SPINAL SURGERY USING CHARITE ARTIFICIAL DISC MORRISTOWN MEMORIAL HOSPITAL, MORRISTOWN, NJ Broadcast June 24, 2005

Transcription

1 SPINAL SURGERY USING CHARITE ARTIFICIAL DISC MORRISTOWN MEMORIAL HOSPITAL, MORRISTOWN, NJ Broadcast June 24, 2005 NARRATOR 00:00:17:00 Today, orthopedic surgeons and spine specialists at Morristown Memorial Hospital will perform a Charite spinal disc replacement surgery, the first alternative to spinal fusion or treating degenerative disc disease. In the surgery, the disc is placed in the spine through an incision just below the belly button. The diseased disc is removed and the artificial disc is placed in the space. This program is part of Morristown Memorial Hospital s ongoing educational efforts to bring the latest information in healthcare to patients and physicians. During the program you may send your questions to the OR surgeons at any time. Just click the MDirectAccess button on the screen. 00:01:04:00 Welcome. My name is Dr. Carl Giordano. I m an orthopedic spine surgeon here at Morristown Memorial Hospital and we re here today to perform a total disc replacement on a young woman with a painful degenerative disc disease that s been unresponsive to conservative care. I m going to introduce some of my associates that are here with me today. Dr. Amit Patel, who s a vascular surgeon, who will be performing the exposure and approach to the spine. Dr. Dean Dent, the anesthesiologist who will be keeping the patient asleep while we do the procedure and helping to monitor her. There s also the nursing staff, Christina and Clare, who will be helping as well with this procedure. While Dr. Patel gets started on the exposure, I m just going to give you some brief background on the concept of this operation and the way it s performed. Dr. Patel is now making a, incision on the anterior lower abdomen that s about two inches in length. Through this anterior approach, we ll be able to access the front of the spine. The concept of this operation is a disc in the lower back is painful and no longer functioning as a healthy, pain-free shock absorber. Patients either have a choice of living with that condition or, if it does become disabling, either fusing that disc to obliterate that painful disc by removing the dysfunctional disc tissue and replacing it with bone graft or by replacing that tissue with a artificial disc that maintains some motion and allows fairly normal activity and lifestyle. The big advantages of the disc replacement are it doesn t limit any motion of the spine, it doesn t place any excess stress on adjacent levels, and it has a much quicker recovery than a fusion operation. It does have fairly limited indications. It s traditionally reserved for patients with truly disabling back pain. It s not typically performed for patients that want to become better athletes, but patients that want to just resume more normal lifestyles. It s typically reserved for patients that have single-

2 level degenerative disc disease with no associated stenosis or arthritis of the joints themselves. So, for patients that are good candidates, it does offer a good alternative to the traditional fusion. 00:03:38:00 The recovery for this operation is much faster than a fusion operation. Typically patients will recover within a six-week period and be able to resume a lot of normal activities fairly quickly. Compared to a fusion where the patients will typically be left with several months recovery. Now the exposure that s being performed, I m going to let Dr. Patel talk to you about some of the layers and I m going to give him a hand holding some of these retractors if he needs it. 00:04:10:00 We ve made a transverse incision to get to the 5/1 disc space and I see a little bit of scarring here as this woman has had prior surgery. 00:04:23:00 She s had a prior C-section and it does caused some of the tissues to mat down and scar a little bit. 00:04:35:00 Once we get behind the rectus muscle, then we re going to go retroperitoneal and I am going to go lateral to the rectus on her because of the scarring. 00:05:01:00 The exposure on this operation is certainly key to the success. Without a good visualization of the area where we re working, it does make the operation a lot harder. This particular patient has a single degenerative disc at L5/S1, the lowermost disc in the lumbar spine that is degenerative and very painful. Typically the way we try and confirm that this operation will be successful is we do some testing on that disc to confirm that it s incompetent and generating some pain. That test that we typically perform is called a discogram and it s a test where you stick a needle into the disc space and inject some fluid and dye to pressurize the disc space and by doing that, you can recreate the pain and confirm that that particular disc is the pain generator. And if that is the case, by excising that pain generator, we are excising that painful tissue and replacing it with an artificial disc. What Dr. Patel is doing now is he s sweeping his fingers around her abdominal contents. We re not actually seeing anything in the abdomen or the belly, but we dissect around the tissue planes and he can actually feel the spine as he puts some of these retractors in place.

3 00:06:49:00 It s a retroperitoneal exposure so we don t go into the abdomen, we re going around it to the back from the left. That, actually it s easier for us and recovery is easier as well since we re not intra-abdominal. The retractor system allows us to visualize better. 00:07:19:00 A lot of the dissection is done fairly blunt. The vascular surgeon can feel the tissue planes, feel the blood vessels and gain his orientation by feel and it helps to minimize the size of the incision. 00:07:47:00 The level L5/S1, I always make a transverse incision as it is more cosmetic. That should help us to visualize. Can you see that? 00:08:27:00 Now if we could zoom in kind of into this area here, this right here is the anterior part of the spine that we re working on right now. And Dr. Patel is sweeping some of the soft tissue of that disc space off so that we re looking directly at the disc space itself. In general, this tissue is just swept aside. In women, the concern of using a cautery in this region is not as big a concern as it is in men but the tissue sweeps aside easily. It s that much easier for us. 00:09:16:00 You can see the middle cecal vessels there. 00:09:22:00 It s right here, if you can see it. It s the middle cecal vessels that I m holding. And that s a clip that s going on that vessel right now. 00:09:57:00 Okay, you can see the disc space and the middle cecal vessels have been mobilized. On the left lateral side, the iliac veins are here, and that s these dark structures here. For this level it s not that crucial, it just has to be held laterally while the procedure s performed. And on the right side would be the right iliac artery and that, too, is kept to the side as the spine procedure is performed. There s a small vein to the right which I will also clip and then she should be ready for Dr. Giordano.

4 00:10:53:00 That s excellent exposure of the entire disc space with most of the vessels swept way to the side so they re out of harm s way. We re about ready to start the discectomy part of this. Now it might be difficult to see, but the disc space itself doesn t look normal. There s a lot of irregularities and bulging to it. It seems somewhat incompetent. It s got a circumferential bulge appearance to it. It might be a little difficult to see that on this video. I wonder if we could maybe get a little more overhead and shoot a little bit more down. Oh, that s actually a great view right there. It s perfect. Okay. That s a great shot. 00:11:43:00 This is the disc space. I m going to now cut into it. Now I m just circumferentially incising the disc space, make it easier to remove. 00:12:35:00 The vessels are held aside, and I think if you take a look from above, you can see the disc bulging that s been incised. 00:12:46:00 I m going to take now a device called a Cobb Elevator and try and peel the disc off of the bone. A lot of times the damaged disc will separate out fairly easily off of the bone. 00:13:36:00 Okay. 00:13:40:00 Dr. Giordano, this is from Raquel. She asks: It has been confirmed that there is no longer a disc in the area of L5 of my lower back. Will this limit my ability to have a disc placed there without having one to replace? I really want relief, an alternative to fusion. I m an active person that would like to maintain what motion I have left. 00:14:06:00 Yes, I m going to answer that question. I just want to take a moment here to just show you what some of the damaged and degenerative disc looks like that has come out so far. I ll hold it in front here. We re going to keep working as I answer that question. I m going to keep taking some of the disc material out. But, basically, for patients that have a degenerative disc, the fact that most of it has dissolved already does exclude someone from having a disc replacement operation. When somebody says to me, however, that the entire disc has degenerated and collapsed, the only concern would be that it may be so degenerated that it s already too collapsed and too arthritic and some of the secondary changes in the disc space itself and the joints may have occurred, which make it difficult to do a disc replacement on because we like to see these ideally on patients that don t have any secondary changes of arthritis in the joints. But the fact that you re told that the disc has collapsed doesn t typically exclude you because that s what a

5 lot of these patients have, a degenerating disc that s not functioning and most of them are collapsed. So it wouldn t exclude somebody from a disc replacement operation. 00:15:26:00 You can see the remnants of the disc being removed from the space. 00:16:03:00 Okay. Dr. Giordano, this is from Marilyn. She asks: I have been in pain for a year now. She says her back and her right leg. She had an MRI on June 4 th of 05. The findings on the report are: there are changes of a disc desiccation and mild disc space narrowing at L4/5 and L5/S1. At L5/S1 there s a broad-based posterior central disc protrusion without significant mass effect on cecal sac S1 root. There s no central canal stenosis. There are mild hypertrophic changes of facet joint without significant foraminal encroachment. 00:16:54:00 Well, the only concern with that patient would be the indication that there s disease at two levels. In general, this is a procedure where we like to perform it on patients with single level disease. It does indicate that most of the pathology may be at one particular level, the L5/S1 level and if that s the case, then this operation may still be a reasonable operation for her. Again, it s for patients with degenerative disc disease that s painful and that patient would probably have to have a discogram to confirm that she may be a candidate for something like this. 00:17:39:00 Now this is a good view looking right down the middle of the disc space with most of the disc removed. I m going to keep working back here until I get back to the posterior longitudinal ligament and the annulus and completely remove them so I can actually look right back into the spinal canal. I m about ready to put in a distractor so I can actually distract this space open and see a little bit better into the back. I ll take the distractor. 00:18:22:00 So this device goes right into the disc space and we re going to take an x- ray right now and just confirm that it s in good position. You want to take one shot? Okay. So you can see on the image now that the distractor s in the space. I m just going to distract open a little bit and now I can look into the back of that disc space and see more disc material and more annulus. I can already see an area where the annulus is already ruptured and torn which will make my job a little bit easier because I do want to release that PLL annulus so that I can look right into the back and get a curette around the corner to make sure that it s all released and free of all disc material. 00:19:36:00 So I ve got a great view now of the PLL and the annulus and in one corner I can see if we can zoom in way down there you can look all the way in the back and see some remaining PLL, this bright white spot. So that s a good view, here s the white

6 PLL and if you look right over here you can see there s a piece of PLL in this corner that s already torn and I can see some of the epidural space. 00:20:52:00 So I m taking a little curette now and just releasing the edge of the annulus and removing some of that disc material. I m going to try and distract this a little bit more. So this dark blue right here is actually the dura. This right here, this blue is the dura and I m just going to kind of extend that all the way now. 00:21:52:00 Carl, you ve got to back your head up. Take a look in there with your headlight and then they can there s a shot Carl just back your head up and with your headlight look in there and now you can point. 00:22:07:00 Okay, you can see those shiny tissues right here. Part are dura, part are still some PLL tissue. I m going to take an image right now with the angled curette just so I can get an idea of my depth. Take a shot. So you can see on the image that my curette is right behind the back corner of the vertebral body in the canal. That s about exactly where I want to be. Sometimes patients will have a osteophyte or spur there and you want to get your curette around the corner of the vertebral body to remove that spur so that the device can sit as far back as possible. I think we re about ready here. I just want to clean out a little bit more in the corners to put a trial in now. 00:23:14:00 You can also see on the image machine that the space is fairly distracted. Back to probably what it s normal height is supposed to be. Okay. We ll probably take this out now. Now these are different paddles that allow us to size the disc space and get an idea of which artificial disc space we want to put in. You can take one more shot with the image. And then here is the disc space through the overhead, you see that overhead? Here s the paddle. I m going to put the paddle in that space and we re going to take a picture now and see what that looks like on image. That looks like about the right size for this woman. She s not a large woman. Okay, let s try a 3 trial. I ll put it in and then we ll take an AT. We ll try a 10. Let s try a :24:58:00 Would you like to balloon up? 00:24:59:00 You know, I could maybe get the leading edge in. Yeah. Dean, if you could just inflate that balloon a touch? Get an idea where our midline, there.

7 00:25:15:00 You re in midline. Looks good. 00:25:22:00 It looks a little angled. 00:25:23:00 Yeah it does. 00:25:27:00 Okay. We re inflating a balloon that s under her lumbar spine. That s good, Dean. That allows the anterior spine to open up a little bit. You can let that balloon down. Yep. And that helps us get the leading edge in and now we ll let the balloon down so we don t compress the posterior aspect of the disc space. We ll shoot that. X-ray. That looks pretty good. Yup. I like the position of that. That hole that you see in that trial we want just posterior to the midline of that disc space. Now we re going to take an AT and see that the device is truly in the midline of the spine. The positioning of this device is important and a lot of the long-term success of this operation does depend on how accurately it s placed. 00:26:41:00 Do we have another image drape for when we come back for a lateral? 00:26:44:00 Pull back a little bit, Steve. Pull back in a 30-degree. No, no, no. Straight AT. 00:26:57:00 We re going to take a Ferguson view now on the image so that we can look right at the disc space. Okay. So that s a great shot. We re just going to fine-tune the picture now to confirm that we re truly in midline and like the position. Intraoperatively you can judge yourself by some of the intraoperative findings in anatomy and as we finetune it, it looks like the device may be just a touch to the patient s right side so I m going to try to put this about 2 mm more to her left side when I put in the device itself. Otherwise I like, essentially, the position on that. Do you agree? 00:28:11:00 Yeah.

8 00:28:12:00 We ll go back to a lateral. I m going to mark that before I remove that just so I know where I want to put in the final device. 00:28:23:00 Actually, the implant looks very good in the space compared to maybe the spinous processes and look at the sides, you can see the sides of the body. 00:28:47:00 Dr. Giordano, Bill has a question for you. How does arachnoiditis affect this surgery? 00:28:57:00 Well, arachnoiditis is a medical condition where the tissues inside the cecal sac are inflamed. It typically indicates that the nerves are stuck together. It s hard and painful and it is a different condition. This particular disc disease condition that we re treating today is very different from arachnoiditis. Degenerative disc disease is a disease where the degenerating disc is painful and generating pain and by replacing the disc we obliterate the pain. Arachnoiditis is a condition where the nerves themselves are inflamed and this particular operation would probably do very little for that condition. 00:29:44:00 So I m going to now mark with a little cautery where this device was and then we re going to take this out and start with our new device. There is a little screw that could be inserted but I particularly like to just mark it with a cautery. 00:30:44:00 I think we have a little more room towards you than we do towards me. 00:31:09:00 What I m doing now is I m just removing some residual pieces of tissue and annulus. But I can actually look right back and see the cecal sac now and some of the annulus is just torn and laying in that space still. I m just going to put a curette around the corner just to show 00:31:46:00 Dr. Giordano?

9 00:31:47:00 I d like to place one curette here and just put it around the corner just to show people how you can get completely in the canal. Shoot that. Okay. All right, you can read your next question. We ll go ahead and bring the device up. 00:32:09:00 Donna has a question. She writes: I had a spinal fusion at L5/S1 in September of I need to have another fusion at L4/5 this time with a new Charite. My question, I m having my hardware removed in July. Is this an easy procedure and also, will I be able to tell a difference? Is this maybe why I have sensitivity in my lower back and why it is sensitive to touch? 00:32:38:00 Well, in general, when patients have had a fusion, we like not to do a disc replacement on those patients at an adjacent level because the fusion does create some abnormal biomechanics above and below the fusion. And because of that, it might place some excess stress Hey Dean, we ll blow that balloon up again place some excess stress on the adjacent levels and it may lead to failure of the disc replacement. So, in general, patients with prior fusions wouldn t be considered great candidates. We just inflated that balloon again behind the lumbar spine to help us get that leading edge in. Shoot that. What this device does is it creates a little channel in the bone to allow the disc, the actual device, the artificial disc to slide in a little bit easier. That actually looks pretty good. I want to try and put this pretty far back. Shoot that again on x-ray. I can see on the bottom of the sacrum, I m about as far back as I could go. I m going to remove this now. 00:35:01:00 Each time we put instruments in there are some areas on the sides that loosen up and frequently we ll remove them each step of the way. Okay. So this is the actual device, the disc replacement. And these are the two metal paddles. One will go on the top, one will go on the bottom and then we ll distract them open and put an artificial device, or plastic piece, in between the two and that s what allows the motion. Good view. Okay. So the angled portion goes on the bottom and that s right here. So we re going to blow that balloon up again, Dean. And that, again, lets the leading edge of this device get in a little bit easier. 00:36:25:00 Now as Dean s blowing that up I can see the front of the space open up and that will make it easier for me to get this leading edge in. That looks pretty good. All right, I m going to Shoot that. 00:37:23:00 We re just going to drive this in as far back as we need to. You can let that balloon down now. We ll take one more x-ray. Okay. 00:38:08:00 Sometimes if it s hard to get in, I ll actually just try and walk it back a little bit. So, looking on the image on the sacrum, it s about as far back as I could go. I m going to just try and just tap it a little more. I think that s about it. All right. So I like the

10 position of those plates now. I m going to now distract this open and put in a couple of dilators. So these are devices that we put in now just to make sure it s symmetrically gapped open. And these actually don t touch the device itself but just the metal distractor. That pop that you hear is the remaining fibers of the PLL that are just popping, tearing. Some of them way off on the side. We ll shoot that. 00:39:48:00 So you can see it gaps open a fair amount. That s one side and that s the other side, and this is 7.5. I think I m going to stick with the 7.5. If you look into the back now, I m trying to shine my light in there. You can look right down inside there with the plates in position and now we re going to put the polyethylene trial in there and see what that looks like. This is a trial now, I m just putting it in. So, maybe I ll try an 8.5; that went in pretty easy. So that s in position. I m just going to release the distraction. We ll take an x-ray with that. So that actually feels pretty good and I think I m probably going to go with that. 00:41:49:00 You can see the endplates on the device when you look in. 00:41:52:00 Oh good. Okay, I ll shine my light in there. 00:41:56:00 The top endplates you can see. You can see the cupped surface. 00:42:18:00 Dr. Giordano, we have a question from Cathy. She writes: I am fused from her cervical spine 3 to 7. Can this be used on necks and can a fusion be replaced with a Charite? 00:42:30:00 Well, the first part of that question, this device is presently only FDAapproved for the lumbar spine. There are disc replacements being developed for the cervical spine but they re presently not available in this country, but I would anticipate that they would be available within the next several years. The second part of that question is: can a fusion be taken down and converted to a disc replacement operation? And in general, the answer to that would be no because when a solid fusion occurs the facet joint in the back typically becomes arthrodesed and rigid. And to take a fusion down and expect the facet joints in the back to function normally would probably be a little excessive. It s just something we would not anticipate we could be successful in accomplishing. So in general if somebody s had a fusion, they won t be able to be converted to a disc replacement operation.

11 00:43:30:00 All right, so we re loading up now the polyethylene piece, or the plastic piece, that will sit between the two metal plates that we put in. And you can see it s got a certain design where it s got a rounded structure in the middle on both sides and this is what allows the device to kind of rotate in all planes, flexion, extension, lateral bending, rotation. The only thing this device can t simulate in terms of the real disc is compression. There s just no device that s presently available that will cycle millions and millions of times and not fatigue, so this is the best technology we ll offer right now. So I m going to insert this now, between the two plates. Take an x-ray. Now you can see there is a metal ring around it. And that metal ring serves the purpose of just letting us visualize this polyethylene and it lets me know that the polyethylene is in a good position. Once we take this insertion paddle out, we ll be able to get a good view of it. You typically want to rotate that polyethylene to make sure the ring freely rotates. That gives you a good idea that it is in good position. 00:45:18:00 I m not sure we re a perfect lateral here. Maybe we could just free up the image and we ll try and get a better picture. That looks better. We re just going to raise the whole machine north now. We ll shoot that. So that s a better picture. It lets us see the polyethylene ring, that metal ring. And if we can get that to be a perfect lateral, we ll be able to see that that plastic ring is a single line. And now we re getting pretty close to a perfect lateral. Maybe we ll just go north with the whole machine now. So that s a great lateral. And you can see that the device is as far back posteriorly on the sacrum as it could go and it s basically almost completely on the back of that vertebral body. And that actually looks fairly good. You can see how much that disc space has been distracted open back to its normal height. Now I m going to just take a device and try and impact in those teeth a little bit more into the vertebral body. 00:47:00:00 The one thing you have to be aware of in inserting this is a fair amount of force is required to impact it and sometimes the posterior part of the vertebral body can break off and you want to certainly get a good view of it to make sure you didn t do anything like that. If you did, you d certainly have to remove this and take that fragment or piece out. Now this device, I m just going to tap up a little bit, those prongs, and maybe even down a touch. Okay, just to engage those teeth a little bit more. With this device, nothing has to heal. What stops this from moving is just the perfect placement of it and the compressive load that the normal person would put on it just from standing. But, actually, this looks like it s well-positioned. We want to take one last view in the wound itself and we can see what the device looks like inserted. So that s what the disc replacement looks like. Good. So now, we re pretty much ready to close. We re going to remove all the instruments. 00:48:26:00 We re going to take a final lateral and then a final AT just to confirm the position. That s a good-looking lateral. That s the AT and we d like to see that device perfectly in the middle of the pedicles. The pedicles are those rounded circles that you see on either side and they re a better landmark than the spinous process which sometimes can be a little distorted. On this particular patient it looks as though the middle prong of

12 the device is pretty much dead center, so that s a great view. We ll pull the image out and we ll start closing. 00:49:41:00 As you can see, this incision is only about 2 ½ inches, so the entire operation is done through a fairly small incision. We re going to just start closing and answer any other questions that are available. 00:50:07:00 The recovery for this operation is certainly a lot easier than a fusion operation. In general, these patients have pain similar to what a patient would experience from a C-section-type incision. And it certainly does hurt in the beginning, like any operation, but I have had patients that have gone home the next day. I did have one patient that felt good enough to almost go home the first day, although I requested that she stay until the next day. The typical recovery for this patient is to stay in the hospital overnight, possibly stay two nights and begin fairly normal activities fairly quickly, once the surgical site heals. And typically by six weeks I ll allow patients to resume fairly normal activities without significant restrictions. 00:51:22:00 So, to summarize this operation, essentially what we ve done was to take a degenerating disc, a disc with abnormal tissue that wasn t functioning as a normal shock absorber, abnormal tissue that was creating pain in the lower back and replace it with an artificial disc that will maintain fairly normal motion and will allow the painful disc material be replaced by artificial material hoping to eliminate all the pain. I think the success of this operation is dependant largely on how good a candidate somebody is for it and having realistic expectations. 00:52:12:00 Dr. Giordano, I ve got a question from Patty. She asks: what are the risks of having this surgery? 00:52:18:00 Well the risks of this operation, just like any operation, are infection, the risks of anesthesia as with any operation. The specific risks of this operation are we are working very close to some of the blood vessels, the iliac vessels and some of the other regions, the iliac veins, and it is possible to puncture one of those vessels and create a fair amount of bleeding. For the majority of these cases, the blood loss is fairly minimal, you know, only a half a cup of blood is probably lost in an operation like this. The vascular risks are probably the greatest risks with this operation. For men, there is an added risk of retrograde ejaculation, which is a mild sexual dysfunction. And that can occur anywhere from 1% of the time to 17% of the time, depending on which article you read, although most of the good articles indicate that the risks are fairly low, but certainly not zero. For patients that do develop that, in 50% of the patients, they tend to have it resolve on its own. But men certainly have to be aware of that and have to accept that. The other risk is, it doesn t have to cure patients. It s not 100% successful and it may relieve pain, but patients may still be left with some pain and they need to be aware of that as well. But the

13 other risks are rare risks such as dural leak, possibly pushing disc material into the canal or off to the side. But, in general, the risks of this operation are fairly low. 00:54:13:00 Bob has a question. He says he doesn t have a lot of medical knowledge. This question pertains to why your approach is through the front and not the back. 00:54:23:00 Well, this operation can only be done through the front because we need to have a wide exposure and access to the disc space. If the operation were done through the back, the first thing we would run into in the spinal exposure would be the nerve roots and you would not be able to move the nerve roots over to the side enough to do this operation. So it can only be done through the front. We typically monitor the nerves. Throughout this operation, this patient s nerves were being monitored because sometimes when we distract open the space, we do alter the anatomy a little bit and the nerves tend to become irritable. It s unlikely that we re going to compress the nerves because we re distracting the space, but sometimes there are little attachments to the nerve roots in the foramen that become altered and the altered anatomy can create some nerve irritability or pain. So we like to monitor them and just verify that we re not causing anything like that. But this operation can only be performed through the front because it gives us direct access and visualization of the disc space and the disc without having to even visualize the nerve roots or come into contact with them. 00:55:50:00 Hank writes: Is what you are hammering into a space to create enough space for you to insert the disc? 00:56:01:00 Well, what I was hammering was both the device as well as a couple of trials. And this device has some teeth or prongs on it that have to be inserted with a fair amount of force to engage the bone. Typically there is a fair amount of space in that disc space and we can distract it open to whatever height we feel is appropriate. But, you know, you want to somehow gauge through experience what would be the appropriate height and the appropriate distraction and you do get a feel for how hard you have to hammer and mallet that into position to make sure you re not overdistracting. But you can see there is a fair amount of force required to position that device. 00:56:57:00 All right, so this is basically the completion of the operation. A small little dressing is put on the wound and we ll bring the patient to the recovery room now and let her recover and try and get her up walking either later today or tomorrow.

14 00:57:21:00 I just want to thank everybody for joining us today. I hope it was educational and people got a lot out of this. Certainly if you have other questions down the road, you could always contact us by . But, in general, this was about as smooth as this operation could go. Thank you. NARRATOR 00:57:46:00 Thank you for watching the live Charite disc replacement surgery from Morristown Memorial Hospital in Morristown, New Jersey. To obtain more information, to make an appointment or to receive a physician referral, please click the buttons on the screen.

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