarters of the room had no idea I did a podcast, which Why would they I guess if they're not podcast people and I they're all good friends, but I don't see them on a daily basis. So it's super interesting. So you know, if this is useful, please tell a friend.
Chris Dy:So wait, hold on, what about the quarter that did know that you did a podcast,
Charles Goldfarb:I knew we did a podcast and didn't necessarily listen regularly. And there was a core group of listeners who really seem to enjoy it. Listen, if
Chris Dy:one out of four hand surgeons read any paper that I wrote, I'd be thrilled. So take what we've got going here. And hopefully we can continue to grow it.
Charles Goldfarb:That is fair. That is fair. So let's hold maybe the second review, because I don't know if I can handle too much positivity this early in the morning. And maybe you had a great idea for a recurring segment trying to give structure to our podcast.
Chris Dy:Yes, structure is nice. I'm amazed that you and I made it about 18 months without structure, given our personalities, maybe this is the only unstructured space in our lives. But I thought it'd be really fun to talk about our hardest cases, you know, of recent memory. So what about if we asked, you know, and also be great if listeners wanted to send in their hard cases. And if there's any kind of obviously HIPAA compliant way to talk about it, we'd love to kind of talk through a case. But Chuck, have you had anything interesting come your way or something that became interesting?
Charles Goldfarb:Yeah, I thought of when we discussed this segment, I was, you know, merely thinking about cases that would be appropriate to discuss and a couple came to mind but, you know, given your interest in nerve and apparently the listeners enjoy her. I'm not really sure why. I thought a good challenging nerve case would be a nice place to start. All right, well,
Chris Dy:put me on the hot seat here. So okay, for the listeners, I have no idea what Chuck is about to present. Let's see what see what he's got.
Charles Goldfarb:Alright, so here's the background. I have a 33 year old injured worker with cubital Tunnel Syndrome. I treated this patient seven years ago with a subcutaneous ulnar nerve transposition. And she did really well her preoperative symptoms at that time, were relatively classic. She had discomfort at the medial elbow, she actually had an unstable nerve and she intermittently had numbness and tingling in her fingers. She failed conservative treatment. We did a transposition she did well and disappeared. She has continued to work in the same occupation. And she was at work, and she does a physical job and was struck in the anterior medial elbow about six months ago. And since that time, has had really intense nerve type pain, burning pain, primarily at the elbow, but radiating to the fingers. And so that's what she presented with when she came back to the office say six months ago. So I guess I would stop there and maybe ask how you process this and what your examination might look like for a patient such as this.
Chris Dy:So I mean, this is the thing about a subcutaneous transposition, it takes the subcutaneous layer nerve and just moves it to a different subcutaneous position, perhaps now when it's anteriorly, transposed, it's still it's less vulnerable to the, to the traction across the medial epicondyle aisle and is less prone to ergonomic issues as it sits kind of where people rest their their arm. But it's still prone to trauma, it's not, you know, deeply positioned, and then the setting of something like a known traumatic event, I guess you have to try the things that we all want to try first. So if it's more of a pain component, I would consider starting something like gabapentin or pregabalin. Although I recognize those medications are no fun for patients. In a from a personal perspective, once my mother in law started gabapentin and I heard about the side effects, my honest honestly my prescribing patterns changed a little bit. It's it's a tough medicine to titrate up, it's a tough medicine for a patient to titrate some people fly through it have no problem, but you definitely have to tell them about the side effects, particularly the somnolence just the abnormal way that they feel. pregabalin is a good alternative. I know that you know other people who like nerves like Dr. McKinnon, that's one of our go to medications. It used to be super expensive. I believe it's generic now, you know, so that does change things a bit. But I typically would start with that, and then also with a visit to one of our expert therapists.
Charles Goldfarb:Okay, so a bunch of questions. Or let's start with what you said last, so what would you ask from the therapist? And what is your goal with therapy? Are you buying time? Or do you honestly think therapy is going to make this patient better?
Chris Dy:I think that the risk benefit ratio in therapy is is fantastic. You know, so if therapy, if the time that the therapist spends with the patient's aides is an extra set of eyes and ears and a situation that is not normal, be the expertise they can provide and helping to quiet down that nerve through local modalities, stretches, you know, honestly, a hand to hold sometimes is also really helpful. And then the other thing I would do is probably limit some of the work related activities if it's possible. And this is where you have more much more expertise than I do in terms of how to handle this situation in the context of work comp.
Charles Goldfarb:Yeah, I think that that's a great point, I would, I would say a couple things, you know, I've been taking care of injured workers for my entire career. And there has been some evolution, but patience is not often part of the equation from the work from the, you know, the workers comp side. And so a long duration of therapy? Probably not okay, I think it would be reasonable for the first month or so I follow these patients monthly to try some therapy. I don't think that would be shot down necessarily. But I don't think we could expect a long duration of therapy. And you're right, you could put some restrictions on for sure. But once again, how long that will be tolerated by the employer? I don't know. The second thing I would say. So interestingly, this patient had experience with gabapentin, and it was not a good experience and refuse to consider that medication. I'm not a huge believer for the reasons you said I've had some patients with adverse events, what is the role if any of steroid medication,
Chris Dy:um, you know, I for this particular situation, I do not like a steroid injection. And I've talked, I think it was some of our trainees in the past about why we don't use steroids in general for cubital tunnel, while the we may use it for carpal tunnel, there are different disease processes. You know, in carpal tunnel, there's swelling within the carpal tunnel instructors like tendons, and your goal is to try to quiet the swelling in that in that small confined space. Whereas in cubital tunnel, say the nerve is actually inside too. There's not a swollen structure, you know, the the nerve is experiencing traction as it as the elbow flexes. So it's traction and compression. And, you know, the nerve itself is swelling. And I don't love the idea of putting a ton of steroids or local anesthetic around nerves in general. And then for the transpose nerve, this would not I don't think it would provide a long term relief. I guess you could make an argument maybe to try it once. But to me, it's not going to be something where that's going to be the thing that secures her it gets her back to work and keeps her out of your office. You know, going forward.
Charles Goldfarb:You did. Perfect. So you have taught me well. I did not offer steroids. I did offer their modulating medication which patient did not want and we sent her to therapy with some mild activity restrictions. She comes back a month later, not better. honestly probably a little worse. With continued pain, as I guess I would say the primary complaint with secondary complaints of numbness and tingling in the fingers. weakness on exam. Two point discrimination and this is static two point which is my preferred modality was five millimeters diffusely intrinsic hand strength was good. The nerve was clearly highly irritated on my examination. So we're now about, let's say 10 weeks after this trauma, have failed four weeks of therapy and anti inflammatories. And now she is back in your office. What's next?
Chris Dy:So I mean, I guess to summarize the way I would think about this is a mechanical, irritated, likely swollen nerve without any advanced signs of, of ulnar neuropathy on examination in terms of motor and sensory, but the fact that the nerve is highly sensitive and irritable kind of pushes us towards considering operative treatment. You know, some listeners would have probably said, Why don't you get a nerf study from the get go? I think that'd be fine. To get a nerf study from the get go, I think it's probably time to get it now.
Charles Goldfarb:Okay. Thank you. And that's exactly what we did. And I would like to know what you do routinely in these situations, because it might be somewhat different. I, you know, ordered a nerve conduction study with an EMG. And we also got an ultrasound I do not always get ultrasound. Ultrasound was helpful in this case. But do you feel that ultrasound is now in your practice, essentially always indicated?
Chris Dy:I think so. I mean, some of it is me learning when to use ultrasound, and it is in the non revision setting in the primary owner neuritis, cubital tunnel setting, I think it is useful because it can help provide some clarity to two things for the quote, electrode diagnostically negative cubital Tunnel Syndrome, but there is some swelling in the nerve. I think there's something to be said about that. Because perhaps enough of the nerve, quote fibers are working. So that the nerve study comes back normal, at least on the conduction velocities and likely on the amplitude and for that early stage kind of disease, there probably aren't going to be any signs of deactivation on the EMG. And the ultrasound may show some swelling. The second thing, as we've talked about in the past, with it being for it being useful is you know, the fact that it can help you in terms of accurately diagnosing subluxation of the nerve now in the setting. And that's why for those two reasons. That's why I pretty much always if it's available through the you know, through the physiatrist, or electro diagnostician who's doing the exam will get an ultrasound. Some could make the argument, why don't you just transition only to ultrasound. And that's a whole different topic. In this setting, it is incredibly helpful to have the information as to how swollen the nerve potentially is. And honestly, in some cases, and not in this case, because I know that you did the first surgery, but sometimes you want to make sure the nerve is actually been transposed. That is not always the case. And I've I've been told by patients that they had their nerve transpose I've looked at their incisions and said, That's way too small, and the nerve is actually not transposed.
Charles Goldfarb:I think that's fair. And I am. I'm a real believer in really small incisions. But I'm going to repeat that because I didn't I'm a believer in really small incisions. But this is one surgery where a little bit longer incision makes a lot of sense, because what I really want to avoid, is the nerve not running the straightest course possible. And so I agree with you, I think understanding what was truly done in a first surgery matters.
Chris Dy:So let's be honest, so we all know that the the skin around the around the medial elbow is very compliant. There's a lot of pliability within that and yes, you can. Technically you can transpose the ulnar nerve to a really small incision. But what happens when you do that is exactly what you stated is that you do not get the nerve going in the straightest line possible, you end up getting kind of an Omega sign on that nerve. I think that's john Isaacs that told me that term, or as the sign is, I think Dr. McKinnon calls it where the nerve will be transposed to the front of the elbow, but then as you get as it comes back down or comes back posteriorly towards that fascia around the intersection of the FCU and the remainder of the flexor pronator fascia. It kinks right there. And that's my issue with small incision ulnar nerve transpositions.
Charles Goldfarb:I totally agree with you. I didn't know that. You know, I'm not as nerdy in the nerve world as you are. I don't mean that offensively. I mean that. Yes, yes. Yes. Complimentary way
Chris Dy:18 months of podcasting, become bulletproof to the nerve hating.
Charles Goldfarb:So I like the term omega nerve, or whatever you said from Jonathan Isaacs, because it really you know, I don't know all the Greek letters. But I do know what an Omega looks like. I don't know all the fraternity letters either, but I know what an Omega looks like so I can see it. Thank you for sharing that.
Chris Dy:I'm so glad we've added something to your knowledge base today, Dr. Goldfarb.
Charles Goldfarb:You have I love it. I use it every day now. Alright, let me share the nerve study results with you. So the nerve conduction study findings, I'll just hit a few highlights showed that there was normal distal onset latency, amplitude and conduction velocity, except for a decrease conduction velocity at 40 meters per second across the elbow.
Chris Dy:Now, so I'm assuming this, you know, I don't put a lot of stock in sensor amplitudes because they're technically so variable, I'm assuming those came back as normal to for the ulnar nerve. They did. And on the EMG part, are there any deactivation findings on the FDI? Or the ADM or any owner if they don't if they checked the other extrinsic musculature? They did not. But they did note that the first dorsal enter osseous muscle showed increased motor unit amplitude. Okay, got it. Are there any fibrillation or sharp waves listed? there? We're not. Okay. And then is on the recruitment pattern like that far right column on the EMG. any abnormalities listed in the recruitment pattern for the motor units? The MEPs?
Charles Goldfarb:Hold on, let me look. So there are no recruitment pattern abnormalities demonstrated.
Chris Dy:So I mean, to me, based on what you've described, it sounds more like a chronic, the footprint of chronic changes, but nothing acute. So I'm not sure how it was interpreted by the electrode diagnostician, but that's based on what you've told me. That's what I would say.
Charles Goldfarb:So as expected, you are right on the money, you are an expert in this field, it was interpreted as a chronic older neuropathy at the elbow. And it was noted by ultrasound that the nerve was indeed subcutaneous. The maximum cross sectional area of her nerve was 15 millimeters squared versus 10. Okay, as the normal Okay, so we have as you predicted a large swollen nerve without any really exciting new findings, but with a chronic pattern identified. And so
Chris Dy:let me ask you one more question, because I know that it's going to come up. So on your examination, were there any signs of compression at guiones? canal?
Charles Goldfarb:There were not and i i am not the world's greatest believer in the existence of Guyons problem in this situation, or distal ulnar tunnel as I often call it as influenced by Doctor Gelberman. There were not negative Tinels no type of compressive findings, nothing.
Chris Dy:Okay, cuz I know that there are some listeners shout out Dr. Rob Gray, who believe that releasing Dion's in every case is the way to go. I can't remember which forum we learned that.
Charles Goldfarb:But But here's the question, is it and I understand that is it about releasing a current possible construction site? Or is it about releasing in advance of nerves swelling, quote, unquote, during the recovery?
Chris Dy:To speak for those who believe in it? The answer would be? Yes. As Dr. Boyer would
Charles Goldfarb:love it. Yes, it would be. Well, I
Chris Dy:mean, I think that this comes into like where the to me work comp kind of comes into the picture here, right. So you want to do I think, at least the way that I interpret the care of the injured worker is you want to consider doing everything possible for these patients from jump. So to me, this patient looks like they're heading towards a revision ulnar nerve transposition. And then you could make the argument I think, with reasonable, new with some good justification to consider releasing the distal ulnar tunnel. Now one thing that, you know, for those that are listening in, if you're ordering your nerf studies, it's really hard to diagnose with accuracy, distal owner tunnel compression on a nerve study, because you're relying a lot on the, on the sensory component of the nerve conduction studies. So oftentimes, if you really want to get a lot electrodiagnostic, quote, evidence, compression at the dishonor tunnel requesting a contralateral assessment of that particular component can be useful. Now, obviously, you don't want to do more to the patient than you have to but if you're trying to dial in on that on your nerve study that is useful. I would still argue that that is more of a clinical diagnosis, and maybe a sonographic diagnosis that electrodiagnostic one, but there are a lot of camps or a lot of thought out there as to whether we're making too big of a deal of releasing a nerve prophylactically in whether the nerve is actively compressed or not.
Charles Goldfarb:I like that that's very helpful. And let's be very clear, this is the concept of performing a distal ulnar tunnel decompression is level five evidence but from you know, a number of Really good, highly thought of surgeons, but the science doesn't guide us now. I think the science would be hard pressed to guide us here. Is that your take?
Chris Dy:Well, I mean, we're kind of diverging from your case here. But you know, I think that the concept of a an injured nerve swelling downstream is based in a lot of really good lab based science. It occurs in rats. Now you make the argument, right, that perhaps what happens in rats doesn't happen in humans. But I think that it does occur. Now whether it reaches the tipping point of actually becoming clinically an issue is a different argument. Now, if you look at the literature in humans for this particular question that you're asking in the setting of ulnar neuropathy, something at the elbow, there isn't great evidence for it. There are a couple of case series. So I'd argue we're pushing into level four evidence for the comp supporting the concept of distal decompression helping in the setting of a recovering nerve injury. And the two case series I remember are kind of a hodgepodge of various peripheral nerves. So there's nothing truly dialing in on this question of ulnar nerves. So like much in the literature, if you believe in a concept and want to believe that you can find a paper to support what you believe, if you don't believe in the concept you can hate on the literature and say there's not enough evidence to support it. Just like you know, all those papers that have been published recently jbjs about whether or not to fix this radius fracture, so you can find an RCT to support what you want.
Charles Goldfarb:For sure. So before I tell you what I did, I'm here if I'm hearing you correctly, and this injured worker and I'm saying this a little tongue in cheek, you're going to throw the kitchen sink at this patient. And so you are going to perform a submuscular a revision ulnar nerve transposition, you are likely going to perform a distal honor tunnel decompression. And are you going to also supercharge that nerve? Dr Dy?
Chris Dy:100%. No on the supercharge. You know, so base. This is the beef I have with some of the supercharging fever is I don't think that is completely rooted in in the indications that were originally described. So some of the prerequisites as I understand them, and I think I've been taught by Dr. McKinnon on this, that, you know, you need to have a nerve that is actively crying or muscles supplied by that nerve that are actively crying for re innervation. So you need something that's acutely Diener rated. So you know you just the way you describe the nerve studies when I asked you are there fibs in sharp waves, there are no fibs and sharp waves here. So this is not an acutely denervated nerve. So supercharging, this, that whatever gets to the to the distal on their motor component, the distal on their motor component is not asking for help. Clinically, the muscles are great. You've described that the intrinsic strength is good. I'm presuming there's no atrophy. So this is something where I don't think you're going to do a whole lot of good you describe the motor amplitudes of that owner nerve as being normal. This is a healthy nerve, it's just irritated at the elbow and just needs to be put in a place where it's not irritable anymore.
Charles Goldfarb:Perfect, perfect. Okay, so failing time, failing conservative management, including therapy, anti inflammatories, but not the nerve modulators. And with approval from workers compensation, the patient was taken to the operating room, and a sub muscular transposition was performed. This was one of those challenging cases where her scar tissue was overwhelming. And so we use the same incision, I made my incision a little anterior to me like a con dial, we found the nerve, we extended our decision I made a you know, reasonable decision to start, but we made it a bit longer, we found healthy nerve approximately no pathology until we got directly over the flexor pronator mass. And then we encountered scar tissue like we all dread, honestly. And we meticulously dissected and freed the nerve, honestly, with a cuff of some tissue, because I didn't feel there was any reason it wasn't circumferential. But we took some circum some of the abnormal scarring with the nerve and performed as the lengthening of the flexor printer mass, which I'd love your thoughts on Place the nerve in a nice position so muscularly and went about our business. So thoughts?
Chris Dy:Um, well, you have no one else but yourself to blame for that scar. Because you did the first
Charles Goldfarb:amen, it is so true.
Chris Dy:You know, so I do. I do a lot of revision surgery. It's actually funny when I was coming out of training, I was talking to Dr. McKinnon, about the you know, doing all the nerve transposition. So he's like, Oh, yeah, don't worry, Chris. You know, you're not gonna do any revisions until you're well into your practice, you know, you're just going to be doing primary. So here's how you do a really good primary. She taught me how to do a great primary ulnar nerve transposition, as that all of the other partners at our orthopedic group, and then in my clinic, the stuff that's coming in revision on their nerve trace positions just like anybody, I guess, in an academic practice with a niche, but I, you know, I do a fair bit of revision on nerve surgery. And it's, it's always something where I look at the trainee with me, I say, look, I do revisions, I just, you know, there's so many small little micro decisions that are made during the portions of these cases where you're trying to free up the nerve, where I know that technically, you can probably do this just as well as I, but I want, I don't want you to have any of the responsibility of this. So or feeling like you know, something didn't go well. So I you know, as much as I try to encourage our trainees to, quote, hold the knife. These are cases that I do myself, at least at this point in my career. And it's a tough dissection. You know, I think that for the trainees, there's a lot to learn by, you know, watching how to dissect and I, at this point, I've evolved to switching between different modalities of dissection for this I love the leaving the cuff. I don't do this all with tsunamis, you know, I use the I love the fissure tsunamis that are out there, they're great. Sometimes I take out an iris tenotomy sometimes I use a 15 blade, sometimes I use a beaver blade in the unis need to be facile in different ways of dissecting. Now, you know, the concept of just spread, spread spread until things pop open is not the case here because what you don't want to do is piss off that nerve even more. And so wide spreads. You know, spreading quote, like a person like one of our former mentors used to tell us is not helpful in this particular setting. Once you've gotten your subcutaneous tissue exposed, I love starting proximately I love going distally I don't I think sometimes going distally can be a little bit more difficult. I like finding the nerve proximal and finding healthy and then starting rolling with my dissection. Now if I'm starting to meet some, if I'm not making headway in my dissection because I'm cutting scar, then I will pivot and start dissecting out the nerve distally in good tissue just to give myself a way to keep the case moving forward. And as you know, once you've gotten that nerve kind of mobilized proximately display unhealthy nerve, so it's easier to see your planes as much as the scar tissue will give you at least
Charles Goldfarb:I think that's really well said, and certainly how I thought about it, how I approached it and do you this is a little bit of just technical but do you believe in the Z link thing, or do you just simply cut the flexor pronator mass and repair it?
Chris Dy:Well, I in principle, I go in every case, to Z, lengthen the flexor pronator mass and then release the flexor pronator or z lengthen the flexor pronator fashion and then release the flexor pronator muscle wherever it seems to make sense for the nerve to lie. Now when you're doing a primary transposition, you you know tend to see where the nerve wants to lie. In a revision case that nerve has been transposed for however long it's it tends to know where it wants to sit. And your job is just just to let it sit deeper. So sometimes I'll release you know, I'll do a lengthening of the fascia in the Z manner. And then on the muscle, I'll take it right off the media because sometimes, or I'll take a just off the media because what I'm trying to avoid now is that that chunk of proximal muscle that's left on the medial epicondyle, potentially acting as an area to create some omega type turns. So I've started more to release it off of the bone itself for the muscle, not for the fascia, obviously being mindful as you had posterior about the medial collateral ligament.
Charles Goldfarb:So I like how you worked at word omega into a really rest for you. Thank you. Thank you. And do you always find the median nerve with a sub muscular? And is it your goal to have the ulnar nerve running parallel to the median nerve?
Chris Dy:So again, to evoke our partner Marnie Boyer, never say never, never say always, I think that's it. But yes, I find a median nerve, I feel better, I listen, nobody's perfect. But given what I do, and who I say I am, I feel like such a jerk if something happened in the meeting nerve, and I didn't at least look at the median nerve during the case, because I know that it is at risk during the muscular release of the for the sub muscular transposition. So you know, let's be honest, you know, some muscular transposition is a surgery that has pretty substantial morbidity. And you know, Ryan shown that in some of his papers, and it hurts, it bleeds and these are things that you know, you need to tell and I know you do, but you need to tell your patients ahead of time when you're deciding what to do. To me, you know, I still, you know, the three options for a primary case are an insight to decompression, a subcutaneous transposition and a sub muscular and I tried to guide them through what each of those surgeries will feel like based on what patients have told me, and then I'll tell them what I think they need based on their nerve. So it's not entirely shared decision making, but I do like to emphasize that a sub muscular, while it is the most definitive does carry some morbidity with it.
Charles Goldfarb:Perfect. So as we kind of wrap this up, I have one final question. So you told me that it was my fault that the patient made a lot of scar tissue with the first surgery. So how am I going to mitigate that with the second surgery? So when do you start therapy? Because that's the only thing I know to do is get that nerve gliding. How do you approach the post,
Chris Dy:I said, everybody's nerve scars. You know, the, when I went on my diatribe about starting and doing revision surgery more than primary surgery, my point was, I'm sure I'm going to be revising some of my own surgeries in the next five to 10 years. So you know, I will have nobody but myself to blame for that scar. But be in an effort to mitigate against that all of my patients will start moving in three days. And that's something that, you know, Dr. McKinnon taught me. And I think that getting that nerve gliding is the only way aside from obviously, meticulous surgical technique without beating up the nerve without posting against nerve is easier to anonomys. Without huge, wide spreads, when you don't need huge wide spreads. You know, when you're dissecting on a nerve, to me, and you're trying to free up that external epithelium or the mesoneurium around it, you just need to spread the width of the nerve spread once to see what you need to cut and then cut that tissue. And that's when I can tell that our trainees have kind of mastered the cadence is when they're not doing huge wide, spreads two or three times over the nerve. And they're just, you know, spread, small spread, cuts, small spread cut, it makes me feel so good when I see them do that, because I know that they understand, you know, how to be mindful of avoiding kind of those blunt, big moves that are going to cause scarring.
Charles Goldfarb:I think that's really well said, and and I worked with a younger resident yesterday. And, you know, it is a matter of applying your centerbrook technique in the right context. And I think that's what residents and all trainees learn, and you know, through the course of their training, and so, wide spreads are appropriate in certain locations. Very, very meticulous spreads are appropriate in other locations. So I think you said that really, really well. So just be clear, when do you send the patient to start their therapy?
Chris Dy:Three days. So my protocol for these is I leave a drain, especially revision, they come back in three days to see me in the office, we've removed the drain, and we send them to therapy, fortunate enough to have great therapy partners who are in office, who can fabricate splints, and start them moving in gently initially, but just getting that nerve moving. And then I will see them back in three weeks. The sutures will typically come out at the therapist office, if it's with a therapist that I work with routinely, which I've got, I'm fortunate enough to have that relationship. And that's just to make things more efficient in terms of office flow. How about what's your protocol?
Charles Goldfarb:Yeah, I don't, I'm not sure anyone cares. They just want your protocol. But I'll share my protocol, and I'll share a pearl. So my protocol is they my patients see therapy, at five to seven days, there is no drain, although I deflate the tourniquet prior to final skin closure to minimize risks there and knock on wood have not had a major issue. I see them back in 12 days to take out stitches, if I put in removable stitches and go from there. My pearl is for those of you who are starting a practice or considering a practice, whether it be nerve or anything, I think Chris has really done a few really smart things. And the main issue is we all want to build a practice that, you know, well. Many of us want to build a practice that has a niche component, something that really interests you. And whether that's congenital or sports or nerve or whatever. And I think what Chris has done really well as he has just said yes to all referrals. And so, you know, I'm sure Chris has no desire to see some of the patients I sent to him. But he's made it very clear that he will see anything and everything that's potentially nerve related. And that opens the door, it makes me really want to send him all patients, just like I know other people in the community feel the same way. And so if you're building a practice, you can't be super selective to start. And I think Chris, you've done it that really well. And that's why you have a thriving nursing practice already.
Chris Dy:I appreciate you saying that. You know, I guess one example of that is, you know, just a very small component is Thoracic Outlet Syndrome. I believe a lot of Thoracic Outlet Syndrome is treated non operatively. A Thoracic Outlet Syndrome is over diagnosed, or perhaps over treated in a surgical manner in my opinion. Do I love seeing Thoracic Outlet Syndrome patients not particular, it doesn't really bring me joy. You know, I like I like honing my exam. But it is something that in terms of if you look at it purely as a, you know, case to new patient evaluation ratio payoff, not good. Because I don't operate a lot on these people. They end up doing really well with their therapy colleagues. But I'll take the TOS referral because it'll get me the Plexus referral. And I'm okay with that. And I feel like that's been the case because I've had some referring Um, physicians, you know, from two or three hours away who have sent me to us case and then send me a Plexus injury. So I will take all of those TLS cases just because I want to do the Plexus stuff.
Charles Goldfarb:So, absolutely. Well said Well said. any final comments as we close our first my hardest recent case to segment?
Chris Dy:Well, I you know, as they say, and many podiums, nothing ruins a good surgery, like follow up. So I want to see how this patient does over time, whenever you can safely tell us, you know, that'd be great to do an update. Maybe if we remind each other we can update each other on the cases. So next time, I'm on the hot seat for a hard case. So I'm looking forward to doing that.
Charles Goldfarb:Outstanding. Well have a great day. This was fun, and I look forward to the next recording.
Chris Dy:You too. Take care. Bye bye.