SNIDigital Innovations in Learning

SNI Digital, Innovations and Learning, a new video journal, Interactive with Discussion, with James Osmond as its Editor-in-Chief, in association with SNI, Surgical Neurology International and

the Internet Journal with Nancy Epstein as its Editor-in-Chief. Are pleased to present a series of programs from the University of California Irvine Department of Neurosurgery, Interdisciplinary

Scobase Surgery Team.

On these topics,

number one, Scobase Surgery, Present and Future, and Principles of Treatment, 50 minutes. My second program is How We Manage Cordoma of the Clevis for 35 minutes,

and the third topic is giant anterior and

middle faucum and angioma for 21 minutes.

There are a number of faculty and departments involved in the skull-based surgery team. I'll introduce you to them in a few minutes, but not only includes members of the department of neurosurgery,

otolaryngology, but it's also radiation, proton therapy, and multiple other specialties.

Dr. Frank Su is the professor of neuroelectric surgery and he's also a professor of biomedical engineering of otolaryngology and is chair of the department of neurologic surgery at the University of

California in Irvine, in Irvine, California.

Edward Kwan is a professor of otolaryngology in the division chief of

rhinology and scobe surgery and co-director of the comprehensive scobe's program at the

University of California in Irvine

and Dr. Dennis Malkasian, who is a professor emeritus in the Department of Neurologic Surgery, the director of neuroanatomy and scope-based laboratory at the University of California in Irvine.

And finally, Alexander Himmsted, who is a resident physician in neurologic surgery at the University of California in Irvine, and was a Vincent P. Carroll research award winner in the Christopher

and Megarts award senior student with the most honors and promise in 2022. Alpha Omega, Alpha, and his junior and senior years. And was graduated, someone come louder from Chapman University and

has worked internationally on the global health in Ghana and Panama. Number one, skull-based surgery, present and future and principles of treatment, 15 minutes. My second program is how we

manage. Cordoma of the Clevis for 35 minutes. And the third topic is giant anterior and middle faucet meningioma for 21 minutes. Can I do? Oh, I didn't know about that. That's never true. Well,

okay, I'm recording everything. So I bypassed that mistake. And I think we're ready to go, Frank, you're gonna go for,

I'm gonna introduce people in just a second, but you're gonna go first, right? Yes Okay. And we're waiting for anybody else.

That balance is your family gonna be joining you 'cause you're on international TV or anything like that. Oh, okay. All right. So I think we can start if some people come, they'll join us. And

so anyway, we'll start. We're really privileged privilege today

to have the,

Frank, Frank Su, who Frank is head of neurosurgery at the University of California at Irvine. And I said that right, didn't I?

I didn't want the governor to pursue me,

and he's developed a terrific program there, and is really known worldwide for his work on skull-based surgery, which we're going to talk about, and we have projected a couple of parts, at least,

one is he's going to tell us about his views on the present and future of skull-based surgery. And I think the next thing, are we going to go into the series of case reports after our case reports

after that for about an hour? Is that how we got it, Alex? Yes. Okay. And Dennis, we're going to be doing all this weekend starting Saturday morning and ending on Monday is that it? Perfect.

Okay. All right.

Frank, if you want to say something a little bit about your background, I think that would be helpful. We've got an audience from around the world that's going to see this video. And we're very

anxious to hear about what you think about this field of skull-based surgery. I

was with Majusami years. It's got to be decades ago when he worked very hard and developed this concept. And it's grown quite rapidly and we'll talk about that. And so anyway, you want to tell us

a little bit about yourself or your team and then go ahead with what you think, where you think the field is going, where it is now, where it's going. Sure. I am Frank Su. I am a neurosurgeon at

the University of California Irvine. And also the the chair of the department currently I

did my training, I'll go backwards.

My fellowship was at the Barrow Neurological Institute. My mentor was Robert Spezler. Before that, I trained at Oregon Health Sciences University, and there was a big skull-based program, so I

learned a lot there. Did my medical school in Maryland, undergrad at Hopkins And I've been at UCI for 13 years. Prior to that, I was at La Melinda for nine years. Skull-based has always been one

of my passion, and it is something you don't take lightly. You have to make a huge commitment with your time, your interests, and you have to be quite dedicated to it and we have assembled UCI at

team great a.

and they're on the panel right now. Dr. Malkazian, he's a Jan, he's got the knowledge that is bigger than Grey's Anatomy. You can ask him any questions. He will give you 10 pictures in his own

drawing and then he will give you more knowledge to learn from.

Equan is our head of the skull base team in from our ENT department. And as you can see, what we're gonna touch upon, this is really a team sports. And it's not nothing to be done by one person or

few people has to be done by a big team. And Alex, instead, he's our PGY5. He's an up and coming superstar. And he's gonna dedicate his life to skull base surgery. I think I give you too much

credit, you're a PGY4, but we'll pretend like a PGY5.

You already mentioned Majisami,

you know, and as a matter of fact, skull base is so rich in history and so many giants in this field that really paved the way. And it hasn't always been easy. They started with really challenging

cases with really high mobility mortality. And, you know, once things were thought impossible, people really took on the challenges and developed many, many techniques surgically and

non-surgically to treat the diseases in the base of the skull and the progress has been made incrementally like no, you know, even though they're big giants, and they all took big steps, but in

the whole scheme of Scoveys, these are kind of tiny, tiny steps. But over time, cumulatively, we move really far forward. And this is 2025. We'll talk about a little bit of the past and the

present and the future And I say the team, because this area obviously crosses many, many borders. We have ET, ophthalmology, neurosurgeons, radiation oncology, reconstructive surgeons,

including ET or plastic surgery,

and the neuro-interventionalists to deal with vasculature, potential embolization And also, let's not forget about the medical oncologists who are trying various non-surgical methods to attack these

diseases.

One of the things that we already know is, and not in me here is so complex, so intricate. And things are coming out and going in and crossing all the nurse vessels and there are many, many

challenges in this area. On top of that, the disease is so diverse. Just to talk about basically, you've got benign problem, malignant problem, and they need to be treated differently. The

skill set that's needed to attack these problems surgically is the most demanding in all neurosurgery. And the risks are very, very high, when we do these procedures. And we can easily alter

people's function, make them worse if we don't do the right thing

And technically we've been. of maximizing the exposure, you know, all those giants in the past, they come up with big openings,

big bony removal, and the whole point is to minimize brain retraction. So when we do these big procedures, we're not, you know, really causing collateral damages in retracting the brain Over time,

we learn which procedure work, which don't work, which will cause harm and which are really our workhorses. Progressively, you know, we gain the knowledge and we try to minimize the exposure with

our colleagues coming from different angles from the endo nasal, trans temporal bone We are refining our technique to attack these problems and we're getting a lot better with that. with all the

studies we're doing anatomically, we know now when to stop, when to leave disease behind and not to cause further harm to the patients. We also gain maturity and wisdom on our judgment when not to

do an operation and when to leave things for radiation

And just briefly, future, I mean, obviously, I don't have a crystal ball. I can't tell you what skull base is gonna be, but just observing all the progress that we're aiming to refine the

approaches with all this technology. We're loaded with technology nowadays. We still don't understand a lot of the biology of the diseases. I think Dr. Melchysin will probably agree with that And

we need to incorporate -

our molecular and genetic information to attack our disease. And it sounds kind of funny, but ultimately maybe we don't have to do all these surgeries one day. We'll put ourselves out of business.

Our goal is to really preserve the function, get rid of the disease, make people live longer, have better quality of life with the skill set that we develop over time

And that's kind of my brief look at the skull base circuit. It's excellent summary,

excellent summary. When we looked, I was looking around the country and looking at the number of skull base programs and there's probably one for every major medical school and in addition to some

others. So we have 100 programs

and we're talking about. disease which primarily is you're talking about acoustic neuroma and pituitary which is a little over 20, maybe

23, 25. And the rest of them are other kinds of lesions, and

many of those are very rare tumors. Is that a correct statement?

Yes.

So if we look at that, and we look at the number of brain tumors, and or what 15, 000, 20, 000 a year or something like that in the country, and 70 of them are malignant or gliomas of some kind,

it leaves the number that are remaining to be about a small number So the question then is,

Or do we have enough people doing this, skull-based surgery? Do we have too many people? Is there enough going around so that everybody can be extremely well trained in a field that you said is

very complicated and the technology's getting complicated? So as we look into the future, how do we look at that?

Well, I think we need to remain really open-minded and flexible. For example, the things I learned in my residency, some of them I'm not using anymore. And some of the techniques

that I'm

using now, I learned with my colleagues like Ed together, developing new ways, new approaches. And then different people join on board, like ophthalmology, we're doing more trans-orbital

procedures. I would say overall, It is very hard to find a skull-based job right now. If you're coming out of training program, I get a lot of inquiries about, oh yeah, do you have a job for me?

And I usually say no, because the programs are

pretty defined in their volume referral pattern. But can we extend that to have a bigger program? I would say yes, and different approaches are being kind of device-invented. Different disease may

pop up. I think things are very dynamic. And I don't think I can say, oh yeah, we have too many or too little right now, because with the endovascular world, things change over a few months.

All of a sudden, demand's opened up, and we need more people. Are you filling the residency slots across the country? I'd heard somebody say that they weren't filling.

Residents here for neurosurgery are filling for sure. What's Sculpey's scholarships? So Sculpey's fellowships,

it's going under transition. For example, North American Sculpey Society started the match couple of years ago. So it's very early in terms of trying to match people with different programs. Prior

to that, without a match, people can just apply anywhere. And for the past few years, our application lined up, we have commitments three years ahead of time. So there's no problem filling with

our Sculpey's fellows, but now the match makes it a little bit different, just like matching in the residency. The process is new and we're still learning how to optimize the experience

when I. when I. when I. When I first trained, that was about five years ago, Denny, and

my scold-based surgery was just being developed by principally by Majej Salmi, I'm sure you know. And I was during the formative years, and it was very difficult. He was an Iranian who went to

Germany, that's very difficult to do, and he worked his way up the system to become a leader, which is extremely difficult culturally,

and did a very good job. And he was very selective on what he did with skull-based surgery, because he was worried about his overuse. What's your thoughts about that?

Well, I think you have to look at what disease you're dealing with, right? For benign diseases, you know, You probably. don't want to be too aggressive in terms of the extended inspection and,

you know, alteration of people's function. I think in the beginning, when they were learning developing these techniques, they didn't know better. So they would go commando and try to take

everything out and they would learn that there are lots of neurological deficits, cranial nerve deficits, you know, or even bigger neurological problems, but now we're really trying to focus on,

you know, what approaches the best, how to tailor our approach to the disease, whether it's malignant disease versus benign disease. And I think it's an art to decide when, how much to do, when

to stop, and we see a trend, you know, in in in acoustic neuroma and meningioma, these benign diseases, we are getting less and less aggressive because there are other modality that will help us.

finish the job. You know, we don't have to do it all surgically. And also, the new approaches, like, you know, that's why we invited Dr. Kwan here. He's a skull-based rhinologist. And this

wasn't there when I trained as a resident. I had to learn on my own, go to courses.

And that opened up a whole door, different corridors to attack tumors. And then, you know, my training was not endoscopic in removing some of these skull-based tumors. But now, my practice and

our practice is 50-50. I mean, it's 50 endoscopic, 50-open. Some practice in major centers could reach 90 endoscopic. And I think Dr. Kwan can probably come in a little bit more on that.

Let me go into one more thing, because we should follow up on that.

but if we take acoustic neuroma and we obviously have a sporadic disease that has

probably some genetic deformity but in NF2 there appears to be a consistent genetic deformity.

As you know Isaac Yang I think at

UCLA does is a proponent of doing a subtotal resection and radiation and so forth and he talks about his results.

Other people believe in complete and total removal

of the tumor and what's the standing world why you just mentioned something this covers two questions. One is the biology of the disease and two is the evolution of the treatment.

Where do we stand? This is not an uncommon tumor about seven or eight percent of them in that way. What's what we're just going to be?

Yeah, acoustic neuroma, our understanding is better now. And it's not one disease, I think it's heterogeneously, whether it's genetically based like an F2 or not, right? And you have to take a

different approach. And the function of the patient is also very important. I think the overall trend is to be less aggressive with the total resection and to preserve the facial nerve function,

preserve your neurological function and leave the rest to either observation or radiation, you know? So that's kind of the overall trend as I know it. And I know in the past, people struggle with,

oh, let's get the tumor out, let's get the whole, you have to get the whole thing out, otherwise it's gonna come back. But I think they also learned that, you know, people come up with deficits

and they don't really like that.

So nowadays, we try to get as much teamwork as possible. And we do have better imaging, monitoring and navigation. So we can do a little bit safer than many years ago. And so we still be able to

take out majority of the tumor leaving some plaster to the nerve and using electrophysiology to know when to stop

Are there people who, I think there are people in France doing this, and you probably know a bit, or working on the genetic composition of these tumors. Is there a molecular treatment coming for

this?

I would say that in regards to a trend that Dr. Sue had mentioned, precision medicine definitely is pretty big. My practice is only anterior skull base, so I don't do any lateral skull base tumors,

but I know it's a very exciting field in the otolaryngology space, and there's usually more and more grant funding focused on this particular disease Just to piggyback off of what Dr. Sue had

mentioned earlier about the endoscopic experience so far, I think one thing that I also talk about in terms of skull base surgery is learning how to dance together. So Dr. Sue has been at UCI

before me, and when I started it was a wonderful mentorship to be able to learn from him and to tackle these increasingly more challenging cases together, and he was talking about 5050. We've

really kind of built that up from almost like a 2080 where it used to be a little bit more open. And then the complexity of the diseases, the locations of the disease have all expanded out as we've

kind of grown together as a team. And that's also with other surgeons, but also trainees partnering with us. It really does take a village. The other thing I also wanted to mention that I think

would be a potential future trend is collaborative research, just to kind of address your point, back to also about how these tumors are often very rare So, banding together in this form of either

collaborative studies or consortia has been a trend in skull-based surgery that's been very common these days. And that's hopefully gonna be able to increase the number of samples that are very

precious for these tumors. There are several examples of that in both neurosurgery and on learning knowledge, but we're beginning to see that this is probably where the future is going

as well. Dennis, what's the molecular future of the treatment like an acoustic neuroma, or.

what is the, and then we haven't even talked about pituitary lesions. What you're thinking about that? Well, it's very close to what Dr. Sue was stating. Number one, there's a lot of work on

the genetics, epigenetics, and all the subcategories of epigenetics, which is outside the DNA, but how RNA can be spliced differently So it will translate differently, how there are inhibitory,

normal inhibitory, small interfering RNAs, and we could go on and on with things that are being discovered that are impressive Taking that knowledge, which is growing,

and assigning it to the profile of a tumor,

profiling that specific type of tumor to a specific patient in their genetic background. To look at polymorphisms that standing by themselves do not cause disease, but when there is another genetic

error or errors, they allow the manifestation of a clinical entity.

So you can see there's a lot of cleaning up of what gateways are the rate limiting aspects of a tumor. I think parallel pari-par-su-to that development, I think surgeons have a role to play,

at least at the beginning.

I think we can be a mechanical delivery system to the tumor. Skull-based tumors are not always macro removal.

you leave something behind. And I believe micro

remnants exist for sure. So we have to be able to take care of those things. And I think placing something that alters the viability of the tumor returning.

It could be a progenitor cell that sticks around, it goes awry and turns into a proliferative state without death and remains with mortality. These are common denominators to malignant tumors. So I

think on the front end, what Dr. Sue said, and I think most surgeons that work with bad disease and gain a lot of experience over their lifetime know that the surgery is not going to cure probably

the better part of it. So I see room. Now, will there be able to be a delivery system that's activated with some type of radiation or laser beam of low intensity? I don't know, that's so far from

where I can, I have no knowledge there, but I can imagine that it would be some things like that. So I think for the foreseeable future,

we do have a role, you made a statement, I don't know if your numbers are correct, but I think qualitatively you're on target. Maybe there are three or four tumors been in geomas, Schwannomas,

pituitary tumors, and then you start getting it to mucous seals and it's a downward slope of frequency But I think I could argue for skull base training.

where I think it expands somebody's technical growth in a way that didn't exist before. I suspect if AI is honestly developed without a lot of bureaucratic financial gains at the prescription, but

where we really use the power of it, I see where we can really expand the technical ability of a surgeon I think it also

opens gateways to thinking that Dr. Sue was alluding to. One of the great powers that leadership requires is thinking outside the box, and that's so far out that it's ridiculous. And to be

open-minded to things that may have merit, but it goes against your grain Dr. Su has an exceptional ability to listen to things. I'm not sure that he is particularly interested in, but he makes

you feel that he's interested in it. And he stimulates you to pursue it. I think

in a training program, that is really critical to give guidance to a young mind, or even an old mind, right? Dr. Osman, even as old guys. I'm 39 years old I didn't know what you're talking

about.

So I think skull-based pathology may be a relatively rare thing. I don't think there'll be too many people that will be able to make a living on it after their fellowship. I do believe this. It

must be more focus, not on a show-and-tell attitude, but real studies And we don't need that many

in the whole country.

I don't know what the number is. There are smarter people than I and more experienced people that come to those numbers, but I think you were alluding to it. We must be very cautious there because

people will do unnecessary things or do necessary things without the full complement of ability, training, and experience. Every private hospital has to be careful in not doing that institutions

and university hospitals that are very well groomed to do that. It's important. Did you just change the subject to spine surgery?

We know that most people can't make a living because there's no rules on spine surgery. It's pretty much a

insular area to my reasons to say you're a surgical candidate. But putting it all together, I think if scholarship is the aim,

It will find its way. And if our demise occurs because technology in other ways substitutes us, that's great. There's nothing wrong with that because we will stimulate that too.

So it's a longer answer than you were expecting, but you know that I would do something like this. Well, that takes me back to Frank and also from Alex's position. Here's Alex's, Alex by the way

you should ask for a raise as he just told you, you were a fifth year and you're only fourth year. So, I mean - No, no, that goes to the faculty. He recorded on videos. So there's no, I mean,

there's no question about it. But anyway, here he is. He said, he's put it all this time and he wants to go into this field. He wants to know, where's it gonna go? Where's it gonna be?

Obviously, Frank, you've alluded to the fact and the technology has been extremely helpful compared to how we initially sought.

We can get very detailed images which we didn't have before. We get three dimensions, we can turn it around. You can look at the vasculature of three dimensions. I don't think people do much

angiography, but you could do that and add that as another element to it. And then you get the endoscopic surgery and you can define very precisely where you wanna go You know it's gonna be on the

other side of it because the 3D should tell you that and so forth. So from my perspective, it would seem to me the technology properly used could be immensely helpful in improving resection and

improving quality of outcome. Is that true?

100. And then we all know that as we train the next generation, They are much better than us in technology. they understand the new devices, the new concept, just like our kids are so much better

than us in all technology.

There's no question all these things will come into play and we're going to have to learn new tricks and then while we teach the fundamental knowledge to the next generation, they're teaching us how

to use new technology and then we can ask Alex, you know, as a PGY 45, what he expects out of, you know, learning. I mean, you know, I've known him for a few years. He's very dedicated to

skull-based surgery and we have many many conversations about this and he's trying to work with Dr. Melchasium in kind of getting our skull-based anatomical cadaver lab.

finished up. So there are a lot of things that, you know, the residents who are interested in this, they can kind of try to get their hands on. And we're learning tremendously from them. So we

can ask Alex what he expects and what he thinks, and I think it's important to hear from them. Another thing you say will be held against you, Alex, I want you to understand that, even though

it's recorded for everybody in the world to see. So feel free to answer that question.

Thank you. Thank you, sir.

Thinking about skull base from a trainee perspective, I think some of the key points that I think about have been discussed a little bit. Number one, the fact that there are more and more people

going into skull base to treat a finite number of diseases or pathologies, even though the population is growing.

So that's one aspect, and I think that the way around that, at least in terms of gaining the skill set, understanding the anatomy, feeling comfortable in the operating room,

I think that's where the anatomy lab comes into play. I think spending many, many hours doing dissections, practicing approaches, understanding not just the corridor, Dr. Malkazian would say,

but the collateral anatomy, so the stuff that's around the corridor and the stuff that you might encounter if something goes wrong and you need to understand. I think that there's a huge role for

that for the trainee. And then the other thing is that, as we discussed,

it becomes less about creating the perfect looking MRI after the surgery

and more about having the perfect looking patient where they are in good shape

and make it through without any big problems. And of course, that's hard and not always possible, but you do everything that you can. Is my understanding to try to achieve that? You're just

passed and you can finish your residency after this program. I was, the patient comes first, you're absolutely right I went to a meeting, a school-based meeting in Israel, was added to me some

years ago. And I was very interested, Frank, you'll remember this, and I want to ask you about this two-head. People would get up and they would show a picture of the patient before surgery.

They wouldn't hear much about the neurologic exam, and they showed the picture after surgery, and they wouldn't tell you much about the neurologic exam. The answer was, look what I've done. And

the answer is the technique became more important than the patient, which is what you were talking about. And so the question is it's quality of life, right? And I've always asked people going to

skull-based surgery, I've asked this to any a number of times. I said, a skull-based surgery is not a disease. It's a path to a disease.

And so there can be many different paths, particularly today, what we can do, Frank, is we can simulate various different approaches through various different paths and figure out what we're gonna

get into. Isn't this right, Ed? And then we come out with, I think approach A is better than approach B, and then it's better than approach C, because I think my risks are. I mean, that's how

I would use the technology.

So the question then is, once you get there, what are you gonna do? Are you gonna, are you gonna, and you mentioned that right? In the end, some total removal is OK. And Alex was saying that

it's because it's OK because the patient's going to be OK. And we'll follow it along. I'm not sure - that's not what I was telling you. It happened at the meeting. I was in 20 years ago. It was

I'm going to show you the beginning. I'm going to show you at the end, what's in the middle I'm not talking about. And I would explain that to him. I said, what's the quality of life of the

patient? We want to go on to the next case. So Ed, what's what you're thinking about this? Is this what's the fundamental focus here?

I think in the last couple of decades, as this was being built out and more people were adopting the techniques and learning about pushing the boundaries of how to access anatomy and doing it

efficiently, there was definitely a push towards, let's take out the biggest tumor through the smallest whole and let's showcase that technique. We've certainly begun to recognize there's a lot of

different other dimensions that definitely need to be considered when taking care of these patients. Thanks very well summarized by what Alex and kind of the tenant of, just because it could be done

does not mean it should be done. So, you know, of course, the patient comes first and in our program, our focus has always been a lot of multidisciplinary discussion So, Dr. Sue and I will

oftentimes, for every patient before the surgery, we are huddling in front of the computer and looking at the scan, talking about angles of attack. And even when there's a challenging case, we're

definitely gonna meet several times to really get a plan in place and offer different options. And, you know, the patient is also focused in that conversation as well. The one thing we're also

striving to do is to create a multidisciplinary style clinic so that we can actually all talk to the patient together

offer some of the options that can be done and see what the patient's goals are and that's a model that a lot of programs already use but you know has also been very popular nowadays. Well I think

you've come to the

a key point and Denny I think you'd probably agree with this we grew up where with single surgeons who headed the department or ENT or some I know some very prominent or no some throat specialists and

in their field at that time we didn't have all the technology we didn't have all the imaging one person which is so one person did everything

and so now we have some specialization and we're getting further some specialization and what you're saying is in order for you to be successful you have to have a team approach.

And as I see it, Denny,

medicine's going to have to evolve in that direction. We had a paper presented, I read this other than New England Journal, it was a renal vascular

specialist who was interested in renal vascular abnormalities. It was not a neurosurgeon. And he had two people who came to his clinic who had a persisting malformation of the face. One man would

come every week because he'd be admitted to the ICU for bleeding. And it was just, it was just an absolutely untenable situation. And it's unprecedented digital. And he went to the laboratory,

developed an animal model to any, which was incredible. So he could reproduce this. He found it was one genetic defect. They didn't found a drug that would work on it. They tested it in the lab.

They brought it back to the clinic and treated these two patients. One man was the one who was very far advanced and the tumor didn't go away.

But obviously, the quality of his life improved and he was better. Although the lady was far advanced and it did shrink a great deal. And it tells me, it thought it was a great story about a

multidisciplinary approach to a very difficult problem, which is what you're doing. And I think, I know Danny and Frank, I know that's the direction you're going. That's the future you're

thinking about. Is that correct?

Yes, that's

correct. And we develop this team based on the need. And each new team member comes on board, brings a different perspective. And we get educated on, oh, we could do it that way. And then

different people come from different institutions. We kind of absorb their knowledge in an approach too. And I want to go back to the quality of life And, you know, and us as the. the surgeons

and the doctors, you know, these are highly complex cases. And when we do these, you know, our, our sphincter tone is very tight, you know, ourselves. And, and the reason is we don't want to

hurt anybody. And we know little mistakes or sometimes when things even go perfectly, patients may not wake up the way you think they should wake up And that is something that we take very seriously.

And, you know, given some AI, some credit, I mean, we talk about AI, everybody talks about AI. I think AI need to know or, or be able to synthesize these data to say, hey, you know, that is

not a good thing to do, right? And, and they may not understand our emotions,

If I do a case and the patient doesn't wake up, well, it hurts me. So that's how we kind of gain wisdom over time. Doesn't matter how advanced the technology is, if the patient doesn't come out

well, then you haven't done your job.

Well, to me, this gets to the place of academia. And I could see the next phase is hiring a full-time in the department, some person who might be working on the genetics of poor DOMA. And I think,

Denny, and I talked about, there's a specific genetic defect there. And, or even work further on what's going on with neurofibromatosis, and

so in order to be able to do this together, you have to put people together on the team who have to exist in that environment I. mean, somebody in some other department 40 of his time working on

the genetics of something else. And so as I see things evolving, what academia can do is be repository for very complicated, difficult problems that cannot be easily treated in the community.

You're never going to eliminate all the doctors in the community, that's impossible. Although academia sometimes has that view, it's impossible. Couldn't take, couldn't 10 of the doctors in

academia can't take care of all the disease in the country It's impossible.

But there is a distinction. And the distinction is, what should we have in major centers like that? And you're putting one together, which is a team, which can be further amplified. And then you

have to get into the issue of compensation. And so forth, the Mayo Clinic has one variety. There are other ways to look at that. As I see it, Alex, going forward,

if I was going to build an apartment, that's what I would try to do. What do you think, Jenny? Do you agree with that or are you gonna hang up on me? No, no, I think you hit some very important

points. Alex would tell you in every resident and fellow that is kind enough to listen to my diatribes. We'll tell you that

you and I were raised that the neurosurgeon should be with the capacity to operate any place in the body. And it's taken me a bit of time to change that to the team approach. Frank and I talk about

this a lot because there are remains of those attitudes and Frank has educated me and I think he's been very successful in bringing various people into the fold and that has been adding to the success

of the training program. It's not just ENT with neurosurgery, with ophthalmology, with vascular surgeons. But we have to think about, do we get immunologists and geneticists involved when we take

so much of the mucosa out? Are we creating an IgM problem, IgA problem? Are we creating a turbinate removal pathology in its own realm? Are these people over 20 years going to get bronchiectasis,

like people get with cartangenosis syndrome, because they don't develop cilia. Well, when we remove that mucosa, we may not be replacing it with cilia. So we may be removing almost 50 of at least

the upper airway in the nasal cavity. Is that enough to worry about? I don't know. But follow up is needed on that But you know what the most important connection is, is with basic scientists.

that have no idea of the trials and tribulations we're running into. And we need to share with them that we are not going to put a hole in the glass ceiling taking care of patients and doing bench

work science. It's just impossible. Dr. Sue and I got to know each other around 2017-2018. And that was a common denominator that we had Is that neurosurgeons cannot build a program, gain their

own experience, take care of a lot of patients, do a lot of surgeries, and do bench work breakthrough science. That's rare if it ever exists. So we need to bring the basic scientists - I don't

care if it's in

hematology and cell division or the genetics of a tumor that really don't think about our problems and we have no idea of their genius, we need to tell them that we do need their help. That means

sharing time and sharing money.

And that's a culture, cultural problem. We don't. True. So I, I think if we're going to talk about teamwork, we really talk about the Manhattan Project, you be bringing biochemists in that are

very good at mathematics and know how to get something to strike something within one millionth of a second. So we got Fat Boy from an 18 year old biochemist that was my endocrinology teacher at

Berkeley. He had no idea what the others were working on. So we really need to think outside the box on these tumors, because skull based tumors are the most aggressive, difficult tumors that we

know of.

from a nasal pharyngeal carcinoma, they will eat through one side andor a cardoma that keeps on coming back. So I am convinced that the teamwork is critical and teamwork must be teamwork. So I

think what we've done then, we've got to get on to some cases you were going to do, Frank, but our talk about. So we've established some real basic principles here One is the field is you're

talking about a limited number of tumors with a couple of exceptions, acoustics

and pituitaries. We didn't talk about that yet. And the second thing is what Alex mentioned, which is fundamentally true. And that is we have, as you mentioned, tremendous technological advances.

But the technology does not come ahead of what is best for the patient. And if we don't remove all of it, we still can come back later, have an intact patient, and make those decisions later. And

then the third thing we've come to is it's so complicated, and it's so multidisciplinary that it's even gonna get more so if we wanna make advances, major advances, and they're gonna be made in

academic centers. And so that means multidisciplinary teams, different methods of compensation, multi-basic science specialties, as Dennis has mentioned. Is that a fair summary?

Yes, it comes from all elements, yeah. Yeah, I think what we could do is, I wanted to give the audience, which is, we're a worldwide here, a perspective on, from some people who got really

terrific judgment on how they're handling this Now I think if you have some cases, Alex, you wanted to present. that will drive home to the people, that it's more than taking some technique or

some instrument from somebody, putting it in and I'm gonna do a better job. It's a

good instrument. Is it gonna make a terrific surgeon? A terrific surgeon can use a good instrument and do an even better job.

We hope you enjoyed this presentation. Views and opinions expressed in this program are those of the author or interviewees and do not necessarily reflect the official policy or position of SI

digital or its management. This information and the program should not be considered to be medical advice. People should consult their own physicians as to their specific medical needs.

For your evaluation and questions, please fill out your evaluation of this video or these videos at the bottom of the homepage.

There's a rating scale you'll see which has five stars. Five is the top or the most or the best or the excellent. And that helps us improve the programs and information we bring to you in the future.

If you wanna ask some questions, can have comments, ever request for your CMA credit or suggestions for us at the bottom of the homepage on the right hand corner, look for the blue icon and just

consent an email directly to us.

The foundation supporting these programs believes there are many ways to learn. SI, Surgical Neurology International, is an internet journal. Its web address is siglobal. And if you have seen as

its editor-in-chief, it's been published for 15 years. And SI Digital, Innovations and Learning, is a new internet video journal. All video, interactive with discussion, its web address is

sidigitalorg. Both are free on the internet 247, 365.

SNI surgical neurology international is red in 239 countries and territories. In the last 15 years, it's the third largest journal of a neurosurgery and readership as

240, 000 readers a year. And SNI innovations and learning is published for 20 months and it's seen in 155 countries. It's the first video journal of neurosurgery and video journal as far as we know

As 20, 000 viewers are more and listeners a year. The goal of the foundation is to help people throughout the world.

SNI offers this program and all of its program on podcasts on Apple, Amazon or Spotify. Look for SNI digital on those commercial programs and you will find the podcasts. The foundation also

supports the medical news network bringing truthful medical and science news to the world

This program and all the programs are copyrighted by the James IOSPE. and Carolyn, our OOSPE. educational foundation, all rights are reserved. If you have questions, write to Dr. OOSPE. at

JamesOSPE. at Maccom.

Thank you for watching the program. We hope you found it valuable.

Skull Base Surgery: Present and Future; Drs. Frank Hsu, Edward Kuan, Dennis Malkasian, Alexander Himstead. University of California, Irvine.

James I. Ausman, MD, MA, PhD

Frank Hsu, MD

Dennis Malkasian, MD, PhD

Edward Kuan, MD, MBA

Alexander Himstead, MD

SNI Digital®, the Global, Interactive, Peer-reviewed, New Video Journal of Neurosurgery and Neuroscience-2024 Edition; "Innovations in Learning" for the 21st century

VIDEO EDITORIAL

NEW SNI Digital® Version 4.2

Search

Filter