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SNI, Surgical Neurology International, an Internet Journal,
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and SNI Digital Innovations and Learning, a new video journal which is interactive with discussion
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in association with the Sub-Saharan African Neurosurgeons
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are happy to present the sixteenth Sub-Saharan Africa International Neurosurgery Grand Rounds held in the first century of each month.
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These Sub-Saharan African International Grand Rounds are dealing with global solutions to clinical challenges in neurosurgery.
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The moderator and organizer of this program is Estrada Bernard, assisted by James Hausmann,
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came to the United States, overcame many challenges to become the only board certified surgeon with four certifications in the world. He's authored 24 books in many scientific papers.
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The second speaker is Mabel Banson and she'll talk about pain services that have been established in Ghana, which is an increasing need across the world in many countries.
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Dr. Banson is in the Department of Neurosurgery in the Neurosurgery Unit
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at the Coral Bow Teaching Hospital in Coral Bull, Accra in Ghana.
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She's the visiting scholar at the University of Florida Health and a lecturer at the University You've got an anacra
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This map here indicates the location of Ghana, which is a country in the western coast of Africa. Situated on the Gulf of Guinea, and although it's relatively small in the area and population,
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Ghana is one of the leading countries in Africa, partly because of its considerable natural wealth And partly because it was the first black African country south of the Sahara Desert to achieve
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independence from colonial rule
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Ramzaskali is originally from Egypt, and he's a
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Coptic Christian. They've undergone a
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tremendous amount of
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religious Thank you very much.
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He left and came to the United States where he had a neurosurgery residency. And then he followed that with, I think he proceeded that with an anesthesiology residency, then neurosurgery.
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Then he, in which he got boards in those two specialties, he was ordered
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in intensive care unit, ICU management and also boarded in pain management. There it is right there He's the, so he's, he's boarded in four specialties. He's been in practice for 35 years and
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he's a solo practitioner, which is the only one probably in Illinois and in its rare. And you see his picture over here. And so Ramses,
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he's written 24 books on his faith and a neurosurgery and his experiences. He's an extremely nice person and Ramses were very happy to have you and
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I can see all the work you've done has turned your hair white.
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I appreciate all of you. And after all, I'm from Africa, obviously, from the great country of Egypt. My first name is Ramses, and this is a strong Egyptian surname Thank you for inviting me.
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And I usually present a lot of slides just to
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for illustrations for all of you. I'm gonna take you to a journey. And I thought if I present an actual case, surgery case that in between had a lot of pain management and highlight this journey
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for you. If you don't get it, They're both from the length of these slides, but just for illustration, it'll get you to update what is new in the chronic pain management when you have tough
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patients like this. So this is, I was trained by Dr. Osman, and actually I was very, very lucky because he taught me so much. I did anesthesia and neurosurgery residency in Chicago at Cuconia
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Hospital I still practice all these four specialties. So when my patient comes, I work them up as an anesthesiologist. I actually take care of him as a pain specialist. I do surgery as a
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neurosurgeon, and then I manage them both so operative as a neuro-intensivist.
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And I understand nobody like me in the entire world that do that, but I dedicated my life in this. And
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let me take you through this. because I have this broad experience and look and this tough problem that we have. So this patient is a 75 years old
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female. This is an actual story started back in March. So it's very fresh. This patient came because she had so many screws in her back. She started to have back pain at the age of 18 years old.
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It was by the age of about maybe 50. The neurosurgeon told her we're going to take care of your back pain by fusion. But this is all what she has. And from there, she continued to have back pain
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and leg pain now in sciatica and the feedback syndrome after the first fusion from L2 to S1. And then after that, the neurosurgeon, which is actually chief of neurosurgery,
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and the spine section decided that we do more screws and this will take care of her pain. So now she has it from T-1011 to L5-S1
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and then he sent her to a pain specialist to take care of her. The pain specialist took her to a journey of drugs, narcotics, she became narcotic addict and then all kinds of drugs and it remained
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like this for five years Her medical team, including the pain team, told her there is nothing else to be done and this is how you're gonna live the rest of your life. She's been dishonored from her
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kids because of her narcotics and all of this. Her husband was overwhelmed with her management and finally somebody sent her to me. And you know, there is a lot to say about independent
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practitioners like me, a walk in clinic. So I'm one of the new researchers that I don't require patience to. to have a referral from any doctors or have an MRI, but this is the requirement when
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you get employed. You cannot just walk to a neurosurgeon. You have to have an MRI, then neurosurgeon have to see the MRI and say, Yes, I wanted to see the patient. But thank God for America and
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thank God for the independent practice that still exists, not to the national healthcare that I can just, so this patient came to me out of desperation. And this is her complaint My entire back
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hurts. My leg is weak. I am repeatedly false and part of it because of her legs, as well as of her drugs, and she's incontinent. She has this satija when you touch her legs. She has allodemia.
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She cannot actually dress herself. She's not enjoying a single day. She can't even sleep. She said, I have a lot of burning in my legs.
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And this is the summary that I just told you. And not only that surgeon decided to do from T1110 to L5S1, he decided to also do Coropec to me in a cervical spine and do posterior in the same time.
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And t-run and
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posterior, this is a new stylish model for a spine surgeon. Let's go anterior, posterior and lateral. Let's make the 3D looks beautiful. And this is one of them So now she has the cervical spine
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fused, the lumbar spine fused. And I wanted to tell you that she never had a spondylitises. She even had modic changes in the spine. She never had instability issues. It's just the back pain.
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Okay, so now she's coming loaded with drugs. So she's government and inflammatory, muscle relaxant, narcotic, she actually took two of them. Norco and tromedol, they were able to discontinue
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that I lauded and the morphine, because there is a lot of.
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in that, so now they go with narco and tramadole instead. And now that what really tipped her off with the her son, as well as her, her husband, that that pain clinic and that surgeon in a
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university setting told her, now we need to go to fentanyl batch. Now in the news in the United States, there's a lot of fentanyl crab coming from different countries to America and people die. So
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the minute she heard about fentanyl, I said, oh no, this is going to kill me.
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So this is where she went, she was going to church, and then they told her about me and all of this. So she came to me with this. In the meantime, she's a patient, high blood pressure, high
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cholesterol. What do you expect us to be in a vitamin D deficiency? She's a couch potato, we call them. Of course, she doesn't move, she's drunk In addition to that, the orthopedic said, maybe
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the knee pain is coming from the knee, let me do knee replacement. And then after that, the lady got depressed. Oh, I wonder why. So she goes to her own psychiatrist. And in addition to that,
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she did her best because the orthopedic is a neurosurgeon told that you need to stop smoking. Otherwise, I'm not going to do fusion. She'll stop smoking. This is the good thing that he did. And
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then she had some other issues, which is osteoarthritis She's married. She has three children. And she is not close to any child. And this is very important because once you get into this
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life of style, the kids is going to run away. You can't even take care of their children or grandchildren. So it becomes like a family crisis. In the meantime, as you can see, she has
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constipation and in artificial surgery and all of the other stuff like this is she had a lift a hip, tendons get bad, the breast is big so they told her let's do breast reduction. maybe you're
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gonna help your yourself. And this is the medication including Lexi Bro for depression. And she's having now the Norco, the Tresadon, because she cannot sleep, the tramadol, and all of this and
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about to do the fenton. This is in addition to every month, some sort of an injection. She cannot even count to me how many different injections she had. I wanted to remind you that this is not
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the only unique case that we have in Chicago or worldwide or in United States while this is all over the place. This is a classic case. She's short lady and they say, but her BMI is not that bad.
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It's 30 and this is her exam. Nothing fantastic about her exam, except she may have a list of bit residual myelopathy, but she definitely fits the criteria that we all have. It's called
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field-backed syndrome, post-laminitum syndrome, chronic-backed syndrome, or the arachonditis as well in addition to that,
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that she had that put her in all this trouble. Okay, and this is the surgeries that we did. Now, interestingly, the last MRI was in 2022. The pink clinic were doing all kinds of procedures on
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her. For all this year, they never got once an MRI or a CAT scan. We are in 2005, and this is what she had. This is how she came to me. It is some of the diagnosis that I came across then The
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only thing you're missing here that you're going to know later is the rheumatoid arthritis. My assumption that she had spondylitis when she was 18 years old, which is very classic, so I decided, I
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said, Okay, I never reject anyone. Anybody, I have a clinic that's walking clinic, so I have no problem to see them. I have no problem to help them to diagnose, and this has been my reputation
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One of the advantages is I was trained under Dr. Asment. Your husband told me that to be a neurosurgeon, you need to be a neuro intensivist, to be a neuro intensivist, you need to be an internist,
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you need to be a pediatrician, you need to be anesthesiologist, and here always we'll have these consults while we're residents, and he will sit down with us every day, and he'll ask me, What is
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the medicine said? And then we have a small booklet, and we read about it. Let's read about lumber-spondylitis, who will become experts in that So everyone graduated under his program means that
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you need to be a holistic. You look at the patient as a patient, not just what you see nowadays. I'm a spine surgeon. I'm only going to look at the screws and the x-rays. This is with a beautiful
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way of training, and I wish that current programs do the same, which they don't. So this is, I debated it, that the board lady did not know everything, like from what level to what level I ask
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in about that. what lived, what lived. She wasn't, she was ignored. They didn't teach her. They didn't tell her. So I have now to start to summarize the entire history. So she has an adjacent
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living disease, obviously, and the
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thoracic spine. So let's look at the x-rays. This is the x-rays that I got, okay? And I ordered this. So this is what the screws, beautiful screws. You cannot tell, it's excellent Thank God
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for the robot, thank God for the navigation system. And look at the corbectomy. I have never heard of a corbectomy, and the patient didn't even have the OBL or calcification in this, because I
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was able to look at these films. This is the front and back, C5 to C7. Okay, well, if you put a corbectomy in only one level, maybe anterior bleeding won't be enough, no. And you can see now
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the thoracic kifosis is getting worse You can tell now this is how the neck is so beautiful, and look at them and look at the elements. So the only space lift is the thoracic spine, that's it. Now,
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and this is here what is, and the problem is he put aniliac screws. So now she has not just S1 screws, it's S, iliac screws here. And you can tell the lumbar doses is fantastic. You can tell the
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sagittal balance that we all learn as a neurosurgeon is spying, sagittal balance is so important Here is it, so beautiful. Like you cannot argue with this type of surgery, and yet she's miserable.
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Never one day after surgery or before the surgery that she got any improvement. You can tell you don't have to be smart to know that she has no spondylitises. He didn't do even occasions. He didn't
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do microdeskic to me, or
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any of this just slammed the screws in. Now there is no lumbar stenosis, like you can see. And I wanted to tell you, There is no sudhu meaning to seal or dioratami. The surgery was fantastic,
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you see that? And here is your arachonditis was clumping of the nerve loose. Watch the core muscles very weak. Watch the sole muscles is very weak, okay? And she had four years of therapy. This
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is like therapy never stopped, okay? Now you start to see that you don't have a changes in the thoracic spine and you may want to
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pay attention to the upper levels, which is T-9, 10 and T-10, 11 When you start to do things and this is the adjacent level, you see that? And this is, it starts to have a lot of vision to be
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changes. So she definitely have adjacent level disease and there's some stenosis into that. Here is your cervical spine, looks beautiful. What is the big deal? There is no stenosis, no
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discrimination. And this lady had a lot of issues. Now this is what we have done. This is the journey that you have done since the age We did physical work. therapy and physical therapy in America
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is not cheap. Sometimes the bill annually goes to 40 to 50 to100, 000. Massage therapy is about75 a month, a
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position. Act your punctures is a treatment. Tennis unit is a treatment. Psychotherapy, biofeedback, reconditioning. So I'm gonna take you through the journey of treatment. And then this is the
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nociceptive pathways that we all know, the nerve index, then you go and you pass the dorsal ganglion, the spinal cord, and this is the medication what we get. In the anti-inflammatory, we all
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know. We can do blocks by the local and aesthetic that block transmission. We can do alpha-2 agonist. We can do dorsal, it works in the dorsal root ganglion. We can do opioids, SSRI.
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All of this is works in the dorsum, horn as well as in the brain as well. We can give gababentin, ketamine and opioids, which is works in the doors of route entry. And we can do some of the
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opioids that works in the ascending pathway. So we have so many drugs that affects the no-deceptive pathways. And this is the definitions you have, whether you wanna drugs to take care of the
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no-deceptive, with the drugs for the trans-seductions, trans-emissions, and all of this. And this is the type of medication I'm gonna come to that. Or even the modulation of the pain to inhibit
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the painful signals and to improve the endorphins and the positive neurochemicals, or the perception as well by giving the alpha agonist, the acetaminophen IV, or the nowadays, they do the
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ketamine IV. But because we have opioid crisis, we decided that let's do non-opioid. And this is made more of the procedures are more attractive. So why are we doing now non-opioids? And this is
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the style now that we have. Now we have a lot of pain clinics say non opioid clinic, but in the meantime, the gift kit, the main IV is about1, 000 for every session. We do a lot of procedures
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now by the pain which it costs from two to4, 000. So this is what it is. This is how the statistics in 2015, 97 million people were using opioids. And here is the death and opioids that is
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increased. It's starting in 2013 And we did cause this. Nobody else caused it. I know they think that the companies use it. But let me tell you, you joined commission with a government agent,
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went to each hospital and told them, you must treat the pain. You must, you must write the pain. And if the pain is scored more than five, this is called dissatisfaction. And it's gonna be
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another model. So everybody jumped, including the companies, to take care of this. And this is coincide with the year, So yes, the government or the corporate or the national can push a new
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things called evidence-based practice. And only later, and I wrote an article about the opioids and Dr. Asman published in surgical neurology before all of this in 2005. And I said the liberal use
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of narcotics and you guys can see it. So it took 15 years from what I wrote or 10 years for someone to wake up and say, wait a minute Now the CDC say pain doesn't kill, but drugs kill. But in the
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past, you can't say that. You cannot say that. So this is what people did not realize that narcotics can stop breathing and the patient looks awake to you. We lost few residents in anesthesia that
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they will go to the bathroom. They will take the fentanyl. They know that they're feeling high. They know they're awake, but they cannot breathe And this is what is not clicking. into these
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people, you look away, but you cannot breathe until you desaturate and then you die. And this is the catch in this embeoids. And
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this is now
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the other side effects that you see. The other thing is that in England they published it many years ago and they say that,
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you know, and in animals when you take opioids, you shut down the endorphins that got almighty created on you. So when you take the opioids now, anyone touch you or little pain, it becomes
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hyperalergiesia. You become extremely sensitive and this puts you into more different type of pain that is very hard to control. And that is why they came and say, wait a minute, let's find drugs
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other than opioids Maybe opioids is the bad. Our youth are dying. I lose a lot of pay a lot of patients. We lose a lot of young adults to this narcotics. So, and this is where it's getting now to
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a different type of abuse and I wrote an article about it. But let's find out what is the non-obiois then that we can use. So you do the NMD receptors like ketamine. Now we have something called
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ketamine clinic. If you're depressed a little bit or you have a chronic pain, they give you 10 and 20 milligram IV. We get10, 000 from you and
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you'll be okay. And then there's a matter of fun. And then some people think magnesium is great and the convulsant will all good at it, whether with our with our, um, Gaba Benton or Brigilepline
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or Tigratol, all
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of this is works. And then they, all the classic anti-inflammatory, whether it's like some or keto, like even. And then you, they cut their own is also good. Um, so this is some of the, uh,
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this is some of the thing or the local analytics, you walk in a clinic, we're going to do a block. And then the Bresidaxid that is very dexametedine that is now getting famous in anesthesia. And
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we use it that calmyolytid pounds is alpha-2 agonist. Clonidine, we injected enterothical or even it's alpha-2 agonist or IV, miscellaneous, thylomol IV. Now we give, we give to patients and
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then sambalta. Sambalta is supposed to be for psychiatric depression, but it turned out it helps in pain, osmolol, but this is, this is to kill And here is the celebrates. It's anti-inflammatory,
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COX2 inhibitor. You're getting eye, this is, but every one of them has side effects. This is not benign, you know, whether GI bleeding or things like that. Ketrolac also, here is the ketrolac.
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You can get it IV or PO. And then the dexamethasone, we're all good at it. And then the lidocaine, you can actually give IV lidocaine. We do that during anesthesia to try to enhance the
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anesthesia giving opioids, it does work, lidocaine has sedative effects. And then the presidaxideximitidine is becoming like the glorious drug that you can combine it during anesthesia in order not
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to use opioids. It's an IV, okay? And then the clonidine that we also can use, but the clonidine is a longer acting. It works in locus seruleus. And then the thylenol is an IV formula was
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available So we give it in a recovery for pain. So all of this is its own non-obioids. And then the sapata that we talked about is a serotonin. It increases the noribenephrine re-uptake. So this
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is
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what you can see now with the wiz drugs. And then the famous ketamine. And I don't know how famous it is in Africa, but it's very famous in America now with the ketamine infusion. But to also use
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during surgery, Spain for the spine, I also use it, but make sure. You understand, it provides hallucination, although it's a very strong analgesic with that. And Texas Murphy as well is an MDA.
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We don't use magnesium, but there's some people believe that ID magnesium is fantastic. The government in we use gababentin. Gababentin becoming very classic. In fact, that when you go to, when
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you want to prove to the government that you are doing the right thing before you put the patient in narco-tramidal, you have to prove that you put the patient to the government. So if you have back
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pain, go back ventin. You have headache, go back ventin. So go back ventin is becoming also a very famous drug. It's an, it's a, it's a, you can see it's alpha two, delta one subunit in the
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Bresynaptic Calcium. It's be all, but it has a lot of things that can affect the division, can gain the weight. And here is the, and here's the Brie-Geblin is the same, but do you think if
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you're allergic to neuroaffin, go back ventin, you can get Lureka, to 150 milligrams, then you're out and you can go up to 300, 000. And I wanted to remind you that these patients are advanced
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in age, like this lady, when you give them these drugs, I have some of them that they've been diagnosed by their husbands and their primary physician that they're demented, dementia. And I tell
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him it's not dementia, it's the terminal that is doing this and just cut off these drugs. But this is real. And I wrote several case reports and an article that Gaba Benton has some issues with
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induced societal. And we lost two or three that I'm fully aware of it. One of them was one of my patients came to me and I saw him and he was having the same track at 28 years old. And he has a
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borderline depression. His physician gave him the Gaba Benton, didn't tell him about the side effects, two years later he comers societal. So what else is there? So we talked about opioids, we
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all good at it. And now we talked about non-obioids. So let's talk about procedures. We love procedures in America. Why? Because if you don't do procedures, you're not going to make money.
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Clinics, I make30. But if I do procedures, maybe200. So procedures is very attractive to the pain people and to the neurosurgeons as well. And this is the intervention procedures. We can go with
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the simple ones Like trigger point injection. So whatever the muscle in the back, standard inject. And they think that this is good. But repeated of this can cause fibrosis. And if the needle is
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too deep, you can cause pneumothorose or hematoma, the patient in the blood thinner. So you have to be careful. But it's simple procedure. You put little steroids, you put local anesthetic, and
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you do the trigger point injection. Very common, very, very common Let me see. Okay. Now, and this is the trigger point injection. They have some side effects, especially if you start to do
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that, and this is what you see, I'm so sorry. So the trigger point injection be very careful, especially when you come to the intercostal area. Now, we're going to go to Anna. It's some other
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procedures, facet injection. So they think that the little facet in the neck or in the thoracic or the lumbar spine, if you inject this facet, it can give you two things One, you may be candid
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for fusion if you demonstrate that this facet is okay. It scores the pain. You may also want to do radio frequency abelor. You may also do radio frequency that I'm going to come to it. So facet as
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an origin of pain, we know that this is true. You can do facet injection. But that injection lasts two or three weeks. So it's not really a long term. Radio frequency abelation to that area Also,
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it may last. weeks and that's it. But these injections, when the medial branch injections and all of this, also has some issues. You can hit that urine, maybe if you don't or you can produce
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spinal anesthesia or meningitis. But this is a very common and simple procedure to do. The pain clinic will do that all the time. What about the famous epidural steroid injection? You can do a
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epidural steroid injection, but you can tell from a SNI digital with Nancy and Osman that they demonstrated by literature review that epidural injections doesn't really work in the
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long run. It actually cause complications. But here in America, I assist you. You can't do surgery unless you do an epidural injections. But anyway, epidural injection can. The way it works
31:26
with me when the patient has a small disc herniation, not large, because at that time, we think is there is the chemical irritation that's causing the pain. Okay, so this is fine. The other
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thing also, if the patient absolutely doesn't want this surgery, doesn't, and you want to give him one or two or three days of relief or a week or two, you can. But as long as you know that when
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you give injection, you can cause more neurologic deficits. But this is how you do the injection. Either you do enter a laminar like the briefest slide, or you come in the side If you come in the
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side is better, the only problem when you come in the side, you may catch a reticular artery, and you may end up by anterior spinal cord syndrome. So you have to use dexamethasone. But the
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epidural, we call it translaminar, is actually in the midline. Okay, and this is how you do the epidural injection. We don't put catheters in people for chronic pain. These days of epidural
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intermittent, You don't do that.
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but there is contraindication, obviously, when there is severe stenosis, when the patient has a foot drop, what are you gonna do with the abidurosoid injection? In fact, one of the levels you
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need to be very careful because we wrote the articles. I did write the articles in L45. If you give abiduro, you can end up by having a foot drop.
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And then these pain people said, well, wait a minute, for arthritis or dyscythesia or complex original pain syndrome, let's stay out of the
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spinal canal and let's go to the sympathetic. So we're going to do a stellar ganglia block in the neck. But you know, you have a lot of vascular, carotid vertebra you can have, but this is a good
33:15
one for complex original pain syndrome, for brachial blexopathy. And you do two to three is not like for good. But believe it or not now, they do more, much more than that. There is a pain
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clinic guide I think it's good for, for, for, for the. for people whose post-traumatic distresses order. Do you believe this? Do you think that Stellit ganglia block and look it up is excellent
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for all the hit concussion and post-traumatic distresses order and he got a contract for veterans coming with this. I don't know, what is the basics with it? But he found in dogs, it does a great
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job. And this is real. I just want you to present to you that they never stop to try to do new innovative things to catch this no deceptive pathways with whatever it is. And the brain clinic people
34:06
are taking over the spine surgery now, as you can see later on how advanced they are. And now the neuromodulation, which is the stimulation, we do a very good job at it now. We do it in the brain,
34:19
as in the old in the old in the 1970s. We do cranial nerves like for trigeminal neuralgia. We do it in the spinal cord, whether the cervical thoracic We're doing that. Those are root gangl in the
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lumber spine. We do in the peripheral nerves. All of this, we put the same electorate with the generator. So we're able to stimulate neuromodulation from the brain all the way down to the nerves
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and the extremities. And they think it's safe. They think it lists drugs, but the complication is still high 30 to 40. And the
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complications can be from lead migration to seroma infection, CSF leak And this is what you see now into this. This is your spinal stimulator. And guess what? We're not gonna put one. We're gonna
35:08
put two. We're not gonna put two. We may put three or maybe four. And we may do surgery and put a contact. We call it surgical leads. That system, it costs80, 000 by the way. And then they
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said, well, okay, there were some pain people, adamant. Quality of life is so important People should never, ever. experience pain. So we're going to put enter the compound in them. And we're
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going to inject morphine or dilated or clanted in or local and aesthetic. They will come everywhere every month and we're going to refill this. And the patient will live with it. And they do live
35:47
with it. But they cannot stop it. But this is how advanced we believe that natural human beings that at some point lived to a hundred years old never saw so much intervention that we were abusing
36:04
them because now the pain is not acceptable and we had to do something. And this is what we've been doing. They put the catheter in and nowadays in my time used to be surgery do it, neurosurgeons.
36:17
Now the pain clinic, we used to do it in the operating room. Now they can use it in surgery center and sometimes in the pain clinic that the pain people are owning the clinic. So now we have that.
36:29
And now you have a PA. And you have a regular patients now coming under patients to help you. And this is how they do it. So now the pain people that they did one year of fellowship can do the
36:43
entire procedure from putting the catheters and thread it all the way to the generator. And they can deal with the complication. They can revise it. They can do all of that. And that catheter
36:55
sometimes goes all the way up to the cervical Especially when patient has craniofacial, craniofacial, or cervical pain, okay? And now with the stimulation also, as you know, not only the cranial
37:08
nerves, we can do it for headache too, and the sub-oxibital headache, and for my grain headache. And it's interesting that this was a text box, and many people using it, and now you hardly see
37:21
people using it, because it's horrible. You do this procedure, you run into so many complications, the same life for buttocks. You run into this this satigia, the same like injection, the same
37:35
like in 1950s, when they said cutting in a nerve is not the treatment, we used to cut the nerve because it can cause severe pain. So what other procedures? Guy for blasting, how are we doing?
37:46
Electoral therapy and the cooling. In fact, they can put the pain people. If you have a back pain, they can put that electrode inside the vertebral body by going through the medical and burning
37:59
the vertebral body And they think they burn the vertebral nerves inside the body. This is all handled by non-surgeons, non-neuro. This is purely pain clinic. And this is the D2, now kyphoblasti.
38:14
It used to be me do the kyphoblasti. Now they do kyphoblasti without. And this is a very attractive to them. And the kyphoblasti is great because it can augment the bone and you think it's the
38:26
origin of pain And so. The side effects of narcotics, I don't have to tell you, the newspaper and the media. So they said, well, this
38:40
drug is called zeconatide, and it works inside by the calcium channels and you can put it to the morphine pump. So now morphine, dilated, we can put this drug and then all of us know the baclofen,
38:52
but baclofen is real and this is for specificity And then they develop this protocol and they say, Don't abuse enterothetical pump. Do this diagram, start conservative, then drugs, then our
39:06
colleagues, then neuromodulation, then at the end do the enterothetical therapy. So we have it done. We have a great policy in the United States of America for all of this and all of this is
39:16
started by a surgeon that decided to put screws in the lady that did not need it. And here is your complications. So what is the new trends now neuromodulation? I don't know in Africa if the pink
39:28
people are doing this. actually doing surgery, look at this, endoscopic this kick to me, or mild procedure, mild procedures where they do decompression by the way. So they said, let us knit
39:39
little bit of like a mantis flavum, intercept and verteflex. This is, this is by the way, companies try to sell it to the neurosurgeon. The neurosurgeon told them, get the hell out of here.
39:59
This doesn't make any sense. So they, this industry found a way to go to the pain people and say, you don't need to be surgeon, and you're going to make a lot of money. In fact, the codes for
40:03
this is equal to the code of my microdiskectum and even much better because
40:21
they do it in the outpatient center. So this is all the procedures now. So if you guys don't know that, be my guess. They do this ketamine, they do laminectomy, they do actually facet fusion.
40:23
They do SI fusion. This is all done by the pain people and no one can stop it, including my organization. your organization, they're not stuck. And now they actually giving themselves, believe
40:34
it or not, and they're very good at it, because they know how to catheterize the spine. So this is an easy way for them. Now, I agree for them, they need to know that the close claim studies
40:49
showed that the pain procedures are really with extensive side effects. And not only that, they can actually paralyze the patients. When you put an electrode, you can run into trouble. So this is
41:02
what you see now. So let's go back to my patients. So what did I do? First, I did a diagnostic SI injection. I wanted to see if the SI joint is actually part of her pain. It turned out to be
41:15
none, okay? So I told her, you know what? I don't respect any drugs. This is me. And your age is gonna make you demented, it's gonna mess your kidney So you need to cut this down completely.
41:29
And I think you're a good candidate for neuromodulation. No one have talked to her about this, which is really strange. But anyway, so this is it. I did medical cardiology, psychology clearance.
41:40
I told her to stop the drugs. And the only ones that I will do surgery, whether it's spine surgery or neuromodulation, if the patient stops the drugs, this is my school. You can call me any human,
41:57
you can call me harsh I, you can call me whatever you want to call me. But this is how I believe in it. The maximum one Norco a day, nothing else. So this lady did it. So I knew that she's a
42:10
solid lady. Now she really wanted to get better. And the only tip of this is a kid who, somebody like me just opened the subject to her. I tell her, I understand your pain. You never needed this,
42:24
this fake surgeries but you have 10 years to live more. 20 years to live more either you're going to live at healthy and take care of your husband that is sick and let your kids love you back and see
42:36
your children or just keep going with your place. So she abandoned with me and based on that I gave her everything I have. So because she had the adjacent level disease, I decided I'm not the spine
42:50
expert that you all know about in the great people. I said I don't believe in using the spine. I understand if you go to any spine surgeon is going to need now you need fusion from C7 to T11. Now
43:03
your entire spine is messed up. I said I'm not going to do that. I don't ever believe in this. I'm going to put you in a straightforward brace and I'm going to do the little decompression and I'm
43:12
going to put the surgically and this is what I did. You can see I don't believe in the in the sagittal balance or the spine things that they talk about. I just did simple decompression I did not put
43:25
a single screw and on the direct vision, I put the surgical. Why did I choose the surgical lead? Because I can't use briefcutaneous. Why? Because the patient has motoristinosis. So you don't
43:36
want to hurt the spinal cord. Number two, the surgical lead doesn't move a lot. So I know once I put it in, it's not gonna move. Okay, so this is what I did. And I did the mitronic and septives.
43:49
And by all means, I don't encourage one company and the others. I think they're all making a lot of money. But if I use what they have helped my patient, I'm totally for it. And this is a closed
44:02
loop, has a closed loop technology. So the spinal stimulator in cases like this selected is good, look at this. Only one contact, you can see it. I did decompression at that level. I put the
44:15
surgical lead and this what I did. T8, 9, and 10. T8, 9, and 10 covers the back, covers the leg because she has pain from the miturassic all the way down. This is the worst pain that she has
44:27
And then five days. She said, Oh my God, I never felt as good as this and I took her back and I connected the generator to this. She went home. This is one surgery called, it took for me 30
44:42
minutes and each time. The pain went down, down, down, down to two, to two out ten. Never, ever she was like this, okay? When you selected the technology that works for the patient, not you
44:57
working for the technology or the coding system. Now she said, wait a minute, her husband is so happy, he comes with smiling. My wife is not forgetting things. She actually leave me alone and I
45:10
sleep the whole night. I cannot believe it. She's already doing some flowers outside the house. Oh my God, she's shopping. She's talking to people in the phone nonstop. She's even volunteering
45:22
in the community. I cannot believe this how much health care in America that's to be the best in the country have done. This is her. This is her two weeks ago. I did the surgery in March. This is
45:38
five month later or six month later. This is her. No walker. No cane. Her legs are strong. She's have a new face in life. This is her. Her husband. Look how smile he is. So a spinal cord
45:53
stimulator. When it's done right, it's good. Pain clinic will never do what I do. They don't know what the compression means in the adjacent and all of this. We need to have the ownership of the
46:06
care of the people of Spain, but we must look at ourselves in the mirror to say, we need to do it for the patient, not to make the freaking money in the end. This is all look good in the x-rays.
46:18
If you look at Lincoln and Facebook, you're going to find every center in the world will put the x-rays of the patient. Never once! that they put the patient pictures. Why? Because the majority
46:33
of them, I have my assumption, they're afraid that that patient is actually not doing good and it's gonna write a bad
46:42
code about them, okay? It started to like what Asman told me, treat the patient, not the MRI, not the x-ray, not the government, not the coding system. So this is what you see. So this is a
46:54
lot of talks about because I don't want to take any more time from you This is how the spinal cord then a stimulator works. And all of this is so many theories, not just the gate theory, it's also
47:07
through the chemicals in the dorsal root area, in the gray horn, in the spinal cord, at the spinal cord level, at the inhibitory in the brain, and all of this. This is all what this is done.
47:19
There's also a proof that in your apathy, spinal cord stimulator is good And in England, I heard they do it for circulation good. And now this is the doors of root ganglion, another abuse from
47:32
Bain Clinic. They put, look at this, they can go to the electric inside the spinal cord, inside the spinal canal and then they curve it and go out without decompression. Now this tells you that
47:44
they can have a lot of serious complications. And then they have, they start to work with the birth suppression, with all of the stuff, the DRG and all of this to make it much better So this is,
47:58
and I think that I'm gonna stop here and we can have questions. This galley, yeah, yeah,
48:08
I know, let me finish this another time, okay, bye. So now let me, I wanted to see how I can get my picture 'cause Dr. Osman taught me all the time, be able to like to see you. So are you
48:22
still with me? Yes, you can stop sharing your screen And yeah, I'm here.
48:28
So I'm still alive. Dr. Osman told me, say that people wanted to see you and you keep talking. So I got my lecture. Okay, terrific. Okay. Well, thank you. You went, you went through the
48:41
full range. I think by, I'm sure there will be lots of questions and, and comments. Now, one thing I wanted to, to say from the onset is that, you know, in the situation like this field back
48:55
syndrome, as you will know, it can be a misnomer if, if they didn't need surgery in the first place. Yes, yes, yes. So, I mean, I think that's lesson one, the proper, the proper indication.
49:09
Yeah, and I don't know if you shared with me as well, that this minimally invasive bogus, that they keep talking about it, and how people do the minimally invasive with the robot and all of this
49:20
and all is about putting the screws in the right place. What I have seen in six months, they start to have pain. and you look at these nerve glutes, it's stenotic, because the flamoratomy was
49:31
limited, all of this limited, and they'll all get profiled, who has failed back syndrome, or chronic back syndrome.
49:39
Well, I have some other comments and questions, but I'll open it up, I'll lead, would
49:48
you, go ahead. Thank you very much for such an eye-opening talk, really, we enjoyed it. I have two questions, doctor The new trend is that they put a plasma infusion to the back or to the knee.
50:00
What is your opinion? The second is that they use the weight loss, manjoura, or all these new weight loss things for the people who are always to diminish the chance of the thing. I wonder if you
50:14
would consider this for your patient to lose weight, not to insult them, but this is one of the things that they do to decrease the pressure on the spine Thank you very much. So both of them are
50:27
very good. And actually, since the ozambic and all of this came, I start to see beautiful women walking in the hospitals. So there is no doubt that it's all working. There is women and men that I
50:41
thought, even the priests in my church, I thought that they're always gonna be like this. And now they're becoming beautiful and thin and skilled at it. So there is no doubt. But losing weight is
50:55
good for every act. Not just for the health for all, but also you get an idea that this patient really wants to live, wanted to take care of themselves. One thing I have learned and the other was
51:08
meant to with me and the good doctors, you can't help with the patient that they don't want to help themselves. So losing weight is really great. But I have a little catch though into this. I had
51:20
patient came crying in my office because the spine surgeon kicked him and said, I don't operate in obese people like you. And they had a simple disc herniation. This was all they had, a simple
51:36
disc herniation. And I operated in them. And they got better. They were able to walk and they kept going. So there's no issues with that. One second. So this is the other one about the stem
51:50
cells. You know, I don't know because every patient that we had, it didn't help. So I have no experience into this. Except in America is a very attractive because thousands of dollars cash
52:05
insurance.
52:07
Thank you. So sorry about that. Yeah. Thank you. Thank you.
52:14
Who's next to us. I'm glad that you. You mentioned about the use on the paddle Electro the surgical lead for and it looks like you did it for the trial. I've been an advocate of that and did that
52:31
in my practice as well, placing the petal leaves for
52:36
the trial because as you mentioned, the most stable, less prospect for lead migration and also they provide better coverage than having two percutaneous, slender percutaneous leads.
52:54
And so I got to the point where I would say, you know, if you filled a trial with percutaneous
53:01
leads, you still might be a candidate because you may not have had an adequate trial without a petal lead. Yeah. And I totally agree with that. And this, and I, when I do the surgery, I know
53:14
for sure that this patient is going to fly because I get them through all of that Yeah. And you're you're you're you're you're in writing those money.
53:26
any questions? I mean, I think we had a very good
53:33
review of the different modalities and I'll be interested in knowing for the people in Africa how much of what Dr. Ghali talked about is available
53:50
and I know we will be going shortly to Dr. Banson's discussion and she will discuss some of that as it relates to Ghana but I'm wondering with other participants how much is how much availability do
54:11
you have where you are? I think, Walker, please go ahead
54:17
Yeah,
54:19
thank you, Dr. Ghadi, for your presentation to the very interesting European specialist. And I would agree with him that there are many procedures that have been taken over by pain specialists.
54:35
I work in Agacad, and I work with the Dr. Bevereh Tesseram as well. We do spinal cord stimulators, but they are very expensive. So there are few patients who end up getting them. However, we do
54:50
them together with the neurosagion, with spinesagion,
54:56
so that they are well-placed and as a military-disciplinary aspect of care of the
55:02
patient.
55:04
We also do ketamine infusions, especially for patients who have high impact chronic pain. And by the time we give ketamine,
55:15
there has to be an assessment of the multi-sprenal cyst team having tried everything, including psychotherapy, physiotherapy. other medications, and then we use ketamine as an intervention, but
55:30
also to facilitate the other therapies for it.
55:36
We insist on doing it in the hospital so that people don't abuse it. It gives relief on the psychological support for the patient We have psychiatrists who use it as well for depression and other
55:53
psychiatric problems. We do transfer epidemiosteroid injections. We do run clinics and the rehabilitation for patients,
56:04
but I agree with Dr. Gary that with pain management has to be multidisciplinary so that you can have total support of the patient
56:18
Dr. Gary, you talked about ketamine,
56:22
you ever give it in the spine?
56:26
Inside the spine? Yeah, like the dozo horn or something like that. You mean, no, IV during spine surgery? No, no. In the spinal? Yeah. No, no. I know in the past, they put too many drugs,
56:44
but we never did in the spine. I think I heard about it in the past. Do you guys do that or no? No,
56:53
of course, I was just thinking out of the box Yeah, no, there was a study came from Brazil that they put music in. They tried different drugs, but they didn't work. So for both Dr. Gala and Dr.
57:09
Walker, when you use ketamine, intravenous ketamine for people with chronic pain, what's the frequency of administration? Oh, it becomes a, the pain clinic loves it. Detailed the patient come
57:24
once a week hundred one thousand dollar. Yeah, and they think it's good for depression. They also think a magnetic stimulation in the brain is good for depression and good for chronic pain.
57:38
There's so much, and you know, it comes back to how can we diagnose the objective pain and we have any MRI or something
57:52
to do. But tell me about in Africa, the pain people, you have a lot of pain services, pain clinics. I know I heard in Egypt they have some.
58:02
Well, Dr. Marco, when you stepped up, Dr. Gali, Dr. Marco indicated that they have a multidisciplinary program where he is in Kenya. So maybe he could respond. And as you respond, Dr. Marco,
58:16
I'd like you to comment on what Dr. Gali said about the frequency and the cost, Given the economic. concerns where you are, what are you able to do with
58:31
IV ketamine for people with chronic pain?
58:36
Just as I said, ketamine,
58:39
the dose is vary. That's why FDA also can't come up with a way of prescribing it. We give it to high impact chronic pain patients. Those are like 7 of the chronic pain patients who are basically
58:58
debilitated by the pain. However, we do not give it until other team members have agreed with us that we need to give it. And it is an intervention that helps a patient to go on to do the other
59:12
therapies, like physical therapy, psychotherapy. Most of the pain patients actually don't listen to anybody if the pain is high. They look at you and like, Why are you talking to me? I need to
59:24
spend the code down. Things like psychotherapy, rehabilitation, are really hindered by that pain. So if you do give ketamine, it helps to break that. But then the part is so much, depending on
59:37
the patient. And that's why we have to have a multidisciplinary kind of approach to eat. So that the patient knows the problems and everybody's an agreement with it. The way we do it is
59:51
for chronic pain, we do it a bit longer compared to the psychiatrist, we do it for 14 minutes. Then we give it for like six days, we run it for maybe 12 hours or four hours, give it between three
1:00:05
days to six days. Then we repeat it after two months. But in those two months, they have to do their homework that they're supposed to do. Talk to their psychotherapist or psychiatrist, do their
1:00:17
physiotherapy, go back to their rheumatologist or spine surgeon or
1:00:23
any other primary doctor. And then to repeat it again, we have to convene as a team again. Those people are involved in their care. And then they
1:00:38
have to show progress
1:00:42
of improvement.
1:00:45
And then we know that it's working for them or not. But most of them, those high chronic pain patients, it gives them a break over around the month or two, they
1:00:56
continue their medications as well.
1:00:59
Sounds like you're giving it sparingly to enable them to participate or benefit from the other treatment modalities. Yes, exactly. Because if they don't, then they are really debilitated. And as
1:01:14
you know, all of you pain can be really debilitating, not only for the patient, but their psychosocial structure And then for - the other question was about - in practice in Africa.
1:01:28
So we at Inaga Khan, in Nairobi, we have a pain management unit, and we have three pain specialists in the hospital.
1:01:40
We work within the surgeons that work here, as well as pain surgeons, orthopedics. We also have a rehabilitation program for patients We involve psychologists and psychiatrists because of the CBT.
1:01:55
But the other places I know where they are. In Nairobi, there are also other pain specialists, but there are also natheists. They get busy with anesthesia. But in Inaga Khan, they see the whole
1:02:06
of East Africa, which is like five countries. We only have one unit in Inaga Khan. That's a population of around 100, 3 million people. And then having Egypt pain management, I think also, I
1:02:20
read a paper from Nigeria as well, but one of the robust uh pain management services is in South Africa uh and I think also Egypt uh now from the poster I saw where Ghana is also going to be having
1:02:39
the pain management. So they um they're doing do surgery now like in America all this might put this kick to me and let me uh decompression? No, no, we
1:02:54
uh we do transform in the idea of steroid injections, we do steroid ganglions, lambasic antibiotics uh but not and then for the implantation of the spinal cord, we work with the spinal cord. And
1:03:06
do
1:03:09
you do you have um do you have a law or some sort of way a practice that you have to do a bit during injection before you do microdiscectomy in a large discrimination like in America? No, no, we
1:03:23
don't have a law but The team we work with in the hospital, we discuss and
1:03:31
then sometimes they ask me to do the injections to see, take a patient into a physical rehabilitation program and counseling, pain and CBT.
1:03:42
Let's go get them optimized for surgery in case nothing works. And at least in that way, they're also physically conditioned to handle surgery
1:03:53
Okay, I think we should see if Dr. Benson is available. We passed it all and if Dr. Benson, are you available to proceed with your presentation? She had been - Yes, I am. Oh, great,
1:04:09
fantastic. Thank you, Dr. Ghali.
1:04:15
And we'll have some additional discussion after Dr. Benson's presentation, but wanted to go ahead with that. I'm here Okay. I'll listen to Dr. Benson.
1:04:25
So Dr. Benson, if you can share your screen and proceed, please.
1:04:32
Just say, if you can jump in anytime you're ready. I'll just say a couple of comments. Ramses,
1:04:40
I'm stunned with your presentation. First of all, the case was an incredible, an incredible example of
1:04:50
how much could be done to a patient for a small symptom and what had done to her life was just a disaster.
1:05:01
And then you reviewed all the different approaches of pain medicine, and it's probably because of my lack of education, but it's way beyond what I thought and how things can be done. And then what
1:05:17
you did to treat this lady by doing some minimal procedures and getting her offered drugs in re-establishing our life is. what was remarkable and the questions it raises, are we doing too much? And
1:05:32
that's both surgery and pain medicine. How do we control that? How do we do it appropriately?
1:05:39
It's just an overwhelming problem. A lot of abuse from doctors and patients. I mean, it's just an extremely complex problem.
1:05:56
The second speaker is Mabel Banson, and she'll talk about pain services that have been established in Ghana, which is an increasing need across the world in many countries.
1:06:11
Dr. Banson is in the Department of Neurosurgery, in the Neurosurgery Unit,
1:06:18
at the Coral Boo Teaching Hospital in Coral Boo, Accra in Ghana.
1:06:26
She's the visiting scholar at the University of Florida Health, and a lecturer at the University of Ghana in Accra.
1:06:37
This map here indicates the location of Ghana, which is a country in the western coast of Africa, situation situated in the Gulf of Guinea, and although it's relatively small in area and population.
1:06:55
Ghana is one of the leading countries in Africa, partly because of its considerable natural wealth, and partly because it was the first black African country south of the Sahara desert to achieve
1:07:09
independence from colonial rule.
1:07:15
So I would like to acknowledge that, uh-huh Go ahead, let me just, let me just say, Dr. Benson is at the Colibu
1:07:24
hospital in Accra, Ghana. I learned that she was the first female trained in neurosurgery in Ghana, and we're very glad to have her present today on pain services in Ghana. Please, Dr. Benson,
1:07:40
proceed Thank you so much for the invite, and then thank you for the introduction. I would like to acknowledge that I've seen heavily in the participants. I'd like to say hi and I also see Winnie,
1:07:57
Winnie, nice having you here.
1:08:02
So today, well, my presentation is quite short.
1:08:10
I'm just going to talk about what we have and not so much into details as what particular procedures that we actually have here. Yeah.
1:08:26
So this is the outline I'll go through
1:08:30
and that's has been
1:08:34
introduced. A neurosurgeon from Ghana, this is the Ghana map and then we are situated at the West African part of Africa, the West African continent.
1:08:49
So we are surrounded by our neighbors to go Burkina Faso and Códivua. And then to the southern area is the Gulf of Guinea. We do get referrals from our neighbors as well
1:09:12
I work in the Coley Booty Chair Hospital, there's a two-bedded hospital and serves most of the country's specialties, and particularly neurosurgery, it's one of the biggest centers in Ghana.
1:09:28
I also am a part-time lecturer with the University of Ghana where I graduated from Recently, I had my fellowship in minimally invasive neurosurgery, and during that fellowship, I also had the
1:09:43
opportunity to have a fellowship in interventional pain management, and then revisits my spine neurosurgery as well
1:09:52
So following that, I came back and started trying to establish something management services.
1:10:07
I'll get a bit into that later. Now, some of the centers and these centers I'm coming to talk about actually,
1:10:16
they actually offer services for all specialties in Ghana as well. Now Ghana has major specialty areas located in the southern, particularly in Rita Acra region, which is the capital city of the
1:10:33
country. And then we have those in the northern region and the Ashanti region taking care of the northern aspect of the country. Now when you take the Rita Acra region, we tend to have
1:10:50
majority of the hospitals located here. We have the Kolibbutichian Hospital, we have the Resenti built one, which is the University of Ghana Medical Centre. And then we have the Texas Southern
1:11:02
Military Hospital also. And then the Rita Acra Regional Hospital All these are. centers of excellence that have quite a wide range of specialty offerings. And then we also have a teaching hospital
1:11:20
in the southern sector but located in the Kipkus region.
1:11:26
Then in the northern aspect, we have
1:11:31
Ashanti region,
1:11:33
which is mainly covered by Confanochi teaching hospital. And then the tamale teaching hospital. In the private sector, we get quite some supports from there. And we have the trust hospital, of
1:11:48
course, the bank hospital. And Eureka, Eureka has really been
1:11:54
has contributed quite significantly. And they actually offer pain clinic services at their center. And we also have the other facilities that support. Our managing disciplines mainly is
1:12:11
neurosurgery and anesthesia.
1:12:14
Then, palliative medicine. What happens here is that, and I think probably most budding pain service areas, have the specialties involved in the particular patients treating their pain. So we
1:12:31
don't have really a structured system for pain management When it comes to interventional pain, most of them were being done by neurosurgeons, but now anesthesia counterparts have taken over and
1:12:46
things, and
1:12:49
with personnel, it happens that, aside me, we have one anesthetist who trained in pain, interventional pain. And he started about three years ago, has established a pain clinic in the anesthesia.
1:13:08
an anesthesia clinic and has been doing quite some procedures. And he's been quite influential in establishing some level of pain services for Ghana.
1:13:24
And one of the things he does is try and collaborate with all other teams to try and treat these patients Like I mentioned, our infrastructure for pain is unstructured. And we have treatment mainly
1:13:41
being done, but a specialist involved. And we barely have facilities offering pain services, but pain services are offered in these hospitals I've mentioned already And as we all know in most LMICs,
1:13:59
we have limitations when it comes to consumables and the number of equipment that are available to us.
1:14:08
where the pink clinics
1:14:11
that are available,
1:14:15
the Colubutichan Hospital and the St. Jude Department office that, and then the Iraqi, that I mentioned, the private facility.
1:14:27
Most of the cases that we see at these clinics, are that of back pain. Previously, when the Colubu one was started, almost all the patients were those patients that had back pain. Then recently,
1:14:42
the back pain has come to just about 40 to 50 of the kind of cases we see. Then we see the oncological cases, we see
1:14:57
the headache cases. And we are not getting people with trigeminal neurologists also coming. So the clinic is really expanding. And the numbers are also expanding it will get your points, we have
1:15:04
to actually build more. facilities for these.
1:15:10
So because of back pain, most of the things we tend to do are really the bigger out blocks and the selective blocks and trigger points blocks as well.
1:15:20
And when it comes to operative procedures, then of course that falls mainly on the new resurgence for the back pain. And then on college card cases and others fall depending on which specialty is
1:15:33
involved.
1:15:37
Following this, the Ghana College of Physicians and Sages, which is our national college, has started training in interventional pain, and this is being done under the anesthesia faculty, and it
1:15:54
has actually started increasing the personnel for this specialty, so we are getting this one. Now, what does the future hold for us? I think that we need to continue to build capacity. We need
1:16:14
centers, pain clinics available that have multidisciplinary care for us and for our patients as well. We need to have local international collaboration One has started and this platform actually
1:16:30
forms a platform for such a collaboration. And I think with some of these, we'll get quite an established pain management service for Ghana and our nearby facilities, nearby countries. And
1:16:50
this is what I think would the future holds. Thank you so much for this presentation. Okay. Well, thank you
1:17:04
Thank you very much, Dr. Benson. You can stop sharing your screen and we'll open it up for discussion, questions. I wanted to ask you, well, how are you treating your cases of trigeminal
1:17:19
neuralgia?
1:17:23
So for now, it's mostly medications. We don't have
1:17:32
a reduced pregnancy
1:17:37
to use. So mostly, we tend to go more medications for now. And then when it comes to, we don't do microvascular decompression here, too.
1:17:51
We don't do microvascular decompression.
1:17:55
So then we,
1:17:57
it's one of the things we are also developing to try and factor these things in, probably because we are not seeing enough of the cases. So we are building capacity towards there as well.
1:18:19
Okay. And you had mentioned your interest in pain management and you just finished the recent stint in the US. With your interest and with the interventional pain specialist that you have at your
1:18:31
facility now? Have you begun to do any collaborative work? And Dr. Mwaka in East Africa mentioned that they have a program that they've started where they're doing some collaboration. What's the
1:18:48
state with where you are?
1:18:53
So more or less, I just came back. But my anesthesia colleagues have been doing quite some collaborations They have partners in the US that they go to
1:19:07
learn certain procedures. Their residents that they are training do that quite often. So they go and come back. Are there any comments or questions from the audience?
1:19:22
I don't think that Africa is the spread of print clinics is
1:19:30
unique because I heard also from some of my fellows that Canada also only had few centers. England also has few centers. And so this is a worldwide issue, probably except in America because it's
1:19:42
very lucrative in America to be vain. Although after cutting down the
1:19:55
reimbursement, not a lot of, not a lot of being people going to pain The other trend that I see negative is the
1:20:07
pink clinic in America and how recruiting people in family practice and psychiatry and neurology. So you start to imagine now that those people are going to actually do graduate and do procedures.
1:20:20
And this is, to me it asks, do the neurosurgeon on the spine surgeon wanted to give up doing a bit Europe and like the old days. and
1:20:35
handled as intraspinal procedures. And this is an important topic here in America. I don't think the organization is able to stop them. So I don't know if this something is good. Well, I think
1:20:50
you have a unique perspective, having trained in neurosurgery and in interventional pain and neurocritical care. And you have obviously
1:21:02
have a connection with Egypt And so I'm very interested in your perspective on what might be an optimal way for these places in Sub-Saharan Africa that don't have much going on now, but are starting
1:21:16
to develop it. How would you recommend going about that developmental process? Yeah, this is really a very good question. So I'm also, and I'm also, believe it or not, I'm an NCCiologist too.
1:21:32
No, right, and I fully practice all of them.
1:21:38
So
1:21:41
in resources that is low in Africa and particular, I will propose that actually the spine surgeon should be able to do a lot of the spine procedures. I'm gonna tell you why, because the spine
1:21:58
surgeon, whether new or off the bat You mean as long as surgeons should do the intervention of procedure? An intervention procedure. And then if you really zoom into this issue, you don't really
1:22:11
need a pain people to come and the pain clinics to come, because those pain people will be trained from America or so, and they have completely different look at the spine and the pain procedures I
1:22:27
think that a spine-comprehensive brain surgeon will be able to tailor. First, he knows the anatomy very well. Number two, he will respect if you need surgery and let's cut the losses and don't
1:22:44
waste your time in a video, or it's gonna say, you know what, let's go ahead and pursue the surgery. But then it lift the medication. The medication itself can be handled by medical duct They
1:22:59
know the complications of these medications, whether internal medicine or family practice. This is one idea. The second idea is the unique few of interventionalists that they do these procedures,
1:23:16
but you also wanted to make sure that the pain people do the medications. So this is what I would consider
1:23:27
So you would suggest that they should - try to get training in, in the typical repertoire of interventional pain spares, for said blocks, epidural injections, translamino, transliraminal
1:23:46
injections,
1:23:48
and all of that. And this should be easy for them. Or you should construct what that pain people will do. Like say, intra spinal injections in between because we do a number drains, and we do all
1:24:03
of that, that they can do this. And all you need is a PA position assistant or intermediate that works with the that spine surgeon. And then the advantage for me is while I'm doing the injection,
1:24:18
I get to know the patient well, if this patient freaks out and go into a coma, or this is I need to be very careful with this type of patients. If the patient tells me that I didn't get Any
1:24:31
improvement at all, it gives me some impression about the patient. But if you restrict, not restrict, if you will identify what the pain person will do that the spine surgeon cannot do and the
1:24:44
family practice cannot do, you can say, okay, we need, we can handle it as in these countries, like what? Let's say that the pain person will do the facet, they do a radio frequency, this is
1:24:57
all outside the spine and let's him also handle the medication.
1:25:03
But I will do that. Now, the other thing that you and me need to talk about is do you really think that your injections makes a big difference? Do you really think facet injections makes a big
1:25:16
difference? You know what I mean? Because, you know, this is all game because there's a specialty called pain that they wanted to make sure that the patient has no pain, no pain at all. And all
1:25:29
of this is our temporary, you know what I mean? So what we're actually doing. Oh, I agree with you 100.
1:25:39
When you look at the literature, maybe about half of the, maybe about 50 of people respond to epidural steroid injections, and half of that seems to be a placebo effect. Yes, yes, yes. And then
1:25:53
we always love to publish what England have done. They say they got this 10, 000 people. And they this is really seriously, the people and drugs and all of the stuff. And the other people did ice
1:26:06
packs, they found the ice pack is better than all of this. So you know what I mean? So, you know what I mean? Like, like at some point, you wanted to say, maybe we actually put putting in
1:26:19
their mind to keep doing these non structural corrections of the spine. And then the other thing you wanted to think about it as well, is really important is are we doing more of unnecessary spine
1:26:35
surgeons and that is why we have all these problems because once you have a spine surgeon do surgery the spine surgeon cannot continue to see the patient he has to send them to someone that to say
1:26:48
okay this is chronic pain we're gonna do this we're gonna do this and then if you send the patient back to the primary physician what he's gonna do so maybe we need to read again about this maximally
1:26:60
invasive distribution of a spine surgeons the spine surgery and spine surgeons so sorry i have my own disclaimers yeah interesting well Ali it looks like Ali it looks like you've been trying to say
1:27:14
something please go ahead yeah i have a question from dr golly what is your opinion about the anterior cingular gyrus ablation that they do at the end of the thing that they cannot drink the pain
1:27:27
Because there are no resurgence. Few I know that they have done that for extreme cases that there's no treatment. What's your experience or what do you know? Because this is something collaborative.
1:27:38
I appreciate you can comment on that. Yeah, so the last time we did this was back in 1989
1:27:46
because what happened is you actually do what they have done in the past by front of the victim is in all of this. You alter that person forever. So, and the concept for someone to have a brain
1:28:02
surgery for pain, it doesn't fly anymore. It does not fly. Just to tell someone I'm gonna experience pain but you're not gonna alter your perception of that. The only time that we used to do with
1:28:16
restriction in 1980s is by having a psychiatric evaluation to that patient and it has to be central pain. So if you have a center of pain, like a bolster stroke, severe hemyside pain, and you
1:28:33
can't treat it at all, you may consider that. But a lot of people will not go for it. A lot of patients, because it's a brain surgery. What I found interesting that you can do as many surgeries,
1:28:45
but if you say, I'm gonna do brain surgery for this, no, there's no way. And you don't even have to talk about anti-singilotomy You can say, What about the motor stimulation? The stimulation of
1:28:56
the motor cortex, for instance, that shows that it can improve little bit. Now we have more technology said, and instead
1:29:10
of putting the motor stimulation, let's do magnetic stimulation in the brain. So, although it's a good idea back then, but now I don't think we're gonna get a lot of attractive, unless you
1:29:16
consider radio surgery. Like you say, we're gonna do the ATT or singlets, because now they replace the surgery
1:29:25
Right, Jimin and neurology, and it just buzzed that nerve. You know what I mean? With skull-based surgery, don't take the tumor out, let's buzz it. So maybe they can rediate these certain areas.
1:29:37
Thank you, sir. Thank you, and look forward to that. Thank you for the intelligent questions that you have. This is wonderful. Thank you, Dr. Young, who was a painless patient. I learned it
1:29:47
from him, and I know he used, he had offered to, one, is the RF, using bilaterally, or do the gamma knife, which takes a six month to one year till the pain goes away. That's what I learned
1:30:01
from him, in the extreme cases. That's why I ask you, thank you very much. Yeah, extreme changes to the different story, you know, from one case to one hand. Also, if I
1:30:11
can talk to Dr. Osman one minute, Dr. Strada, Dr. Osman, I think it's time for you to write a letter to the American Board of Neurosurgery. because most of the neurosurgeon trained are doing a
1:30:24
spine surgery. Because there's not many brain tumor or something to do. And they make them aware these are the side effects. And many cases we see with failback syndrome, it's a routine,
1:30:38
unfortunately. To bring it to their attention, what they are doing in training the neurosurgeon, new neurosurgeon, it's wrong. Yeah, to bring the patient, I mean, room five Yeah, really, I
1:30:51
appreciate it. If you consider that you discuss this with them, because these are the intelligent conversation we have in all these specialists, not only Africa, in America, because this is the
1:31:03
big money-making area with the spine surgery, spine neurosurgeons. I really appreciate you can consider writing a letter to the American Board of Neurosurgeons, what your thing is wrong And this is
1:31:17
not the correct way to train in neurosurgeon. Thank you, Doctor.
1:31:22
Okay.
1:31:25
Yeah, Dr. Osman wrote a lot of things and I agree with that.
1:31:32
So I have read your article and so I have read many of his. I really appreciate. Ramses, let me ask you a question. I'm in Africa. I have patients who have pain. As we've seen, some of these
1:31:48
people are getting into it What's your advice to them and how do we control abuse?
1:32:03
This is, this is, this is a very good question,
1:32:08
how to, how to, how to do, I think that the first thing, you do the procedure that actually have results,
1:32:17
treat the human being as a human being. If, if this person is sensitive of so-called pain, or if this person really have a structure or a problem that you can see, at some point we have to come up
1:32:31
with this. Having a back pain, it doesn't mean that we need to put screws in your back, because a lot of these problems that are asked when I'm afraid, that is, is not doing a role, is generated
1:32:45
by unnecessary surgery or unnecessary management. This is the first So if we have a highly educated, bracketically, not based on incentive to do what is right for each person, this is gonna be a
1:33:02
fantastic saving. Is it really a cost saving? This is the firm. The second is do the right surgery for the right person. Don't take shape little part of the desk and leave the list of the desk or
1:33:16
the firm and the stenotic and it will cost much more money. So prevention is very important and doing the right thing The abuse, it's a big problem because it's a social problem. It's a cultural
1:33:31
problem. We're putting in patients' brain and I tell them, I tell them beside the fix before the benefits, we putting in people that pain is bad. I tell them pain is good. If the pain is coming
1:33:47
from some sort of a source, but if I can't see it, then this is a benign pain and we need to find anything else other than procedures and surgeries. education, high in the skilled, it doesn't
1:34:02
have to be so many people. And then start to stop. The very important is the unnecessary procedures that we put it into the patients.
1:34:15
Okay, thank you very much. Thank you, thank you. Are there any more questions Mr. Rata? I think we've exhausted this subject here
1:34:27
and - Sure I think we've had a good discussion and I appreciate Dr. Gali and Dr. Benson doing their presentations. So unless there's any -
1:34:39
I think Gabrielle has another comment there. Okay. Go ahead Gabrielle, please. Okay, yeah, I'm listening to this. Yeah, I'm speaking from Nigeria.
1:34:51
I've had a privilege of practicing in different regions in Nigeria and I must confess. that we don't have so much of the feedbacks as syndromes.
1:35:07
Maybe because we don't instrument as much, I'm away, the number of centers do so. But I'm also aware too that there are a lot of questions with regards to instrumenting.
1:35:23
And I think if in Nigeria and choose this to build this capacity by training in functional neurosurgery outside the country and coming back to establish centers to manage pain for
1:35:41
failed vaccine drums or other causes of
1:35:45
pains from
1:35:48
arising from neurosurgical complications. I think the person would likely run out of business. Probably that's the reason why we don't have more to a functional neurosurgeon's around box. We do
1:35:59
need functional neuroscience for other neurosurgical problems like those I have to do with spasticity and the
1:36:10
neuro, sorry, some neurological conditions, but for pain, maybe my senior, they may have different experience, but from the various regions I have had to practice I have not really had so much,
1:36:27
but I have only seen one peer back syndrome with my experience or very decade in neurosurgical practice. And that for me is just
1:36:40
a too small ticket, a case to really be so
1:36:46
bothered getting,
1:36:50
I mean, building capacities for But I think as we probably grew in our neurosurgical practice here. Probably as we have more cases, we probably, me, live the shows of the country to build our
1:37:05
capacities and be of help to those that have pins from neurosurgical complications, particularly peer back syndrome, particularly. So this is my one experience.
1:37:20
And so this is my experience. Okay. Go ahead. Yeah, so this is my experience and I think I should air it out. Some of us may have different opinions, but this is my own personal opinion, my own
1:37:36
personal experience with regards to issues of peer back syndrome, pins from a peer back syndrome. Thank you very much. So, but this is a very important comment and very important observation in
1:37:52
Nigeria. You don't have the syndrome we have in America, which is incentive. and make more money by doing more. So first, in Nigeria, when you do surgery, you do it because
1:38:08
it's needed to be done. And it's not for functional pain. And I think people, when I say functional pain, they feel that I'm doing something inhuman. I believe strongly there is an organic pain
1:38:23
and there is a functional pain If you don't see the problem objectively, if structurally there is no problem in the MRI, you don't have to fix it by quote unquote dark desk or this is a facet
1:38:38
injection, it gets you a relief. So Nigeria, first your surgery is excellent and you do it because it needed to be done and you see the pathology. Number two, you're not getting insensitive like
1:38:51
in America Every screw, it will increase your reimbursement by1, 000.
1:38:57
So this is the second, and this is a bad syndrome that we have. We have here, because the overhead is a lot. Number three, you don't have industry that keep pushing you, and you're not part of
1:39:11
the manufacturing screws. So it's a good idea to use your own screws. And number four, you don't own the facility, healthcare facility, that the more patient you get, the more incentive we get
1:39:25
So all these incentives you don't have. So this is all under your control. What not under your control is the patients. Your patients is fantastic. Your patient, when they have real pain,
1:39:37
organic pain, they come to you. If they have soft pain, we'll call it soft because it's a more polite ways. If we have a soft pain, they don't run the doctor and demand much be treated. So you
1:39:50
already have a good patient selection, and you have good surgeon And I'm glad you attest that you don't have a lot of feel back syndrome. Excellent comments.
1:40:01
Okay. Well, I think, I think a very good point to end on the proper indication is essential and you've got to have the right indications for surgery oils you might have a higher incidence of a
1:40:21
fill-back syndrome. Thanks again to our speakers and we will end the meeting One more thing I wanted to say for Dr. Osman. Dr. Osman, one of the things now
1:40:33
I start to use because there's so much abuse from physical therapy. You send the physical therapy, they'll get developed for100, 000 because the
1:40:43
therapy's been used for the whole year as I lead patients and Africa has an access to that is just go to AI, just go to Google and then Google show me therapy for carpal tunnel.
1:40:58
Show me the therapy Mackenzie test for for for for lumber spine and this is we'll see tons of of of of money spent and resources. So we may be in a chance of Dr usman at this point and it's rather
1:41:15
that the what the usman did the heaven this this news news goes all the way is also the AI and the digital technology You may reach this people home in Africa and others and it saves you a lot of
1:41:30
money. I will encourage you to do all of that. In fact, I mean, in fact, I made a test. I know I'm talking a lot. I made a test to Dr usman Strada. You're going to really, you're not going to
1:41:42
be surprised. I have a 17 years old patient came with a typical set that can back pain for six months. She goes to the doctor, he tell her arthritis.
1:41:56
We're going to do injection. We're going to give me the case six months. And then the lady came because I did surgery in her mother. And she came to me. I said, lady, her name is Joanna. I said,
1:42:06
Joanna, I want you to talk to AI and tell him about the symptoms. She said, I have back pain and leg pain. AI said, you have a say, Erica, you probably have a disc herniation. You need to do
1:42:21
therapy. See, you didn't have to go medical I'm serious, I'm really serious. This is like blow your brain because nowadays health care is something else, you know what I mean? So I will, I will,
1:42:35
if I'm an African L, I will get my money into AI. And I will start to have robots from Eleanor by Eleanor Moss and let him do the non-surgery stuff. And we can be a happy surgeon. Well, we know
1:42:51
most of the time people don't need surgery your body can heal itself. Okay. Very good. Well, thank you all and we will reconvene for another session next month. Okay, thank you, Australia, for
1:43:06
arranging it.
1:43:08
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