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SNI, Surgical Neurology International, an Internet Journal, and information resource with NCFCN as it's editor-in-chief,
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and SNI Digital, a new, editorially selected, neurosurgery and medical information multimedia platform, with operative videos, expert interviews, podcasts, and global interactive discussion for
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the next-generation of clinicians with James Ousman as it's editor-in-chief.
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Are pleased to present in cooperation with the University of California at Irvine, Department of Neurosurgery and Interdisciplinary Scale-based Surgery Team, a lecture discussion by Denny Mocasian
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on the embryological origins and surgical anatomy of the CP angle
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who's assisting Dr. Malkasian.
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He's in the Department of Neurologic Surgery at the University of California at Irvine. He graduated Alpha Omega Alpha, had many of the student awards, graduated from Chapman University, some will
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come out here. And has contributed his time and efforts in global health in Ghana and Panama.
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Moderator is James Oussman, who's the creator, CEO of SNI and SNI Digital, and the former professor at the universities of Minnesota, Michigan and Illinois, and UCLA. And former head of
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neurosurgery at Henry Ford Health Systems and UIC, University of Illinois at Chicago. He's a futurist entrepreneur in healthcare consultant. And in part three, Dr. Malkasian and
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the discussants talk about the future of neurosurgery by 2100.
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Yeah, and let's say 50 years from now, and we see this coming now. We have all this neural navigation developing. We have imaging that's incredible. You can see it in the microscope, and you can
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see it in 3D. You can see it in the other sides and so forth. And we have to understand what we went through We now have, we have very detailed angiography. You and I grew up at a time where you
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did carotid injections to do angiography. And there was nothing before that. And we do ventricularography. So to think that nothing's gonna change would be kind of a stupid thing to say. But what
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do you think? You think that technology, the imaging technology and so forth is gonna get us to a point where we won't take care of problems like this We have other ways of dealing with this
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aneurysm.
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other ways of dealing with CP angle tumors or biochemical ways of dealing with them. Are we gonna reach that point so that this period of neurosurgery that you're just spent two hours telling us
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about is gonna vanish? What do you think about that? How about that question, Alex? Does that hit the nail on the head?
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That's I think the question that a lot of trainees are wondering when they're - Yeah, right What do you think, Teddy? Well, there are gonna be major changes because
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the neurosurgeon isn't offering
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a resolution to much of the pathologies that we face. I think that's why a lot of people go into spying. And I think they're gonna be disappointed that they too are not gonna be able to make people
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better they think they will be. In the long run, they're gonna be relapses. These are not structural alterations have a very limited calling, trauma, removing a mass that's not malignant, that's
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not gonna return. But the rest of it is going to have to be dealt with at a very sophisticated, advanced biological level. And so I think we will have to fit into that You've heard me say this
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before, so I know it's old news to you. That
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we can't do much better with the glioma than we're doing from a surgical standpoint, 'cause it's a disease most likely the whole cerebrum. And so you take out what you think is tumor, people tell
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you, yeah, the margins and all that. No, no, no, there are molecular genetic changes, epigenetic changes on and on. they're already kicked into motion, it's just when that gate is gonna open.
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So I do think there's gonna be a major requirement, and I try to share that with the residents. Then be careful what you choose. Even things like DBS, they're not gonna be the answers to people
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that are getting fat. Nobody wants an electrode in their head, that has to be changed and the battery has to be changed. It's gonna have to be understanding the molecular aspects of it, and
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treating those. But does that remove the need for neurosurgery? I don't know, it does. It may remove the need for neurosurgeons because other surgeons will do the more technical work like remove a
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clot. Some tumors will be benign, the two is better, you remove them, then play with them. So is this a pessimistic view? No, things move on.
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And we'll just have to see. I'm not sure in Dr. M. Sid's career that it will change so much. That will require a number of
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changes that we can't even imagine.
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Let me venture into the changes we can't imagine territory We've got a series of, and this is all conjecture, Alex, so it's maybe worth less information. Somebody will show this information
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20 years or 30 years from now be laughing at it and see how crazy these guys are. We're going through a series of lectures now on SNI Digital given by a professor. He used to, he used to follow
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who's in France And what he's doing is going in and taking a. medium to low grade gliomas out and he's doing this with incredibly long survivals that we don't see in places around the world and he
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and the basic thing is he says you've got to think not about the tumor you've got to think about the brain and so his surgery is functionally based and he says a camera line imaging because the brain
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has got plasticity and what what the imaging may show may be different the next day or if I come back and operate on somebody some months later the speech area has been shifted already to the other
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side of the brain or someplace else and he said the only thing that matters is to make sure you you maintain the connect white matter connections so you maintain quality of life you've heard the
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lectures Alex that's what he says right okay okay so I think one number one neurosurgery is going to change dramatically. I don't think you can operate on the brain. CP angles different, I'm gonna
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come to that. I don't think you can operate on the brain without understanding what I'm going to do to preserve the brain and not the tumor, which is quality of life over the tumor. So I think
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there's gonna be, this is gonna change all the residency programs throughout the country. It's gonna take probably a couple of decades to do that, all the training programs, and we're gonna change
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all kinds of neurosurgery That's the first thing. All the technology is gonna continue to go on. And I could see that Dennis made incredible, incredible detailed diagrams I've never seen before.
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And you have to see that and understand that anatomically in order to understand what you're operating on. The machine, will the machine be able to integrate all of Dennis' knowledge using imaging,
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ABC and 4. ABC and D to get that information. Well, I remind you what Defoe has found. He said no matter what the imaging shows, it's not reliable. And the brain shift may alter things. So that
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doesn't help you either. Will they have fixes for that? I think they're probably working on it desperately. That's a hard problem to solve because you never have imaging that's accurate. And will
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it take into account
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neuroplasticity? So I'm thinking of going to one of the biomedical companies and to construct something so I can get to the CP angle, just like Danny said. And it would tell me all these, it would
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put arrows showing all these things that are going on. Is that going to make me a better surgeon? And I'm going to have a better result? Or the answer is, it could. But in the end, there still
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has to be something that Frank Shua had at the end of the conversation and presenting his patient. It is the judgment to know when to stop.
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And the computer won't tell you that. And you have to know that. And the other thing that will happen is what Dennis said, is you're gonna have to have very sophisticated neurosurgeons to do this
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kind of work. And that means they're gonna have to be in centers to do that And right now we don't have enough vascular surgeons who know what to do. They can't even do aneurysm surgery well. So I
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think that's another thing. And the third thing, Danny, is something you talk about. Are we gonna be treating tumors instead of what Dr. Defoe is gonna do? And what else we've talked about? Is
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cancer gonna turn out to be a metabolic disease? And
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we have papers on SNI
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digital about that And are we going to find? I have chemical answers to that and there's no question that what the answer to that is to that. Yes, the answers to that, yes. Of course, the cancer
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is, it's got major metabolic effects. And a cell is metabolically dependent, the mitochondria, all of it, we'll get
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there. We're not there now because we don't even think that way
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I think there are some people that do, but the pragmatism in the business that runs the medical profession needs faster returns on its investments.
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And I can't fault them for that, but I think
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it will take a crisis for that to change. I think you're right, I agree with you. I think you're right We've got a health care system that is.
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that is absolutely broken and is broken across the world. Well, I was reading in JAMA this week where they're talking about manipulation of the neck and osteopaths should be doing that and massages
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and things, these are this not one of the money in medicine and attention, these are the general aims of life. They don't need this attention but it's there because people need jobs and they get a
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professional title and it's certificate and that's chewing up a lot of money for people that should just live with what they have. They haven't got such bad problems. I agree. So this is for
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another time but I thought I'd ask you particularly after you just did a fabulous job going into this and it's very humbling, listening and seeing what you've said, your pictures are outstanding And
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if anybody just didn't want to put aside two hours. and listen about this, they would learn an enormous amount about medicine, neurosurgery, humility, and what you can do and what you can't do
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and what you have to know to prepare, to operate on a patient with zero complications. Right? Well,
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I wish I could ask to be given credit for most of this, but I have to tell you,
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the magnitude of whatever I know, I'm not sure it's all great, but I know this, that I am a product
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of mentorships that were very serious and guidance
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as to the highest level of moral ethics and the purest level of attaining
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I have to say thank you to my mentors. I'm not sure where I would have been if some of those people did not touch something that lit me up. So, yeah, I'll take some credit for the effort, but my
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journey always reminds me, is make sure you pass this on.
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Yes, Alex, I was gonna ask you one final question on this idea I think the average resident ought to hear this two hours series.
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The question is, should the average resident, regular everybody
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going through, hear this two hour symposium, basically, on
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anatomy, biologic anatomy and surgery and management
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That's
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a kind of a loaded question, I think. I think
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that a lot of residents who are not interested in skull-based surgery or complex cranial surgery would think that it's not helpful to them. It's wasting time. But I don't know that that means that
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they should watch it because I think that the principles discussed in how to think about a problem, how to think about an approach and how to think about the relevant anatomy when you're going in and
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performing an operation on somebody is valuable to everybody. Well, I think that's an excellent answer. I appreciate the confidence and I know you're telling me an honest answer. But the question
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is if you're chairman of a department,
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would you have all the residents watch this?
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probably the ones interested in skull-based and vascular.
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Do you think that spine surgery eventually is going to come to a point where you're going to need something like this in detail? There's going to be biochemical treatments for osteoarthritis.
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Nobody's done an ant to do, does routine angiograms on the spine? So we don't know if there's vascular occlusions. And the reason is because it's too hard to do what we had that, how many Denny,
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that was almost 100 years ago
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And yet we don't have no idea, we wanna know about the vasculature in the brain, we know nothing about the vascular of this spinal cord. Can you imagine, do you think that we're gonna, somebody
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did this, a Dr. DiCiro did this in the 1960s, in 10 cases of spinal cord trauma, found all kinds of lesions.
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And the answer is, do we not wanna know or is it too hard to find out or too complicated? Yeah, I think those things are probably true, not a lot of people are skilled enough to do that. But so
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we're getting to a point where you got to be open to the fact that there are going to be lots of changes and lots of new things and you're going to evaluate what's new is good and what's not good and
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so forth. And so the others are going to get to this detail. Does it make sense for pituitary tumors to grow and have to radiate them and do something else? Don't you think I'm one of the most
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accessible lesions in the body that we ought to know biochemically what's going on and treat it? I mean, it makes no sense.
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You know, a lot of the
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opinions that
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we have developed because of a journey in life. And this is what makes different aliquats of
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people defined by their age and what stage of life they're in.
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We're at a stage of life, Jim, that we reflect a lot on the mistakes that we made and other people made. And that kind of skews us in a certain mental state. And I think we're right. But there
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won't be advancements without the enthusiasm, without the
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limits and costs That's incosions that you and I have learned.
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And maybe nature sets it up this way, that that's kind of dangerous, but yet advancements won't come without that,
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what I call alpha animal that I don't particularly want to be myself. So what am I saying? I think we get there. I think ultimately humans advance And it astonishes me with humans.
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can't, can see that I can't. And I think we're really a smart animal.
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I really do.
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Okay. Denny, I want to thank you. Alex, I want to thank you for helping set this up
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