The Sunday Telegraph
October 22nd 2000
Dr James Le Fanu
"By now, one might think that the human
anatomy is thoroughly understood, down to the
finest detail, but this is not the case. It is
only within the past 25 years that the Australian
orthopaedic surgeon Harry Crock has revealed that
the blood vessels which nourish the spinal cord
form a network of astonishing complexity. His
combination of careful dissection and injection
with special dyes produces wondrous images - like
bare trees in winter - which Leonardo da Vinci
would, i am sure, have admired.
Surgeons must, Mr Crock insists, respect the
integrity of this blood supply; indeed, not doing
so accounts for the high failure rate of so many
back operations. Thus, the severe shooting pains
of sciatica, usually attributed to a prolapsed
disc pressing on a nerve, are often associated
with impairment of the blood supply.
When Mr Crock re-operated on a patient whose
initial disc-removing operation had failed to
relieve the symptoms, he found that "as in
the majority of cases", widening the bony
canal in which the nerve passes restored the blood
flow with permanent relief of pain. A quarter
of Mr Crock's re-operations were on patients who
had been labelled as "psychologically disturbed"
by their previous surgeons and denied further
treatment.
Now retired Mr Crock has recently completed a
film - with the support of the charity DiSCS -
to alert the next generation of spinal surgeons
to the technique he has pioneered with such success.
The Journal of Bone and Joint Surgery
Volume 84-B 2002 Number Seven (September)
ISSN 0301-620X
R W Marshall
"Interesting and well-illustrated…
experienced spinal surgeons can learn something
from this video and it may lead to some useful
amendments to their established techniques"
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"The author brilliantly
presents the relevant anatomy in drawings, video and 3D
animation. Essential details shown in macroscopic anatomic
specimen of marvellous quality illustrate the blood supply
and venous drainage of the cauda equina and the lumbar
nerve roots. The clinical presentation and radiographic
appearance of spinal canal stenosis due to isolated discs
resorption is excellently pointed out and underlined by
CT and MRI images. Designed as a complete surgical manual
the viewer is going to be introduced step by step to the
procedure beginning with patient positioning and terminating
with wound closure. The relevance of the lumbar aponeurosis
for the function of the lumbar spinal muscles is discussed
in detail which has been hardly described in orthopaedic
textbooks. The complex and technically demanding technique
of the complete spinal canal decompression is demonstrated
in extraordinary simplicity. A vital marker for the adequacy
of the decompression in particular of the nerve root canal
is illustrated by photographic views of the venous refill
of the perineural veins. The importance of the venous
refill in procedures to decompress the spinal canal has
gradually found wider acceptance. It is essential to the
success of the operation.
I warmly recommend this video to every spinal surgeon
in training."
Dr. Jens Himstedt
Orthopaedic Surgeon
Dusseldorf, Germany
" The demonstration of a surgical procedure in
a video format is not a small undertaking. It requires
a surgeon of considerable experience in the operating
suite, a teacher who can deliver the lesson in a logical
and memorable fashion and an artist who can clearly
illustrate his concepts. Mr Harry Crock, fortunately
for those of us interested in the spine, meets all of
these criteria. He has gained a world-wide reputation
for his skill as a surgeon, for his insights and diligence
as an investigator of the blood supply of the spinal
column, for his logical clarification and his rhetorical
precision as a teacher and as an apt demonstrator, via
the visual arts, of his findings.
Crock's original anatomic studies of the spinal column,
its contents and constituents, both on microscopic and
gross levels, have led to a fuller understanding of
how the spine can thrive and how it can deteriorate
according to the status of its blood supply. To the
array of the textbooks he has written presenting his
discoveries and concepts, both is the dissecting lab
and in the clinical setting, he has now crafted a brief
- only twenty minutes in length - depiction of the method
of performing a decompression of degenerative spinal
stenosis of the lumbar spine.
The script begins with a patho-anatomic presentation
of the process whereby the symptoms are produced and
the imaging of studies which pinpoint the sites of the
compression. Crock's studies have given him full justification
for his cautions and admonitions in the surgical approach
to the posterior elements of the spine. He gives specific
directions for entering the space anterior to the lumbodorsal
fascia, for preserving the inter-spinous ligaments and
for avoiding the devascularisation of the lumbar paraspinal
muscle groups. In this portion of the videotape he emphasises
the preservation of the arterial channels.
The judicious disruption of the attachments of the
ligamentum flavum from the laminar surfaces of both
the superior and inferior vertebrae is clearly demonstrated
allowing visualisation of the facet's hypertropic spurring
causing the stenosis. Mr Crock, by means of curettes
and a power drill, demonstrated the process whereby
the canal stenosis, either central or lateral, is eliminated.
The venous drainage of the nerve roots is restored to
normal, relieving the vascular compromise which is the
'sine qua non' for effective relief of the patient's
symptoms. A few words on closure conclude the narrative.
The visual presentation is complemented by a voice-over
by Mr Crock.
The beauty of this video production is that it addresses
a problem which is increasing in prevalence due to the
demographics of our population and it provides a rational
and methodical answer to that problem. The answer has
been refined by Mr Harry Crock, a spine surgeon with
four decades of experience and with the intellect to
distil from those forty years what is good for the patient
and what is not. Moreover, there are many practising
surgeons, in addition to spinal surgeons in training,
as well as medical students yearning to see what surgery
on the spine is about who will benefit from seeing this
laudable lesson."
William J Kane MD PhD
Minneapolis, USA
" Viewing this film is a must for anyone involved
in spinal surgery, especially those in training. The
film is an illustration of a great teacher's and innovator's
approach to spinal surgery based on a lifetime's study
of anatomy especially of the blood supply to the spine.
It is very rare that one sees such an elegant and careful
approach to the problem of spinal root canal stenosis.
In the past the approach to this problem has been overly
simplistic removing elements of the spine including
the midline structures"
John Scott Ferguson
Consultant Orthopaedic Surgeon
Northampton, England
" I am very impressed with the content and conceptual
development of the techniques of spinal surgery in this
film. The explanation at each step is well done and
clearly expressed. One important point is that the viewer
must listen very carefully to each point for there is
much to learn. It is nor for casual viewing and listening.
This film will be especially valuable for residents
and registrars learning the techniques of spine surgery.
Including the points about care of the arterial circulation
and of the venous return at the appropriate places is
excellent. It is my impression that very few spinal
surgeons are aware of the importance of the blood flow,
both arterial and venous side."
Emeritus Professor J T Hartman
Texas, USA
"Henry Vernon Crock is a world-renowned spinal
surgeon and like all master surgeons he has learned
many hints and tricks to ensure the success of his procedures
and to minimise the risks of complication. With his
ability to take comprehensive and current views on spinal
surgery, he has made a magnificent treatise on specific
problems and issues of lumbar nerve root canals and
intervertebral foramina decompression - brilliantly
presented in video and 3D animation.
In painstaking dissections and beautiful photographs
the anatomy of the lumbar spine including the anatomical
principals of spinal cord circulation are put to practical
use. People will get delight studying the detailed demonstration
which is of the highest quality and then marvel at the
extraordinarily well-produced pictures of the surgical
technique. The key procedures and essential steps are
excellently pointed out and illustrated from preliminary
stages to the completion. The master surgeon describes
pitfalls, how to avoid complications, and provides his
personal perspective at appropriate points, including
a splendid animation to demonstrate perineural venous
refilling, which occurs when nerve root canal and foramina
decompressions have been successfully performed. Once
the perineural veins have been seen to have refilled
and distended, decompression can be confidently predicted
to have been adequate.
This work of science and art covers all the critical
elements needed to be an effective surgeon in lumbar
spine decompression, and for non surgeons to understand
the value and role of spinal surgery in different conditions
I do not hesitate to highly recommend this work to
all spinal surgeons in training"
Dr Cordelia Becker
Surgeon in training
Dusseldorf, Germany
"This is a useful introduction for trainees, the
diagrams help to clarify the anatomy and the principles
of the surgical decompression. I particularly like the
importance attached to setting the patient up on the
table with adequate protection of vulnerable areas and
also the supervision of this positioning by the surgeon.
I think this is excellent stuff for a trainee, these
risk management details are so often overlooked"
Mr Robin Hollingsworth FRCS
Consultant Orthopaedic Surgeon
Surrey, England |
