From: MARK TRAMO To: "jeffrey E." <jeevacation®gmail.com> Cc: Lesley Groff Subject: Re: Jeffrey Epstein Date: Wed, 29 Jun 2016 16:50:05 +0000 Attachments: LSSTxNEJM2008.pdf Hey JE - was just starting to type this and your email arrived...coincidence or clairvoyance? I. Saw your spine last night. The anterior-posterior diameter of a normal lumbar spinal canal varies between 15 and 27 mm. At that one bad level in your lumbar spine, the AP diameter measured 8 mm = severe stenosis, not a lot of room for all the right and left lower lumbar nerve roots and all 10 sacral nerve roots to fit through. No surprise you have Neurogenic Claudication. 2. It's great you responded to Medrol. Let's see how long it lasts. Side effects preclude taking it regularly. It doesn't change the mechanics of the problem: epidural compression of multiple nerve roots by bone and related hard tissues. 3. Your anatomy, failure to respond to more than a year of epidural injections (presumably 3 or more per year) and physical therapy (presumably done daily with a proper regimen), and >10-yr life expectancy favor surgical treatment, though I hesitate to opine strongly because I don't have all the data. If I examined you and found ANY myotomal weakness, dermatomal sensory loss, denervation on EMG, or conduction abnormalities on NCS or SEP, that would reinforce my impression that you need surgery. I can't opine about the type of surgery other than to say your severe stenosis involves only one level, so you shouldn't need anything approaching reconstructive surgery with multi-level fusion. 4. I'm attaching a NEJM paper you might find informative. I did a pubmed.org search and found some recent papers discussing minimally invasive lumbar decompression (MILD; the most recent from Iran!) and other techniques. I think you are best served by consulting an expert spine surgeon. One of the authors of the NEJM paper is down the block at ComellINYH/HSS (my old training ground): https://ww